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AMD fRNL£R£«E^ j SUfldRCNCFMrTRAI/SOFFICE 8fcv.-7—1901 Pk* GRIGG & ELLIOT, 9 NORTH FOURTH STREET. 1838. 7 /*■-%» „&* /'-'?> .k-l-r.,.- Jt fr Q /***" W 35 183? v. I Entered according to the act of Congress, in the year 1831, by John Eberle, M. D., in the clerk's office of the district court of the United States, in and for the eastern district of Pennsylvania. Philadelphia: T. K. & P. G. Collins, Printers, No. 1 Lodge Alley. TO GEORGE M'CLELLAN, M. D., PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE, &C. &C, THIS WORK IS INSCRIBED, AS AN ACKNOWLEDGEMENT OF THE HIGH REGARD ENTERTAINED FOR THE POWERS OF HIS MIND, AND THE GENEROUS SENTIMENTS OF HIS HEART, BY HIS OBLIGED FRIEND, THE AUTHOR. PREFACE. In the composition of this work, an effort has been made to exhibit a distinct view of the essential phenomena and principles pertaining to the various subjects which it em- braces, with an especial endeavor to avoid the extremes of unsatisfactory brevity on the one hand, and of fatiguing prolixity of detail and discussion on the other. With the exception, therefore, of a few instances in the introductory portion of the work, the author has indulged but little in controversial discussion and general speculation. His object has been, to give a digest of facts and established principles, rather than of opinions and points of disputation. He has not, however, failed to give an exposition of those pathological and therapeutic principles, which appeared to him fairly deducible from the particular phenomena brought under consideration; and whatever his own experience and reflections have led him to differ from others, he has freely, though he trusts with becoming deference, stated his sen- timents. It will be perceived, that no general doctrine or system of pathology is exclusively or especially favored in the following pages. Medicine, as it is now generally culti- vated, is strictly eclectic. The judicious and unprejudiced physician will neither condemn nor adopt unreservedly any of the leading doctrines advanced in modern times. He will see something to admire and embrace in the systems of Brown, of Cullen, of Darwin, of Broussais—and even of 1* VI PREFACE. the fanciful Hannemann; although when offered to his acceptance as doctrines of universal application, he may very reasonably refuse his assent. It will be seen also, and perhaps by some regarded as a defect, that no formal classification has been adopted in the arrangement of the work. Nevertheless, the order that has been observed in the succession of the various subjects, is probably as natural as that obtained by any of the modes of systematic arrangement usually pursued in works of this kind. It is now generally, and very justly believed, that the artificial, classific, ordinal and specific distinctions of nosology have an unfavorable influence on the progress of comprehensive and philosophical views in pathology. The primary elements of disease, like those of matter, are pro- bably but few in number. A few elementary modes of morbid action (if the expression may be used) modified in their general results or phenomena, by different grades of intensity, modes of combination, and the structures impli- cated, constitute the fundamental morbid conditions, of which the phenomena by which diseases are described, are merely the external manifestations. It is here that the unfavorable tendency of nosological distinctions mainly exists. Instead of leading the student to contemplate the morbid symptoms as the mere external expressions or signs of disease, modified by various accidental circumstances, and especially by the structures chiefly affected, the artifi- cial divisions of nosology are apt to lead him to regard the groups of symptoms, usually associated, as so many distinct essences, possessing fixed and specific peculiarities of cha- racter. To these objections, the arrangements founded on the particular structure primarily implicated in the disease, are not liable. It must be admitted, however, that correct and philosophical as such a classification may appear to be in theory, the attempt to reduce it to practice is attended with PREFACE. Vll many very serious difficulties. Nevertheless, should an- other edition of this treatise be called for, it is the intention of the author to arrange its materials upon this plan of classification. It is not improbable that various errors may have escaped the author's attention in the course of the work; but he has no apologies to offer for any defects it may be found to possess; and he sends it into the world, in the hope, that, with whatever blemishes and deficiencies it may be chargeable, it will be found a useful compilation of facts and principles in pathology and practice. ADVERTISEMENT TO THE THIRD EDITION. It will be perceived, that the arrangement promised in the first and second editions has been adopted in the pre- sent one. That it may be obnoxious to objections in some of its details, cannot be doubted; but the general scheme, it is believed, will be acknowledged to accord better with the present state of pathological science, than the more artificial and complicated classifications repudiated in the Preface. Considerable additions have been made to the present edition. The subjects of pneumo-thorax, infantile convul- sions, pericarditis, and hysteritis, omitted in the first, are introduced in this edition; and the chapter on the general pathology of fever has been entirely re-written. To these chapters are now added those of diagnosis and cholera asphyxia; the latter being placed, from an accidental cause, as an appendix to the second volume. Many pathological and therapeutic observations, also, have been introduced throughout the work; and no inconsiderable number of typographical errors, as well as errors of language, which had escaped the author's attention, have been corrected in the edition now offered to the public. CONTENTS OF VOLUME I. PRELIMINARY OBSERVATIONS ON THE PATHOLOGY AND ETIOLOGY OF FEVER. CHAPTER I. Page Of the Pathology of Fever in General,.....13 CHAPTER II. Of the Causes of Fever. Sect. I. Of Predisposition, and Predisposing Causes, 39 Sect. II. Of the Sources of Morbific Causes, and their General Character, 42 Sect. III. Atmospheric Temperature, and its relations with the Animal System, ---------44 Sect. IV. Of Miasmata,.........50 Of the relations of Miasmata to the animal System, &c. 59 Sect. V. Of Contagion,.........64 CHAPTER III. Of the General Course, Type, and Stages of Fever, 70 CHAPTER IV. On General Diagnosis, -......-77 I.—GENERAL IRRITATIVE DISEASES OF THE BLOOD-VESSELS INDEPENDENT OF LOCAL INFLAMMATION. CHAPTER V. Of Intermitting Fever, --.....- 103 CHAPTER VI. Remitting Fever,.........128 X CONTENTS. Page CHAPTER VII. Yellow Fever, ........146 CHAPTER VIII. Continued Fever, --------- 154 Sect. I. The Synochal Grade of Idiopathic Fever, or Simple Inflammatory Fever, .........158 Sect. II. The Synochus Grade of Idiopathic Fever, - - - - 163 Sect. III. Typhus,..........179 II.—GENERAL IRRITATIVE DISEASES OF THE BLOOD-VESSELS, CONNECTED WITH OR DEPENDENT ON LOCAL INFLAM- MATION. CHAPTER IX. Of Inflammation in General, -......200 CHAPTER X. Of the Phlegmasia of the Alimentary Canal, and its Accessory Organs. Sect. I. Of Glossitis,.........207 Sect. II. Of Tonsilitis, - - -......209 Sect. III. Of Parotitis,.........212 Sect. IV. Of Acute Gastritis, -------- 214 Sect. V. Of Chronic Gastritis,.....--. 218 Sect. VI. Of Acute Enteritis, - - -.....224 1. Acute Peritoneal Enteritis, ----- 225 2. Acute Mucous Enteritis, ------ 233 Dysentery,........233 Sect. VII. Of Chronic Enteritis, ------- 248 Sect. VIII. Of Acute Peritonitis, ------- 252 Sect. IX. Of Chronic Peritonitis, ------- 260 Sect. X. Of Acute Hepatitis, -------- 265 Sect. XL Of Chronic Hepatitis, ------- 275 Sect. XII. Of Splenitis,......... 280 CHAPTER XI. Of the Phlegmasia of the Nervous System. Sect. I. Phrenitis, ------__._ 283 Sect. II. Arachnitis, ----^--____ 287 Sect. III. Cerebritis—(Ramollissement du Cerveau,) ... 300 • CONTENTS. XI Page CHAPTER XII. Of the Phlegmasia of the Respiratory Organs. Sect. I. Pneumonia,.........304 Pleuritis,.........304 Peripneumonia, ---._.__ 307 Pneumonia Biliosa, ---._._ 308 Sect. II. Cynanche Laryngea, -------- 320 Sect. III. Cynanche Trachealis, ------- 323 Sect. IV. Acute Bronchitis,........336 Sect. V. Chronic Bronchitis,........342 Sect. VI. Phthisis Pulmonalis,.......352 CHAPTER XIII. Of the Phlegmasia of the Urinary and Genital Organs. Sect. I. Nephritis,..........367 Sect. II. Cystitis,..........372 Sect. III. Chronic Cystitis,........375 Sect. IV. Hysteritis,.........377 Sect. V. Chronic Hysteritis,........382 CHAPTER XIV. Of the Phlegmasia of the Sanguiferous System. Pericarditis, ------ - 384 CHAPTER XV. Of the Phlegmasia of the Fibrous and Muscular Structures. Sect. I. Acute Rheumatism, -------- 390 Sect. II. Chronic Rheumatism, - - - - - - - 401 Sect. III. Gout,..........407 CHAPTER XVI. Of the Inflammatory Affections of the Eves. 1. Catarrhal Ophthalmia,......421 2. Rheumatic Ophthalmia, ------ 424 3. Purulent Ophthalmia, ------ 425 4. Scrofulous Ophthalmia,......429 5. Syphilitic and Strumous Iritis, - - . - - 434 CHAPTER XVII. Of the Cutaneous Phlegmasia.—Exanthemata. Sect. I. Variola,.......... 436 Xll CONTENTS. Page Sect. II. Vaccina,..........451 Sect. III. Modified Small-Pox,.......458 1. Varioloid Affections, ------ 458 2. Varicella,........464 Sect. IV. Rubeola, Morbilla,........467 Sect. V. Scarlatina,.........478 Sect. VI. Erysipelas,.........498 CHAPTER XVIII. Minor Exanthemata. Sect. I. Herpes,..........512 1. Herpes Phlyctenodes, - - - - - - 513 2. Herpes Zoster,........514 3. Herpes Circinatis, - - - - - - - 517 4. Herpes Labialis, - - - - - - - 518 5. Herpes Preputialis, - - - - - - - 518 Sect. II. Pemphigus, --------- 519 Sect. III. Urticaria,.........526 Sect. IV. Miliaria, - - -......530 Sect. V. Lichen, - - - - - - - - - - 532 Sect. VI. Eczema, -.......-- 536 Sect. VII. Erythema,.........540 Sect. VIII. Roseola,.........542 Sect. IX. Purpura, --------- 543 CHAPTER XIX. Vascular Irritations with a flow of Blood. Haemorrhages, -------- 549 1. Epistaxis,........556 2. Haematemesis, -------- 559 3. Hematuria, -------- 562 4. Haemoptysis, ---.....565 5. Menorrhagia, --------571 CHAPTER XX. Phlegmasia of the Lymphatic System. Phlegmasia Dolens,.......576 A TREATISE ON THE PRACTICE OF MEDICINE. PRELIMINARY OBSERVATIONS ON THE PATHOLOGY AND ETIOLOGY OF FEVER. CHAPTER I. OF THE PATHOLOGY OF FEVER IN GENERAL. The history of practical medicine consists of little else than a review of the doctrines which have successively risen and sunk again, concerning the nature and treatment of fever. Whatever other objects of interest or importance within the dominion of medical science may have attracted the attention of physicians, fever has at all times been viewed as presenting the most extensive and inviting field for observation and the exercise of ingenuity. It is in this department that observation and research have been most industrious in accumulating materials, and that hypothesis has luxuriated in her wildest exuberance. When, indeed, it is considered that the destroying angel has made his most desolating visitations under the form of febrile epidemics, and that in the long list of human maladies, fever occurs in perhaps nine cases out of ten, the paramount importance of this subject is strongly forced upon our convictions.* * "If we except," says Van Swieten, " those who perish by a violent death, and such as are extinguished by mere old age, and which are indeed few, al- most all the rest die either of fever, or of diseases accompanied with fever. We read in Pliny with what fear and trembling the Romans endeavored to have Vol. 1.—2 14 GENERAL PATHOLOGY OF FEVER. From a retrospective glance over the history of our science, we are forced to acknowledge that there is, perhaps, no subject which is more eminently calculated to humble the pride of human reason than this one. In relation to this subject, pathology has been in a continued state of revolution and instability. The human mind has been engaged with it for near three thousand years. Theories have risen and sunk again in a continued and rapid series of succession; each has had its hour " to strut upon the stage/' and its votaries to yield it faith; but the stream of time has hitherto overturned all these insubstantial, though often highly wrought fabrics. Has the mind then made no real advancement in relation to the pathology of fever? Are we now no nearer correct and rational views concerning this important subject, than were our forefathers? Has genius always wandered in idle quest, and brought back no sub- stantial trophies from the regions of pathological speculation on this point? Far from it. Like the assymptotes of the parabola, the human mind is continually verging towards truth, although it may never reach it in relation to the essential nature of fever. There has probably never been a theory or doctrine promulgated on this subject, which did not clear away some old rubbish, or bring to fuller view some of the relations of the phenomena it presumed to eluci- date. The dreams of speculation have vanished; but the facts and correct principles which were necessarily mingled with them, re- main as so much valuable treasure saved out of the wrecks of former systems. The mass of solid materials which has been thus gradually accumulated, has now in a great measure displaced those vague and hypothetical foundations upon which former doctrines in relation to this subject were constructed. Hypothesis is no longer tolerated in science. Philosophy does not acknowledge her as a legitimate ser- vant. The cyclus of her empire has gone by; and the genius of rational induction is now the only power under whose direction the votary of science presses forward to conquest in the fields of know- ledge. Like many other things which are at once obvious to the senses, and concerning the existence of which almost every one can decide, fever does not admit of a strictly correct and unobjectionable defini- tion; since there is not a single symptom which is invariably present, and which can be regarded as absolutely essential to its existence. Boerhaave collected together, from a great number of authors, all this universal disease—-fever, appeased by their supplications in the temple of Fanum; and hence, perhaps it is, that fevers are called diseases by Hesiod, and that Horace calls all diseases simply fevers, when they rushed out of the box of Pandora— ' Post ignem aetherea domo Subductum, Macies, et nova febrium Terris incubuit cohors.'" Van Swieten's Com. vol. v. p. 1. GENERAL PATHOLOGY OF FEVER. 15 the symptoms which had been observed in fevers. He then struck from this list, all those symptoms which do not appear in all, but only in certain modifications of fever—retaining such only as by the common consent of authors and his own observations, were found to be present in every instance of fever. The result was that only three symptoms were left standing—namely, a quick and frequent pulse, preternatural heat of the surface of the body, and a sense of cold or chilliness in the commencement. But he might have gone farther, and struck from his list these symptoms also; for it is quite certain that cases of fever do occur in which there is nei- ther preternatural quickness and frequency of the pulse, nor an increased temperature of the surface of the body; nor is a sense of chilliness, though perhaps the most constant of all the febrile symp- toms, universally present in the initial stage of fever. Notwithstanding the great difficulty, or rather impossibility, of giving a strictly unexceptionable scientific definition of fever, yet the train of phenomena which this state of disease presents under all its modifications—varying more or less in their concomitance and succession—offers, upon the whole, a character sufficiently distinct and definite for easy and certain recognition. Pathologists have divided fevers—according to the mode of their development—into idiopathic and symptomatic, and the propriety or impropriety of this division constitutes, at the present day, one of the most important, and warmly contested subjects in pathology. By the former class, are understood those fevers that are developed and sustained by causes, which produce a general morbid state of the system, independent of local inflammation or fixed irritation. Those who admit the existence of such fevers, suppose that the re- mote febric cause produces a deleterious impression on the sentient extremities of the part upon which it acts, which, deranging function after function, according to the catenation of the organic sympathies, finally results in a state of general disease, characterised by the or- dinary phenomena of fever; or, as they presume, the remote cause may gradually change the healthy character of the circulating blood, which, acting as a morbific irritant on the heart and arteries, gives rise to febrile reaction. Many eminent pathologists, on the contrary, contend that such fevers can have no existence; and that all febrile excitement is pure- ly symptomatic, and of course essentially and wholly dependent on a pre-established local irritation or inflammation. According to these views, the direct influence of the remote cause of fever is limited to the production of the primary local inflammation or irritation, the subsequent pyrexial phenomena being the result solely of this pri- mary local affection; in other words, the secondary and sympathetic excitement of the pre-established focus of irritation. At the head of those who advocate the exclusive symptomatic nature of fever is Broussais, who, whatever may be thought of his peculiar doctrines in relation to this subject, has manifested a professional zeal, and an 16 GENERAL PATHOLOGY OF FEVER. activity and acuteness of intellect, which have justly placed him high among the " greater lights" of our profession. Not satisfied, how- ever, with the adoption and defence of the general doctrine of the universality of symptomatic fever, Broussais contends that the in- flammation, or irritation whence the febrile sympathies radiate as from a focus, is almost universally located in the mucous membrane of the alimentary canal; and hence gastro-enteritis is with him the fons et origo of febrile phenomena. That fever is a very common result of local inflammation, is un- questionable. So intimate are the sympathetic relations between all the various parts of the animal body, that no structure or organ can be strongly irritated without causing a sympathetic irritation in other organs or structures. If the primary irritation involve the sanguiferous capillaries, the irritation will be communicated by sym- pathy to the general vascular system, and fever will be the result; but if the local irritation be purely nervous, it will be diffused, and as it were locked up in the general nervous system, and give rise to convulsions, or some other form of general nervous affection. With- out doubt too, inflammation of the mucous membrane of the aliment- ary canal is much more common in febrile diseases than was for- merly, and by many is still supposed. It is even probable that in many instances of fever, such an inflammation constitutes the pri- mary and essential cause of the febrile phenomena. This is, per- haps, most apt to be the case in those instances of fever which result from the combined agencies of impure and indigestible diet and at- mospheric vicissitudes. But although we may admit the correctness of these observations, yet to refer all fevers, remitting, intermitting, and continued, to gastro-enteritis, is as remote from truth as it is detrimental in its influence on practice. The advocates of the physiological doctrine, as it is called, endea- vor to support their sentiments in relation to this subject, by the phenomena detected on post-mortem examination, and by arguments founded on physiological principles. It is affirmed that marks of inflammation almost universally occur in the mucous membrane of the alimentary canal, in subjects that die of febrile affections. The capillary vessels, to a greater or less extent, of this membrane, it is said, are found injected; and in many instances other and less equi- vocal traces of previous inflammation are discovered. Admitting that such manifestations of inflammation are as universal as they are asserted to be, is there not much reason to believe that, very fre- quently at least, the inflammation supervened during the course of the disease, as a consequence of the fever, rather than that the inflam- mation was pre-established, and became the immediate exciting cause of the febrile phenomena? We frequently see inflammations super- vene in parts exposed to observation many days after general fever has been fully established. Indeed, when it is considered that in all febrile affections, the secretions which are poured into the intestinal tube, are unnatural and vitiated—that the process of digestion is sus- GENERAL PATHOLOGY OF FEVER. 17 pended, or much impaired, and consequently, that fermentation and decomposition of the contents of the stomach and bowels are espe- cially favored—is there any cause to wonder that we should so often meet with traces of inflammation in the digestive organs in those who die of febrile affections? The Broussaian mode of treating fe- vers, although especially meant to obviate such inflammations, ap- pears to me, in one respect, well calculated to favor their occurrence. The almost total proscription of purgatives from the list of our re- mediate means for the treatment of fever, so far from lessening the tendency to gastro-enteritis, tends, I conceive, in general, to an op- posite result. In a recent work by Bouillaud, there are upwards of sixty cases of fever reported, in not a single instance of which was there a purgative medicine administered by the mouth. In all of these cases, however, marks of inflammation, and in the majority ul- cerations were detected in some portion of the mucous membrane of the bowels. That this should have been observed, will not appear strange, when it is considered that in all the cases, most of which continued from three to four weeks, all the acrid and vitiated con- tents of the intestines were suffered to remain, undisturbed, to act on their delicate lining membrane. To one not thoroughly imbued with Broussaism, it does appear strange that any one should withhold a laxative, under the appre- hension of its causing injurious irritation, and yet suffer, without any such fears, the most irritating substances to lie quietly in the bowels. It is true, laxative lavements were repeatedly resorted to in these cases, but that these did not disturb or remove the acrid materials which were inclosed in the bowels, is abundantly manifest from what Mr. Bouillaud himself has stated. After having gravely told us that in all the cases he describes, the traces of mucous inflamma- tion in the bowels were tres prononcA, he states that, "in general the stomach and small intestines were filled with a yellowish or greenish bile, and that the residue of the alimentary substances which were found in the small and large intestines, invariably exhaled an intolerably fetid smell, and frequently exhibited the consistence of mustard. This residue, mixed with various fluids secreted in the intestines, appeared to have undergone a complete process of putrefactive decomposition, as was evident from the extreme offensiveness of the smell, and the fetid gas which dis- tended the bowels."* Can it be reasonably supposed that the transient and moderate irritation of a purgative in these cases would have been more inju- rious than the constant impressions of the acrid and irritating sub- stances which were so long left in immediate contact with the bow- els? It is thus, it can hardly be doubted, that many instances of gastro-enteritis, so abundant in the practice and dissections of the Broussaian school, are developed. Were laxatives employed with * Traite Clinique et Experimental des Fievres. Par J. Bouillaud, Paris, 1826. 2* 18 GENERAL PATHOLOGY OF FEVER. due moderation, it is probable, that the so much dreaded gastro- enterite would in some instances, at least, perhaps in many, be prevented, and the world deprived of a large proportion of those triumphant demonstrations which are continually brought out in formidable array in support of the physiological doctrine. As a further offset to the evidence adduced from post mortem ex- amination, it must be observed, that so far as the mere redness or injected state of the mucous membrane is concerned, we can draw- no certain inference as to the previous existence of inflammation in this structure. That these phenomena are frequently the result of changes affected in articulo mortis, or post mortem, is fully de- monstrated by the observations of Mr. Yellowly and of Mr. Seeds.* * " It must have happened to every one," says the former of those writers, " accustomed to the examination of dead bodies, to see appearances of vascular injection in the villous coat of the stomach. Such appearances have very fre- quently been referred to inflammation, but they have probably been but little studied. I have several times been present at the examination of bodies, where the vascularity of the villous coat of the stomach was so considerable as even to give rise to suspicions that the appearance had been produced by something de- leterious. I was therefore induced to embrace frequent opportunities of viewing the state of the inner surface of the stomach, and I so often found in it the ap- pearances alluded to, as to induce me to imagine, that the opinion which is commonly entertained of their being marks of disease, is not well founded. In persons suddenly destroyed, when apparently in perfect health, he found the mucous membrane of the stomach highly injected." Mr. Seeds too, found that in animals bled to death, the membranous structures frequently exhibit a state of injection which might, at first sight, be readily mistaken for inflammation. It is well known that the arterial tubes possess a power of contracting to a considerable extent, by what Bichat calls the contractility of texture, and that this power is not limited to the period of life, but continues some time after death. It is equally ascertained that the capillaries are endowed during life with a peculiar degree of sensibility which causes them to resist the entrance of such fluids as they are not destined to convey in the performance of their natural functions. This peculiar sensibility, by virtue of which, the serous capillaries refuse, or contract against the intromission of red blood, would seem to depend on the regular influx of the nervous influence. That this is the case, appears highly probable, if not certain, from the different results arising from the forci- ble injection of fluids into the arteries of living and dead animals. " Push into the aorta of a living animal, by means of a, syringe, different fine fluids, and you will never see them fill the capillary system, or issue by the exhalents;" when, however, the same experiment is performed on an animal soon after death, the fluid will be found to pass readily into the serous capillaries, and pass out by the exhalents, excretory ducts, he. {Bichat.) Mr. Buniva's experiments, quoted by Bichat, with injections upon dead and living animals, illustrate this fact in a very striking manner. He fixed the pipe of a syringe into an artery of a living animal; on endeavoring to force the fluid into the vessel he found very great resistance, the piston passing down very slowly, and only with the application GENERAL PATHOLOGY OF FEVER. 19 Broussais and his followers are, indeed, fully sensible of the ob- servation of Celsus: Neque quicquam esse stultius quam, quale quid vivo homine est, tale existimare esse morienle imojam mor- tuo; for where they fail in detecting a red and injected state of the mucous membrane of the bowels, they account for its absence by ascribing it to a post mortem change; thus availing themselves of this fact when it affords an argument in their favor; whilst they manifest an unwillingness to allow any importance to it when it is adduced against their doctrine. It cannot, indeed, be presumed that the injected state of the mu- cous membrane of the intestinal tube, so often discovered in those who die from fevers, is always, or even generally, to be ascribed to a mere post mortem change; but that such changes do sometimes, nay, often occur, and that they have been assumed as evidences of previous inflammation, there can exist but little doubt. The first obvious effect of the remote febrific causes, consists almost universally in a diminution of the nervous energy, and con- sequently of the action of the heart and arteries. This is manifested by the weak and contracted pulse, the general languor and lassitude, the diminished temperature and the sense of chilliness which usher in all febrile affections. These initial phenomena of fever are espe- cially conspicuous in intermittents, remittents, and in catarrhal affec- tions. There is nothing in the character of these symptoms which can justify the inference that they are dependent on inflammation. " Inflammation," says Dr. Armstrong, " cannot exist in the cold stage of fevers, all the phenomena of which are directly opposed to inflammation." The course and phenomena of intermitting fevers present us indeed with insurmountable objections to the "physiolo- gical doctrine.'''' The periodicity of these fevers is strongly op- posed to the idea of their immediate dependence on the gastro-ente- of much force. On causing the animal to be suddenly killed, by dividing the spinal marrow just below the occiput, the fluid passed rapidly out of the syringe into the artery, although but little force was applied. While the capillaries retained their full portion of vitality, they resisted the introduction of the fluid; but as soon as they had lost their sensibility, in the death of the animal, they yielded like passive tubes to the fluid forced upon them by the vis a, tergo. The application of these facts to the post mortem production of a red and injected state of the membranous structures, especially the more vascular ones, is easily to be understood. So long as the serous capillaries retain their vitality, they resist the entrance of red blood into them. As soon, however, as their vital pro- perties cease to exist, they lose the power of resisting the intromission of red blood—becoming, in fact, mere passive and yielding tubes. But as the arteries continue to contract on their contents, some hours after the extinction of life, they must necessarily force the blood forward into the relaxed and unresisting capillary system, into which it will therefore be driven, as into a sponge, and give to the more vasf ular structures, the red and injected state, so often found on post mortem examination, where no previous inflammation whatever existed. 20 GENERAL PATHOLOGY OF FEVER. ritis. It is, indeed, true, that affections of an inflammatory charac- ter, have been known to recur in a strictly periodical manner; but such cases must be viewed as anomalies, and altogether contrary to the almost universal course and character of phlegmasial diseases. An inflammation which observes a perfect periodicity in its attacks, must be sui generis. If intermitting fever depend on inflammation of the mucous membrane of the alimentary canal, then must this in- flammation be periodical, and therefore essentially distinct from the inflammation which produces remitting fever; for in this malady- it must be continuous. These two forms of fever are, however, produced by the same remote cause; and we are" therefore forced to admit, by the assumption of this doctrine, that the same remote cause is capable of producing two kinds of inflammation essentially distinct from each other. The character of the remedies, too, which have been found most effectual in arresting intermitting fever, is di- rectly opposed to the idea that gastro-enteritis constitutes its proxi- mate cause. Who can believe that quinine, arsenic, black pepper, and other remedies of a similar character are peculiarly calculated to cure inflammation of the mucous membrane of the alimentary canal? Indeed, these very articles appear to be particularly dreaded by the disciples of this doctrine, on account of their tendency to create gastro-enteric irritation, and yet all experience goes to prove that they are decidedly the most prompt and valuable means for the cure of intermitting fever. M. Broussais' theory of the mode in which the remote causes of febrile affections produce gastro-enteritis is gratuitous, and but little calculated to satisfy the understanding. "Every irritation," he says, " which is capable of producing a perception in the brain, passes back by the nerves to be repeated in the mucous meSn* branes." Thus, if a person be inoculated with small-pox virus, the irritation of the primary pustule, or of the inoculated point, is con- veyed to the brain, whence it is reflected by the nerves upon the mucous membranes of the alimentary canal, where it establishes an inflammation. This intestinal inflammation constitutes the essential cause of eruptive fever, and the eruption itself is only a metatastic disorder of the cutaneous system. The assumption then, " that every irritation which is capable of producing a perception in the brain, is reflected by this organ to be repeated in the mucous membranes of the alimentary canal, forms the main principle in the Broussaian doctrine of the etiology of fever. That the mucous membranes of the intestinal tube possess a very wide sphere of sympathetic rela- tions, is a fact indeed as undeniable as it is important in a patholo- gical point of view. But that this structure constitutes a subordinate sensorium commune, to which all morbific impressions are especially conveyed, after having been perceived by the brain, is a position which all the zeal and ingenuity of its advocates have as yet failed, and I apprehend will ever fail to place upon that firm basis, which it ought to have to serve as a foundation of our pathological faith. GENERAL PATHOLOGY OF FEVER. 21 I do not mean to object to the general fact, that all impressions capable of ultimately exciting fever, are in the first place communi- cated to the sensorium commune, and thence reflected throughout the system, and sometimes upon some particular organ or structure; but this reflected impression does not, it may be justly maintained, necessarily, establish a focus of irritation, nor always, or even gene- rally, fall especially upon the intestinal mucous membrane. If the impressions of morbific causes are always transferred to the mucous membrane of the alimentary canal, the impressions of all agents, remedial as well as others, must of course be referred to the same structure. This however, does not accord with the results of observation. When mercury is rubbed on the skin, the salivary glands, the gums, and the mucous membrane of the mouth, receive the chief impressions excited by this agent. Will it be contended that a gastro-enteritis must be established before salivation can be produced? If opium be applied to any part of the body, the im- pressions are concentrated in the nervous centre. When cantharides are applied to the surface, the irritation is conveyed to the neck of the bladder, and not to the mucous membrane of the bowels, and yet fever may be the result. From these and many other similar facts that might be adduced, it is manifest that the supposed law of the animal economy, by which, as is alleged, all febrific impressions are reflected from the brain and repeated in the mucous membranes of the bowels, is gratuitous, or to say the least, highly improbable. The fallacy of those doctrines which confine the primary inflam- mation to some one structure exclusively, is strikingly illustrated by thfe circumstance, that different writers have fixed on different structures, as the parts primarily affected in fevers. Thus Clutter- buck maintains, with Broussais, that fever is always a purely symp- tomatic affection depending on local inflammation pre-established by the febrific cause. He asserts that this primary inflammation is invariably located in the brain and its membranes, and adduces the phenomena discovered on post mortem examination, in testimony of the correctness of his doctrine. Broussais, on the other hand, asserts that the primary inflammation is not in the brain, but in the mucous membrane of the bowels, and appeals with equal confidence to the appearances exhibited on dissection for confirmation of his doctrine. This discrepancy is in itself sufficient to show the weak founda- tion on which these two doctrines rest; for if the evidence afforded by autopsic inspection in relation to this subject were not extremely ambiguous, it would, one may suppose, be impossible to draw from it conclusions so very discrepant, and yet so nearly equal in point of plausibility. The advocates of the gastro-enteritic pathology of fever, place no inconsiderable reliance for support to their doctrine on, what they are pleased to assert, their superior success in their remediate ma- nagement of fevers. Leeches, and an almost total abstinence from 22 GENERAL PATHOLOGY OF FEVER. food, with cooling, acidulated, mucilaginous drinks, constitute near- ly the whole of their remediate applications; and they claim for this mode of treatment, a greater success than that which they allow to others who pursue a more active course of treatment in fevers. It does not appear, however, that the golden age of medical success, so confidently promised by Broussais, on the introduction of his doc- trine, has as yet arrvied;* for the statements which have been pub- lished in France, in reference to the comparative mortality under the Broussaian, and the other modes of treatment, give no support to the claims of superior success set up for the former. We might, however, admit the excellence of the Broussaian mode of treating fevers, without yielding our assent to the correctness of the doctrine that the gastro-enteritis is primary where it does exist. There exists but little doubt in my mind, that in continued and remitting fevers, active purgation is not unfrequently carried to an injurious €xtent; for, although we may, and, as I conceive, ought, to reject the opinion that such fevers depend essentially on the gastro-ente- ritis, yet we cannot doubt, that a very considerable degree of irrita- tion, amounting in many instances to inflammation, does often super- vene during the progress of the disease, as an epiphenomenon, and unconnected with the origination of the fever. In cases where such a condition of the mucous membrane of the intestinal canal occurs, during the course of the disease, the soothing treatment recom- mended by Broussais, is no doubt more salutary than the vigorous purgative plan so commonly pursued in this country and in England. Unquestionably, intestinal irritation and inflammation perform an important part in febrile diseases. These conditions may arise as con- sequences of the general febrile reaction, as well as from harsh and repeated purgation, and the use of other irritating remediate agents. But it is equally probable that gastro-enteritis is often excited by acrid and vitiated secretions, and other offensive materials retained in the bowels in consequence of withholding suitable laxatives, in the commencement and during the progress of the malady. Brous- sais has done much good, by awakening the attention of the pro- fession to these pathological conditions; and thus furnishes another proof of the fact, that new doctrines, though fundamentally erro- neous, seldom fail to do some good, by directing the views of phy- sicians to important circumstances, which were previously over- looked, or too much neglected. * In 1821, Broussais asserted "that the tables of mortality declare in favor of the new doctrine, and that its influence upon population would be more favorable than that of the introduction of vaccination.'''' Unfortunately, however, this happy influence of the nouvelle doctrine, remains yet to be realised;* and the advocates of the doctrine may console themselves for the tardiness of this influence, with the certain prospect of not being very soon deprived of the opportunity of pub- lishing their ordinary quantum of post mortem examinations. * Refutation de la Doctrine de M. L. Doct. Broussais, Par. L. Castel. GENERAL PATHOLOGY OF FEVEE. 23 In leaving this subject, I deem it right to observe, that however widely we may differ from Broussais in relation to the pathology of fever, all must admit that he has just and high claims to the respect and gratitude of the profession for the light which he has thrown on the nature, symptoms, and treatment of mucous intestinal inflamma- tion, as well as on the physiological and morbid sympathies of the animal system. Broussais is unquestionably one of the most enlightened and inge- nious pathologists of the present day. His is now the only general doctrine which especially occupies the attention of the profession. Like all the preceding great doctrines in medicine, it is destined, perhaps, to culminate for a while in the firmament of our science, and to attract its host of worshippers; but, assuredly, sooner or later it must sink again, and add another to the long list of once highly favored, but now exploded and neglected doctrines. That the Broussaian system contains much that is valuable, it would be un- just to deny; but to these concessions in its favor, there are, unless the majority of competent judges greatly err, offsets of no small moment. In relation to this doctrine, as indeed of every one else, it behooves us to embrace the usefuland reject the false; in short, to adopt the good advice of Lucretius, "-----------doctrinam acri Judicio perpende; et si tibi vera videtur Dede manus—aut si falsa est, accingere contra." Having now given a summary of the principal objections which may be urged, successfully, I conceive, against the " new physiolo- gical doctrine," I proceed to an exposition of the following proposi- tions, as embracing the leading, and it is believed, tenable points of t doctrine, in relation to the mode of origin and character of febrile diseases. 1. Fever is a general disease—the sanguiferous system being essentially and predominantly disordered. 2. The morbid vascular excitement of fever is located, essentially, in the capillary system of blood-vessels—consisting in irritation, and not in mere increased or decreased action. 3. This irritated excitement may be the result of morbific causes acting directly on the internal surface of the sanguiferous system; or, of irritating impressions conveyed sympathetically to this system, from a primary focus of irritation. 4. The first link in the chain of morbid actions, which occur in the development of fever, always commences in the nerves. 5. The remote or exciting causes of fever rarely produce local inflammation, anterior to the development of the general febrile reaction. Their action is confined to the production of morbid im- 24 GENERAL PATHOLOGY OF FEVER. pressions on the nerves, which passing inwards to the brain, usually cause a temporary depression of its energies, and consequent dis- turbance in the equilibrium of the nervous and vascular excitements; at the same time that the morbid impressions reflected by the brain throughout the system, contribute to the functional disturbance and irritation of certain internal organs or structures. 6. Although local inflammation is not essential to the production and support of fever, yet, in many instances of idiopathic or general fever, more or less inflammation supervenes, after the febrile reac- tion is established; and occasionally the development of the febrile excitement and local inflammation is effected simultaneously. 7. Inequilibrium of excitement, and local determinations of blood, constitute an important characteristic of fever; for, although strictly a general malady, there are always some organs or structures in a state of increased morbid excitement, whilst at the same time, others are in an enfeebled, languid, or torpid condition. In stating that fever is a general malady, it is not presumed that every structure of the organisation is in a state of actual disease; but as the nervous and vascular systems are so intimately concerned both in the composition and functions of every part of the body, it may well be inferred, that where these two systems are in a morbid condition, as they manifestly are in fever, every other irritable and sensible structure must suffer more or less functional derangement. Nevertheless, it cannot be questioned that the essential morbid ex- citement, which constitutes fever, is located in the sanguiferous sys- tem. The disordered action of the heart and arteries—the increased temperature of the body—the altered state of the secretions—the morbid appearances on dissection—and, in most instances, the changed state of the blood, afford sufficient evidence of the para- mount disorder of the blood-vessels in febrile affections. The morbid vascular action of fever is an irritated and not a mere increased action of the heart, arteries, and capillaries. There exists a wide difference between irritation and mere excitation. The former is the result of stimuli acting either directly or indirectly upon an organ or structure, whose vital properties are in a deranged or morbid condition; and is therefore always essentially connected with a disordered state of the nerves of the part affected. This re- sult is not simply a greater or less degree of the natural or healthy excitement, but an action or excitement essentially morbid or dis- tinct from healthy action. Mere excitation, or increased action, on the other hand, is the result of stimuli acting on an organ or system whose vital properties remain in a healthy or underanged condition. A few ounces of alcohol, for instance, will cause a high degree of arterial action in an individual not accustomed to this stimulus; and the same effect will be produced by any sudden and violent bodily exertion, as running, rapid walking, &c. Here then, there is in- creased action of the heart and arteries, with an augmented state of the animal temperature; but this does not constitute'fever. The GENERAL PATHOLOGY OF FEVER. 25 vital properties remain in their normal condition, and the organs thus inordinately excited, return to their natural and healthy grade of action, as soon as the exciting cause ceases to act. As, however, all excessive action tends to weaken, and finally to derange the vital properties of the over-excited parts, so, when such stimuli are very protracted in their influence, they may, at last, disorder these pro- perties and give rise to fever. Without such a derangement or mor- bid condition of the sensibility and irratibility of the heart, arteries and capillaries, no fever can occur; for so long as the vital properties retain their natural state, all irritants or stimuli, can produce only a greater or less degree of normal excitement, and the secretions will be diminished or increased, but not depraved. As soon, however, as these properties have departed from their healthy condition, every stimulus, whether natural or morbific, must necessarily excite mor- bid actions. Hence, it may be concluded that every cause which produces fever, in whatever way its influence may be conveyed to the sanguiferous system, must necessarily derange its vital proper- ties, either directly or indirectly, before that general irritated vas- cular action which constitutes fever, can be established. It is evident, therefore, that although the characteristic pheno- mena of fever depend on morbid action of the heart, arteries and ca- pillary vessels, the nerves also are essentially and primarily disor- dered in febrile diseases; for irritation, as has just been observed, necessarily implies a morbid or deranged condition of the vital properties, and it cannot be doubted that, so far, at least, as the ca- pillary system is concerned, these properties are derived immediate- ly from the nerves. From a careful analysis of the phenomena of fever, it would ap- pear that, although the sanguiferous system, generally, is prominently, disordered in fever, yet the essential febrile excitement is especially located in the capillary system of blood-vessels. Fever cannot ex- ist without capillary irritation or derangement of the secretory and excretory functions. So long as the capillary functions remain free from morbid excitement, or the principal secretions continue to be performed in a healthy manner, no increased action of the heart and arteries can constitute fever, but only an over-excited state of these organs, which will subside when the exciting cause is removed. A person who is thrown into a violent gust of passion, experiences ve- hement action of the heart and arteries; but unless the capillary ves- sels are brought into a state of morbid excitement, or irritation, it will not be fever, but simple super-excitation.* On the other hand, manifest disorder in the action of the heart and arteries, does not appear to be essential to the existence of fever. Fevers of the most * Some of the sentiments stated in this chapter, do not differ materially from those given by Dr. Southwood Smith, in his interesting work on fever. The views here given, whether correct or incorrect, I have taught in my public lec- tures for seven years past. Vol. I.—3 26 GENERAL PATHOLOGY OF FEVER. malignant and fatal character—attended with unequivocal manifes- tations of capillary disorder, such as haemorrhage, petechias and in- flammation not unfrequently occur, in which no obvious deviation from the natural action of the heart and arteries can be detected. Dr. Smith, in his very valuable treatise on fever, observes, that the order in which the morbid actions which constitute fever, occur, " is, first, derangement in the nervous and sensorial functions; this is the invariable antecedent: secondly, derangement in the circu- lating function; this is the invariable sequent: and thirdly, derange- ment in the secreting and excreting functions: this is the last re- sult in the succession of morbid changes. Derangement in the functions of secretion and excretion never copies first in the series: derangement in the nervous and sensorial functions never comes last in the series: derangement in the function of the circulation never comes either first or last in the series, but always the second in suc- cession." That derangement of the nervous system constitutes the initial link in the chain of morbid actions which occur in the development of fever, cannot be doubted. The mental and muscular languor— the general malaise and uncomfortable sensations—the pains in the loins and extremities—the morbid sensibility to low temperature— the dejection and irritableness of temper, and the confusion and weakness of the intellectual powers, which so universally usher in febrile diseases, afford unequivocal evidence of pervading derange- ment of the nervous system. In relation to the subsequent order of the morbid changes which supervene in the development of fever, however, we cannot adopt the sentiments expressed by Dr. Smith. The assertion, that the heart and arteries are universally and necessarily deranged, next in order to the primary disorder of the nervous system, and before the capillary or secretory extremities of the blood-vessels are brought into a state of morbid excitement, appears, I think, contrary both to correct physiological principles, and to the results of observation. It is well known that the extreme vessels, the secreting capillaries, are incomparably more closely connected with, and dependent for their functions on, the nervous system, than the heart and larger blood- vessels. It is scarcely necessary to refer to the experiments of Wil- son Philip and other modern physiologists in support of this obser- vation. From this physiological principle alone, then, we would be led to infer, that the extreme vessels—those which are immediately, or at least very intimately, concerned in the process of secretion and calorification—would be the first to suffer derangement of function from general morbid excitement of the nervous system. That capil- lary derangement is, in fact, the immediate sequent of the primary functional disturbance of the nervous system in the evolution of fever, appears to me ^sufficiently demonstrated by the phenomena presented in the forming stage of the disease. Who does not know that torpor of the cutaneous exhalents is one of the most common GENERAL PATHOLOGY OF FEVER. 27 initial symptoms of fever? This function is frequently prominently deranged, before any manifestations of the morbid action of the heart and arteries can be detected. When kiono-miasmata acts slowly upon the system, we often find, along with the above-named symp- toms indicative of disordered nervous excitement, decided evidence of functional derangement of the liver, as well as of the perspiratory vessels. The utter groundlessness of Dr. Smith's sentiments on this point, may indeed be predicated on the simple circumstance, that it has led him, necessarily, to deny, that pneumonia, hepatites—in short, all the affections embraced under the general term phlegma- sia, are fevers! Believing, as he does, that the order of morbid changes, from the nerves to the heart and arteries, and finally, to the secretory capillaries, is universal, and as invariable as the laws of nature, he is, of course, obliged to deny the name of fever, to the ge- neral sympathetic phenomena which occur in consequence of local inflammation—for in these symptomatic fevers the successive mor- bid changes occur, he says, in a different order. " Febrile diseases," he observes, "are commonly divided into idiopathic and symptoma- tic—a division which is liable to the fundamental objection, that the diseases included under the second head are not fevers, but inflam- mations. There are no fevers but idiopathic fevers." And the reason why the general symptoms of the phlegmasia do not consti- tute fever is, he says, because " in pneumonia, in enteritis, in hepa- tites, &c. the spinal cord and the brain are never the organs in which the first indications of disease appear; the earliest indications of disease that can be discovered, having their seat in the affected organ itself, and it being only after the disease has made some pro- gress, that the other organs (the heart and arteries, and the brain) and functions are involved." Ingeniously as Dr. Smith has argued upon this subject, very few, it may be presumed, will agree with him in denying, that the general morbid actions arising from local inflammation, are truly and essentially febrile. In truth, however, the alleged diversity in the order of the morbid changes of idio- pathic and symptomatic fevers, has no existence. Local inflamma- tion, like every other exciting cause of fever, that does not act di- rectly on the heart and arteries, can affect the general system only through the medium of the nerves; and hence, we almost invariably find the same train of symptoms accompanying the rise of fever from inflammation, as is known to usher in idiopathic fever. What do we observe when fever comes on from a wound?. The patient, at first, experiences some degree of febrile languor—accompanied with a sense of slight chilliness, mal aise; and derangement of the exhalent functions of the skin. These symptoms, though often so slight and transient as to be scarcely perceptible, invariably precede the occurrence of the febrile reaction of the heart and arteries; and hence the order of sequence in the morbid actions, which take place in the development of symptomatic fever, aoes not differ from that which obtains in idiopathic fever. The nerves always receive the 28 GENERAL PATHOLOGY OF FEVER. first shock and morbid change. This speedily gives rise to more or less conspicuously deranged action of the secretory capillaries— and finally, the heart and arteries are morbidly excited. While Dr. Smith more confidently than prudently, asserts, that, "there can be no fever but idiopathic fevers," Broussais and his disciples assert that, "the existence of idiopathic fever is impossi- ble." Such are the contradictory extremes to which theory is apt to lead the understanding! That fever may occur both with and without local inflammation, may be disputed by theorists, but can- not be doubted by those who observe diseases with unbiassed judg- ments, in the light of common sense. It must, indeed, be admitted, that local irritation or local morbid action, invariably occurs, as the initial morbid condition, whence the series of consecutive deranged actions in the evolution of fever have their origin. This admission does not imply a concession in favor of the Broussaian doctrine, since it is predicated, in part, on the demonstrable position that the local morbid excitement is not un- frequently located in a greater or less extent of the lining membrane of the blood-vessels themselves, and produced by irritating agents admitted into the circulation from without, or by retained recremen- titious elements acting directly on the internal surface of the san- guiferous system.* It appears to me that there is no pathological fact which is more susceptible of satisfactory illustration, than that fever frequently arises from morbific causes acting immediately on the sanguiferous system, and establishing a primary irritation in a greater or less extent of its internal lining membrane. Without denying the all pervading influence of that principle of the living system, called sympathy—or still more comprehensively without denying that all the phenomena of life, whether of health or disease, are but so many manifestations of the action of the living solids, it is a truth equally undeniable, that the blood may and does frequently serve as the medium through which deleterious agents act immediately on the heart and arteries, and thus give rise to fe- brile phenomena. " The veinous system," says Bichat, " may be regarded as a general reservoir, into which are poured all the mate- rials which are to be thrown out of the body, and all those which are to enter it. In this last respect, this system of vessels performs an essential part in the production and support of diseases. The deleterious substances may be introduced into the blood-vessels with chyle, and produce ravages in the system in circulating with the fluids. There can be no doubt, moreover, that, besides the princi- ples which convert the veinous into arterial blood, there often passes through the lungs into the circulation, deleterious miasmata, which produce diseases, as my experiments on asphyxia have proved. The intestines, the lungs, and the skin are the three avenues through * M. Bouillard, whose work I have already mentioned, advocates this view of the etiology of certain varieties of fever. GENERAL PATHOLOGY OF FEVER. 29 which the morbific agents may gain admission into the circu- lation."* That foreign substances are readily taken up by the absorbents and veins, and conveyed into the circulation in an unassimilated state, is now no longer a subject of doubt or dispute. It appears to me highly probable, that miasmatic agents act upon the animal sys- tem, in part at least, by being admitted through the lungs, into the current of the circulation. Some contend that these aerial morbific causes act primarily on the stomach. It is asserted, that the miasma, becoming entangled in the saliva, and swallowed with this fluid into the stomach, establishes a primary morbid impression in its delicate mucous membrane. It is alleged, in confirmation of this opinion, that the stomach, possessing a very extensive circle of sympathetic relations, and being highly sensitive to impressions, is peculiarly calculated to become the primary focus of morbid excitement from external morbific causes. It is affirmed, moreover, that the initial symptoms of fever point out the primary influence of the febrific cause on the stomach. The depressed or abolished appetite, the nausea and vomiting, and the peculiar sense of uneasiness in the epi- gastrium, are considered as affording strong evidence of the correct- ness of this opinion. It is asserted, finally, that the lungs are endow- ed with an inferior degree of sensibility, and that their sympathetic relations are by no means very extensive, and that, therefore, they are but imperfectly adapted for receiving and propagating morbid impressions from external causes. In reply to these arguments, it must be observed, that it does not seem probable that a sufficient quantity of miasmata could gain ad- mission into the stomach to produce disease. As to the evidence drawn from the character of the premonitory symptoms, it cannot afford any available support to this doctrine. A severe wound, or contusion, will give rise to nausea, vomiting, and immediate loss of appetite. Such phenomena only show that the stomach readily sympathises with impressions made on every part of the body, when of sufficient degree of intensity. With regard to the alleged insen- sibility of the lungs, or their limited sphere of sympathy, we might admit its justness without being reduced to the necessity of adopting the opinion that miasmata act primarily on the stomach. It is not presumed that aerial morbific agents act simply on the nervous ex- tremities of the respiratory passages, and thus give rise to a chain of sympathetic morbid actions. It is contended, that agents of this kind pass through the lungs into the current of the circulation, or effect certain morbid alterations of the blood, in consequence of which, the lining membrane of the heart, arteries, and capillary sys- tem, is irritated, and the vascular system thrown into a state of febrile excitement. That agents of this kind are absorbed into the circulation, and act upon the system through the medium of the * Anatom. Gener. vol. I. p. 284. 3* 30 GENERAL PATHOLOGY OF FEVER. blood, may be inferred from a number of familiar facts in relation to the inhalation of odoriferous effluvia. The inhalation of the fumes of turpentine, of garlic, and of various other substances, of a similar character, is speedily followed by the manifestation of these odors in the urine. How are we to account for the extraordinary effects which arise from the inhalation of nitrous oxide, and of the vapor of sulphuric ether? It does not seem probable that these effects are produced by the mere action of these causes on the pulmonary nerves; for when these substances are taken into the stomach, the nerves of which are so highly sensitive, no such consequences ensue. These facts go to show, that substances capable of affecting the animal economy, will, when admitted into the lungs in a gaseous form, promptly and powerfully exert their peculiar influence upon the system. There are no good grounds, therefore, for denying that miasmata and contagious effluvia, may produce their deleterious effects through the same avenue. The bronchial tubes and cells, ex- pose a very extensive surface to the impressions or absorption of such agents; a circumstance, which, it may be presumed, is well calculated to favor their morbific influence on the system. The experiments of Magendie, in relation to the effects of putrid effluvia on the animal system, may also be cited in favor of this opinion. On exposing animals to the inhalation of putrid effluvia, some suffer- ed no injury, whilst others rapidly emaciated, and died at different intervals within twenty days. When, however, the putrid sub- stances, from which the effluvia experimented with, emanated, were introduced into the stomach, no obvious inconveniences were expe- rienced by the animals.* To these facts we may add, that small- pox virus, when swallowed into the stomach, will not, or, at all events, extremely seldom, infect the system; whereas, every one knows how readily the disease is communicated by inhaling the effluvia, which emanate from the bodies of those who labor under the malady. It appears very evident, therefore, that seriform febrific agents act upon the system through the medium of the respiratory organs; and the facts just mentioned, render it highly probable, that they enter into the current of the circulation, and act immediately on the inter- nal surface of the heart, arteries, and capillaries, perhaps more com- monly, on some portion of the latter set of vessels. It is not presumed, however, that agents of this kind, always, or perhaps at any time, act exclusively through the medium of the blood, in the way just stated. Any part of the organisation which exposes a sensitive surface to the impressions of such causes, may no doubt, enable them to operate injuriously on the general system. All that is here contended for, is, that morbific agents of every kind but especially gaseous substances, do often pass into the circulation, and that being thus mixed and carried along with the blood through- * Journal de Physiologie, 1823. GENERAL PATHOLOGY OF FEVER. 31 out the system, they act directly on the nervous extremities of the internal membrane of the vascular system, and thus excite febrile reaction, without the previous establishment and agency of local in- flammation.* Besides the source of direct vascular irritation already referred to, there is another one, perhaps still more common and extensive in its influence; namely, retained recrementitious matter, in conse- quence of accidental glandular torpor or inactivity. When an ex- cretory organ is impeded in its functions, and ceases to effect a due elimination of the recrementitious matter which it is destined to cast off, the effete elements must necessarily remain in the blood, unless some other organ vicariously supplies the function of the tor- pid emunclory. A source of vascular irritation will thus be created; for it cannot be presumed that recrementitious matter, even in its elementary state, can long remain commingled with the blood, in inordinate quantity, without giving rise to more or less of morbid excitement. " Thus, if from certain causes elements entering into the composition of bile, abound in the blood, a source of disorder or of irritation is present in the blood. This irritating cause must act upon those parts which are sensible to its impressions, and to which it is incessantly and immediately applied. Derangement of the whole vascular system becomes the consequence of such irrita- tion offered to the nerves, ramified upon the heart and blood-vessels, but more especially in the organ destined to combine and to secrete, under new forms, the materials now so abundantly presented to it."t Thus, too, if the cutaneous exhalation be arrested in conse- quence of the sudden influence of cold, a large portion of the recre- mentitious perspirable matter will be retained in the circulation. If this be not removed out of the system, by the vicarious action of some other organ, the blood will become surcharged with substances, which the welfare of the economy requires to be cast off, and which must necessarily impart to it a morbific, or irritating quality. This circumstance, together with the internal congestions which usually attend torpor of the cutaneous exhalents, becomes a direct source of irritation to the heart and arteries, and consequently of febrile ex- citement. With all the evidence which we possess, therefore, that the blood frequently becomes charged with substances of an irritating or dele- terious character, there can, surely, exist no reasonable doubt, that fever is sometimes the result of direct and primary irritation of the heart and arteries; for it will not be denied, that agents which are * Dr. James Johnson, the very able editor of the Medico-Chirurgical Review, observes—" It has always been our opinion that febrific causes made their first impressions on the nervous system; but this, we think, does not disprove that absorption first takes place—still less that absorption is not necessary at all.— Med. Chir. Rev. } London Medical Repository, No. 102, p. 509. 32 GENERAL PATHOLOGY OF FEVER. capable of causing morbid impressions on the nerves of the skin, the alimentary canal, or of any other organ, will be equally capable of producing irritation in the heart and arteries, when brought in im- mediate contact with their internal surface; and no one, certainly, will maintain, that irritating impressions made upon the whole or a part of the internal surface of the vascular system, will not be as likely to excite that morbid vascular action which constitutes fever, as when the irritation is conveyed to this system sympathetically, from some remote local inflammation. Evident, therefore, as it unquestionably is, that fever may, and often does, arise from morbific impressions made primarily on the vascular system, it is nevertheless equally manifest, that it is, perhaps, still more frequently the result of a purely sympathetic irritation, proceeding from local irritation or inflammation pre-established by the febrific cause. This latter mode of febrile origin, is, according to some modern pathologists, the only possible way in which fevers can arise; as if morbific impressions made directly upon the blood- vessels, could be less apt to derange their functions, than when com- municated to them sympathetically through the medium of the nerves. It is probable, however, that the primary morbid condi- tion whence the sympathetic febrile actions emanate, consists much more frequently in mere irritation of functional derangement, than in actual inflammation. I presume that those febrific causes which do not make their impressions directly on the lining membrane of the heart, arteries, or capillaries, by being admitted into the circula- tion, cause, in the first place, irritation and consequent functional derangement in one or more important organs or structures of the system. In consequence of this local irritation or deranged action, the equilibrium of excitement and of the circulation becomes dis- turbed, the vital properties deranged, and the sanguiferous system finally brought into a state of febrile reaction. Fever, as has already been observed, always, perhaps, commences by a local irritation, or morbid excitement. Even when the disease results from causes that act immediately on the internal surface of the vascular system, the irritation, or primary morbid excitement, is probably confined, at first, to a comparatively small portion of this system. Every agent, whether morbific or medicinal, appears to have a tendency in its ulterior operation to affect particular organs or structures in preference to others. On whatever part of the sys- tem the primary impression is made, the excitement produced, is chiefly conveyed to some particular organ or part, according to the peculiar character of the primary impression. Ergot, whether re- ceived into the stomach, or injected into the rectum, produces an excitement in the nerves of the part to which it is applied, which is especially conveyed to the gravid uterus, and so far as can be per- ceived, to no other part. The infusion of jalap, introduced into the circulation, will act upon the alimentary canal, and produce purg- ing: cantharides whether taken into the 6tomach or applied to the GENERAL PATHOLOGY OF FEVER. 33 surface is apt to inflame the neck of the bladder; and, in short, the influence of almost every agent appears to possess a kind of elective affinity for some particular organ or structure of the organisation. That this should be the case, might indeed be inferred from physio- logical principles, independent of the evidence of experience. That each organ and structure of the animal system is endowed with a peculiar modification of the vital properties, may be regarded as an established fact in physiology. In this principle we may perceive the reason why different agents manifest peculiar tendencies to act on different parts of the system. Without doubt when an impres- sion is made on the system, it will be most felt by that structure, whose specific or peculiar vital properties are most in relation with it. When an impression is made on the nervous extremities of any part of the body, the excitement produced is conveyed by the nerves to the brain, and from this organ, it is reflected or radiated through- out the whole nervous system. That this is the ordinary course of nervous excitement from impressions made on the sentient extremi- ties, will scarcely be disputed by any one who has carefully attended to the functions of the brain and its appendages. It is impossible to give a rational explanation of many sympathetic phenomena, unless we trace the course of nervous excitement from its origin, to the brain, and thence to the part which manifests the sympathetic ac- tion. If, then, each organ and structure of the animal system be endowed with its peculiar modification of excitability* we may justly presume, that some parts of the organisation will be insensible, whilst others will be more or less sensible to particular impressions, and consequently there will be some parts in which a new excite- ment will be produced by the impressions reflected by the senso- rium commune, whilst, in other organs and structures no immediate effect will be produced. Thus, if tartar emetic be kept in contact with the external region of the stomach, the impression which it causes will be conveyed to the brain, which in its turn will reflect the impression throughout the whole nervous system; but as the stomach alone is endowed with a mode of feeling capable of receiv- ing this peculiar impression to a prominent degree, it will be in this organ that its effects will be most conspicuous.t * The word excitability is here used to express the power of being excited into action, and includes both sensibility and contractility. f The author of a Review of the first edition of this work, doubts the cor- rectness of this assertion. It must be admitted, that tartar emetic, when applied to the external surface, very rarely produces either nausea or vomiting. I have nevertheless, met with one remarkable instance of this kind. At three different periods a solution of this article was applied to the epigastrium, and at each time he experienced very distressing and protracted nausea. The general fact, however, which it is intended to illustrate by the above observation, cannot be disputed. It is well known, as has been observed in the preceding page, that to whatever part remedial substances are applied, they manifest the same ten- 34 GENERAL PATHOLOGY OF FEVER. Let us suppose, then, that a febrific agent acts primarily upon the nerves of the stomach or of the skin, or of any other part of the body. The impression produced, will be conveyed to the sensorium commune, whence it will be reflected throughout the whole nervous system. But as the various tfrgans and structures of the system are endowed, each with its own peculiar modification of the vital pro- perties, some may be insensible, whilst others, perhaps are peculi- arly susceptible of receiving and responding to the reflected mor- bific impression; and these, it may be reasonably presumed, will be irritated and functionally deranged, before the other organs or struc- tures become affected. From the part thus primarily irritated, the morbid excitement passes from organ to organ, or tissue to tissue, according to their various sympathetic relations with each other, and with the part primarily affected, until the whole system becomes morbidly excited. It is extremely improbable that the morbid excitement or impres- sion caused by a febrific agent, can ever bring every part of the sys- tem, simultaneously, or pari passu, into a state of morbid action. The direct influence of the remote or exciting causes of fever, do not, probably, extend beyond the simple impression which they make on the sentient extremities. Every subsequent morbid change in the development of fever, must depend wholly on the relative affinities of the various structures with each other, and with the cha- racter of the primary impression; and, from what has been said above, it can scarcely be doubted, that the primary impression or nervous derangement, resulting directly from the action of the mor- bific cause, always terminates in the production of prominent mor- bid excitement in some particular organ or structure preliminary to the actual development of the general febrile vascular reaction. That the primary morbific impressions are, however, almost uni- versally directed upon the mucous membrane of the alimentary canal, as is asserted by Broussais, appears to be as far from truth, as that all fevers are purely symptomatic. Almost every organ or structure of the system may, without doubt, be the first to suffer functional de- rangement or irritation from external morbific impressions. The lungs, the liver, the brain, or the skin, &c. sometimes receive the reflected impressions, and become the primary focus whence the fe- brile actions emanate. Observation, moreover, discountenances the opinion that the primary local derangement thus produced, amounts often to the grade of inflammation. Deranged or irritated excitement of an organ or structure, may be adequate to set on foot a train of morbid changes which will ultimately terminate in febrile reaction. A draught of cold water while the body is in a state of free perspira- tion, may, in its ultimate consequences, establish fever. In this case dency to act on particular organs or structures, as if they were taken into the stomach. I have known tobacco applied to the feet to give rise to nausea and vomiting, and every physician must have observed similar facts. GENERAL PATHOLOGY OF FEVER. 35 the impressions of the cold water on the nerves of the stomach, are transmitted through the medium of the sensorium commune, to the cutaneous exhalents and capillaries. A state of torpor and functional derangement of these vessels, together with the deranged sensibility of the cutaneous nerves, immediately ensue, and the patient experi- ences a sense of chilliness, with more or less constriction of the ex- treme vessels. These, then, are the first sympathetic phenomena arising from the influence of the remote or exciting cause; and from these morbid changes, others proceed in regular sequence until the fever is fully developed. Thus, from the torpor of the exhalents and diminished circulation in the external capillaries, three patho- logical conditions necessarily arise, which tend especially to excite febrile reaction. In the first place, a large portion of recrementitious perspirable matter will be retained in the circulation; secondly, the retreat of the blood from the extreme vessels will cause it to accumu- late in-the heart and large internal vessels; and thirdly, the action of the liver* and other internal organs, will be more deranged in consequence of their direct sympathetic relations with the cutaneous exhalents. But although the organs which sustain the primary irritation— and from which the morbid febrile changes are diffused throughout the system, as from a centre, are not, perhaps, at first in a state of actual inflammation, yet, as they are already morbidly irritable and irritated, they will be especially apt to pass into a state of complete inflammation soon after the febrile reaction is established, and an increased momentum given to the blood. It may be observed, too, that when a morbific cause acts directly on the stomach, as in the example just assumed, the fever will be apt to become early com- plicated with conspicuous irritation or inflammation of the mucous membrane of this organ; in consequence of having sustained the direct injurious impressions of the remote cause, and consequently, being, from the very onset of the disease, in a morbid condition. It must be remembered that inflammation consists not only in congestion of the inflamed capillaries, but also in an altered or mor- bid condition of their vital properties; and hence, when an organ is already in a state of morbid excitement or irritation, inflammation will very readily ensue, when, by a general increased momentum of the circulation, the blood is urged into the debilitated and morbid capillaries. It is on this account that we so often find inflammation supervening in the stomach and intestinal canal in fevers. The mu- cous membrane of these organs being so much exposed to the action of irritating causes, is far more frequently the seat of irritation than any other structure of the system, and it is almost invariably in a more or less deranged condition in all general diseases. This being * Vide Johnson on the Diseases of Tropical Climates. Of the correctness of his sentiments, concerning the influence of what he calls the cutaneo-hepatic sympathy, I entertain no doubt. 36 GENERAL PATHOLOGY OF FEVER. the case, it is evident, that this structure must be especially liable to secondary inflammation in febrile affections; and this, in fact, is fully confirmed by experience. Inequilibrium of the circulation and excitement, is one of the most important characteristics of fever. Although fever is emphatically a general malady, and a morbidly excited condition, it must not be supposed, that every sensible and irritable structure, though func- tionally deranged, is in a state of increased excitement. While the heart and arteries are energetic, and morbidly active, the muscular system is usually languid, and enfeebled. An increased activity of the intestinal capillaries and exhalents, may be attended with dimi- nished activity of the capillaries and exhalents of the external sur- face. Inordinate action of the kidneys is often accompanied with torpor of the liver, and always with torpor of the cutaneous exha- lents. Sometimes the capillary system is inordinately active, whilst the heart and arteries manifest but little or no increase of excitement; and occasionally the brain and nerves are in a state of great activity, with very feeble reaction of the heart and arteries. The same ob- servations apply to the distribution of the blood. Whilst it is mor- bidly deficient in some organs, it will be excessively abundant in others; whilst the capillaries of one structure or organ are engorged and inflamed, those of other parts will be devoid of the regular por- tion of the circulating fluid. These facts have a most important bearing on practice; for they point directly to the fundamental prin- ciple of treatment—namely, to excite and invigorate those organs that are torpid, at the same time that we depress and debilitate those that are morbidly active. It has been supposed that febrile excitement, or the essential mor- bid action of fever, is always the same; and that the various modi- fications which this form of disease is known to assume, depend wholly upon the local irritation or inflammation which may occur, or rather the organ or structure which may be its seat. To a cer- tain extent, this opinion appears to be well founded. It is very evi- dent, for instance, that in proportion as the brain and nerves become affected, so will the fever acquire a low or typhoid grade in its gene- ral character. Of two individuals seized with fever from the influ- ence of atmospheric vicissitude, one will, perhaps, be affected with a low or typhoid form of fever, whilst in the other, the fever will assume a high grade of inflammatory or synochal reaction. In the former, prominent symptoms of severe nervous disorder will attend* and if the disease be violent, decided manifestations of cerebral in- flammation will probably occur. In the latter case, little or no pro- minent signs of cerebral disturbance or irritation will ensue; but in- stead of this, symptoms of local inflammation in the fibrous or serous structures, or in one or more of the abdominal organs, will probably be observed. That the occurrence of irritation or inflammation of the brain should impart a low and typhoid character to fever, and thus give GENERAL PATHOLOGY OF FEVER. 37 fo it a peculiar aspect, is by no means difficult to comprehend; for, it is manifest, that when the fountain of the vital energies, the brain, is prominently deranged, all the powers of life, however excited, must languish and sink. This subject will, however, be more par- ticularly discussed under the head of continued fever, being referred to at present, merely for the purpose of directing the readers's at- tention to the general fact, that fevers, arising from the same cause, and essentially identical, receive important modifications from the seat and grade of the local affections which may supervene. The. mode in which the occurrence of local inflammation may be favored during the progress of fever, has already been mentioned. Besides the peculiar influence of the remote causes, in deranging particular organs or structures, in preference to others, and thus lay- ing the foundation for local inflammation, there are, however, other circumstances which are, perhaps, still more commonly concerned, in favoring the supervention of inflammation, and inviting it to par- ticular organs. The human s)'stem is rarely found in so perfect a state of health, as that some of its various organs or structures are not more or less debilitated or disturbed. The multifarious influ- ences that are continually operating on the animal economy, do not suffer the vital machine to go on without some, though often imper- ceptible, derangement in one or more of its various organs. Add to this, the congenital debility of some structures, and the constitutional prepotency of others, and we have a sufficient number of latent causes, (varying in different individuals, and in relation to some, in the same individuals at different periods,) to determine the occurrence of local inflammation, when the nervous and vascular systems are thrown into a state of tumultuous excitement. Much variation occurs in different cases, as to the period after the commencement of the febrile changes, when local inflammations of this kind supervene. If any organ or structure happen to be espe- cially pedisposed to inflammatory excitement, or wThen the exciting cause is of such a nature as to act with great force upon some organ or structure, inflammation may commence with the onset of the febrile vascular reaction. More commonly, however, the local in- flammation does not supervene until several days after the com- mencement of the fever; and in many instances, not until the latter period of the disease. The occurrence of local inflammation in general fevers, of course, always greatly increases the obstinacy and dinger of the disease; and this is pre-eminently the case, when such inflammations supervene in fevers of typhoid character. Prone, as febrile affections unquestionably are, to give rise to secondary inflammations, many instances occur which remain en- tirely free from inflammation throughout the whole course of the malady, although irregular determinations and inequilibrium of ex- citement appear to be inseparably connected with this form of gene- ral disease. It has been observed above, that fevers, essentially identical in Vol. 1—4 38 GENERAL PATHOLOGY OF FEVER. the nature of the general febrile excitement, often assume prominent modifications, apparently radically diverse from each other, in con- sequence, solely, of the different organs or structures which happen to sustain the principal force of the malady. From this unquestion- able fact some pathologists have inferred that there can be no fun- damental and specific diversities of fever, presuming that the general febrile excitement is always essentially the same; and that all the diversities which occur in the course and phenomena of this mode of disease, are invariably the result of the diverse local affections that may accompany the malady. It appears to me, however, that the occurrence of original and specific diversities in the nature of febrile excitement, is susceptible of very plausible, and, to me at least, sufficiently satisfactory illustration. It is impossible to con- ceive why the capillary system of blood-vessels, in which doubtless all the essential febrile actions reside, should not be as susceptible of radical diversities of excitement as the nervous system itself. Upon this point we may be allowed to refer to the exanthematous affections; for, whatever Broussais and his followers may say to the contrary, some of these diseases are, at least in the first stage, simply febrile, without local inflammation. In the general phenomena of the fever of distinct small-pox, during the first day of its course, there is nothing that is different from an ordinary synochus, and yet no one can for a moment seriously doubt, that the essential morbid excitement of the extreme vessels in this affection, is specifically distinct from that of all other febrile diseases. It is true that this disease is produced by a specific cause; but the morbific impressions made by malaria, are probably as distinct from those of cold, as the impressions of small-pox virus are from those of either of them. No one has ever observed yellow fever or the plague to arise from atmospheric vicissitudes; and malaria by itself, has I presume, never been known to give rise to inflammatory rheumatism, or to simple catarrhal fever. If, then, in relation to the exanthemata, general febrile excitement is unquestionably susceptible of radical and specific peculiarities, the possibility of such fundamental diver- sities in the nature of the morbid excitement of fever, independent of accidental local affections, must be admitted, even in the general fevers, usually denominated idiopathic. It is probable, that koino- miasmala, idio-miasmata, and cold, or atmospheric vicissitudes produce each its peculiar mode of morbid excitement; for, although the general and obvious febrile actions, and even the accompanying local affections which they respectively produce, may not be per- ceptibly diverse, yet, it may be presumed, the fundamental morbid condition or excitement of the nervous and capillary systems, upon which the febrile phenomena depend, is in each variety of fever radically distinct, or sui generis. So far, however, as the fevers occasioned by one or the other of these remote causes, differ in form and general character from each other—as, for instance, the various forms of miasmal fevers—it can scarcely be doubted, that the most GENERAL PATHOLOGY OF FEVER. 39 common source of these diversities consists in the accidental local affections which occur, or the character of the structure most promi- nently deranged, or the greater or less intensity of the operation of the remote cause. CHAPTER II. OF THE CAUSES OF FEVER. The causes of fever are generally divided by pathologists into two varieties, the predisposing and the exciting. The former are all those external and internal causes, which tend to lessen the power of vital resistance to the influence of morbific agents. The latter are those causes which excite actual disease by the deleterious or irri- tating impressions which they make on the animal system. There exists, however, no absolute difference in the nature or character of these two varieties of morbific causes. The same agent, or circum- stance, may manifest its influence on the animal economy, either as & predisposing or an exciting cause of fever, according to the de- gree of intensity with which it acts, or the previous condition of the system. Sect. I. Of Predisposition, and Predisposing Causes. When, either from a general condition of the organisation, or some local functional or organic defect, the animal economy is especially susceptible of the influence of morbific causes, a predisposition to disease is said to exist; and this predisposing condition may be either natural, or accidental, or hereditary. As the human system is continually under the influence of causes which have a tendency to interrupt and terminate its actions, life would be but ephemeral in its duration, and harassed by constant disease, if the animal organisation were not endowed with the inhe- rent power of resisting, to a degree, the influence of injurious causes. It is by the aid of this vital resistance, that man is enabled to live through a long series of years, amidst a multiplicity of causes, which conspire unceasingly to his destruction. In relation to the degree, in which this power of resisting injurious influences is possessed, by different individuals, there exists great diversity; and hence the va- rious degrees of constitutional or natural predisposition to fever, which obtains among different individuals. Thus, the prick of a needle will, in one individual, cause great pain and constitutional irritation; in another, syncope; in a third, convulsions or tetanus; 40 CAUSES OF FEVER. and in a fifth, scarcely any perceptible consequences at all.* There exists, therefore, a natural or constitutional predisposition to dis- ease in some individuals, wholly independent of accidental causes, or mere casual debility; and this constitutional aptitude to disease, depends, probably, on the peculiar organisation of the animal system. Under the head of natural, or constitutional predispositions, must be ranked those specific predispositions, which render the system susceptible of certain specific diseases, and which are wholly lost by the actual occurrence of these maladies. These specific predisposi- tions are especially incomprehensible and mysterious. Neither tem- perament, nor constitutional vigor, nor debility, nor any circum- stance connected with the health of the individual, appears to have any relation with, or influence upon them. With regard to accidental, or acquired predisposition, observa- tion has not left us so entirely in the dark. According to the late Dr. Rush, general or local debility, accompanied by an increased ex- citability, constitutes the state of predisposition to fever. Without doubt, general debility, with increased excitability, must render the system more liable to the action of irritating or exciting causes; yet it does not appear, that this condition of the system can, with pro- priety, be considered as constituting the essential state of the organi- sation which predisposes to fever. It is well known, that the most robust and healthy individuals, are generally the first and most cer- tain victims of febrile epidemics. The vigorous and healthy are often prostrated under the devastating dominion of pestilence, and even under the less ruthless sway of the milder paludal fevers, whilst the feeble and the valetudinarian pass along untouched. It may, moreover, be observed, that in the feebleness of convalescence from bilious, typhus, and other forms of fever, fresh attacks, or relapses, are by no means so common as one would expect, if mere debility constituted febrile predisposition. When we wish to obviate fever, after a surgical operation, we reduce the system by low diet, purga- tion, and perhaps blood-letting.t In a general way, every cause, capable of deranging the health of the animal economy, may, when acting with moderate force, produce such a change in one or more organs, as will predispose the system to fever, requiring only some further exciting cause to evolve actual febrile disease. Predisposition, produced by the influence of acci- dental causes, consists, probably, always in more or less functional derangement of one, or at most, a few structures or organs, or in a disturbance of the healthy balance of excitement and the circulation. I have already stated some reasons which render it highly probable, that the impressions of every morbific cause, on whatever part of the system primarily made, is, in the first place, reflected upon some * Sur le differens Degrees de Resistance vitale dans les Maladies, &c. Par M. L. Martinet, M. D.—Revue Medicale, Oct\. 1824. | Richter's Specielle Therapie, vol. I. p. 36. CAUSES OF FEVER. 41 particular organ, according to the nature of the impression, and the organic sensibility of the various parts of the system. If this be cor- rect, it is manifest, that if the morbific impression, thus reflected upon an organ or structure, be too weak to establish a sufficient de- gree of irritation to excite general derangement, or febrile reaction, the result will be only a slight degree of insulated functional de- rangement, or irritation, which, though not manifested by any feel- ings or appearances of ill health, is still an incipient link of disease, and wants only some additional morbific influences to enable it to put in motion the latent train of morbid sympathies. How greatly mere functional derangement of an important organ aids the cause of fever in developing disease, is often conspicuously illustrated by the influence of digestive derangement in the production of fever. Let but this citadel of the animal system languish, and the enemies of human health will speedil}- attack the outposts, and make an easy conquest of the whole. Hence, of all the precautions which those who visit insalubrious climates may be required to adopt, the avoid- ance of every thing which is calculated to derange the digestive func- tions, is perhaps the most important. By a well-known law of the animal economy, every agent, how- ever deleterious, gradually diminishes, and finally almost destroys the susceptibility of the system to its influence, by long continued or very repeated action. Hence, every agent will, ceteris paribus manifest its operation with a promptitude and intensity, proportion- ate to the degree of previous immunity from its influence. It is this circumstance which causes the difference of predisposition to endemial fevers, between the acclimated natives of insalubrious re- gions, and strangers arriving from northern latitudes. This variety of predisposition depends in no degree on a want of constitutional vigor or general health. The robust and healthy are, in general, as much, if not more, under its influence, as the weak and infirm. By a gradual or protracted exposure to morbific agents, the animal economy loses, insensibly, its natural susceptibility to their influence. When such a change is effected by the combined operation of cli- mate and endemial morbific agents, the system is said to be accli- mated or seasoned, and the individual, thus seasoned, enjoys a com- parative immunity from the diseases of the climate. Besides the foregoing source of predisposition to disease, from causes peculiar to hot climates, there is another and perhaps not less powerful one—namely, atmospheric heat. High atmospheric tem- perature is, strictly speaking, rather a predisposing than a morbific agent in relation to its influence on the human system.* In this respect it exercises a very powerful influence in the production of diseases. Long continued exposure to an elevated degree of solar heat, tends, very considerably, to increase the general irritability of the system, and to lessen the power of vital resistance. Hence, the * Dr. James Johnson on Tropical Climates, &c. 4* 42 CAUSES OF FEVER. frequency of tetanus in hot climates, from injuries, or from the in- fluence of the cool and damp night air; and hence, too, the greater liability to this and other irritative affections, during the hot seasons of our own climate, than in the cold months. Atmospheric heat tends, moreover, to predispose to fever, and other affections, by the profuse and continued perspiration it causes, as well as the redund- ant secretion of bile it is apt to excite. By these over-excited ac- tions of two important organs, the general system is exhausted, whilst the organs themselves are rendered more susceptible to the injurious impressions of one of the most common and powerful exciting causes of disease—namely, cold. In relation to those predispositions to disease which are transmit- ted from parent to offspring, it may be sufficien-t to observe, in this place, that they depend no doubt, on a peculiar physical condition or intimate state of the organisation, which we may presume, is as apt to be imparted by the parent to the offspring, as the contour of the countenance, or of the general structure of the body. Sect. II. Of the sources of Morbific Causes, and their General Character. When we take a general survey of the source of all the possible causes of disease, we find that in relation to their origin, they range themselves under the following four general heads, viz.* I. Recrementitious substances, which, in health, are separated and thrown out of the system, but being retained in the cir- culation, or reabsorbed, become a source of irritation to the sanguiferous system, and, therefore, of irritative diseases. These morbific causes are always secondary, being, them- selves, the consequences of an anterior injurious cause or im- pression. Thus the retention of the perspirable matter can occur only in consequence of the influence of some previous cause, adequate to disturb or arrest the action of the cutane- ous exhalents. The recrementitious fluids, which appear to be most injurious to the animal economy, when retained in the circulation, even in their elementary forms, are the per- spirable matter, the bile, and the urine; and of these the first is, perhaps, the most frequently concerned in the production of disease. The influence of causes of this kind in the de- velopment of disease, is, probably, much more extensive than is generally admitted in etiological inquiries. In all that ex- tensive class of febrile affections which arise from the influ- ence of cold, retained perspirable matter performs, probably, a principal part in the development of the irritative vascular- excitement. Checked perspiration, or, more correctly speaking, inactivity of * Richter's Specielle Therapie, vol. I. CAUSES OF FEVER. 43 the cutaneous exhalents, constitutes the initial link in, perhaps, three- fourths of our febrile diseases. Let it not be imagined, that, as the recrementitious substances which are retained in the circulation are in a simple or elementary state, they cannot possess powers suffi- ciently irritating or active to excite morbid vascular action. In whatever form these substances may exist in the blood, they are still recrementitious, and it is not to be presumed, that materials of this character, could be long retained without an injurious influence on the animal economy. Accidental torpor of one emunctory, is often vicariously supplied, by increased activity of another, and disease thus prevented. Thus if, after the cutaneous exhalents have been rendered torpid by the sudden influence of cold, the flow of urine becomes unusually copious, disease will rarely ensue. Indeed, the all-wise and benevolent Creator has provided against the inju- rious consequences, which must otherwise have resulted from the constant changes to which the function of the skin is necessarily ex- posed by placing in the interior, an organ, whose functions may, in a great degree, supply any accidental deficiency in the action of the former. II. Irritating substances, generated within the body, but wholly independent of any organic actions. These causes of disease are usually generated in the primae viae, and consist of worms, acids, mucous, and various other irritating substan- ces, resulting from the fermentative or putrefactive pro- cesses. Worms have been, and by some are still considered as innocent inmates of the human body. This, however, is most certainly an erroneous sentiment. Without doubt, a few, or even a considerable number of worms lodged in the alimentary canal, may not be able to disturb the general system, when in a state of good health and constitutional vigor; but when the body is debilitated and irritable, as it commonly is during the period of dentition, the presence of worms in the intestinal tube will frequently give rise to the most alarming affections. Worms tend, moreover, to sustain and protract fevers produced by other exciting causes; an inattention to which, frequently renders the progress of ordinary diseases peculiarly per- plexing and unmanageable. It is not uncommon to meet with cases of slight febrile disease in children, from cold, which continue in spite of appropriate remediate efforts, gradually assuming the form of slow remitting fever, with a foul tongue, and gastric disturbances, and at last, suddenly assume a favorable aspect, on the expulsion of a few large lumbrici. The agency of causes of this kind in the production of fever, was, however formerly considered much more extensive than it appears, in reality, to be. Verminous epidemic fevers are described by some of the older writers, and saburral fevers were supposed, as it would appear, very common. Without ascribing so great an importance to these causes, as origi?\ators of fever, it is, nevertheless, unques- 44 causes of fever. tionable that they do, at times, give rise to febrile affections, inde- pendent of all other morbific irritants. Their febrific tendency is, however, much more frequently manifested in the support, or addi- tional violence which they give to fevers arising from other causes, than in originating febrile affections by their own immediate influ- ence. III. Morbific agents, generated out of the animal body, con- sisting, either of deleterious substances floating in the air, or of the sensible properties of the atmosphere, or, finally, mechanical causes—namely; miasmata, noxious gases, heat, cold, electricity, humidity, and mechanical injuries, &c IV. The fourth and last class of morbific agents comprehends those which are generated by morbid organic actions of the living system^ constituting the various contagions. The principal causes, embraced under the last two heads, are so extensive in their influence on the human system, and so interesting and important, both in a medical and scientific point of view, that a separate and full exposition of their respective modes of origin, and physical, as well as morbific characters, will not be deemed inappro- priate in a work of this kind. Sect. III. Atmospheric Temperature, and its relations with the Animal System. A certain quantity of heat is indispensable to life, throughout the whole range of organised beings. Every animated being possesses an inherent power to generate heat, and to resist, to a certain extent, the physical law of the distribution of heat; and, consequently, to maintain its peculiar or specific temperature, when placed in a me- dium either many degrees below or above its own temperature. The constant and rapid reproduction of heat by the vital powers, keeps up the natural temperature of the animal body, although surrounded by a medium which abstracts its heat, with great rapidity. Such indeed, is the evolution of heat by the human body, that an atmo- sphere of the temperature of 98° is generally oppressive and unplea- sant by the feeling of warmth which it causes, although at this tem- perature of the air, no heat can be communicated by the surrounding atmosphere to the body. The temperature most grateful and invi- gorating to the human system, ranges from about 60° to 65°. " This temperature of the air appears to abstract the heat of the body in about the same proportion in which it is generated in the healthy state of the system; and this degree of the temperature is, therefore the most congenial, for it neither exhausts the vital powers, nor gives rise to unpleasant sensations." There exists, however, considerable diversity in the human con- stitution, in relation to the power of supporting the extremes of tem- perature. This depends not only on the original vigor of the system, but also, greatly, on the influence of habit and modes of living. A CAUSES OF FEVER. 45 person endowed with a vigorous constitution, and with habitual good health, will bear a degree of cold without any unpleasant feelings, which, to one of a feeble and exhausted system, will be a source of painful sensations and indisposition. Habit, in relation to previous exposure has a powerful influence in varying the effects of temper- ature on the animal system. The same temperature will cause feel- ings of severe cold or great warmth, according as the body has been previously exposed to a high or low temperature. Whenever the surrounding medium abstracts the heat of the body more rapidly than it is generated by the regular actions of the animal economy, the sensation of cold will be produced; and the intensity of this sensation will always be proportionate to the rapidity with which the heat is abstracted, and the feebleness of the heat-generating power of the system. I. Physiological effects of cold. When the temperature to which the human system is exposed, is so low as to give rise to the sensa- tion of cold, its immediate effects are; 1. Diminution of the action of the cutaneous exhalents, and of the external capillary blood-ves- sels, giving rise to a pale, shrunken, and dry state of the skin; 2. Diminished action of the heart and arteries—manifested by smallness, weakness, and slowness of the pulse. In relation to the effects of low temperature on the frequency of the pulse, however, there exists some discrepancy of opinion among physiologists. From the experiments of Drs. Stock, Spooner and M'Donnel, it would seem, that although the strength and size of the pulse is diminished by cold, yet As frequency is considerably increased. Against these experiments we may oppose those performed by Currie, Rush and Klapp;* and in my own experiments I have invariably found the pulse diminished, both in frequency and in volume, when cold was applied to any particular portion of the body.t 3. Diminished sen- sibility of the external parts, passing by degrees throughout the whole system. Hence, the benumbed state of hands, fingers, and other external parts, the torpor of the sensorial functions, and the sluggishness and feebleness of muscular action which occur from the protracted influence of severe cold; and in this way, too, an almost * That Dr. Stock and the other experimenters observed what they record upon this point, cannot be doubted. We can readily admit that when the body is sud- denly plunged into cold water, the mode adopted by them, the pulse will at first be accelerated. It must be observed that when the body is suddenly immersed in cold water, the blood is violently driven in upon the heart and larger vessels, and the respiration is performed in a hurried and imperfect manner, in conse- quence of which, the heart is excited into a temporary exertion to overcome the load which oppresses it, and the pulse consequently at first accelerated. f The pulse of the inhabitants of northern climates is habitually slower than the ordinary standard of frequency in the middle latitudes. Amongst the Green- landers, it is by no means uncommon to find the pulse as slow as 40 and 45 in a minute.—Beaupre on the Effects and Properties of Cold, p. 50. 46 CAUSES OF FEVER. irresistible inclination to sleep occurs when the cold is very intense. Artificial somnolency has been produced in certain animals by ex- posing them to a very low degree of temperature. 4. When mo- derately applied, cold increases the powers of the digestive organs. Hence the aphorism of Hippocrates, Hieme ventres calidorus sunt. The appetite increases, and the process of digestion is performed more rapidly in moderately cold and dry than in warm weather. We are informed by Xenophon, that the Greek soldiers, on their return from Asia, were exceedingly harassed by the most severe sensations of hunger, while passing the snow covered mountains of Armenia, although they were allowed their ordinary rations of food. When cold becomes very intense and protracted, however the di- gestive, as well as all the other organs of the system become enfee- bled and inactive. 5. The sudden application of cold, causes a hurried, irregular and imperfect action of the respiratory apparatus; and when intense, it checks or impedes the efforts to dilate the chest and these effects increase, pari passu, with the increased influence of the cold, until at length respiration is performed so imperfectly as to prevent the due decarbonisation of the blood, and the whole or- ganisation sinks into a state of torpor and insensibility. 6. Mode- rate cold is favorable to nutrition. " Man and all animals are fat- ter in winter than in summer; and in the north than in the south." When, however, the cold is applied in an intense grade and pro- longed in its influence, the process of nutrition is disturbed and interrupted. 7. The pulmonary exhalation, and the secretion of urine are increased by cold, and suppty, in a degree, the checked exhalation by the skin from the same cause. Stringuntur tubuli pellis, coguntur et intus Tot variis pellenda viis excreta, $~c. S. Cold, when prolonged in its influence, diminishes the venereal propensity, (Montesquieu, Esp. des loix B. 14. C. 2,) but it does not appear to repress the function of generation; for although the venereal appetite be less constant and urgent in cold than in warm climates, yet the power of procreation would seem to be even greater in the former than in the latter, " In. Sweden it is not uncommon to see women have twenty or thirty children; and in Russia mar- riages are followed by a numerous progeny."* 9. Cold retards the development of the sexual organs, and the period of pube- scence, more especially in the female sex. In northern latitudes the * Beaupre on the Effects of Cold, &c, p. 88. " In the coldest regions, approach- ing the poles, excessive cold retards the generative flame, and we may say ex- tinguishes the lamp of physical love. Beyond the 65th' degree of latitude, population continues to decrease, and ends at Spitzbergen and Nova-Zembla. Lapland and Iceland females are said to menstruate but little; they are apathetic in love, and know but little of the bitter feelings of jealousy, or the vehemence of sexual attachment." CAUSES OF FEVER. 47 catamenia rarely commence before the sixteenth or seventeenth year, whereas, in the ardent climates of the intertropical countries, the menstrual evacuation is apt to make its appearance as early as the twelfth, and not unfrequently as early as the tenth year of age. Cold is, therefore, a sedative 'agent; for, although, when mode- rately and transiently applied, it is generally followed by phenomena attributable to a stimulating influence; yet these are not, strictly speaking, the immediate consequences of the low temperature, but rather of the reaction of the vital energies, after the temporary re- duction of their activity by the cold. When an agreeable glow, and augmentation of the general vigor is experienced after leaving a cold bath, it arises, probably, not from the direct stimulus of the cold, but from its having depressed the excitement of the surface, and in- creased the susceptibility to the action of stimuli; in consequence of which the ordinary influence of the atmosphere, the warmth of the clothing, and even the stimulus of the blood, as well as exercise, and other usual exciting influences, will cause an increased degree of excitement, more especially in the cutaneous capillary system. That the phenomena of increased activity and vigor, which sometimes ensue, are solely the consequence of a reaction in the system, after the cold has temporarily diminished the excitement, and thereby in- creased the susceptibility to subsequent excitation, is fully demon- strated by the fact, that unless the system be endowed with a con- siderable degree of energy and activity, no such favorable effects will follow the application of cold. If cold produced these effects by its stimulating powers, it would, one may reasonably believe, produce them when the system is in a state of feebleness; because mere weakness can never annul the operation of a stimulus, pro- vided the excitability be not exhausted. That cold must necessarily diminish the actions of the system, is evident from its being, in fact, nothing else than a comparatively diminished grade of temperature. For if heat be a stimulus, it is manifest that this stimulus must be lessened in its powers, just in the ratio in which its intensity is de- creased. Thus, if 80° produce a certain degree of excitation, 60° {cseteris paribus) must produce a less degree, and 40° still less, and so on. Correctly speaking, every agent capable of affecting the ani- mal economy, is a stimulus; but when we speak of cold, and its effects, it is to be always understood in a relative sense; for when it is said that cold is a sedative, it can mean nothing else, than that ic is less stimulating than a higher degree of temperature. It is to be observed, however, that although cold unquestionably tends to diminish the actions of the system, yet, when applied sud- denly, it often manifests a very conspicuous exciting agency on the nervous or sensitive system. Thus, a few drops of cold water sprin- kled on the face of a person in a state of syncope, or approaching to this state, will generally produce immediate excitation and return of consciousness. In asphyxia from carbonic acid, or electricity, too, cold water dashed on the face and breast, often causes immediate 48 CAUSES OF FEVER. respiration, and other manifestations of returning life. In cases of this kind, the sudden sensation which the cold produces, acts, pro- bably, as the exciting cause. 2. Cold as a morbific agent.—Cold is, perhaps, the most com- mon and frequent of all the remote causes of disease in the temperate latitudes. Its injurious tendency appears to be much enhanced by being conjoined with humidity; for, a very dry and cold air is far less capable of abstracting the animal temperature, than low temper- ature united with humidity. But the most important circumstances which render the impressions of low temperature prejudicial to the animal economy, relate to the previous condition of the system itself, with regard to the cutaneous transpiration, and antecedent exposure to high temperature. The morbific influence of cold, is always efficient in proportion as the body has been previously exposed to an elevated temperature; and, more especially, in proportion as the perspiration is more or less copious. The most powerful of all the predisposing conditions of the animal system to the injurious effects of cold, is a state of free perspiration, from fatiguing and exhausting exercise or labor, under the influence of high solar heat. In this state of the body, and scarcely in any other, the sudden application of cold to a large extent of the surface, or to the stomach, in the form of ice or cold water, will often suddenly produce the most alarming, and even fatal, consequences.* When the animal temper- ature is not rapidly carried off by free perspiration, and the system not debilitated by fatigue, cold can never give rise to such sudden, violent, and dangerous consequences. The effects here alluded to, as resulting from the impressions of cold, while the body is in a state of free perspiration, from fatiguing exercise and atmospheric heat, appear to be of a nervous or spasmodic character, consisting gene- rally in sudden prostration and effacement of the vital energies of the system. As a febrific cause, cold plays a very important part in the production of disease. It is not, however, merely as cold, or low temperature, that it is most influential as a febrific cause; vicis- situdes of temperature, sudden changes from warm to cold, or from cold to warm weather, are the sources whence febrile disease is so abundantly derived; and these changes are always injurious in pro- portion to the suddenness of the transition, and the greatness of the change. A very gradual change of atmospheric temperature rarely produces disease, except in such as are peculiarly predisposed to in- fluences of this kind. The mode in which cold produces fever has already been explained. Its first effects on the system are torpor of the cutaneous exhalents, and a retreat of the blood from the surface to the internal organs. The recrementitious perspirable matter is thereby retained, and the blood rendered more irritating, or at least surcharged with offensive substances. In consequence of these mor- bid conditions, the heart is excited into increased action, by which * Rush's Medical Inquiries. Currie's Medical Reports. CAUSES OF FEVER. 49 the blood is again propelled into the external capillary system, without, however, overcoming the torpor of the exhalents. If any portion of the capillary vessels be predisposed, by previous debility, to morbid excitement, high vascular irritation will be apt to occur in this part, and probably to the extent of actual inflammation. Should the mucous membrane of the respiratory passages be predis*- posed to irritation, catarrhal or pneumonic affections will be the con- sequence. If the alimentary canal be in a state of accidental or habitual irritation, dysentery or enteritis will probably occur. In short, whatever part of the system may be in a condition peculiarly predisposed to disease, inflammation or high vascular irritation will most likely be developed in it, by the increased momentum of the circulation, and the immediate local impressions of the recrementi- tious elements retained in the circulation.* When the degree of cold is excessive, or very prolonged in its action on the animal system, it gradually abstracts the animal tem- perature to a degree incompatible with vital action, and asphyxia, gangrene, or death ensues. The tendency which very low tempe- rature has to produce these effects, is greatly controlled by the de- gree of constitutional energy, as well as the degree of corporeal exercise, of those who are exposed to its prolonged influence. A person of a vigorous and healthy habit ot body, will readily bear a degree of cold without particular injury, which would soon destroy an individual of a weak and infirm state of the system. In all in- stances where cold is applied in a degree capable of gradually reduc- ing and finally arresting the vital actions, an indomitable inclination to sleep supervenes just before the fatal torpor comes on. When this oppressive somnolency ensues, all feelings of pain or suffering cease—and if it be not resisted, death is inevitable. Heat.—High atmospheric temperature acts much more frequently, as a predisposing than an exciting cause of disease. " Solar heat," says Dr. James Johnson, " produces only the predisposition, while terrestrial exhalations and cold call into action the principal diseases of hot climates. The mode in which solar heat contributes to the production of disease, appears to be either by augmenting the gene- ral irritability of the system, or more generally, by exciting inordi- nate functional action of the skin and the liver, and thereby render- ing them more susceptible of the paralysing impressions of cold. Between the skin and the liver there exists a close and powerful sympathy, in consequence of which, whatever excites the functions gf the former, produces, perhaps, an equal increase of the functions of the latter organ."t Hence, high atmospheric heat very gene- rally produces an increased secretion of bile, by its influence upon the liver through the medium of the skin, whose functions it is so peculiarly adapted to augment. It is manifest that an inordinate * Dr. James Johnson, passim. | Dr. James Johnson, On the Influence of Tropical Climates, §rc. Vol. I.—5 50 CAUSES OF FEVER. activity of these two functions from the influence of heat, must ren- der them extremely obnoxious to torpor or inactivity from the sud- den application of cold; and it is equally obvious, that a sudden tor- por of these two important emunctories cannot occur without an immediate injurious consequence upon the whole system. Solar heat is, moreover, extensively concerned as an indirect cause of febrile affections, by favoring the production of marsh miasmata. By its expansive and exciting influence, it sometimes gives rise to sudden and dangerous local determinations, particularly to the head, causing apoplexy, and that state of cerebral oppression called a stroke of the sun. Sect. IV.—Of Miasmata. The term miasmata is here used as designating a highly import- ant class of febrific agents of a gaseous form, which act on the ani- mal system through the medium of the atmosphere. This class of agents consists of two orders, namely;—1. Infection, comprehend- ing those febrific effluvia which are generated by the decomposition of vegetable and animal matter; and—2. Aeriform contagions, gene- rated by the animal system in a state of disease. 1. Infection; or that variety of febrific agents which is produced by decomposition out of the animal system, consists of two genera, namely;—1. Those which result from the humid decomposition of vegetable and animal substances contained in the public filth of cities, in marshes, and in other soils and situations furnishing these mate- rials. This genus is usually designated by the term marsh miasm; but from the common or public source of these morbific effluvia, it has been proposed, and by some adopted, with much propriety, I conceive, to distinguish them by the compound term koino-mias- mala. 2. Those febrific effluvia which are generated by the de- composition of the natural exhalations and excretions of the human body, accumulated and confined in crowded and ill-ventilated habi- tations. These deleterious effluvia, originating from the decompo- sition of matter derived from the human body, have, with equal propriety, been designated by the term idio-miasmala, expressive of the personal or private character of their source.* Before treat- * These distinctive terms were originally proposed and adopted by the late Dr. Edward Miller, of New York, in the year 1804. He observed that there were two species of miasmata; the one consisting of febrific exhalations from marshes and other soils, and the other of effluvia generated by the decomposi- tion of personal and domestic filth. " In order to distinguish these two varie- ties of miasmatic agents, and, at the same time duly to fix in the mind the im- pression of the origin and production of them, it is judged expedient to designate each, by terms which will, invariably, express the process of nature in their formation. As the Greek language has been generally resorted to in the framing of scientific nomenclature, I shall employ the adjective koinoz, common ox pub- CAUSES of fever. 51 ing of these febrific agents, in an etiological point of view, it will be proper to describe, more circumstantially, the manner and circum- stances in which they are generated, as well as their physical cha- racters, so far as these can be known. I. Koino-miasmata, usually designated by the terms marsh- miasmata, or malaria. This morbific agent was not unknown to the ancient Greek physicians. They personified it under the em- blem of a many-headed monster, whose devastating influence was so severely exercised over the luxuriant fields of Argolis, that it was made one of the labors of the potent son of Alcmenus to rid the country of this dreaded source of pestilence. Hercules, accordingly, drained the extensive Lernean marshes, and thus dried up this abundant source of pestiferous emanations. Heat and moisture are indispensable to the generation of koino- miasmata; without these, no decomposition can take place, and with- out decomposition no deleterious agents can be generated from dead vegetable and animal substances. In latitudes where the atmospheric temperature seldom rises above 60°, the diseases which arise from this agent occur but very rarely, and perhaps, never in an epidemic manner. The Lithuanian marshes of Russia do not render the sur- rounding districts insalubrious. It would seem, indeed, from along series of observations, that koino-miasmata are seldom evolved, to a degree sufficiently copious or active to create extensive disease, so long as the temperature of the air does not rise above 80° of Fah- renheit. It is, however, not necessary that moisture should be pre- sent in great abundance for the production of miasmata. Indeed, grounds completely covered with water, send forth but very little of this deleterious effluvium, however favorable the temperature, and other circumstances may be. Hence, copious and continued rains, by inundating marshy soils, render such localities compara- tively salubrious, (Dalzille, Ferguson.) Ferguson was led to infer, from his observations on this point, that miasmata were extricated wholly independent of the humid decay or decomposition of vege- table and animal matter, and apparently without the agency of hu- midity. He asserts that this aeriform poison is never extricated, in any considerable quantity, until the moisture of the soil is so fardis- lic, to denote one species of miasma, and iaios, personal ox private, to denote the other. The application of these terms will be readily understood. That por- tion of the air charged with miasmata, exhaled by solar heat, from the surface of swampy ground, or from masses of filth overspreading the open area of cities, according to this distinction, is denominated Atmosphera koino-miasmatica. And that other small portion of air, contaminated by miasmata, emitted from, and surrounding the body, clothes, bedding, and furniture, of persons immersed in the filth of their own excretions, and of those associated in the same family with them, accumulated, long retained, and acted upon by animal heat, is denomi- nated Atmosphera idio^miasmatica."—Attempt to deduce a Nomenclature, $rc. Med. Repository. New York, 1804. 52 MIASMATA. sipated as to leave the ground in the last stage of the drying pro- cess. This, however, is decidedly contradicted by almost universal experience. In proof of his opinion, among other observations, he says: " In the months of June and July our army marched through the singularly dryr rocky, and elevated country on the confines of Portugal, the weather having been previously so hot, for several weeks, as to dry up the mountain streams. In some of the hilly ravines, that had lately been water-courses, several regiments took up their bivouac, for the sake of being near the stagnant pools of water that were still left among the rocks. Many men were seized with intermitting fever." From this, and similar facts, he thinks himself warranted to conclude, that the humid decay of vege- table and animal matter has no immediate agency in the production of miasmata, and that moisture, particularly, is not essential. But " half dried ravines and stagnant pools of water," are surely no evi- dence of a want of humidity, and present, one should think, pre- cisely the conditions most favorable to the emission of miasmata from vegetable and animal decomposition. It may be observed, that in every instance adduced by Dr. Fer- guson, in proof, that the extrication of miasmata does not depend on the humid decay of vegetable and animal matter, the soil from which the miasmata was emitted had been previously thoroughly saturated with water, during the rainy season, and moisture must, therefore have existed in sufficient abundance, a short distance un- der the surface of the soil, however parched the latter may have been. Under such circumstances, miasmata might be abundantly- sent forth, without any obvious humidity and vegetable decomposi- tion on the surface; for the vegetable and animal remains, collected during the rainy season, must have been gradually decomposed dur- ing the drying process, and left, in part, at least, mingled with the portions of the soil on the surface. In this state, then, the slow evaporation of the humidity under the surface, in passing up into the air, would dissolve the putrid but dry particles of animal and vegetable remains, and convey them in the form of an effluvium into the circumambient atmosphere. That a considerable degree of humidity is especially favorable, and even essential, to the evolution of miasmata, is evident from the circumstance that marshes, stagnant pools, and the oozy shores of rivers, have, in all ages, and in all countries, been found the most insalubrious portions of the earth during the hot seasons. As to the variety of soil most favorable to the production of mi- asmata, we possess no very definite or certain information. It has been asserted, that an argillaceous soil is most favorable for the ex- trication of this effluvium; but its tendency in this way, appears to depend solely on its greater compactness, in consequence of which, it retains humidity much longer than other soils, and thus favors the formation of marshes, and of standing pools of water. It is not, however, from marshy or low and humid soils alone, MIASMATA. 53 that this morbific effluvium is disengaged; for, " there is scarcely a spot of this earth's surface to be found, that is not covered or imbued with both vegetable and animal remains in a state of decomposition, and ready to afford pabulum for the sun's rays, with or without hu- midity to extricate malaria.'"* Wherever vegetable matter meets with sufficient heat and moisture to cause it to enter into humid de- composition, there miasmata will be evolved, and in our own climate there are very few, if any, situations, that do not at times furnish all these conditions, to a greater or less extent. A mixture of fresh and salt water in marshes, appears to enhance the copiousness and virulence of miasmata to a very obvious degree. It is a singular fact, that the water of the sea is much more apt to enter into putrefactive decomposition than fresh water; and this, no doubt, depends on the great quantity of organic matter which it con- tains. M. Monfalcon mentions some interesting examples illustra- tive of this fact.t The extensive pool of Valdec, in the south of France, is quite saline. Not more than a few rods from it is a large pool of fresh water called Engrenier. When the waters of these two pools rise, and run into each other, as they occasionally do, much sickness soon occurs throughout the adjoining parts. In the vicinity of Lukes, on the south of the Ligurian Appenines, there is a large marshy plain accessible to the high tides of the ocean. The neighboring districts were almost uninhabitable from the pestilen- tial effluvia which emanated from this marsh, until the waters of the sea were separated from the sweet water of the marsh by means of sluices and hydraulic works, when it became healthy, and the popu- lation increased rapidly. Of the nature of koino-miasmata, we possess, as yet, no certain knowledge. Examined chemically, the air of the most pestiferous marshes is found to differ in nothing from the purest and most salu- brious air. According to the experiments of Professor Julia, of Lyons, it would appear, that 1. The deleterious influence of koino-miasmata, depends on par- ticles of putrid animal or vegetable matter dissolved and sus- pended in aqueous vapor. 2. The air of marshes does not differ from atmospheric air in any of the principles which chemical analysis can detect. 3. None of the gases disengaged from bodies in a state of putre- faction, exhibit themselves in a sensible quantity. 4. The disorders caused by koino-miasmata, are not in any de- gree dependent on the predominance of azote, of carburetted hydrogen, of ammonia, of nitrous oxide, &c. in the air. That koino-miasmata consist in particles of putrid vegetable and animal matter, dissolved in aqueous vapor, receives considerable support from the experiments of Gaspard and Majendie on the effects * Dr. James Johnson, Med. Chir. Rev. | Histoire Medicale des Marais. Paris, 1828. 5* 54 MIASMATA. of putrid exhalations on animals, and which have already been cited in a former part of this volume. Majendie found, that on exposing different animals to the exhalations of putrid animal matter, affections were produced analogous to those which are known to occur in man from the influence of pestilential miasmata. It is not improbable, therefore, that such putrid materials, suspended in vapor, constitute the deleterious principle of miasmata of this kind; and it may be reasonably presumed, that the different modifications of disease pro- duced by this agent, in different localities, depend in a great degree on the different degrees of concentration, as well as on the particu- lar character and proportion of the substances from whose decom- position the putrid miasmal particles are derived. It can hardly be doubted, that the relative proportions of animal and vegetable mat- ter whioh may enter into miasmal exhalations, will determine the violence of their influence, and modify its results on the system. Plausible as these sentiments may be, it should not be forgotten that they are founded on no certain data, and that we may, after all, as yet, be remote from the truth in relation to this subject. Whatever may be our views concerning the essential nature of koino-miasma, observation has made us acquainted with certain of its physical qualities, as well as with its general effects on the human system, and which is perhaps all that it imports us, in a practical relation'especially to know. Koino-miasmata possess a greater specific gravity than atmo- spheric air, (De Lisle.) They cannot, consequently ascend into the air without being attached to and carried up by lighter bodies: and these vehicles consist, without doubt, of aqueous vapors. Hence, persons sleeping in elevated chambers, are much less apt to contract miasmal diseases than such as are lodged on the ground floor, (Hun- ter on the diseases of Jamaica, Blane, Lempriere,'* De Lisle.) And hence, too, the greater salubrity of hills, and very elevated parts, than the adjoining low grounds. The ancient Romans appear to have been fully aware of this fact, and they availed themselves of it by almost uniformly selecting very elevated positions, or hills, for the sites of their towns. It is true, that some very remarkable ex- ceptions have occurred to this fact. Bancroft mentions the great mortality which has repeatedly been observed, on the top of Mont6- fortune, at St. Lucie: and on the Hospital and Richmond hills, at Grenada, while the surrounding low situations were comparatively salubrious. Dr. O'Hallaran, in his account of the yellow fever of the south and east coasts of Spain, mentions similar examples of the great prevalence of miasmal diseases on very elevated situations, * Drs. Blane and Lempriere, in their report to the Secretary of War, con- cerning the Walcheren fever, observe: " On no account should ground floors be used to sleep on: the more lofty the buildings the better, for the tenants of the upper stories not only enjoy the best health, but, when taken ill, have the disease in the mildest form."—Bancroft on Marsh Exhalations. MIASMATA. 55 whilst the surrounding marshy grounds were but little infested with this deleterious effluvium. He refers particularly to Monjui, a hill 700 feet high, overlooking Barcelona, the air of which, he says, is so deleterious, that it was found necessary to relieve the stationary guard every eight or ten days; and, he adds, that the injurious influ- ence of the exhalations arising from the swamps below manifested itself more conspicuously upon the summit of the hill than in the subjacent parts. Dr. Blane, who mentions similar facts, explains them by supposing that the vapors formed on the low and swampy grounds ascend, and, with the miasmata which they hold in solution, pass over the lower situations and impinge and settle on the neigh- boring hills. It is, indeed, by no means uncommon to see fogs, which rise out of the low grounds, ascend and hover over the tops of the neighboring mountains, and it may well be presumed, that these fogs will convey along with them a large portion of the mias- mata which may be extricated from the same grounds whence the aqueous vapors arise. Koino-miasmata is abundantly precipitated to the surface of the earth during the night, and more especially during the first hours after the setting, and shortly before the rising of the sun. Hence, in part, the greater liability of contracting miasmatic diseases from exposure between the setting and the rising of the sun, than after the sun is considerably above the horizon, (De Lisle, Bancroft, Sir James Fellows, Johnson.) The most dangerous period in the twenty-four hours of the day, is " that which accompanies the set- ting and that which immediately precedes the rising of the sun, and the least critical time is when the sun is at its highest point above the horizon," (De Lisle.) In these facts we have strong evidence of the correctness of an observation already made—namely, that the miasma is united with and suspended in the air by aqueous vapor, which, falling in the form of dew, carries down along with it the deleterious miasmatic particles. Koino-miasmata may be arrested in its progress or passage from its source to other parts, by whatever is capable of impeding and intercepting the progress of aqueous vapor. Thus the interposition of a dense forest, of a high wall, or fence, of a chain of elevated hills, in short, of any mechanical obstacle of this kind, has been known to protect the inhabitants of villages, of camps, of convents, and of single habitations, from the pestiferous influence of neigh- boring marshes. De Lisle relates several very remarkable facts illustrative of this observation, (Monfalcon, Bancroft.) A convent situated on Mount Argental, near the village of St. Stephano, was, for a long time, remarkable for its salubrity, until the trees by which it was surrounded were cut down, when it became extremely sickly. From the same circumstance, miasmata are sometimes confined by obstacles of this kind, and so accumulated in particular localities, as to acquire a high degree of concentration and power. Marshes surrounded with dense forests, in warm climates, have often given 56 MIASMATA. unequivocal illustration of this fact. The same effect, in causing a stagnation and accumulation of miasmata, has been observed in most situations environed by high hills. In some of the valleys in the mountainous regions of South America, malaria are thus aceumu- lated to a degree which gives them the utmost virulency, while the surrounding elevated parts are entirely free from miasmal diseases. This is remarkably the case of Acapulco, which, as Dr. Macculloch* observes, may be regarded as a striking instance " of the imprison- ment of malaria by hills." It is in this wa}', too, says this writer, that we " may explain the peculiar virulence of jungles and pine swamps, and even of woods every where." Considerable diversity of opinion has been expressed as to the distance to which miasmata may be diffused from their source, in a state of sufficient concentration, to produce fever. In a quiescent state of the atmosphere, the sphere of activity is, probably, much more limited than has been generally supposed. Bancroft thinks, that they are rarely carried beyond a quarter of a mile, even by un- obstructed currents of air, in a state sufficiently active to produce fever; and he adduces several observations which seem to confirm this opinion. Unquestionably, however, currents of air passing over marshes, often convey the miasmata, which arise from them, to a very considerable distance—sometimes several miles, in a state of concentration fully adequate to the production of their usual de- leterious effects on the human system. "In Italy," says Dr. Mac- culloch, " the poisonous exhalations of the lake Agnano reach as far as the convent of Camaldoli, situated on a high hill, at the distance of three miles, proving that thus far, at least, malaria can be convey- ed by the winds." The account of the thirty Roman noblemen mentioned by Lancisci, is an interesting and striking illustration of this fact. They were sailing near the mouth of the Tiber, on a party of pleasure. Suddenly the wind shifted, and blew over the putrid marshes. Twenty-nine out of the thirty were soon seized with intermitting fever. The effects, often truly frightful, of the harmattan, after becoming loaded with the pestilential effluvia of the swamps of Benin, afford also a strong illustration of this fact From this circumstance, it not unfrequently happens, that those who reside on the leeward margin of marshes, or sluggish streams, are extremely harassed by miasmal diseases—while those who sojourn on the windward side, remain almost entirely exempt from these affections. Dr. Macculloch relates an instance from his own obser- vation, which strikingly illustrates this fact. " An army was en- camped in a very pestiferous plain, yet the health of the men did not suffer, because, being near the shore, the sea-breezes predomi- nating at that season, swept back the malaria into the interior country. From some cause, the encampment was transferred to another point, without recollecting that the change of the regular winds was ap- * An Essay on the Production and Propagation of Malaria, &c. MIASMATA. 57 proaching, They did commence—sweeping in a new direction across the plain; and, within a few days, many thousand men were disabled or destroyed." During the autumns of 1820, '21, '23, and 24, there was scarcely a family between the eastern shore of the Schuylkill and the city of Philadelphia, that did not suffer from intermitting and remitting fevers; whilst among the inhabitants of the western shore, and of the high grounds a short distance back, there was, comparatively, but little sickness. The cause of this difference manifestly consist- ed in the course of the wind, which, during the periods here men- tioned, as indeed is generally the case, blew almost continually from the west, northwest, or southwest; and thus swept the miasma, which was generated along the oozy borders of the Schuylkill, in an eastern direction. Violent storms, and copious showers of rain, tend powerfully to free the atmosphere from koino-miasmata. The former violently disperses them, and the latter sweeps or washes them down to the surface of the earth. Nothing is more common than to find mias- matic epidemics to remit immediately after copious floods of rain or violent storms, (Rush, Bancroft, Monfalcon.) A humid air is a much better vehicle for the transportation of miasmatic exhalations, than a dry one. The particles of the mias- matic poison attach themselves to the humidity of the air, and are thereby carried along by currents of wind. It is to be remarked, however, that, although atmospheric humidity appears to favor the dissemination and action of miasmata, yet observation would seem to show that when these efnuyia pass over a surface of water, they become absorbed, or in some way lost. This circumstance may, in part, account for the short distance assigned by Bancroft to the dis- semination of miasmata from their source; for in all the examples which he adduces in support of this opinion, the miasmata were con- veyed over bodies of water. II. Idio-miasmata.—This variety of miasmata is generated by the decomposition of the matter of perspiration, and the other ex- cretions of the animal body; and hence it most frequently occurs in the confined and crowded hovels of the poor, in crowded jails, ships, hospitals, and wherever many individuals are confined in apartments not duly ventilated. From an inability to procure separate dwell- ings, the poor are generally obliged to take up with small apartments, into which two or three families are often crowded; and in order to save fuel, and indeed frequently from the total want of fuel, every access of the external cold air is carefully cut off. Add to this the filth and want of proper changes of clothing, almost inseparable from extreme poverty, and you have a combination of circumstances pe- culiarly calculated to generate a miasma, by the putrefactive decom- position of the animal exhalations with which the air and every ar- ticle of clothing in such apartments must be saturated. It is chiefly during the cold season of winter that this variety of miasmata is 58 MIASMATA. generated. When the weather is warm, the air of crowded and filthy apartments is constantly renewed by the doors and windows being kept open, and the accumulation and stagnation of the animal exhalations thereby prevented. Dr. Smith observes, that this miasm is especially apt to be generated in the apartments of the sick, par- ticularly "of those who are laboring under the typhus state of fever."* It may be observed, however, that the exhalations which emanate from the body in estate of disease and which possess the power of producing the same disease as that, under whose influence they are evolved, cannot, with strict propriety, be ranked with the present class of miasmal poisons. They belong to the contagions. I would restrict the term idio-miasma, to those morbific effluvia, which are generated by the decomposition of the animal secretions, whether formed in a slate of health or disease, and to the ordinary exhalations from the body, when accumulated in such a manner as to deteriorate the atmosphere of confined rooms, if these be really capable in themselves, and without decomposition, of exciting fevers. Idio-miasmata are always quite limited in the sphere of their influence. Beyond the room or habitation in which they are gene- rated their operation cannot extend; unless, indeed, they are absorb- ed or adhere to articles of clothing, and are conveyed abroad in a state of sufficient activity to act on the human system. Whenever fever is found to spread from a source of idio-miasmata, it is in con- sequence, doubtless, of the generation of a new contagious miasm by the disease, which is produced in the first instance by the idio-mias- matic poison. I am well aware that this opinion involves what has been declared a manifest inconsistency—namely, the origination of a contagious disease by a common or general exciting cause. All such objections, founded merely on speculative inferences, may be met by facts, which must stand good, however irreconcilable they may appear to be with the dogmas of philosophy, or with admitted principles. It is a fact, for instance, that typhus may be originated by the miasm resulting from the decomposition of the secretions or exhalations of even healthy individuals, crowded and confined a long time in narrow and unventilated apartments. And that, although not necessarily a contagious malady, typhus may, under peculiar cir- cumstances, generate a specific virus which is capable of exciting the same disease in others, is a fact supported by a mass of testimony which cannot be, reasonably, rejected. " There are few physicians," says one of the most eminent medical writers of the present day,t " who believe that epidemic or endemic fevers arise from specific contagion, though facts daily teach us that typhus, yellow fever, dys- entery, &c. occasionally, and under particular circumstances, give out a something, (call it what you please) which produces a similar * Elements of the Etiology and Philosophy of Epidemics, p. 52. f Dr. James Johnson, Med. Chir. Rev. vol. VII. (1825,) p. 65. MIASMATA. 59 disease in the healthy stander-by, who happens to come within its range. If we may venture to prognosticate, we would anticipate that this will be, as it assuredly now is, the more general opinion among practitioners.'''' From the circumstance of this variety of miasmatic poison " be- coming innoxious when diffused in the atmosphere, even a few feet beyond the apartments in which it is generated," none of the forms of disease, which it is capable of producing, are apt to occur epidemi- cally. Typhus, nevertheless, has been known to occur in a manner well entitled to the name of epidemic. The late widely spread epi- demic of Ireland was surely strongly characterised in its progress and extent of diffusion by every feature which can give to diseases the character of an epidemic. Though engendered and nursed in the lap of wretchedness and poverty, it did not, in its desolating sway, fall exclusively upon those who were suffering under the dis- tressing privations of penury. Its fatal visitations were abundantly made to the ample and airy habitations of plenty and comfort, and almost— -------aequo pulsat pede pauperum tabernas Regumque turres. The question here occurs: If "idio-miasmata becomes innoxious by being diffused in the atmosphere even a few feet beyond the apartments in which it is engendered," how can typhus, which is manifestly originated by this effluvium, become epidemic, or be pro- duced in large and well ventilated dwellings remote from the usual sources of this miasm? Is it by the idio-miasmata attaching itself to the clothes of individuals, or to other substances by which it may be conveyed from one to another place? If this be admitted, then idio- miasma must possess the character of a contagion. Is it not more probable, that in the majority of instances of this kind, the disease is propagated by a specific virus, generated by morbid secretion, and conveyed as other contagions of an aeriform character are conveyed? It does not seem probable that idio-miasmata can be disseminated by fomites. If it can be so disseminated, it must possess all the charac- teristics of a veritable contagion. Of the relations of Miasmata to the *ftnimal System, Spc. Having given an account of the physical character and conditions under which the two infectious effluvia, koino and idio-miasmata, are evolved, I proceed to the consideration of their relations, as morbific agents with the human system, as well as with each other. Upon this subject I stand largely indebted to the ingenious and truly7 philosophical work of Professor Smith, of New York; for, although I have long since entertained similar views in relation to the com- bined agency of these miasmal poisons in the production of fevers, yet the enlarged, systematic, and precise views taken of this subject 60 MIASMATA. by Dr. Smith, have afforded me some new and interesting insights into this part of the etiology of fevers. The class of fevers arising from koino-miasmata are very distinct in their general character, and we may presume, in their essential natures, from those which are the result of idio-miasmata. The former give rise to intermittent, remittent and bilious fevers; and the latter miasm is the source of typhus, and the low nervous fevers of former writers. The deleterious power of koino-miasmata is manifested not only by the violent and fatal fevers which they are known to produce so abundantly, but also by the more slow inroads they make on the physical and moral condition of those unfortunate beings, who are habitually exposed to their influence. The indigenous inhabitants of marshy districts, in warm climates, present an aspect of suffering and wretchedness from this cause, which is well calculated to draw forth the commiseration of those who are more fortunately located. Continually exposed to the deleterious influence of these baneful ex- halations, man, in such situations, exhibits a state of feebleness and early decrepitude, strongly indicative of a broken-down constitution, and deep, irremediable chronic disease. So deep and pervading, indeed, are the effects of malaria on the human system, that it never fails to debase, in a remarkable manner, both the physical and moral constitution of a people, who through successive generations, reside in situations abundant in perennial sources of miasmata. Not only does the stature and symmetry of the body suffer conspicuous dete- rioration, but the mind becomes torpid, feeble, pusillanimous, and the moral sentiments debased. But while such chronic and constitutional effects are wrought by the habitual endurance of koino-miasmata, the system loses its sus- ceptibility of being excited into those violent commotions of febrile action, which this agent is so apt to produce in individuals less accus- tomed to its impressions. The natives of marshy districts are com- paratively much more rarely affected with the higher grades of miasmal fevers, than those who are only occasionally brought within the sphere of its influence. In the former the agency of this poison proceeds as it were by a slow and concealed combustion, whilst in those who are not accustomed to its influence, its effects burst out in a raging and rapidly consuming flame. There can be but little doubt that koino-miasmata varies in its powers, and often very considerably, according to various circum- stances in point of locality, and the relative proportions of the ani- mal and vegetable matter which supply the materials for its compo- sition. Dr. James Johnson, whose authority I am always disposed to respect, has expressed his belief in the occurrence of such diver- sities in the peculiar morbific powers of this agent. " The fever of Batavia," he observes, " differs from the fever of Walcheren—the fever of Antigua, from the fevers of the Ganges—and all these dif- fer materially from the plague of the Levant." That certain coun- MIASMATA. 61 tries and localities have an especial tendency " to generate one mode or variety of fever; while in other situations, some other variety as exclusively prevails," is an observation founded on abundant testi- mony of unquestionable authority. In Germany, intermittents almost universally assume the tertian type; in Italy, the quotidian type greatly predominates; and in Hungary, paludal fevers are pecu- liarly apt to be attended with petechia?. " The fevers of the Pontine1 marshes are noted for the shortness of their intermissions; whilst Holland is not less remarkable for the variety of the types than the slow progress of the fevers. In Spain, as in Africa, the West Indies, and the southern parts of the United States, the black vomit and the yellowness of the skin are similarly characteristic symptoms."* Even in localities situated within a short distance from each other, the most remarkable difference occurs in the character of the fevers which they engender. Thus, " the fevers of Walcheren," says Dr. Macculloch, "differ materially from those of Bresken on the oppo- site shore of the Scheldt; and in France those of Rochefort differ as completely from those of the Lyonnais." It cannot be presumed that the relative proportions of animal and vegetable matter-should be the same in different localities, and equally improbable is it that the same kinds of these materials should be present in the different situations where miasmata are generated. There must be great, diversity in both these respects, and a corres- ponding diversity in the essential morbific qualities of the miasmata evolved from them. I have already mentioned the experiments of Majendie in relation to the effects of putrid animal substances on the animal system. From these it appears, that " different kinds of flesh, when in a putrid state, produce different effects on the animal economy,"t and it is, therefore, reasonable to conclude that mias- mata will differ in their powers according to the greater or less pro- portion and kinds of the animal and vegetable matters concerned in their production. The influence of koino-miasmata on the human system, like that of other general causes of disease, is much under the control of the physiological state of the animal economy, of idiosyncracy, of tem- perament, predisposition, and of accidental external causes. Thus of a number of individuals exposed for a certain time to the same miasm, some may become affected with intermitting fever, others with mild remittent fever, some with malignant bilious fever, some with bilious colic, some with dysentery, and others, perhaps, will escape the disease entirely. The influence of high atmospheric temperature in predisposing the system to the deleterious impressions of miasmata is, proba- bly, very considerable. Long continued exposure to solar heat appears to have an especial tendency to affect the biliary organs, and * An Essay on Malaria, &c, by John Macculloch, M. D. f Journal de Physiologie, Janvier, 1823. Vol. I.—6 62 MIASMATA. to render the system generally irritable. These conditions, it may be presumed, are peculiarly favorable to the morbific influence of malaria; and it is not improbable that they sometimes contribute, in a considerable degree, to render the miasmatic fevers of intertropical or hot climates, so peculiarly viblent and dangerous. Dr. Maccul- loch dwells much on " errors of diet" as a predisposing cause of the miasmal fevers. It would appear, that the free use of animal food, in tropical climates, is peculiarly calculated to favor the morbific influence of miasmata; and this is said to be especially the case when fhe animal food is taken " in the middle of the day, or frequently in one day." On examining Niebuhr's narrative, says Dr. Macculloch, "it is most apparent that the deaths of his companions were the con- sequences of gross feeding." " On this question," says the same writer, " there can perhaps be no better evidence than the opinions and practices of the intertropical nations themselves, among the mass of whom this subject seems well understood; while in many coun- tries it is a caution actually often given to Europeans by the natives, though most generally neglected by them. It is, probably, from long experience, in some measure, of its advantages, as well as from more obvious causes, that a vegetable diet is so general throughout the aborigines of the torrid climates; while it is doubtless from prin- ciple, also, that among the people of Africa, to the northward, at least, the sole or the principal meal is supper." The class of diseases produced by koino-miasmata, if we take into view their various modifications, is by no means limited in its range. The most simple form of disease arising from this cause is the inter- mittentiever. In proportion as this febrific effluvium increases in potency, so does it produce fevers of a higher and more violent grade. The range of activity of this miasma extends from the sim- ple tertian of the temperate latitudes to the malignant and fatal plague of the East, or the scarcely less fatal bilious fever of Batavia. Besides general fevers—assuming an endless diversity of charac- ter in different seasons and climates, koino-miasmata produce, also, various other affections, both local and general. Dysentery, cholera, and diarrhoea, are enumerated among the maladies produced by ma- laria. It may be doubted, however, whether miasmata, by itself, without the co-operation of other causes, has any particular tendency to excite these affections. I apprehend, that in many instances occurring in malarious districts, as elsewhere, atmospheric vicissi- tudes, or cold, exerts no small degree of influence in determining the disease upon the alimentary canal. During the autumn of 1814, one-fourth, perhaps, of the men of four regiments encamped near Baltimore, were affected with intermitting and remitting fever in the month of September. The weather was remarkably warm, equable and dry. The months of October and November, however, were rain}7, extremely variable in temperature, and the majority of the men, who were previously lodged in covered rope-walks and houses, were now encamped in tents. A week after the rainy and MIASMATA. 63 cold weather set in, dysentery and diarrhoea began to appear abun- dantly, and in the course of three weeks more, there were but very few cases of intermitting or remitting fever, but more than eight hundred cases of dysentery. Nevertheless, the capability of mias- mata of producing these forms of intestinal disease by its own un- aided powers, is not to be questioned, although it is, I think, equally evident, that the co-operation of sudden changes of atmospheric tem- perature, or cold, is especially calculated to enhance the tendency of the miasmata to occasion these diseases. From these remarks, cho- lera ought to be excepted, for the cholera of India, at least, is'most undoubtedly the product of a miasmatic agent. Dr. Macculloch mentions tic douloureux as a common consequence of the influence of miasmata—more especially in Italy; and the occurrence of periodical hemicrania, from this cause, is by no means unfrequent, even in our own climates. In truth, there is scarcely a malady that may not be produced or stimulated by the operation of malaria on the human system. The period which intervenes between the reception of koino- miasmata and the first manifestation of its influence on the human body, is extremely various. Of many persons exposed to it at the same time, some may be immediately affected, others in a few days, some not until several weeks have passed, whilst, others may remain free from its effects a still longer time. As the powers of koino-miasmata most probably vary consider- ably in different countries and localities, it may be inferred, as has already been observed, that the fevers which they produce are im- pressed with a corresponding diversity in their character; an obser- vation would seem to confirm this inference. Dr. Smith thinks, that whatever external or general diversities may occur in fevers pro- duced by this miasma, " their pathology or essential nature is every where the same." This is highly probable; for the diversities in question would seem to depend more on the mere grade of violence, local affections, and general course of these fevers, than on any radi- cal difference in their essential pathological conditions. Upon this point, however, it becomes us to speak with diffidence, as this ques- tion cannot be solved by mere closet inferences and reasonings, but by close observation and careful experience, in relation to these fevers as they occur in various countries, climates, and localities. How far a mixture, or the combined agency of koino and idio- miasmata, may operate in producing novel or anomalous varieties of fever, it is impossible to say; but that such a combination does sometimes occur, and give rise to fevers of a peculiar or mixed cha- racter, will scarcely be doubted by any one who has given due atten- tion to this interesting subject. Professor Smith, to whose work I have already so frequently referred, has given this subject a compre- hensive and minute consideration, and to whom, indeed, the credit is due for introducing this interesting point of etiology to the notice of the profession. " Let us suppose," says Dr. Smith, " the circum- 64 MIASMATA. stances in which typhus originates, to occur in summer, such as the crowding of individuals into small apartments, badly ventilated, and rendered offensive by personal and domestic filth. These causes would obviously produce typhus in its ordinary form. But suppose there exist at the same time, those exhalations which occasion plague and yellow fever, or intermittent and remittent fevers. Under such circumstances, we should not expect to see any one of those diseases fully and distinctly formed, but a disease of a novel or modified cha- racter." There exists no doubt in my mind, of the correctness of Dr. Smith's observation, that the late Bancker Street fever in New York, as well as the peculiar fever which prevailed among the blacks in this city, a few years ago, was engendered by the united influence of these two miasmal poisons. 1 once had a striking illus- tration of the anomalous and fatal character which the united action of koino and idio-miasmata are apt to impart to fever. During the fall of 1814, while attending in the capacity of regimental surgeon, in the encampment at Baltimore, ten men affected with mild remit- ting fever, were lodged in a room of confined dimensions, and as the weather was cold, the room was kept pretty warm by fire, and the doors and windows as little opened as was admissible. The adjoin- ing room was exceedingly crowded with invalids, and but little at- tention paid to cleanliness and ventilation. In a short time several cases of fatal typhus occurred in this room. Soon after this, the patients who were affected with intermitting fever in the next room, manifested new and more alarming symptoms; blood began to ooze from their gums; extreme tenderness of the epigastrium occurred; the intellect was but little disturbed; the eyes were dull, watery, and staring; the temperature of the skin and the pulse nearly natu- ral; the animal powers so little prostrated, that one of the men died a few minutes after he had been sitting up with his back leaned against the wall of the room. They were all immediately removed to the Baltimore Hospital, and all except one died in a few days. There can be no doubt, that this peculiar modification of febrile dis- ease was the result of the impressions of idio-miasmata (engender- ed in the house,) made on systems already under the morbific influ- ence of koino-miasmata. Sect. V.—Of Contagion. By a contagion is understood a deleterious agent secreted by the animal body in a state of disease, which, when brought to act on a healthy individual, will produce a disease specifically similar to the one from which it derives its origin. Contagions occur under two distinct forms, and may therefore be divided into two varieties: viz. 1. Those which consist of a palpable matter or virus; and, 2. Those which consist of an imperceptible effluvium. The chronic contagious maladies are propagated exclusively by a palpable virus, and consequently always by actual contact. Those acute contagious CONTAGION. 65 diseases which are not attended by a specific local affection, or an exantheme, are, on the other hand, exclusively propagated hy a morbific contagious effluvium, and by consequence, solely through the medium of the atmosphere. Those acute diseases, which are essentially connected with a specific local affection, or an exan- theme, are communicated both by a palpable virus, and by an im- perceptible effluvium, and consequently both by actual contact and through the medium of the atmosphere. We perceive, therefore, that of the extremes of a purely local, and a purely general malady, there is, on the one hand, communication of the disease solely by a palpable matter, and, on the other, by effluvia only; and that where the local and the general affections meet in the same disease, as es- sential concomitants, (in the exanthemata) there the two modes of propagation also obtain.* It must be observed, however, that though in a practical point of view we may properly adopt these distinctions between contagions communicated by contact and through the medium of the atmo- sphere, yet, in reality, an actual contact must, necessarily, always occur between the contagion and the individual, before it can possi- bly produce disease, whether the contagion be a palpable matter, or an imperceptible miasm. The only material difference consists in the mode in which this contact is effected. One of the most remarkable peculiarities of contagious diseases, is their inherent and undeviating tendency to preserve their essential individuality, under whatever circumstances of age, sex, constitution, temperament, modes of living, climate, and place, they may occur. Thus, the small-pox of the present day, differs in no essential cir- cumstance from the same disease, as it was observed and described by Rhazes more than eight centuries ago; and the itch has changed in nothing since the time of Galen. Any certain contagion can, so far as we know, produce only one disease; and if the system has become insusceptible of such disease, its peculiar cause is no longer a mor- bific agent in relation to that system. The laws of the acute contagious diseases differ entirely from those which govern the rise, progress and declension of the chronic con- tagious affections. The former observe the utmost regularity in all these respects. The rise, advancement and decline, in short, the whole series of essential phenomena, are governed by laws as stead- fast as those which regulate the motions of the planets. The latter class of diseases, on the contrary, are extremely irregular in their course, having no definitive period of duration, nor established order and duration of the successive phenomena of their course. * This arrangement is adopted from Dr. Hosack's very lucid classification of contagions and their peculiar diseases. There is no writer of the present day, whose views upon the character and arrangement of this class of maladies, de- serve higher respect and attention than those which have been promulgated by Dr. Hosack. 6* 66 CONTAGION. The power which the acute contagious diseases have of destroy- ing the susceptibility of the human system, to the subsequent influ- ence of their specific causes, constitutes one of the most remarkable and mysterious characteristics of this class of maladies. In this re- spect, they differ as far from the chronic affections of this kind, as they do from the febrile diseases produced by general or non-con- tagious causes. In consequence of this law of acute contagious diseases, no malady of this kind can ever relapse during the period of convalescence. Considerable diversity of sentiment has been expressed in relation to the distance to which contagious miasmata may be dispersed from their source, in a state of sufficient activity to generate disease. That their sphere of activity is very limited, however, has been abundantly demonstrated, both by direct experiment and observation. The experiments of Dr. 0. Ryan, professor of physic in the college of Lyons, prove that the contagious miasm of small-pox does not extend more than a few feet beyond its source.* The most malig- nant contagions are rendered inert and harmless by being diffused in the atmosphere, and even by diffusion in the air of a well ventilated apartment. Ventilation diminishes the activity of contagious effluvia simply by diffusing the miasm in a large portion of atmospheric air, in consequence of which those who become exposed to it, receive it in weak and inefficient doses. I Contagions are perpetuated and conveyed to great distances from their source, by being absorbed by, and attached to, various sub- stances, such as clothing, furniture, bedding, &c, with which they are often transported even across the ocean. Animal substances, such as wool, hair, and articles manufactured from them are said to retain contagious matter with the greatest tenacity. The more the sub- stances which have become saturated with contagion are kept from the access of the open air, the more virulent and active will be its powers when it is brought to act upon the human system. Thus, articles of clothing, after having been impregnated with contagious virus, will retain the power of infecting much longer, and in much greater intensity, if they are kept confined in close rooms, or locked up in chests or closets, than when they are freely exposed to the open air. It is by articles of this kind, locked up in trunks, that the small-pox, and other contagious maladies, have been conveyed to distant parts of the world in ships, although no person on board may have been sick with the disease during the voyage. The arti- cles which are thus imbued with contagious virus, are calledyb?m7e,s. It was the opinion of Cullen, that contagions are more powerful when they are thus lodged in fomites, than when they arise imme- diately from the human body, or when in a separate state. The same opinion is expressed by Dr. Lind. The influence which peculiar atmospheric constitutions have on * Rees's Cyclopedia; article Contagion. CONTAGION. 67 the activity of contagions, and on their tendency to dissemination, is a subject as interesting as it is inscrutable. The most careless observation is sufficient to convince any one, that there exists in the varying constitutional, or perhaps accidental conditions of the atmo- sphere, a powerful modifying principle in relation to the powers of contagious agents. At times, it would seem impossible for a con- tagious disease to extend the sphere of its ravages; for, although spo- radic cases may occur here and there, yet no neglect in relation to proper seclusion, will enable the disease to assume an epidemic or endemic character. During other periods, on the contrary, the acci- dental importation of fomites, or the occurrence of a case of conta- gious disease, acts like a spark of fire thrown among combustible materials, and speedily spreads disease extensively among the people. The same powerful atmospheric influence shows itself in the diver- sity of character, in relation to the grade of violence, malignity, and general diathesis, which the same malady is observed to assume at different periods of its prevalence. That these things depend on some modifying agency of the atmosphere, there can exist but little doubt. What this condition of the atmosphere consists in, it seems impossible to ascertain; it is probable, however, that it has no imme- diate connection with either the temperature or the hygrometrical state of the air; for, with the exception of typhus, which is mani- festly favored by cold weather, the contagious diseases of every kind prevail equally during the heat of the summer and the cold of the winter. The mode in which contagions are either favored or retarded in their progress by atmospheric constitutions, consists, probably, not in any influence which they may exert immediately on the powers of the contagion, but rather, perhaps, in their ten- dency to modify the human constitution, so as at one time to render it peculiarly susceptible of the influence of the contagion, and at another to diminish, or for a time to annul, the natural predisposi- tion to its operation. Of the primary source of contagion we know but very little. It is probable that each contagious disease was at first developed, inde- pendent of/contagion, by the accidental concurrence of various cir- cumstances, which, in the infinite series of such contingencies, may not again occur for many centuries. That a disease may be origi- nated by the concurrence of general causes, without the agency of a contagion, and which may afterwards communicate itself to others, by a specific virus of its own elaboration, we have a familiar example both in typhus fever and in itch. There is reason to believe, indeed, that various contagions have been thus produced, which have long since passed away from the face of the earth;* and it is not an idle * The sudor anglicanus, so accurately described by Caius, appears to have been a highly contagious disease. It visited England five times in the period of seven years, and swept off a vast number of victims by its fatal violence. In many instances, those who were affected with it died within an hour, and few who 68 CONTAGION. conjecture to say, that new contagions may hereafter arise, which, after having exhausted their power on mankind, may again disap- pear for ever, or until a similar concurrence of causes, which at first evolved the contagion, again occurs. m , It is an intersting fact, that contagious diseases sometimes origi- nate in the lower orders of animals, and are afterwards communi- cated to the human species. Hydrophobia and the vaccine disease are familiar examples of this kind. Professor Remur has published some observations which go to show that other diseases, such as the virulent coryza of horses, the plica of long-haired animals, and the gangrenous inflammation of the spleen which occurs in cows, may be communicated by immediate contact to man. The following rules have been recommended for preventing the spread of contagious maladies to those who are obliged to approach patients laboring under diseases of this kind (Haygarth.) 1. "The chamber in which the patient lies, must be kept clean and freely ventilated. No bed curtains must be allowed to be drawn around the patient." 2. "Dirty clothes, utensils, &c. should be often changed, and im- mediately immersed in cold water; and washed clean when taken out." 3. " The discharges from the patient must be instantly removed; and the floor around the patient should be rubbed clean once a day with a wet cloth." 4. " Avoid the current of the patient's breath, as well as the efflu- via which ascend from his body, and from the evacuations." 5. " Visitors ought not to go into the patient's chamber with an empty stomach; and in doubtful circumstances, on coming out they should blow from the nose and spit from the mouth any contagious poison which may adhere to these passages." Although it is quite certain that contagions will adhere to and im- bue various substances, especially clothing, so as afterwards to repro- duce the same disease, at a distance from their source, and often a long time after they had been generated; yet it seems to be well as- certained, that such substances, (clothing) can rarely be so greatly imbued with contagion by a slight and transient exposure to the poison, as to be capable, afterwards, of producing disease in the healthy. The clothes of transient visitors, for instance, will scarcely ever imbibe sufficient contagion to communicate the disease to others. Dr. Clark affirms, " that in eighteen years of medical practice, he never communicated the contagion of small-pox nor of scarlet fever to any one, although he had frequently, on the same day, visited many patients sick with these diseases, and in their most malignant forms." sunk under its malignity suffered longer than four or five hours. It has not been known to occur for several centuries past, its contagion having long since be- come wholly extinct. CONTAGION. 69 Mere ventilation is inadequate to destroy the contagion deposited in fomites. To effect this important object, a great variety of means, such as exposing them to various vapors and fumes, have been devised. Without enumerating the different disinfecting agents which have been successively brought forward and again rejected, it will be suf- ficient to mention those which experience has shown to possess active powers in this respect, and which are now relied on as unquestion- able disinfecting agents. The nitrous acid vapors have been much employed for disinfecting ships and houses in which contagion has been found to exist. Such was the evidence brought forward of the efficacy of the nitrous acid fumes in purifying infected places and fomites, that the British parliament voted a national donation of five thousand pounds to Dr. Carmichael Smith for the discovery. This vapor is readily obtained by mixing with powdered nitre, in a cup, a little of sulphuric acid, and applying gentle heat with a lamp. At present, however, chlorine, and the chlorides of lime and soda, are regarded as decidedly the best disinfecting agents we possess. M. Labarraque's disinfecting soda liquid is a compound of soda and chlorine, and its efficacy in destroying infectious matter, has been conclusively demonstrated. " It is now much used in removing the offensive odor arising from drains, sewers, or all kinds of animal mat- ter in a state of putrefaction. Bodies disinterested for the purpose of judicial inquiry, or parts of the body advanced in putrefaction, may, by its means be rendered fit for examination; and it is employed in surgical practice for destroying the fetor of malignant ulcers. Clothes worn by persons during pestilential diseases, are disinfected by being washed with this compound. It is also used in fumigating the chambers of the sick, for the disengagement of the chlorine is so gradual, that it does not prove injurious or annoying to the patient. In all these instances chlorine appears actually to decompose the nox- ious exhalations by uniting with the elements of which they consist, and especially with hydrogen." " Pure chloride of soda is easily prepared by transmitting to satu- ration a current of chlorine gas into a cold and rather dilute solution of caustic soda. In preparing the disinfecting liquid of Labarraque, it is necessary to be exact in the proportion of the ingredients em- ployed. The quantity used by Mr. Faraday, founded on the direc- tions of Labarraque, are as follows: Dissolve 2800 grains of crys- tallised carbonate of soda in 1.28 pints of water, and through the so- lution contained in a Wolf's apparatus, transmit the chlorine evolved from a mixture of 967 grains of sea-salt and 750 grains of peroxide of manganese when acted on by 967 grains of sulphuric acid diluted with 750 grains of water."* * Turner's Elements of Chemistry. 70 GENERAL COURSE, &C, OP FEVER. CHAPTER III. OP THE GENERAL COURSE, TYPE, AND STAGES OF FEVER. The series of phenomena which intervene between the commence- ment of a fever, and its termination in convalescence, constitutes what is technically called its course. The course of a fever is either intermitting, remitting, or continued, according as its phenomena intermit, or remit, or are continuous. The series of phenomena which constitute the course of a fever, may be divided into six periods or stages; viz. the forming, the cold, the hot, the critical, the declining, and the convalescing periods. It should be observed, however, that these stages are not always distinctly marked, in violent and continuous forms of fever, although very few fevers occur in which the primary stage of oppression, the stage of excitement, and the period of declension, may not be dis- tinctly observed. The febrile paroxysm of an intermitting fever offers the most distinct exemplification of the successive changes or stages which occur in the course of a fever. 1. The forming stage—the stadium prodromorum includes the period which intervenes between the first impressions of the febrific cause, and the actual commencement of the febrile phenomena. This period is characterised by a variety of feelings or sensations, which, though manifesting a deviation from the healthy condition of the sys- tem, do not constitute any definite state of disease. These constitute the premonitory symptoms. Their duration is very various; and in some instances, though very rarely, they are entirely absent—the disease making its attack at once, without any previous manifesta- tions of its approach. This is most apt to occur in fevers of very vigorous reaction, and in such as are of a malignant character. The longer or shorter duration of the premonitory stage depends, how- ever, probably as much on the different powers of vital resistance, as on the difference in the degree of concentration or activity of the remote febrific cause. The whole train of premonitory symptoms may be regarded as the result of the struggle between the vital pow- ers and the febrific cause. If the cause be feeble, and the vital re- sistance great, its first impressions may give rise to some unusual or unpleasant sensations, until the system finally triumphs over its influ- ence, and disease be obviated. When the relative powers of the cause and the vital resistance are more nearly balanced, the struggle between them may be prolonged, until the latter yield and disease be developed; and where the system resists feebly, whilst the fe- brific cause acts with energy, the contest will probably be short, and the fever occur suddenly, with violent symptoms. There exists, nevertheless, in almost every febrific cause, a natural tendency to GENERAL COURSE, &C, OF FEVER. 71 produce some peculiar premonitory symptoms, although the general and most conspicuous of these phenomena are pretty nearly the same in almost every form of febrile disease. In general, those fevers which are apt to run through a protracted course, have a much longer train of premonitory symptoms than such as are violent and of short duration. Thus, the premonitory period is almost uniformly much more protracted in typhus and typhoid, than in the synochal fevers. The following are among the most common symptoms of this initial period of febrile affections: loss of appetite; disturbed sleep- yawning, stretching, lassitude, wandering pains in the limbs and back; an unpleasant sensation in the stomach; a harsh and dry skin- irregularity of the bowels; a general feeling of mal-aise; nausea- eructations; interruptions of the ordinary habits and appetites; fret- fulness; discontent; slight headache; slight creeping sensations of cold; the drying up of old sores; tremors of the extremities; changed expression of the countenance; giddiness; and perhaps some other slight deviations from a state of perfect health, or the ordinary habits and feelings of the individual. If we examine the symptoms of this stage in the usual order in which they occur, we will perceive that the nervous system is the first that suffers; this is manifested by the lassitude, languor and slight transient pains which usher in this stage. Next, the digestive organs are brought into a state of slight suffering; and finally the skin. The heart and arteries appear to be the last organs which are brought into morbid action in the development of fever. 2. The cold stage.—Nearly all fevers commence with more or less sensation of chilliness. The feeling of cold is not always at- tended with an actual subduction of sensible temperature. In some instances the skin of the patient feels warm to the touch, whilst he is shivering under the severest sensations of cold. It is manifest therefore, that in such cases, the feeling of cold depends in reality on an altered or morbid condition of the sensibility of the skin, in consequence of which its power of perceiving (if I may use the ex- pression) the ordinary degree of animal temperature is diminished. In most instances of febrile chills, however, there occurs an actual reduction of the temperature of the surface, especially of the hands and feet. Not unfrequently these parts feel quite cold to the touch of a healthy person, whilst the surface of the trunk and the forehead are of the natural temperature, and sometimes apparently even higher; although the sensation of chilliness experienced by the pa- tient will be diffused throughout his whole system. The chills are attended with a pale, contracted, and dry state of the surface; the volume of the body is diminished; the respiration confined, irregu- lar, anxious, and oppressed, attended frequently with a short dry cough; the head feels confused; the tongue is dry, attended some- times with great thirst; the pulse becomes extremely small, frequent, and feeble; nausea often occurs, and sometimes vomiting. The sense of chilliness is usually diffused over the whole body; though in some 72 GENERAL COURSE, &C, OP FEVER. instances, it is partial, and occasionally, limited to a small part of the body. In general, the more violent the chills are, the more vigorous will be the subsequent arterial reaction. As the cold stage gradually subsides, the arterial reaction regularly rises, until chilliness has wholly gone off, and the disease has entered into the— 3. Third, or hot stage.—This stage is characterised by what may be termed the essential phenomena of fever: viz. augmented heat, and a return of the natural fulness and color of the surface; flushed countenance; a full, quick, frequent and vigorous, or a small, tense, quick and frequent pulse; throbbing pain in the head; eyes promi- nent and sensible to the light; a dry and hot skin; urine scanty and high-colored: continued wakefulness, &c. These symptoms, with more or less intensity, continue for a longer or shorter period, until the acme of the febrile condition has arrived at the period of— 4. Crisis supervenes. By crisis, is understood, in the most gene- ral acceptation of the term, that period in the course of a fever at which it has arrived at its highest point, and a determination either to a fatal or favorable issue takes place; and by which, therefore, the fate of the patient is determined. The period .during which this decision occurs, is necessarily always short; and is almost uni- versally attended with some evacuation. The most common criti- cal evacuation of a simple febrile paroxysm, consists of a very greatly increased flow of perspiration, and hence the subsequent period during which this evacuation is continued, is called the sweating stage, but which I would call— 5. The stage of declension—stadium decrementi morbi.—This stage may be considered as commencing immediately after the fa- vorable crisis has taken place. In the rapid, continued fevers, and in a single paroxysm of an intermittent, one crisis only occurs; but in by far the greater number of protracted, and especially in remit- ting fevers, the crises continue to recur through the whole period of declension at every tertian exacerbation, until the disease is finally subdued. The duration of this stage is extremely various. In gen- eral, the period of declension will be pretty nearly in proportion to the period occupied in the progress of the fever to its acme. The space of time which is occupied by one paroxysm of a fever and its succeeding intermission, or which intervenes between the regular periodical exacerbations of fever not paroxysmal, is called the revolution of a fever. The revolutions of fevers are various in point of duration; some fevers completing theirs in twenty-four hours, others in forty-eight, whilst others require seventy-two, and some even ninety-six hours. The form which a fever assumes, in this respect, is called its type; so that a fever which occupies twenty-four hours from the commencement of one paroxysm to another, is said to be of the quotidian type; whilst one which revolves every forty- eight hours, is of the tertian type; and when this period is extend- ed to seventy-two hours, the fever is of the quartan type; and a period of ninety-six hours, constitutes the quintan type. The quo- GENERAL COURSE, &C, OP FEVER. 73 tidian, the tertian and the quartan types, constitute the three principal and primary types of fevers; all of which are, however, subject to modifications which may readily mislead the careless ob- server, so as to confound them, or mistake one for the other, especi- ally the quotidian and the tertian. It has been observed, that in fevers of the quotidian type, the paroxysms generally come on in the morning—a circumstance which has been almost invariably verified in my own experience, and which is, indeed, so constant, that Cullen was induced to notice it in his definition of a quotidian. Tertians commonly come on towards noon; but they are much less regular, in this respect, than fevers of the preceding type. Two simple tertians sometimes go on contemporaneously, in the same patient; so that, instead of the paroxysms recurring only every other day, they occur daily, as in a quotidian. These cases are called double tertians, and are dis- tinguished from quotidians, by the paroxysms of the alternate days being similar in relation to the precise time of their occurrence, grade of violence, duration, and other circumstances. Thus the paroxysms on the odd days will perhaps recur at 9 o'clock in the forenoon, whilst those which happen on the even days will come on at 2 or 3 o'clock in the afternoon, so that, although each day has its paroxysms, the fever cannot be properly considered as a quotidian, but the contemporanenos progress of two simple tertians, the one having commenced a day sooner than the other. Fevers, however, rarely assume the double tertian type from their commencement. They usually begin and continue for some time, in the simple ter- tian type—the duplication occurring afterwards; and when the type thus becomes doubled, the new or accessory paroxysms are gene- rally considerably milder than those of the original or simple ter- tian. It is asserted, that a double tertian seldom terminates without first assuming the single tertian type—the accessory or weaker paroxysm disappearing first.* There are other varieties of double tertians, mentioned by the older writers, such as the tertiana duplicata, in which two pa- roxysms occur every second day, and none on the intervening one; the hsemitritseus of the ancients, in which a paroxysm occurs daily, the intermissions or remissions between the first and second, the third and fourth, being much more prolonged than those which oc- cur between the second and third, the fourth and fifth, &c. Authors also mention a triple tertian—tertiana triplex. The quartan type, also, has been known to assume similar modi- cations. Double and triple quartans are mentioned in the books; as well as other anomalous varieties of this affection. Before I proceed to the consideration of the particular forms of fever, it will be proper to say something concerning crisis or criti- cal days—a subject which, though but little regarded at the present * Ritchter's Specielle Therapie, vol. I. Vol. I.—7 74 GENERAL COURSE, &C, OF FEVER. day, appears to me entirely worthy of attention. It may, I think, be assumed as a safe principle, that doctrines or sentiments, con- cerning facts which are objects of mere observation and experience, cannot be wholly erroneous or illusory, after having obtained the entire confidence, through a series of more than twenty centuries, of a vast number of as accurate and devoted observers of nature as have ever adorned our profession. Without professing a belief in the correctness of the doctrine of crisis as it was taught by the ancients, and by many of the moderns, we may yet admit, on good grounds, it is conceived, that there exists a natural tendency in the operations of the animal economy, whether in a state of health or disease, to certain periodical fluctuations, which, under particular circumstances, manifest themselves in a way sufficiently conspicuous to exhibit an obvious revolution in the increase and declension of the morbid actions of the animal system. It was early observed, that there are certain regular periods in the course of many febrile affections, at which prominent changes are wont to occur, preceded generally by a manifest aggravation of the symptoms, and followed or attended by certain evacuations. These evacuations, from their being almost always followed by an obvious abatement in the symptoms, were called critical, a(nd were thought to consist of noxious or febrific mat- ters, thus thrust out of the system by the sanative powers of nature. Fever was supposed to be nothing else than an effort of nature, to prepare and cast out of the system the morbific materials which disturbed the regular actions of the animal economy, and that the amendment which ensued was the immediate consequence of such eliminations of morbific matter. At the present day it is, however, more correctly maintained that these critical discharges are the ef- fects, and not the causes of the melioration which occurs about the periods at which they take place; and that they are to be viewed, rather as the first manifestations of a favorable change in the condi- tion of the system, than as the immediate causes of such a change. That this is the correct view in relation to the nature of such dis- charges, there can, indeed, exist no doubt; but this view of the sub- ject does not deprive it of its importance, and directs our attention rather to the periodical exacerbations and inherent tendencies in these maladies to terminate their course at one period in preference to another, than merely to the evacuations which are apt to super- vene at such times. In no forms of fever, perhaps, are these ten- dencies to terminate at a certain fixed period, more frequently mani- fested than in intermittents. There appears, in these fevers, a ten- dency to a septenary revolution, which I have often seen verified in the most unequivocal manner. If an ague of the quotidian type be suffered to run on, until it terminates spontaneously, the termina- tion will almost universally occur, if it occur at all, either after the seventh, fourteenth, or twenty-first paroxysms; and I have repeatedly found, that febrifuge remedies, exhibited immediately after these sep- tenary periods, will arrest it with more certainty, and with much GENERAL COURSE, &C, OF FEVER. 75 less liability to relapse, than when employed during any of the inter- vening intermissions. From the same inherent tendency, the re- lapses which are so common in this disease, will, in a vast majority of instances, occur about the septenary periods from the time of the last paroxysm, and most commonly about the eighth or fourteenth, and sometimes for several periods about the twentieth day—(Jack- son,* Sprengle.t) Observation has shown, that the crises of fevers happen almost uniformly on the odd days, reckoning from the commencement of the malady. According to the observations of Hippocrates, the crises occur in conformity to the tertian type, until the fifth crisis, or the eleventh day of the fever, after which they observe the quartan type, occurring only every fourth day. It must be observed, how- ever, that these evacuations do not occur exclusively on the days just indicated, for they are sometimes, though rarely, found to hap- pen on the intervening days. Galen supposed, that when the crisis falls on any other than a critical day, the fever has been diverted from its natural tendency by the accidental occurrence of irritation in some part of the system. Galen divided the critical days into the perfect, the secondary, and the intercurrent. The perfect are those which happen on the seventh, fourteenth, twenty-first, and twenty-eighth days. The secondary, or less perfect, occur on the intermediate day between each perfect or septenary crisis; namely, the fourth, eleventh, eighteenth, twenty-fifth, &c, days. If, for ex- ample, it was observed that a slight deposit in the urine, or a mode- rate flow of sweat took place on the eleventh day, it was regarded as an indication of a more perfect crisis on the fourteenth day. The intercurrent crises occur on the remaining odd days—that is, on the fifth, ninth, thirteenth, &c. Such are the principal points in the doctrine of crisis, as it was taught by the ancients, and more espe- cially by Hippocrates, and his commentator Galen. No one at the present day, however, pretends to have observed the many minute distinctions and phenomena, which are embraced in the ancient doc- trine on this subject; indeed, there are very few who regard it as at all worth any attention; and the profession seem long since to have thrown it into the common mass of error and misconception, which has been formed out of the wrecks of former systems, and doctrines. However antiquated it may appear, at the present advanced stage of our science, to profess some faith in the general correctness of this doctrine, I cannot, at the risk even of being set down as a cherisher of obsolete and exploded sentiments, divest myself of the conviction, that among much that is erroneous and absurd in this doctrine, there are important and fundamental truths, which ought not to be care- lessly rejected. In order to understand the nature of crisis, every fever must be * On the Diseases of Jamaica. f Handbuch der Pathologie, Band. II. p, 171. 76 GENERAL COURSE, &C, OP FEVER. considered as having a tendency to some one of the principal types mentioned above. A simple tertian intermittent, may be regarded as the elementary type of fever. In fevers of this type, an exacer- bation or paroxysm, and a crisis, will occur on every odd day; and if we consider a continued fever as made up of tertian paroxysms prolonged and running into each other, or as possessing a natural, though countervailed tendency to the elementary or tertian type, there will, in like manner, occur more or less considerable tertian exacerbations, with their accompanying discharges. From what has already been said concerning the manifest septenary movements of intermittents, the tendency of continued fevers to terminate on the fourteenth or twenty-first days, which can scarcely be denied, would seem to be in conformity to an original law of the animal economy, under a state of febrile excitement. The evacuations which usually accompany the crisis of fever are, 1. haemorrhages; 2. a flow of sweat; 3. an increase or changed character of urine; and 4. diarrhoea. Critical haemorrhages are gene- rally attended with an increased action of the heart and arteries, and often with a manifest determination to, and congestion in the part from which the discharge occurs. They must be regarded as mere manifestations of a previous change in the system, and hence this kind of critical evacuation cannot be substituted by an artificial abstraction of blood; since, although blood may be abstracted, the peculiar action of the solids, which constitutes the actual crisis or change to a favorable tendency, cannot be thus produced. Crisis, by haemorrhage, is generally confined to inflammatory fever; or, more correctly speaking, to fevers attended with an increased acti- vity and action of the heart and arteries. Critical haemorrhages most commonly proceed from the nose, and, according to the observations of many of the older writers, are frequently preceded by the dicro- tus pulse, in which two distinct wave-like beats occur during each dyastole of the artery. Immediately before the irruption of the blood the carotids beat strongly, the face becomes flushed, sparks appear before the eyes, the eyes are red and suffused with tears; and, in some instances, frequent sneezing, and a thin watery discharge from the nostrils occur just before the haemorrhage appears. Criti- cal sanguineous discharges have also been known to occur from the uterus, the rectum, and sometimes, though very rarely, from the stomach, and even from external parts. Crisis, by an increased flow of perspiration, is by no means un- common. Catarrhal and rheumatic fevers are more apt to terminate by this mode of crisis, than any other forms of febrile affection. This discharge is not, however, to be regarded as indicative of a favorable change in the malady, unless it be generally diffused over the whole surface, and especially, unless it be attended with a tur- bid state of the urine, or a copious sediment in this latter evacua- tion. The surface should, moreover, be soft, and of a natural tem- perature—that is, not cold and clammy. GENERAL DIAGNOSIS. 77 Crisis by urine, independent of perspiration, is a very uncommon mode of termination in febrile complaints. A critical urine derives its favorable character not so much from the mere quantity of the evacuation, as from its appearances and the materials with which it is impregnated or mixed. For inspection, the urine which is evacuated at the termination of a paroxysm, or in the morning, ought to be chosen. In a truly critical urine there may be seen at first a cloud floating in the upper part of the vessel, then a globular body of mucus about the middle, and a sediment at the bottom.* So universal is the concurrence of a critical urine, and a general moisture of the skin, that these two evacuations may be considered as essentially connected. A critical discharge from the bowels is less common than those I have already mentioned. It occurs most frequently in bilious fe- vers, and in such febrile affections as are attended with some visceral disease within the abdomen. These discharges do not, however, occur as the others do, in the acme or exacerbations of the fever, but during the periods of remission. They are generally very copious. The signs of an approaching crisis by diarrhoea, are a pe- culiar trembling of the under lip; stammering speech; a full and wave-like pulse; pain and rumbling noise in the bowels; discharge of wind; a moist tongue; itching in the nose; paucity of urine, &c. (Richter.) CHAPTER IV. ON GENERAL DIAGNOSIS. Nothing so much distinguishes the experienced and truly well- qualified physician from the mere hap-hazard recipe-doctor, and routinist, as the ability to estimate correctly, the import of symp- toms; to trace their various relations with each other, and to deter- mine from them the seat, nature, and extent of maladies. The num- ber of those who are remarkable for accuracy in diagnosis, is always very small; for eminent proficiency in this respect, can be obtained only by persevering observation and study, aided by a minute and comprehensive acquaintance with physiology and pathology. Diagnosis embraces a much wider range of inquiry, than that which is presented by the actual phenomena of diseases. It is not * Vogel, Richter, Hufeland. I have frequently noticed these appearances in the urine, evacuated after a paroxysm of intermitting fever; and I am well satis- fied that it is a common occurrence in the urine discharged soon after fevers have commenced to decline. 7* 78 GENERAL DIAGNOSIS. alone from morbid symptoms that the intimate character and tend- ency of diseases can always be satisfactorily determined. Age, sex, moral and physical temperament, climate, occupation, habit of liv- ing, corporeal conformation, previous diseases, hereditary predispo- sition, and the character of the predisposing and exciting causes, often afford important aid in the formation of a correct diagnosis. In chronic diseases, especially, the light which may be obtained from circumstances of this kind, is frequently of the utmost importance in this respect. The manner in which patients are examined, also, has a direct and important bearing on diagnosis. A confused, desultory, or imme- thodical mode of investigating the symptoms of diseases, and the various circumstances which may have contributed to determine their character, seldom leads to a clear and precise diagnosis. In- deed, the manner in which a physician examines his patients, affords no inconsiderable criterion for judging of his practical qualifications. Method, regularity and deliberation, in this respect, are almost always associated with skill in diagnosis, and consequently in the treatment of diseases. The first objects which strike the attention of the physician, on approaching a patient, are his countenance, attitude, motions, and voice. It is natural, therefore, to commence the examination with these symptoms. In many instances these external conditions of the patient afford very important information as to the nature and seat of maladies; and in no case, perhaps, can they be entirely ne- glected without losing very useful suggestions in relation to the diagnosis. The countenance should be deliberately and closely examined, and its deviations from the healthy aspect and expression noticed. Many diseases are attended with expressions of countenance so pe- culiar and striking, that they may be at once recognised by the ob- servant and experienced physician. The attitude, motions, and external condition of the patient's body, must, also, be particularly noticed. The degree of emaciation—the color and condition of the skin, and the general physical habit and conformation, should be observed. The various regions of the body should be carefully ex- amined, more especially in diseases of a chronic and obscure cha- racter. In some general maladies, such as scurvy, syphilis, scrofula, &c, the ecchymoses, glandular indurations, eruptions, blotches, exos- toses, nodes, &c, afford important diagnostic evidence. Old cica- trices, too, merit particular attention; particularly when seated along the neck and in the groins. The former almost always indicate a scrofulous diathesis, whilst the latter afford good grounds for sus- pecting the existence of a syphilitic taint. The existing disease, for which the physician .is called to prescibe, may have a very intimate connection with one or the other of these maladies or constitutional taints; and as patients are apt to neglect giving proper information on this subject, or even seek to conceal the fact of their having been GENERAL DIAGNOSIS. 79 affected with such a disease, these old marks or cicatrices are'some- times of essential service, to a full and satisfactory investigation of the case under examination. Having attended to these external circumstances, the examination of the case must be pursued, by interrogating the patient. The manner in which the examination is conducted, is of great import- ance. A careless, irregular and hurried, or a peevish, fretful and impatient manner of examining, seldom fails to lessen the good will and confidence of the patient, for his medical attendant; whilst a mild, deliberate, earnest and interested deportment, not only gains the patient's confidence and respect, but contributes very materially to a full development and correct understanding of the nature of the malady. The questions should always be proposed in terms per- fectly intelligible to the patient; and when there is reason to doubt whether the interrogatory has been correctly apprehended, it should be repeated in different terms. The employment of a pompous and technical phraseology, is more apt to excite the contempt and dis- trust of intelligent patients, than to draw forth correct and satisfac- tory responses. It is of considerable consequence, also, to follow a determined and regular order in the questions put to the patient. Without a proper attention to order or method in this respect, important ques- tions are apt to be forgotten, and some which have already been pro- posed and answered, uselessly repeated. Although the interrogato- ries should be sufficiently numerous and varied to obtain a full view of the symptoms and feelings of the patient, and of the circum- stances which may have contributed to the development and modi- fication of the disease, yet trivial and irrelevant questions should be avoided. The following order of inquiry appears to me the most natural and advantageous. 1. Ascertain the age, occupation, and place of residence of the patient. In many instances, indeed, these circum- stances, more especially the last, can have no useful bearing on the diagnosis; but this is by no means always the case; for, in some cases, very important diagnostic and practical suggestions may be obtained from a careful consideration of these facts. 2. Inquire next at what time the disease commenced; whether it came on gra- dually or suddenly; whether the existing symptoms differ from those which attended the disease at an earlier period; whether the progress of the complaint is continuous or paroxysmal, constant or occasional, uniform or attended with exacerbations and remissions; whether, in the course of the disease, new symptoms have super- vened, and former ones disappeared, and whether the permanent symptoms have increased much in violence since the commencement of the complaint. Correct information in relation to these circum- stances is often indispensable to a satisfactory diagnosis. " In many instances, indeed, the succession and general progress of the symp- toms, afford more useful data for the formation of a correct diagno- 80 GENERAL DIAGNOSIS. sis, than a consideration of the symptoms existing at the time of examination. Unfortunately, the majority of patients are incapable of giving a proper account of the early symptoms and progress of their maladies; and the physician is thus frequently deprived of the light which a correct and circumstantial exposition of the preceding symptoms and course of the case might afford." 3. The patient should now be asked whether he experiences any pain, and if so, in what part of the body. He should be directed to place his hands on the region in which the pain is felt; for patients are apt to express themselves very vaguely and incorrectly in relation to the part in which the pain is seated. Thus we are often told that pain is felt in the stomach, yet when the region is pointed out with the hand, it is, perhaps, found to be seated in the lower part of the abdomen or within the chest. Inquiry must also be made whether the pain be acute or darting; dull and aching; stinging or burning, or throb- bing;—whether it be deep seated or superficial, continuous or inter- mitting, wandering or fixed, transient or protracted; and, if inter- mitting or paroxysmal, whether its occurrence be periodical or at regular and uncertain intervals. Pressure should be made on the part in which the pain is located, and its effects carefully noticed; and it is particularly important to ascertain whether there is soreness or tenderness to pressure in certain organs or regions of the body, more especially in the various regions of the abdomen; although the patient may not complain of any pain in these parts, when undis- turbed by pressure. It will also be proper to ascertain whether the affected parts are swollen, discolored, or in any other way changed from their normal or healthy appearance and conformation. 4. The state of the sanguiferous system should next be inquired into. The pulse must be attentively and deliberately examined; and in doing this, attention must be paid to the circumstance, that the pulse of an infant, during the first three or four weeks after birth, beats between 120 and 130 strokes in a minute; and that its natural frequency un- dergoes a gradual reduction as age advances, until about the age of puberty, when it arrives at the standard of a healthy adult pulse, namely from about 72 to 80 pulsations in a minute. It should be observed too, that climate, the time of day, corporeal exertion posi- tion of the body, and mental emotions or exercise, exert, often, a very material influence on the state of the pulse. In the morning, whether in health or disease, the pulse is generally considerably slower and softer than after dinner or towards evenjng. In feeble and nervous individuals, we often find the pulse much more frequent when they are standing up, than when in a recumbent position. In this case the muscular exertion required to maintain the erect pos- ture operates on the circulation in the same way as exercise, and therefore accelerates the action of the heart and arteries. Nothing, however, is so apt to give rise to a wrong estimate of the state of the pulse, as that mental excitement and flurry which feeble and irritable patients are apt to experience on the entrance of the physician into GENERAL DIAGNOSIS. 81 the sick chamber. 1 have frequently found a difference of more than twenty pulsations in a minute, between an examination made immediately after entering the room, and a second one, some ten or fifteen minutes afterwards. It is therefore an important rule, to delay examining the pulse, until the agitation of the patient's mind has subsided. By introducing the examination with some encou- raging and cheering remarks, and proceeding in the order already mentioned, there can seldom be any risk of mistake, from this source, as to the actual state of the pulse. In examining the pulse, the patient's arm should be held in a horizontal and semiflexed position. Two or three fingers must be applied to the artery, and the pressure gradually varied in force, in order to form a correct estimate of the degree of tension, vigor, hardness or compressibility of the pulse. Thirty or forty pulsations, at least, ought to be felt before the fingers are taken off. It is not uncommon in certain obscure cerebral affections, to find an intermission in the pulsations, at intervals of from ten to thirty and even a greater number of beats. A transient examination, may not only fail to detect such intermis- sions, but is in general, quite insufficient for obtaining a satisfactory view of the precise character of the pulse. All conversation should be forbidden, both on the part of the patient and the attendants. In certain affections, and when the system is under the influence of cer- tain remedial agents, (as digitalis,) it will be proper to examine the pulse in different positions of the patient's body; namely, in the recumbent, sitting and standing postures. This is particularly useful in certain organic affections of the heart. There is, perhaps no department of symptomatology in which a high degree of profi- ciency is so seldom met with among physicians, as that which relates to the morbid manifestations of the pulse. Many seem to think that the only modifications of the pulse, which are worthy of particular attention, relate to its frequency, fulness, hardness, tension and regu- larity. There are various other states of the pulse, however, which though not easily described, communicate to the experienced and diligent observer, definite and important views concerning the pa- thological conditions with which they are associated. The ancients, and even some of the moderns, undoubtedly carried their refine- ments and pretensions, in relation to this subject, to an absurd ex- tent. It is not improbable, however, that among much useless rub- bish, which in the progress of our science, has been swept away concerning the organic pulses, as they were called, some valuable facts and principles were included, which might be advantageously revived. Be this as it may, a faithful and continued attention to the morbid states of the pulse with diligent and well directed efforts to obtain definite conceptions of its various modifications, and to asso- ciate them with their respective pathological conditions, will, in general, result in the acquirement of a precision and readiness of dis- crimination, and accuracy of diagnostic application, which few who have not made the pulse a particular object of study and observation 82 GENERAL DIAGNOSIS. can well conceive or credit. 5. Having ascertained the condition of the pulse, the attention should be particularly directed to the organ or part in which the primary or essential malady appears to be seated. Inquiry must next be directed to those structures or organs which are known to hold the most intimate sympathetic relations with the part or organs principally affected. Thus, if the patient complains of much pain, or of other unpleasant sensations in the head, after having obtained a circumstantial account of the cephalic symptoms, the examination should be directed to the state of the alimentary canal. Again, if there is a fixed pain in the lumbar region, the important question whether the pain be located in the kidneys, or in some neighboring structure, may, in general, be rea- dily settled, by attending to the condition of those organs with which the kidneys sympathise most strongly; namely, the stomach the ureters, and the testes. If there is a retraction of the testes, pains shooting down along the ureters, with nausea and vomiting, the fact of its being a renal affection may be regarded as sufficiently ascertained. In the investigation of diseases, it should be recollected that the prominent and most annoying symptoms are by no means always located in the part where the primary and actual malady is seated. A slight inflammatory affection at the origin of a spinal nerve, not unfrequently manifests itself by severe and protracted pain in some remote part of the body; as in the chest, the abdomen, or the inferior extremities. When, therefore, a fixed pain is unattended with any other manifestations of disease in the part; when there is neither inflammation, nor soreness or tenderness to pressure, we may pre- sume, that the primary affection, upon which the disease depends, is located in some other part of the body; and on proper inquiry, it will perhaps be found to be seated at the spinal origin of these nerves, which are distributed to the structure in which the pain is felt. To ascertain whether this be the case, firm pressure must be made on each of the spinous processes of the vertebral column. If, in passing successively from one spinous process to another, the pa- tient flinches and complains of pain in one or more vertebrae; it may be inferred that the source of the painful affection is probably seated at the root of the nerves which pass out from that part of the spine. Many diseases, which appear to be of a general character, con- sisting seemingly in mere functional derangement, are nevertheless intimately connected with obscure and frequently very serious local affections. The diagnosis, in such cases, is generally extremely difficult. In some instances, a probable opinion, as to the existence, seat and character of such obscure and local affections, can be formed only by taking into view the effects of certain remedies and the na- ture of the exciting causes, in connection with the actual symptoms and general progress of the malady. Inflammation of some portion of the mucous membrane of the alimentary canal, often attends general diseases with manifestations so slight and inconspicuous, as GENERAL DIAGNOSIS. 83 sometimes to escape the notice of even attentive observers. In rela- tion to the diagnosis on this point, especial attention must be paid, in the examination of the symptoms, to the appearance of the tongue; the condition of the alvine evacuations; the effects of irritating in- gesta; the effects of firm pressure on different parts of the abdo- men, with regard to the sensations which it excites; the state of the skin; and if the malady is of a chronic character, the temper and condition of the mental faculties. It should be particularly noticed, whether the surface of the tongue be red, and of a granular or smooth appearance—whether irritating and solid ingesta give rise to pain and distress in the stomach, or tormina in the bowels; whether pres- sure on any part of the abdomen gives rise to a pain or a feeling of soreness; whether the skin in connection with these symptoms be dry; harsh, and contracted, and whether the temper is morose, gloomy, taciturn and irritable. The particular appellation of these phenomena will be fully illustrated in a subsequent part of this chapter. I proceed now to the consideration of the particular diagnostic signs, as presented by the countenance, the attitude, the nervous system, the alimentary canal, the blood-vessels, the respiratory or- gans, the cuticular surface, the lymphatic system, and the secretions. 1. The countenance is variously and often strikingly changed by diseases, and ^affords in many instances, highly important diag- nostic indications. Hippocrates strongly recommends the study and examination of the countenance in disease. His attention, however, was directed principally to the prognostic signs, manifested by the countenance, and the observations which he has left us, on this sub- ject, are among his most valuable contributions to our science. In relation to diagnosis, however, we find but few observations in his writings, concerning the morbid expressions of the countenance. This point has been more particularly attended to, in latter times; and although there is still much room for profitable inquiry, yet the facts and principles which have already been established, are suf- ficiently numerous and interesting, to show the importance of attend- ing to the countenance, as a source of valuable diagnostic information. M. Jadelot, physician to the Hbpital des enfans trouvies, has published some interesting observations on the physiognomical expression of certain forms of disease in children. According to his observations, there are three principal physiognomical trails, which, in children, are often very conspicuous—each indicating a peculiar morbid condition of the system. The first consists of a distinct pale or lead-colored streak with an appearance of depression, commencing at the greater angle of the eye, and terminating a little below the projection formed by the cheek bone. This he calls the oculo-zygomatic trait. This trait indicates disorder of the " cerebro-nervous system." It is strongly marked in all those maladies whose primary and principal seat is in the brain or on the nerves. It is likewise present, whenever the ner- 84 GENERAL DIAGNOSIS. vous system, more especially the brain, participates actively in affec- tions which are in the first place located in other structures or organs; but in cases of this kind, some other facial trait usually co-exists, which indicates the character of the complication. Thus, for in- stance, when intestinal irritation from worms or other causes, finally occasions hydrocephalus, epilepsy, &c, the oculo-zygomatic twit will be added to the previous physiognomical expression indicatrve of the intestinal disorder. The second trait begins at the upper part of the alae nasi, and em- braces, in a semicircle more or less complete, the outer line of the orbiculares oris. It is not uncommon to observe, towards the mid- dle of the cheek and forming a tangent with this trait, another one which in certain faces constitutes the dimple of the cheek. These two traits, says M. Jadelot, are referable to similar affections. The first he calls nasal, the second genal. This trait, and its accessory, indicate disorder, particularly chronic irritation or inflammation of the alimentary canal, and of the abdominal viscera. It is observed in diarrhoea, indigestion, verminous irritation, &c. The third trait begins at the angle of the lips, and is lost on the margin of the chin. This is called the labial trait. It seldom forms a deep line, being modified by the changes which the neigh- boring parts undergo. The other traits are more or less deeply marked, according as the diseases to which they belong, are more or less severe or protracted in their course. This trait attends diseases of the heart and of the respiratory organs, and may almost always be observed in cynanchae, carditis, hydro-pericardium, organic affec- tions of the heart, pneumonia, &c. M. Salle observes, that at the onset of all severe diseases, the in- spection of the child's countenance may serve as a useful guide to the physician in discovering the organ principally affected. " The pre- sence or absence of the oculo-zygomatic trait, in the initial stage of the disease, will inform him whether the cerebro-nervous system be primarily affected, or whether its supervention be merely the result of sympathy." He asserts that at a single glance he has often been enabled to pronounce, with confidence, the existence of abdominal disease, by observing the presence of the nasal trait. It is said to be particularly conspicuous in dysentery, and chronic diarrhoea. I have,for several years past, attended very carefully to these obser- vations of M. Jadelot, and am entirely persuaded that they are correct, and of essential service in the diagnosis of certain diseases of children. In addition to these physiognomical expressions, the singular change of countenance, which, according to Dr. Wolff,* occurs in children laboring under chronic or sub-acute peritonitis, deserves to be mentioned. This writer asserts, thet in the hydropic stage of this affection, " the skin at the root of the nose, immediately between the eyes," acquires a swollen or bloated appearance, by which the * Hufeland's and Osann's Jour, der practischen, Heilkunde, May, 1829. GENERAL DIAGNOSIS. 85 general expression of the countenance is strikingly altered. " The parents of my patients," he says, " frequently noticed a change in the expression of the countenance, without being able to say in what it consisted; but as soon as I directed their attention to the tumefac- tion of the skin, at the spot mentioned, they agreed with me, that the change in the appearance of the child's countenance arose from it, and were surprised that they had not discovered it themselves." This singular trait, he asserts, is one of the most constant and cer- tain diagnostic signs of the disease, after serous effusion in the ab- domen has commenced. Sprengle observes, that chronic disease of the spleen is, almost invariably, attended with a remarkable bluish tinge of the tunica albuginea. I have verified this observation in several instances. During my term of attendance last winter, at the Commercial Hos- pital of this place, a patient was brought into the house, laboring under some chronic malady. At the first glance of his countenance, I noticed the singular blue tinge of the albuginea. I pointed it out to the students in attendance, and stated the diagnostic inference which, according to the observations of Sprengle, this appearance justified—namely, that the patient was laboring under some chronic affection of the spleen. This man has since died, and on post-mor- tem examination, the spleen was found very much enlarged, and otherwise disordered in its structure. Pain, whether from spasm or inflammation, always causes a pe- culiar contraction of the muscles of the countenance. The physiog- nomical expression of pain is, indeed, so characteristic that the most inexperienced will readily interpret it correctly. An attentive and experienced observer may even perceive, in the peculiar contraction of the features, in what class of organs, or in what organ, the cause of the pain is seated. Thus when the diaphragm is inflamed, the pain, from the situation in which it is felt, might be supposed to be seated in the stomach, the liver, or the spleen; but the peculiar grin- ning expression of the countenance, (risus sardonicus,) which at- tends injuries, or inflammation of the diaphragm, indicates, at once, the true seat of the disease. Pain depending on inflammation of the mucous membrane of the alimentary canal, generally gives an expression of gloom, irascibility and discontent to the countenance; and this is more especially the case when the stomach and duodenum are affected. When the lungs are the seat of painful sensations, there is an expression of great anxiety depicted in the countenance, attended with an unusual ex- pansion of the nostrils, during each inspiration. Even, when there is no acute pain, in affections of the lungs, this peculiar anxious ex- pression of the countenance and expansion of the alae nasi, generally occurs, in consequence of the congested condition of these organs impeding the respiratory functions. Dr. Marshall Hall observes, that the more acute the pain is, in inflammation of the thorax, the more contracted, in general, will be the features. When the pain is very Vol. I.—8 86 GENERAL DIAGNOSIS. severe, the alae nasi are acute, and elevated, and the nostrils are strongly contracted and expanded, by the alternate acts of respira- i tions. In addition to this, there is sometimes a vivid flush on the cheeks, terminating abruptly, and bounded by a very pale streak to- wards the nose. In great difficulty of breath\ng, from a congested state of the lungs, the countenance is not only marked by an ex- pression of anxiety, but becomes, also, more or less suffused with a dark or livid hue, accompanied with turgidity or fulness. When- ever, therefore, this livid appearance, and turgidity of the vessels of the face occur, in diseases of the lungs, we may be assured that there exists either great sanguineous congestion in these organs, or an effu- sion of fluid into them. This is still more certainly the case, if with these physiognomical signs, the surface of the body is rather below the natural temperature. The countenance peculiar to tubercular phthisis, is so striking, that even the most careless observers, in general, readily recognise it. The delicate paleness of the face; the circumscribed flush on the cheeks in the afternoon; the pearly whiteness of the tunica albu- ginea; the quivering motion of the lips and chin in speaking, are well known as the invariable and ill-boding attendants of pulmonary consumption. In "inflammation of the abdominal viscera," says Dr. Hall, "at- tended with severe pain, the muscles of the face are in a state of con- tinued contraction; the features are unnaturally acute, the forehead is wrinkled, and the brows knit. The nostrils are acute and drawn up; the wrinkles which pass from them obliquely downwards, are deeply marked, the upper lip is drawn upwards, and the under one frequently downwards, so as to expose the teeth. The state of the features is aggravated on any increase of the pain from change of po- sition or external pressure. When the abdominal pain arises from spasm, the muscles of the face are exceedingly contracted and dis- torted, during the paroxysms of pain; but in the intervals of the pa- roxysms, the countenance assumes a calm and placid aspect." In organic affections of the heart, the countenance generally ac- quires a very peculiar expression. In cases of this kind, the prolabia are more or less livid, the face puffy or cedematous, and of a peculiar dingy hue, or suffused with a livid flush. This circumstance is worthy of notice, in relation to the diagnosis between organic affec- tions of the heart, and hydrothorax. In the latter affection, the coun- tenance almost always exhibits a pale, or pale-livid aspect, instead of the vivid flush so common in cardiac diseases. (Hall.) In the soporose affections, also, the countenance is variously and characteristically affected, and affords important diagnostic indica- tions. In an apoplectic attack, the face is generally flushed, or livid, and the blood-vessels of the head and neck turgid. The muscles of the face are frequently paralytic on one side, so as to destroy the natural symmetry of the features ; the mouth is drawn towards the unaffected side, whilst the eyebrow, nostril, angle of the mouth, and GENERAL DIAGNOSIS. 87 cheek of the paralysed side sink down. The flush and fulness of the face, do not, however, continue throughout the whole course of the disease; towards the fatal termination of the attack, the counte- nance usually becomes pale, and somewhat contracted. In syncope, the countenance is pale, shrunk, and covered with a cold perspira- tion, presenting a death-like appearance; and in that state of insen- sibility which, sometimes, occurs in hysteria, the countenance is nearly natural, both in color and expression. In the two latter affec- tions there is no unusual sanguineous congestion in the head. The blood is accumulated in the lungs and heart, and hence, when re- covering from the state of insensibility, patients generally experience a sense of great weight and pressure in the chest, more especially in the region of the heart. Chlorosis is always attended with a very peculiar and characte- ristic appearance of the countenance. " The incipient stage is denoted by paleness of the complexion—anexsanguious state of the prolabia, a slight appearance of tumidity of the face, or fulness of the eye- lids." In some instances, a tinge of green or of yellow is observa- ble in the pallor of the countenance, and the eyelids are of a dark lead-colored hue. " In the confirmed stage of the disease, the face is still more pallid; the prolabia acquire a slight lilac hue, and the integuments, in general, a puffy and tumid appearance. In the more chronic form of this malady, the countenance exhibits an appearance of sallowness, of squalid or dingy paleness, with a ring of darkness occupying the eyelids, extending a little towards the temples and cheeks; and in some instances a similar dark streak surrounds the mouth." Dr. Hall observes, that this sallowness or icterode appear- ance of the countenance, must not be confounded with the different shades of icterus, or bilious tinge. In icterus or jaundice, that is, when the discoloration depends on the deposition of bilious matter, the tunica albuginea of the eyes, is invariably more deeply tinged with yellow, than any other portion of the surface; whereas, in the more icterode, or sallow appearance of the complexion, observed in chlorosis, and in some other chronic affections, the eyes do not ex- hibit any distinct tinge of yellow. When, therefore, the countenance of a patient presents a yellowish hue, without a similar tinge of the albuginea, we may conclude that it does not depend on the presence of bilious matter in the circulation, or on biliary derangement. In chronic irritation of the bowels, from worms, or other irritating substances lodged in the alimentary canal, a remarkable pale tume- faction of the upper lip frequently occurs, in connection with the nasal and genal traits, mentioned above. This swollen state of the lip is generally but transient in verminous affections. It usually comes on at night, during sleep, and seldom continues more than two or three days. A somewhat similar swollen state of the upper lip often occurs in children affected with scrofula; more especially when the disease is principally seated in the mesenteric glands. In cases of this kind, however, the tumefaction is much more perma- 88 GENERAL DIAGNOSIS. nent; there is also more lividity of the prolabia and the cheeks, and the peculiar trait mentioned by Jadelot, (the nasal and genal,) are not present. In inflammation of the arachnoid membrane, the expression of the countenance is generally strikingly characteristic. Besides a gene- ral expression of surprise, confusion, and discontent, which it is im- possible to describe, but which cannot easily be mistaken when once seen and contemplated, the most prominent morbid expressions of the countenance are those furnished by the eye. According to the observations of Martinet and Duchatelet, the pupils are either much dilated or contracted; the conjunctiva presents a greater or less de- gree of redness; and when the inflammation has made considerable progress, and is about terminating in effusion, or structural lesion of the brain, there is squinting, and constant rolling of the eyes, or they are turned upwards so as to conceal the cornea. In nearly all instances, the upper eyelids become paralysed, so that the patient, in endeavoring to look at any object, is unable to raise the lids by their proper muscles, and is therefore obliged to draw them upwards, together with the integuments of the forehead, by the contraction of the occipito-frontalis muscle.* Martinet observes, that these latter symptoms, namely, the turning up of the eyes and paralysis of the upper eyelids, are the most constant symptoms manifested by the countenance in this disease. Whytt and Camper also declare that they are among the most certain diagnostic signs of this dangerous malady. Sprengle (Handbuch der Semiotik) says, that the appearance of the tunica albuginea affords an excellent diagnostic sign between, scarlatina and measles. In the former, he asserts, the albuginea ex- hibits a uniform red tinge, with little or no suffusion of tears; in the latter malady, the redness is not general or uniform, the injected capillaries of the conjunctiva leaving intermediate spaces of a natural or white color. (Ziegler's Beobachtungen, p. 94.) The countenance in common synochus, or general inflammatory fever, usually exhibits a very different aspect from that which occurs in fevers depending on acute local inflammation seated in the thorax or abdomen. In the former, the face is more or less tumid and flushed, the conjunctiva of the eyes is injected or red, and " the nos- trils are rapidly and conspicuously dilated and contracted by the hurried respiration." In acute symptomatic fever, on the con- trary, the countenance is generally somewhat pale and contracted, and there is no hurried movement of the nostrils, nor redness of the eyes, if the inflammation be not seated in the head. In the acute bronchitis of infants the face is invariably remarkably pale: whereas, in infantile remittent and common synochus fever, from cold, it is almost constantly suffused with a flush. It must * Recherches sur l'inflammation de l'arachnoide, cerebrale et spinale. Par P. Duchatelet et L. Martinet, Paris, 1821. GENERAL DIAGNOSIS. 89 be observed, however, that in the advanced stage of pneumonic inflammations, whether in infants or adults, when the minute bronchial ramifications have become loaded with mucus, or serous effusion has taken place into the pulmonary tissue, the countenance acquires a more or less distinct livid hue—a phenomenon always indicative of great danger. On the other hand, the countenance, which is flushed in the early stage of synochal or remitting fever, becomes pale and somewhat shrunk, towards the termination of the disease. 1 pass on in the next place, to notice those diagnostic circum- stances which relate to the attitude and motions of the patient. The morbid variations of attitude are best understood, by contrasting them with the healthy postures of the body during sleep. " It may be presumed, that, both in health and in disease, that posture is assumed which affords the most repose to the system in general, and most relief in the performance of its various functions. In healthy and undisturbed sleep the usual posture is that of one side; the head and shoulders.are generally somewhat raised, and, together with the thorax, bent gently forwards; the thighs and legs are in a state of easy flexion. The position is apt to be changed from time to time, the person lying on one or the other side alternately. The posture of the body during sleep, here described, is such as affords the most ease and repose to the different viscera, and most facility and disincumbrance in the performance of their functions, and such as allows of the greatest muscular relaxation compatible with these more essential points." The supine position (decubitus dorsalis) when attended with twitching of the tendons, or tremor of the extremities, always indi- cates great muscular debility. When in the progress of a continued fever, we find the patient to assume this posture with the inferior ex- tremities extended, we may presume from this symptom alone, that the disease is assuming a sinking or typhus character. This is still more decidedly the case, when in connection with this position the patient gradually slides down towards the foot of the bed. It requires much less muscular exertion to maintain the supine posture than any other that can be assumed. In a very debilitated condition of the system, there is not enough of muscular power to preserve the body in the lateral posture. If the patient be placed on one side, he soon turns on his back, and is utterly unable by his own exertions to resume the lateral position. Celsus observes, that when a person affected with fever lies on one side, with the legs slightly retracted, he may be regarded as not in a very dangerous condition. In relation to the degree of muscular energy manifested by pa- tients, there exists a marked difference between adiopathic and symp- tomatic fevers. In common acute fevers of an idiopathic character, the patient soon feels very weak, and cannot support himself in the erect posture, without great and exhausting efforts, and a feeling of faintness. This is rarely the case in symptomatic fever. In fevers S* 90 GENERAL DIAGNOSIS. of this kind, the sense of prostration is seldom great, nor do we observe the muscular tremor, vertigo and faintness on assuming the erect position. In the diseases of the chest, the position assumed by the patient is often highly characteristic. In hydrothorax, the patient usually lies with the head and shoulders considerably elevated, by additional pillows. When out of bed, he is often observed to sit up, with the arms placed along the side, and the hands fixed and pressing forcibly on the chair or sofa on which he sits; in other cases he leans a little backwards, still supported by the arms and hands, which are placed behind his back. " This kind of posture is often constant, or imme- diately resumed, if any accident occasions it to be changed; it gives rise to an elevation of the shoulders, from which the body is sup- ported, or as it were suspended." The attitude of course varies with the degree and progress of the hydropic effusion in the chest. In order that the patient may continue to enjoy some rest while lying down, the head and shoulders must be more and more raised, until at last, he is, sometimes, incapable of remaining in bed, and is obliged to sit up " with the legs hanging down." When hydro- thorax is associated with organic disease of the heart, or of the lungs, the necessity of remaining in the erect posture is, in general, par- ticularly urgent. These circumstances admit of a ready explanation. The effused fluid in the chest, produces distress and difficulty of breathing in proportion as it presses upon and impedes the free action of the lungs. In a recumbent position, with the head and shoulders low, it is obvious that the fluid must envelop and encum- ber a much larger portion of the lungs than when the patient is sitting up, or lying with the shoulders elevated; for in this posture the fluid sinks down to the bottom of the thorax and leaves a considerable part of the lungs free from its embarrassing pressure. Hydropic accumulation in the chest may be distinguished from mere organic disease of the heart or of the lungs, attended with symptoms resem- bling those of hydrothorax, by making firm pressure on the abdomen and attending to the effects. If there is thoracic effusion, the patient will experience general agitation, cough, and a sense of suffocation when pressure is thus made on the abdomen. This arises from the abdominal viscera being pressed up against the diaphragm, by which the fluid in the chest is raised, so as to embarrass the lungs and cause the phenomena just mentioned. In organic affections of the heart, without thoracic effusion, no effects result from abdominal pressure. In affections of this kind, as well as in hydrothorax, the patient is unable to remain easy in a recumbent posture with the head low, more especially in very severe cases. But in addition to this cir- cumstance, the effects which arise from corporeal exertions in organic affections of the heart, are much more violent and distressing than in hydrothorax. Almost every muscular effort or unusual exercise produces, to an extreme degree, dyspnoea, anxiety, and agitation. Ascending stairs, or a hill, seldom fails to bring on a paroxysm of GENERAL DIAGNOSIS. 91 the most alarming palpitation, and suffocative breathing. Although similar effects result from the operation of these causes in hydrotho- rax, yet, they are much less violent and alarming than in cardiac diseases. When in hydrothorax, the dropsical effusion exists only on one side of the chest, the patient invariably lies on the affected side. Inflammation in the abdomen, with acute pain, is in general attended with a characteristic position of the body, and which dis- tinguishes affections of this kind, very pointedly, from spasmodic pains of the stomach and bowels. In acute abdominal inflammation the patient assumes a certain position and carefully avoids active muscular exertion and change of posture. In spasmodic pains in the abdomen, or colic, on the contrary, the patient usuallyi" writhes to and fro," and constantly changes his posture. In abdominal inflammation the patient lies on the back, with the knees drawn up, and the head and shoulders raised by additional pillows, so as to relax the abdominal muscles and obviate as much as possible, pressure on the inflamed viscus. Great care, moreover, is taken to prevent any pressure from the hands or bedclothes on the abdomen, and all the necessary motions of the body are performed with peculiar caution and slowness. In spasmodic or colic pains, so far from avoiding pressure on the abdomen, the patient often lies on the belly, or presses forcibly on the bowels with his hands. After the paroxysm of pain in colic is over, the patient resumes an easy position; but in the absence of an aggravation of inflammatory pain, the same cau- tious posture and manner are still retained as before. (Hall.) When the inflammation is seated in one of the kidne)7s, the patient when in bed, inclines his body a little forwards and towards the side affected. By this position the muscles of the loins on the affected side will be somewhat relaxed and the pressure on the inflamed kidney diminished. When, in the advanced stages of typhous or typhoid fevers, attended with delirium, the patient is observed to keep his inferior extremities constantly drawn up, while recumbent on the back, retention of the urine may be suspected. I have known patients affected with typhoid fever, and in such a condition as not to be able to give an account of their sensations, in whom protracted retention of the urine was detected solely by noticing this retraction of the legs, or constant raised position of the knees. In most instances of inflammation of the liver, the patient cannot lie on the left side without great aggravation of his sufferings. This symptom is, indeed, not always present in hepatitis, and when taken by itself, cannot be regarded as of any particular diagnostic import- ance. When it occurs, however, in connection with other symp- toms indicative of hepatic inflammation, it may be considered as no inconsiderable evidence of the existence of this affection. If in a case of hepatitis, the patient is observed to lie easiest on the left side, we may infer that the inflammation is principally seated on the con- cave surface of the liver. 92 GENERAL DIAGNOSIS. Next in order are the diagnostic signs manifested by the tongue, gums, cavity of the mouth, fauces, and teeth. In examining the tongue, particular attention should be paid to its color, form, sur- face and mode of protrusion. In the simple forms of fever, unat- tended with inflammatory irritation of the mucous membrane of the stomach, the tongue is slightly coated with a white fur. This state of the tongue is rarely attended with dryness, and does not, in gene- ral, indicate a very great degree of gastric derangement. When in the progress of a disease the tongue changes from a white and some- what loaded state, to a clean and deep red appearance, we may infer with confidence, that inflammation has supervened in the mucous membrane of the stomach. A clean and red appearance of the tongue, attended either with a rough or a smooth surface, is always to be regarded as conclusive evidence of an inflamed or highly irri- tated condition of the mucous membrane of the alimentary canal. In dysentery, we generally find the point and margin of the tongue of a deep red appearance, whilst the centre is loaded with a streak of brown and dry fur. This is particularly apt to be the case, in the chronic form of the disease. In chronic gastritis, and enteritis, the tongue almost invariably exhibits a dark red appearance. In some instances, this redness is attended with a rough or granulated surface, and in others it presents a smooth or glossy appearance; sometimes the whole surface of the tongue exhibits this red and rough or glossy appearance. This is generally the case when the inflammation is seated in the stomach. In many instances, however, these appear- ances are confined to the tip and margins of the tongue, more espe- cially when the inflammatory irritation is located in the mucous membrane of the colon. In fevers depending on acute inflammation, not seated in the mu- cous membrane of the alimentary canal, the tongue seldom exhibits any prominent deviations from its natural state. Thus in fevers from wounds, from regular gout, and from external phlegmanous inflammation, the tongue generally varies from its healthy condition only by being covered with a thick white fur, and by unnatural dryness.—(Hall.) In the commencement of typhus fever, the tongue is coated with a white fur, as in common synochus fever; but the white tongue of typhus differs from that of simple acute fever, in being covered with a thick layer of transparent, tenacious slime, which in the progress of the disease becomes dry, brown, and finally nearly black. The appearance of the tongue affords a good distin- guishing sign between tubercular phthisis pulmonalis, and hectic fever with cough from hepatic or gastric disease. In genuine pul- monary consumption the tongue very generally retains nearly its natural appearance; whereas in affections of the stomach and liver, simulating phthisis pulmonalis, the tongue is always more or less coated with a brown fur, accompanied usually with a depraved taste. In the early stage of chlorosis the tongue presents a pale and tumid appearance, with enlarged and prominent papillae. As the GENERAL DIAGNOSIS. 93 disease advances the tongue becomes more and more pallid, clean, and smooth, and finally acquires a peculiar flabby and semi-transpa- rent appearance. The gums and prolabia are very pale and exan- guious, and generally somewhat swollen. Hall gives the following description of the morbid appearances of the tongue in dyspepsia. " In acute dyspepsia, the tongue is in general loaded, the mouth clammy, the taste bitter or nauseous, the breath fetid, whilst the sur- face ofjthe face is generally oily. In some severe cases the coat on the tongue is very thick, and eventually peals off, leaving its surface smooth, red, and tender, attended with an oedematous appearance of its substance. In very protracted and severe cases of dyspepsia the tongue is apt to become clean, with universal enlargement of the papillae over the surface as in the beginning of chlorosis; or its sur- face is formed into lobules resembling in form those of the base of the cerebellum. In cases attended with chronic inflammation of the mucous membrane of the stomach, the surface of the tongue becomes red, smooth, and glazed." The appearance of the tongue in chlorosis does not differ materially from that which it presents in chronic dyspepsia, except that in the former disease it is pale instead of red, and indicates, in addition to gastric derangement, a defect in the pro- cess of sanguification.—(Hall.) A contracted and pointed tongue, is a very common attendant on inflammatory affections of the brain and its meninges. This state of the tongue is often to be observed in very severe cases of typhus; and when it does occur we almost invariably find it associated with other indications of cerebral inflammation—such as red and promi- nent eyes, constant delirium, flushed cheeks, &c. In fevers attend- ed with stupor or general torpor, depending on congestion, the tongue instead of being contracted and pointed presents a dilated and flabby appearance. This relaxed and dilated state of the tongue is seldom accompanied by delirium; but instead of this, there is usu- ally a general diminution of sensibility and irritability, as well as of muscular power and the temperature of the surface. Dr. Miner mentions this appearance of the tongue as one of the most constant symptoms of typhus syncopalis. A tongue covered with yellow, or yellowish brown fur, attended with a bitter taste, indicates prominent derangement of the biliary organs. A tremulous tongue is, in general, one of the first symp- toms of the passage of the synochus fever into a typhous or low state. In the early stage of scarlatina, a number of florid papillae pro- trude through the white coat on the surface of the tongue; and Bate- man states, that this appearance will always enable us to distinguish it from measles. In chronic hepatitis, the gums have a peculiar firm, smooth, or glossy appearance, whereas in chronic dyspepsia, they usually present a soft or spongy condition. The next class of symptoms, to be considered, are those manifest- ed by the nervous system. The most common, and generally the 94 GENERAL DIAGNOSIS. earliest symptom of deranged function of the brain, is disturbed sleep. In the diseases of children, an unusual drowsiness, especially when attended with a disordered state of the alimentary canal and febrile irritation, is often one of the first symptoms to awaken alarm and suspicion of probable disease within the head. Under whatever circumstances profound morbid sleep or coma may occur, it always denotes cerebral oppression from congestion or effusion, or some other cause capable of compressing this organ. When, therefore, in the course of diseases attended with symptoms of cerebral irritation or inflammation, somnolency supervenes, we may conclude that great congestion, or effusion, or disorganisation of the cerebral structure, has taken place. Wakefulness is indicative of great cerebral irritation or exhaus- tion. It is particularly apt to occur from sympathetic excitement of the brain, depending on intestinal irritation, and exhaustion from loss of blood. When morbid wakefulness depends on these causes, it is almost invariably attended with great restlessness or jactitation, a distressing feeling of anxiety in the region of the heart, and a pale and contracted countenance. Sudden starting during sleep is gene- rally connected with intestinal irritation from indigestion or worms. (Hall.) Children whose bowels are loaded with sordes or worms are particularly apt to start in sleep, " and this symptom is one of the most certain diagnostic signs of such a condition of the aliment- ary canal." Similar hurried wakenings occur in organic affections of the heart, and in hydropericardium, and frequently, also, in hydro- thorax; but in these complaints, the starts from sleep are almost al- ways attended with a distressing sense of suffocation, or impending dissolution, great agitation and alarm. Acuteness of hearing and sight occur in the incipient stage of cerebral inflammation; but they are equally, and often more strik- ingly presented in sympathetic irritation of the brain from intestinal irritation, accompanied with exhaustion. (Hall.) As a general ob- servation, however, it may be said that when the senses of sight and hearing are morbidly acute, or when there is intolerance of light and sound, the brain is in a state of irritation, whether sympathetic or idiopathic. Obtuseness of hearing is a common symptom in the advanced stages of typhoid fevers, and indicates a considerable de- gree of sanguineous engorgement, but not inflammation of the brain. Strabismus, and seeing objects double, always denote very consi- derable cerebral disturbance. These symptoms arise from sanguine- ous or serous effusion into, or upon the surface of the brain, and from disorganisation of a portion of the structure. Torpor or defect in the sense of touch, if general or confined to one side of the body, indicates an oppressed state of the brain, and may be both the pre- cursor or consequence of apoplexy. When torpor of feeling is con- fined to one extremity, or only to a part of an extremity, we may infer that the nervous communication between the affected part and the censoriuni commune has been partially interrupted, by compres- GENERAL DIAGNOSIS. 95 sion of the principal nerve leading to the part, or that the nervous extremities of the part have become diseased and incapable of trans- mitting the nervous power. Morbid sensations are among the most common phenomena of diseases. In many affections, indeed, there are peculiar and cha- racteristic modifications of sensibility, which it is of importance to notice in a diagnostic point of view. In strumous disease of the mesentery, an unusual sensibility to cold constitutes a peculiar and very early symptom. " In this disease, the patient is greatly sensi- ble to cold and to the least draught of air, and in cold weather espe- cially, constantly draws near or hangs over the fire, until the hands and legs assume a brown color from the influence of the heat." Pain may depend on inflammation, on spasm, or on nervous irri- tation. Each of these kinds of pain has a peculiar character by which it may in general be readily distinguished. The pain of in- flammation is attended with great tenderness or soreness of the affected part—is increased by pressure—generally continuous, and always attended with more or less of febrile irritation. Spasmodic pain, on the contrary, is intermitting—is neither throbbing nor burn- ing, like that of inflammation, nor is it attended with redness, swell- ing, augmented heat, or febrile excitement. Pressure, which always increases the pain of inflammation, generally mitigates spasmodic pains. Neuralgic pain differs from inflammatory and spasmodic pain, by occurring in transient and extremely violent paroxysms. It darts with the rapidity of lightning along the ramifications of the af- fected nerve. It is not attended by swelling or increased heat, unless some degree of inflammation be associated with it; and the slightest agitation or touch is apt to renew its excruciating paroxysms. It is a fact demonstrated by daily observation, that the character of inflammatory pain is peculiarly modified by the nature of the structure in which the inflammation resides. This circumstance ne- cessarily arises from the physiological fact, that each structure of the animal system is endowed with a peculiar modification of the vital properties. From this variety in the general character of inflamma- tory pain, according to the structure in which it resides, we fre- quently obtain important diagnostic indications. In the mucous membranes, inflammation is attended with a burning or stinging pain, and is seldom very violent: in the serous membranes the pain is lancinating, and generally extremely acute; in the fibrous tissues, it is dull, aching and gnawing; in the nerves, rapid, darting, remit- ting and excruciatingly severe ; and in the parenchymatous and cel- lular structures, it is dull, throbbing and heavy. Thus the pain ex- perienced from inflammation of the pleura, is acute, piercing, and generally extremely severe; whilst that from inflammation of the substance of the lungs is dull, pressing, and generally inconsiderable in violence. The pain attending inflammation of the mucous mem- brane of the stomach is of a burning, gnawing, or stinging character; that of the liver is acute, throbbing, and generally accompanied with 96 GENERAL DIAGNOSIS. a sense of fulness and tension in the right hypochondrium and epi- gastrium. The character of the pain may, moreover, assist us in determining in what portion of this organ the inflammation is prin- cipally seated. When the substance of the liver is the principal or exclusive seat of the inflammation, the pain is seldom very acute or violent—being obtuse, heavy, and heating. When the convex sur- face of this organ is affected, the pain is usually extremely severe, darts upwards towards the left or right shoulder, and is always much increased by external pressure, deep inspiration, cough, and motion. In cases where the concave surface is the seat of the inflammation, the pain is, in general, dull, accompanied with much anxiety in the epigastrium, nausea, and often, vomiting. Cases of this kind, fre- quently resemble gastritis; but may be distinguished from this affec- tion by the pain, distress and vomiting not being increased by taking warm liquids into the stomach. In many instances, the painful sensation is referred to a different and often remote part, from that in which the primary irritation or affection is seated. Irritation in the neck of the bladder, frequently gives rise to pain in the glans penis; inflammation of the liver often causes pain in the left, and sometimes right shoulder; and severe and protracted pain in the knee and legs, is generally among the first painful sensations attending hip disease. In many cases, indeed, pain in the knee is felt for a considerable time before any unpleasant sensations are experienced or complained of in the hip; and I have not unfrequently known various applications made to the knees of children for the relief of pain in that part, which was subsequently found to be merely symptomatic of scrofulous disease of the hip. Inattention to these and similar facts, has often led to very useless and painful applications, and placed the physician under the morti- fying, and indeed, justifiable imputation of ignorance or culpable carelessness. The next class of symptoms to be considered, are those manifested by the morbid conditions of the alimentary canal. From the nature and appearance of the alvine evacuations, we may often derive im- portant diagnostic information. The functional derangements of the liver are, in general, readily distinguished by the character of these evacuations. Ash, or clay-colored faeces indicate either deficient se- cretion of bile, or obstruction to its regular flow into the intestines. This condition of the biliary organs is almost always attended with increased irritability of the stomach. When the alvine discharges are liquid, and of a bright green color, as is frequently the case in infants, the existence of much acid in the bowels may be confidently inferred. Bile, as it comes from the liver, never possesses such a color. It is only by being mixed with acid in the intestines, that it acquires this appearance. However dark and vitiated the bile may be before it is discharged into the bowels, it will always communi- cate a yellow color to water. It becomes green in the intestines by the action of the acid it meets there. According to the observa- GENERAL DIAGNOSIS. 97 tions of Dr. Cheyne, the appearances of the stools afford a good diagnostic sign between infantile remittent fever, and hydrocephalus. In the former disease, the alvine discharges are, generally, dark- brown or mud-like, and extremely fetid. In hydrocephalus, the stools are usually gelatinous, dark green, sometimes black, like tar, and of a peculiar sickly smell. Watery and reddish stools, contain- ing small flakes of mucus, resembling the washings of flesh, always indicate a high degree of inflammatory irritation of the mucous mem- brane of the small intestines. The diagnosis of diseases is also much aided by an attention to the morbid conditions of the respiratory organs. In general, the greater the velocity and momentum of the blood, the more rapid is the respiration. In acute diseases, attended with a frequent and full pulse, breathing is always accelerated. In affections of the head, at- tended with sanguineous congestion in the brain, respiration is gene- rally more or less irregular, unequal, and suspicious. When the congestion, and consequent cerebral compression, is so great as to produce partial insensibility, the breathing becomes slow, irregular, and sterterous. Whatever obstructs the functions of the brain, or interrupts the nervous communication between it and the respiratory apparatus, impedes or destroys the function of respiration; and the slowness and irregularity of the respiratory acts will be in propor- tion to the degree in which the functions of the brain are oppressed. In pneumonia, breathing is sometimes performed by the action of the diaphragm alone, without any perceptible elevation and depres- sion of the ribs of the affected side. In abdominal inflammation, with acute pain, on the contrary, respiration is performed, almost ex- clusively by the action of intercostal muscles, the alternate rising and falling of the abdomen, so conspicuous in thoracic inflammation, being almost entirely absent. " This peculiarity of breathing," says Dr. Hall, " may be distinctly observed by looking on the chest and drawing the bed-clothes tight over the abdomen: the respiration has sometimes the appearance of heaving of the chest; every movement of the diaphragm is cautiously avoided, on account of the motion which its action communicates to the abdominal viscera. The dia- phragm and abdomen begin to move, as the pain diminishes, whether from mitigation of the disease, from sinking, or from gangrene." In inflammation of the substance of the lungs, or of the mucous membrane of the ultimate bronchial tubes, respiration is performed with great difficulty, and in violent cases with distressing anxiety and labor. " The shoulders are elevated, and the lower part of the sternum is drawn back, during each act of inspiration, whilst the abdomen is at the same time suddenly protruded, and the upper part of the chest raised." In the diseases of children, the manner in which respiration is performed often throws important light on the character of the disease. When, with more or less cough, the in- spirations are short and catching, more especially when the counte- nance, at each inspiration, exhibits an expression of pain or suffering, Vol. I.—9 98 GENERAL DIAGNOSIS. the existence of pectoral inflammation may be confidently inferred. If the countenance is pale, and the breathing wheezing and labori- ous, the inflammation is probably seated in the mucous membrane of the bronchia. Laborious and anxious breathing on muscular exertion or strong mental excitement, particularly from walking up hill, or ascending stairs, is strongly indicative of organic disease of the heart. The dyspnoea of hydrothorax differs from that of organic cardiac disease, in being more liable to recur in violent paroxysms from the causes just mentioned in the latter than in the former affection. In hydro- thorax, too, the dyspnoea, thus excited, comes on gradually, whilst in organic disease of the heart the paroxysm of suffocative breathing re- curs with sudden violence. Asthma is attended with a peculiar mode of dyspnoea. The act of inspiration consists of a quick and imper- fect dilatation of the thorax, but expiration is much more protracted, labored and wheezing. " When the disease is violent, every muscle subservient to this function is brought into strong exertion, with the exception of the intercostals, which, although excited to strong ef- forts, are incapable of that degree of action which is necessary for the due expansion of the chest. What, however, particularly cha- racterises the dyspnoea of asthma, is the wheezing during expiration." When the breathing is hurried, panting, sighing, and the lungs are but partially filled during inspiration, there is probably much de- bility accompanied or depending on nervous intestinal irritation. This state of the system and of the respiratory organs, is generally attended with great restlessness, jactitation, and inability to sleep. Having described some of the more remarkable diagnostic phe- nomena, in relation to respiration, it remains for me to consider the diagnostic indications derived from the character and attending circumstances of coughing. With regard to the phenomena of cough, therefore, we may notice the following general diagnostic circumstances: Patients affected with inflammation of the pleura, lungs, or peritoneum, always repress the cough as much as possible, in order to obviate the great increase of pain which free coughing invariably produces in these affections. When, therefore, the patient is observed to make great efforts to stifle or suppress the acts of coughing, the existence of local inflam- mation may be confidently inferred. The seat of the inflammation will be pointed out by the other accompanying symptoms. The cough attending acute inflammation of the mucous membrane of the bronchia has a much duller sound, and is attended with much more mucous rattling in the chest, than that which results from acute inflammation of the pleura. This remark applies particularly to the early period of these affections; for in the advanced stage of the latte'r malady, the cough is generally as dull and rattling as in bron- chitis. Cough depending on gastric or intestinal irritation, is gene- rally attended with a peculiar hollow sound: this kind of cough is frequently met with in'children laboring under verminous irritation. GENERAL DIAGNOSIS. 99 The character of the cough will, in general, afford considerable aid in distinguishing phthisis laryngea, from phthisis pulmonalis; or that form of consumption which arises from ulceration in the larynx, from true pulmonary consumption. In the former the cough comes on in violent and spasmodic paroxysms, particularly in the morning on rising from bed; whilst in the latter form of the disease, the cough is, usually, much less sudden and violent in attacks, and is, besides, destitute of the spasmodic or convulsive character of the former. In the laryngeal variety of the disease, the cough has a deep hollow sound, not unlike that which is produced by verminous irritation of the bowels, whereas, in pulmonary phthisis, it always has a " flat- tened and lacerating sound." In the former of these maladies, vio- lent fits of coughing are excited by the patients passing from a warm into a cold air, by inhaling smoke or the dust raised by sweeping, or any irritating fumes, and the same effect is frequently produced by swallowing food. In pulmonary phthisis, coughing is very rarely excited by these causes, and when they do produce this effect, the cough is usually slight and of very short duration. The character and appearance of the matter expectorated, afford important diagnostic indications. In peripneumonia, the tenacity of the matter expectorated is so great, that we may reverse the ves- sel which contains it. and retain it in this position for some time, without detaching it from its sides. Laennec regards this kind of sputa, as pathognomic of this affection,te since it is the only symptom which is found exclusively in this form of pulmonic inflammation." These sputa are somewhat diaphanous and of slightly yellow or greenish color. In acute bronchitis the expectoration is much less tenacious in its consistence, and is generally quite transparent, resem- bling the white of eggs. When the fluid expectorated has a dark appearance, like dissolved blood, and possesses a very fetid smell, we may infer that some portion of the diseased lung is in a gan- grenous condition. In chronic bronchitis, particularly in those cases which result from pertussis, the matter expectorated often presents a white cream-like appearance, bearing considerable resemblance to the whitish friable matter which is sometimes brought up in small quantities in the latter stage of tubercular phthisis. This white matter, in the latter disease consists of the softened substance com- posing the tubercles. Mucous membranes, under a high degree of irritation, often secrete a fluid, which bears a strong resemblance to genuine pus; but which in its composition and properties, is never- theless, strictly a mucus. Various tests have been recommended for distinguishing puruloid secretions of this character, from genuine pus, and a correct decision on this point, is of much importance in forming a satisfactory diagnosis; for when the matter expectorated is found to be pus, there can be no doubt, that the structure from which it proceeds is in a state of active inflammation or ulceration. If, on the contrary, it be found to possess the character of mucus, we may infer, that neither an active state of inflammation nor ulce- 100 GENERAL DIAGNOSIS. ration exists in the diseased organ, but only a high degree of irrita- tion, or sub-inflammatory excitement. The specific gravity of pus is considerably greater than that of mucus—the former sinks in water, the latter floats on the surface. This is the usual test, but cannot always be relied on; for although we may safely pronounce the matter expectorated to be pus, when it sinks quickly to the bot- tom of the vessel, yet we cannot, with entire assurance, infer that it is mucus when it remains floating on or near the top of the wat?r; for a considerable portion of pus is often so intimately mixed with bronchial mucus, as to give it nearly a uniform appearance, and cause the sputa to swim on the surface. The following tests have been proposed, and I think, entitled to confidence.—The muriate of am- monia coagulates pus; but on mucus no such effect is produced by it. Heat coagulates mucus, but not pus. Water added to the solutions of pus in sulphuric acid, and in a solution of caustic potash separate- ly, produces, in each, a copious precipitate. Mucus treated in the same way, does not exhibit the same effect. Dr. Young mentions the following test: A small portion of pus put between two glasses, will, when held near the eye, and looked through at a distant candle, exhibit an iridescent spectrum, of which the candle is the centre. Mucus does not present this phenomenon. The morbid conditions of the external surface of the body should always be carefully observed. In examining diseases, particular at- tention should be paid to the temperature, the color, the state of dryness or moisture, the fulness or constriction, and the roughness or smoothness of the skin. The existence of oedema, or of emacia- tion, are, moreover, important diagnostic circumstances. A yellow- ish or icteric hue of the skin, and especially of the tunica albuginea, are well known indications of derangement of the biliary organs. In the various forms of disease produced by marsh miasmata, this symptom is rarely absent. This appearance of the skin, says Mr. Hall, must not be confounded with the sallow hue which occurs in chlorosis, cancer, and some other organic affections. " Sallowness is not necessarily accompanied by a yellow hue of the albuginea; but the icteric appearance of the skin is always associated with a similar tinge of the eyes. When, therefore, the albuginea is free from this yellowish hue, we may infer that the biliary organs are not particularly disordered, however sallow the general surface may be. When a decided icteric or jaundiced hue of the skin, is asso- ciated with constant and obstinate torpor of the cutaneous exhalents, or dryness of the surface, we may infer that the biliary derange- ment, upon which these phenomena depend, consists of chronic in- flammation and induration of the liver; and this diagnosis may be regarded as still more certain, if, at the same time, the gums have a peculiar and unnatural firmness. A purple or bluish color of the skin when not the immediate consequence of cold, indicates defi- cient decarbonisation of the blood in the lungs. This appearanee occurs, in a striking manner, in the Asiatic cholera. When this GENERAL DIAGNOSIS. 101 livid hue is confined to some particular part of the body, it denotes great venous congestion in the part. Thus a livid color of the face indicates great engorgement of the blood-vessels of the head, and is almost universally connected, or rather dependent on obstructed cir- culation through the lungs, and attended with an imperfect perform- ance of the respiratory functions. A pale semi-transparent appearance of the surface, particularly of the prolabia and face, occurs after profuse haemorrhage, or from what- ever greatly exhausts the system or impedes the process of sangui- fication. This appearance of the skin is always accompanied by great languor and debility, and depends, generally, on a morbid ex- cess of the serous portion of the blood. This state of the system is almost invariably attended with more or less of anasarcous effusion. A pale and cachectic appearance of the face, attended with a leaden hue of the prolabia and a puffy swelling under the eyes, is fre- quently noticed in organic affections of the heart. A cold state of the surface of the body, attended with a sensation of heat in the internal parts, indicates great sanguineous congestions of the viscera. The heat is sometimes very unequally distributed throughout the various parts of the body, and it may be laid down as a general rule, that in whatever part the heat is preternaturally elevated, there is an unusual determination of blood to that part. Thus in hydroce- phalus, the head is almost always considerably warmer than any other part of the body; and in dysentery and peritonitis the abdo- men is preternaturally hot to the touch, whilst the extremities in the latter stage of the disease are unusually cool (Hall). In organic affections of the heart, the hands, nose and cheeks are very apt to become preternaturally cold, whilst the heat within the rectum and under the tongue is generally considerably higher than natural (Fare). A pungent, stinging heat of the surface, or the calor mordax, as it is technically called, indicates a high grade of malignity or a tendency to putrescency in fevers. This pungent heat differs very distinctly from the burning heat which occurs in synochial or inflammatory fever. By laying the hand on the skin of a patient laboring under inflammatory fever, the sensation of heat is at first very great, but on suffering the hand to remain for a short time, the sensation of heat gradually diminishes, until it seems to the touch but little, if in any degree, above the natural temperature of the body. In typhus gravior, on the contrary, the heat (calor mordax) becomes more and more pungent and severe, and the biting or acrid sensation of heat remains in the hand, even after it is removed from the patient's body. The appearances and character of the urine also, often afford valu- able diagnostic indications. In inflammatory affections it is gene- rally very red and small in quantity; in nervous diseases, more espe- cially in hysterical affections, this secretion is usually copious and limpid, or but slightly colored. In diseases of the biliary organs, the urine is almost invariably conspicuously tinged with bile. To 9* 102 GENERAL DIAGNOSIS. distinguish urine colored with bilious matter from the highly colored urine of inflammatory fevers, a small strip of white linen or paper should be immersed in it. If the urine contains bile, the linen or paper will receive a very distinct yellow stain, which will remain when dried. If it be free from bilious matter no such tinge will be communicated, Much has of late years been said concerning the connection between a serous or coagulable condition of the, urine (in hydropic affections), and a phlogistic or inflammatory state of the system. Drs. Blackall, Wells, and Ayre, have investigated this subject with minute attention. It has been satisfactorily ascertained by these and other pathologists, that those cases of dropsy which are attended with an obvious phlogistic diathesis, and especially such as arise from the influence of general causes, the urine, with scarcely an exception, contains a large quantity of coagulable serum. The quantity of serum mixed with the urine may, therefore, be regarded as a pretty correct index of the degree of general inflammatory ex- citement attending the disease. Serous urine may be regarded as a sort of pyrexometer in hydropic affections, which, though not uni- versally to be relied on, is yet sufficiently constant to entitle it to the attention of the practitioner. I am satisfied, from considerable attention to this subject, that in almost every instance where there is coagulable serum in the urine of dropsical patients, the general condition of the system will be found manifestly phlogistic. The mode of testing the urine, for this purpose, is to expose a portion of it in a spoon to the heat of a lamp. When, in hydropic affections, the urine is high colored, and on cooling becomes muddy, or de- posits a red or reddish sediment, we may infer with great proba- bility that the liver is in a state of organic disease (Cruikshank). 103 OF THE ACUTE DISEASES OF THE SANGUIFEROUS SYSTEM. I.—GENERAL IRRITATIVE DISEASES OF THE BLOOD VES- SELS INDEPENDENT OF LOCAL INFLAMMATION. CHAPTER V. OF INTERMITTING FEVER. Intermitting fevers occur under the three primary types men- tioned in a preceding chapter, and occasionally under the various complications which these types are liable to assume. According to the type which they assume, therefore, they are divided into quo- tidians, tertians, quartans, quintans, fyc. The fit or paroxysm of an intermitting fever consists of three distinct periods all of which are characterised by a series of pecu- liar phenomena, each succeeding period being the immediate conse- quence of the one which precedes it. The symptoms which characterise the forming stage of an inter- mittent paroxysm, do not differ from those which usually precede the development of other forms of fever. A sense of great lassi- tude, frequent yawning and stretching, a feeling of uncomfortable weariness of the whole body, and slight aching pains in the loins and extremities, constitute the first manifestations of the approach of an intermittent fever. Cold stage.—After the foregoing symptoms have continued for an indefinite time, the patient begins to experience slight and tran- sient sensations of cold along the back; attended often with an irre- sistible disposition to yawn and change the position of the extremi- ties; the fingers and feet lose their natural temperature, and feel slightly benumbed; the patient becomes restless, and soon tired of the same position; his ideas pass with unusual rapidity through his mind; he is incapable of fixing his attention upon any particular ob- ject, and generally manifests an unusual irritability of mind, or ill temper, or a taciturn moroseness. The sensation of chilliness, with more or less rapidity, extends itself from the extremities over the whole body, the skin becomes universally pale, contracted, and rough; the pulse loses its activity and size, becoming small, con- tracted, frequent, and firm. When the sense of chilliness has passed 104 INTERMITTING fever. from the extremities to the body, a slight trembling of the muscles begins, generally, at first, in the jaws, and extending thence quickly over the whole frame. This trembling is sometimes so severe as to agitate the patient as if he were in a paroxysm of convulsions, and sometimes exhausts him so much as to leave him scarcely able to move his limbs after their subsidence.' These tremors are techni- cally called rigors. During the chills the sensibility of the sur- face is benumbed, and the whole body becomes diminished in volume, so that rings which were previously tight drop from the fingers. The feeling of cold is not confined to the surface, but ap- pears in violent cases to penetrate even to the bones, and to pervade the whole system, "and is accompanied with an indescribable sense of universal pain and fatigue."* The breathing also is hurried, anxious, and oppressed, and frequently attended with a short dry cough, deep sighing, and a sense of weight and tightness in the chest. Along with these symptoms there occurs usually much de- jection and confusion of the mind, and, in some instances, a slight degree of delirium. In very debilitated persons a violent fit of rigors often induces a complete state of stupor or coma, more espe- cially when feebleness of body is attended with general plethora. In many instances, frequent and distressing vomiting occurs, particular- ly about the period of its subsidence, and the ejections are generally bilious, though occasionally ropy, transparent, and insipid. The thirst is always urgent in this stage, and the mouth and fauces are dry and clammy. The urine is clear, colorless, without sediment, and often copious. Generally, the chills are universally diffused over the body; but in some cases they occur partially, remaining confined to one or more parts of the body; and instances have been recorded in which a single extremity only was affected with the chills. In some cases of intermitting fever, the cold stage is attended with but a very slight sensation of chilliness creeping along the back and over the extremities; and 1 have known this stage to commence with violent vomiting, and to terminate speedily in stupor and partial insensi- bility. The duration of the cold stage is very various, ranging from a few minutes to four or five hours. Sooner or later, however, the chills begin to abate; transient flushes of heat pass over the face and body; the chilliness now recedes rapidly, and the heat encroaches pari passu, until it has obtained an entire ascendancy. At this time the nausea and vomiting are usually most severe—both of which often continue until the hot stage is completely developed. The hot stage is characterised by a full and flushed countenance; an intensely hot and dry state of the surface of the body; great thirst and dryness of the mouth; great acuteness of the sensorial powers; a full, strong, and frequent pulse; a more free and regular respira- tion than in the preceding stage, though still more oppressed and hurried than natural; great pain in the forehead; pain in the back * Macculloch, on Intermittent and Remittent Fever, &c. INTERMITTING FEVER. 105 and extremities; sometimes slight delirium just before the com- mencement of the succeeding stage; a scanty and deep-colored urine without sediment. This stage is as various in its duration in dif- ferent cases, as the preceding one. It continues, however, almost always much longer than the cold stage. The temperature of the skin is always very considerably augmented. Fordyce observed it as high as 105° of Fahrenheit. This stage terminates in the last or,— The sweating stage.—When the perspiration begins to appear, an obvious abatement of all the febrile symptoms occurs. The sweat appears at first about the head and breast, and thence gradu- ally extends over the whole surface of the body. On the appear- ance of this evacuation, the pulse loses its hardness and frequency, but still retains its fulness. The breathing at the same time be- comes free and natural; the febrile heat subsides rapidly; and the urine, though still very high-colored, deposits a lateritious or pale red sediment. This gradual melioration of the febrile symptoms continues under the free flow of the perspiration, until the paroxysm terminates in a state of perfect convalescence or apyrexia. The apyrexia, or intermission, though entirely free from febrile phenomena, cannot, however, be regarded as a state of health; for, during this interval, the patient usually feels some degree of lan- guor; becomes easily fatigued; complains often of a want of appe- tite, and an indisposition to bodily or mental exertion. He pos- sesses, moreover, an unusual degree of sensibility to the impressions of cold air; and his countenance exhibits a pale and sickly aspect. In some, though comparatively few instances, the appetite is good, and the patient experiences no feelings of indisposition whatever during the intermission. The more conspicuous the symptoms of imperfect health are during the intermissions, the more difficult, in general, will it be to prevent its recurrence; or, the more readily will it relapse after it has been suspended. Intermittents of every type are subject to certain prominent modifications in relation to their general character, which, as they have important practical bearings, deserve particular attention. We meet with intermittents, for instance, which are attended with une- quivocal manifestations of an inflammatory character; others occur in which symptoms of great internal venous congestions are equally conspicuous; a third variety of intermittents will exhi- bit strong symptoms of biliary and gastric irritation', and a fourth variety will be characterised by phenomena indicative of a more or less malignant character. According to these circumstances, intermittents may be divided into the four following varieties, viz: 1, the inflammatory, 2, the congestive; 3, the gastric; and 4, the malignant intermittents. 1. Inflammatory intermittents occur most frequently during winter and in spring. Quotidians are more apt to assume this cha- racter than tertians; and tertians more apt than quartans, (Richter.) In young, robust, and plethoric subjects, vernal quotidians are espe- 106 INTERMITTING FEVER. cially prone to manifest inflammatory symptoms. Intermittents of this character, generally begin with strong rigors. In the hot stage, the temperature of the surface is very intense, and the pulse is pecu- liarly strong, hard, and full. The most characteristic marks of in- flammatory intermittent, occur, however, during the intermission. However profuse the perspiration in the last stage, the apyrexia does not become complete. The pulse remains quick, somewhat tense and accelerated; the thirst is still considerable, and the skin dry and warmer than natural; the whole system is irritable; the temper is fretful or discontented; slight headache is experienced; and tran- sient pains are often felt in the extremities and the back. In many instances a short and dry cough occurs, with some oppression in the chest, or other pectoral affections. Richter observes, that inflam- matory intermittents are very rarely attended with symptoms of gastric disturbance from vitiated secretions, bile, &c. The intermis- sions in agues of this kind are usually short. (Richter.) 2. Congestive intermittents occur seldom. They happen ge- nerally in persons of exhausted and debilitated habits; and in such as are of an irritable and nervous temperament, connected with habitual or accidental debility. They are characterised by a very protracted cold stage, deep-seated pain in the head, vertigo, fainting, a sense of weight or oppression in the breast, coma, a small and weak pulse; the hot stage coming on very slowly, and developing itself very im- perfectly, so that instead of hot skin, flushed countenance, and a full and vigorous pulse, the system continues to be oppressed, the skin scarcely warm, the countenance pale and contracted, the breathing confined and anxious, and the pulse frequent, small and tense, with an internal sensation of heat. 3. Gastric intermittents are characterised by prominent symp- toms of gastric and intestinal irritation, redundancy of biliary secre- tion, and other saburral matters lodged in the alimentary canal. The ordinary intermittents of the temperate climates, occurring in autumn, are usually of this kind. Intermittents of this modification are attended with a foul and bitter tongue; much nausea and bilious vomiting; great pain in the forehead; diarrhoea, an icteric hue of the skin and albuginea; urine loaded with bilious matter; thirst for acid drinks, and sensation of weight or fulness in the right hypochon- drium. Intermittents of this kind are apt to produce visceral disor- ders, more especially indurations of the spleen and liver; and finally, a cachectic condition of the system which it is often extremely dif- ficult to remove. (Richter.) 4. Malignant intermittents are of frequent occurrence in hot climates, and are always of the most dangerous character. They are characterised by a very copious and fetid perspiration in the third stage, together with colliquative haemorrhages from various parts of the body, sometimes petechia, and other marks of malignity. They run their course with great rapidity, death usually taking place in the third paroxysm. (Alibert.) INTERMITTING FEVER. 107 Irregular and anomalous intermittents. Intermittents do not, however, always pursue the regular course that has just been de- scribed. In some instances, anomalies of a remarkable character occur, both in relation to the phenomena, and the succession of the stages of the disease. I have known a case, in which the first twro paroxysms occurred, in a perfectly regular manner; but after employ- ing arsenic, unsuccessfully, during the second and third intermissions, the paroxysms returned without a cold stage, the patient experi- encing, instead of it, a peculiar feeling of numbness on the top of the head, with great dulness of hearing, for. about forty or fifty mi- nutes before the supervention of the hot stage. There are instances on record, of the inversion of the natural order of the cold, hot, and sweating stages; several distinct instances of which occurred under my observation in the fall of 1828. Cases have been noticed, in which the perspiration, in the third stage, was substituted by diar- rhoea; and Cleghorn states, that he saw tertians, which terminated by an increased flow of urine, with scarcely any sweat. In infants, the paroxysms of intermitting fever are sometimes ushered in by convulsions; but the convulsions are most apt to occur at the commencement of the hot stage. Indeed, the cold stage of very young children is seldom marked by distinct rigors. A pale and shrunken countenance, with an obvious reduction of the tem- perature of the surface, yawning, and stretching, usually manifest the presence of this stage in infants. There are certain affections, not of unfrequent occurrence, which, from their strict periodicity, as well as from their apparent origina- tion from the same causes that give rise to intermittents, are termed masked agues, febres intermittentes larvaise. Thus, neuralgia, in various parts of the body, sciatica, rheumatism of the eye, haemi- crania, toothach, cramp in the stomach, dysentery, cholera, hiccough, mania, and acute pains in other parts of the body,* have been known to recur in a manner strictly periodical, and to have yielded readily to the same remedies which are found to arrest the course of an ague. These affections, when thus perfectly periodical, generally manifest their alliance to intermitting fever, by being almost always preceded by a very slight sensation of chilliness, and by being at- tended with a moist skin and a turbid urine at the termination of the paroxysm. (Ritcher.) Intermittents are sometimes complicated with other affections, such as dysentery, cholera, jaundice, and visceral inflammations. The vernal intermittents are most apt to become complicated with inflammatory affections; and those which occur in autumn are most frequently combined with disorders of the alimentary canal and ner- vous system. Paralysis and apoplexy, according to the observations of Dr. Macculloch, are by no means uncommon occurrences in inter- * Macculloch on Intermittent and Remittent Fever, &c. See also, Journ. General de Med. No. 291, foot note. Also, Gazette de Sante, No. 17. 108 INTERMITTING FEVER. mitting fever; and they occur, sometimes, as direct consequences of the influence of the miasmata, without any distinct febrile phenomena. Many of the affections which supervene in intermittents, appear to result from the inroads of the fever itself on the constitution; but the majority of these maladies, whether occurring as concomitants, sequelae, or substitutes of the fever, are, without doubt, direct con- sequences of the deleterious influence of the remote cause. Drops)'', jaundice, scirrhous, &c. are, probably, usually the result of the gen- eral febrile disease. Unquestionably, too, aneurismal enlargements of the heart and large vascular trunks, must be regarded as the con- sequence of the violent congestion of the blood which occurs in the internal organs during the cold stage. In the same way, apoplexy sometimes occurs in the commencement of intermitting fever; for the blood recoils so powerfully from the external to the internal vessels, in the cold stage of the disease, that those who are, in other respects, predisposed to determinations to the head, are liable to suffer apoplectic oppression of the brain from this cause. Dr. Mac- culloch warmly opposes the opinion, that in apoplexies of this kind, there is any particular congestion of blood in the brain. The cases which I have myself seen, however, do not permit me to doubt that they were essentially connected with cerebral pressure from inor- dinate vascular turgescence. It is not unlikely, however, that those apoplectic symptoms which occur as the immediate consequence of the powerful influence of miasmata on the brain, independent of chills, or torpor of the vessels of the surface, are in no way depend- ent on cerebral compression from sanguineous congestion. Paralysis, neuralgia, mania, &c, as well as the above named affec- tions of the alimentary canal, are, however, almost invariably direct malarious affections; occurring, with or without any manifest febrile phenomena; and frequently exhibiting their affinity to intermitting fever, by their paroxysmal and strictly periodical character. For a full exposition of the nature, phenomena, and management of these miasmal diseases, the reader is referred to Dr. Macculloch's Treatise on Intermitting and Remitting Fever. But if intermitting fever has a tendency to produce other affec- tions, it has been found also to remove various diseases of a chronic and obstinate character. Celsus observes, that intermitting fever is often remedial of itself. (Lib. II. cap. 8, p. 70.) The tendency of quartans to cure epilepsy, is mentioned by Hippocrates; (Epidem. 1.) and we are told that the celebrated mathematician De la Hire, was permanently relieved of an habitual and most violent palpitation of the heart, by an attack of ague of the quartan type. (Academ. des Sciences, l'An. 1718. Hist. p. 110.) Fordyce states, that rheuma- tism, cutaneous eruptions, hysteria and indigestion, have been effec- tually removed by attacks of intermitting fever; and Vogel asserts, that he has known asthma and hypochondriasis cured by this disease. Almost all writers, however, attribute much more sanative power in this respect to quartans than to either of the other two types. INTERMITTING FEVER. 109 Intermittents, when suffered to pursue their course without being controlled or embarrassed by external influences, appear to have a natural tendency to terminate spontaneously, after a certain number of paroxysms have been passed through. Quotidians, for instance, if they are simple and regular, will tend to terminate their course on the seventh day, and tertians on the fourteenth. Quartans will gene- rally run on to the sixth week. Of the natural tendency of the two former types to terminate at about the periods just indicated, I have the strongest conviction from my own observations. The disease may not generally terminate spontaneously at these periods, but its tendency to do so will be such, that if assisted by a proper febri- fuge, it will not only more certainly be arrested, but a relapse will scarcely ever occur, unless the remote cause continues to act on the system. Every one who has had considerable experience in the treatment of intermittents, must have been struck with the great fre- quency of relapses, even where the patient has been removed out of the sphere of the influence of the remote cause. From what 1 have observed in relation to this subject, I will venture to say, that if the usual febrifuges were withheld until after the seventh paroxysm, such an occurrence would, under all circumstances, be comparatively very rare. I have already adverted to the tendency of intermitting fevers to relapse at stated intervals; and although I cannot under- take to reconcile the apparent opposition in these statements, namely, that fevers of this kind tend naturally to terminate and also to re- lapse at the septenary periods; yet of the truth of the observation 1 entertain the strongest conviction. Prognosis.—The intermittents of temperate climates are among the least dangerous of febrile affections. In hot latitudes, however, they often assume a highly malignant and fatal character. Death from a simple and mild intermittent does nevertheless sometimes occur; and when this happens, it is nearly always in the cold stage, and with symptoms of apoplexy. I have met with two fatal in- stances of this kind., The violent internal congestions which occur during the cold stage, are well calculated to produce cerebral op- pression and apoplexy, particularly in persons who are naturally predisposed to this malady. In general much less danger is to be apprehended from this disease in the young, robust, and vigorous, than in persons of feeble, nervous, and depraved habits of body. In individuals of the latter habit, there is sometimes not sufficient vital energy to react and develop the hot stage, and they occasionally sink into a state of lethargy or fatal apoplexy. The more irregular an intermittent is, in relation to its type and particular phenomena, the more difficult in general it is to effect a permanent cure. Post- poning agues are more favorable than such as anticipate their pa- roxysms. The latter tend to the continued form. A scabby and humid eruption about the mouth and nostrils is a favorable sign. When habitual discharges, whether natural or morbid, re-appear after having been suppressed by the ague, perfect convalescence generally Vol. I.—10 110 INTERMITTING FEVER. soon follows. The state of the digestive functions has an important bearing on the prognosis of intermittents. So long as digestion is performed with considerable activity, and there are no decided marks of gastric irritation, very little difficulty in general will be expe- rienced in removing the disease. But when these functions are pro- minently deranged, and there are manifestations of much debility of the stomach, we may calculate on meeting with considerable diffi- culty in our efforts to prevent the return of the paroxysms; for even should a temporary stop be put to the progress of the disease, the liability to relapse in this state of the digestive apparatus, is such as to render the best directed treatment often abortive. Delirium seldom occurs in intermittents, and when it does hap- pen, it must be viewed as unfavorable; and even more so than mere coma. In malignant intermittents, delirium is common; indeed, it may be regarded as almost peculiar to the worst varieties of this disease. Difficult and oppressed breathing, attended with hiccough and frequent deep sighing, is a bad sign. Sydenham observes, that a tumid and hard abdomen, with swelling of the tonsils, is in general indicative of a fatal termination. One of the most unfavorable signs is a profuse and prolonged colliquative and offensive diarrhoea. Bloody urine also is very unfavorable. The latter symptoms are almost exclusively confined to the violent intermittents of hot cli- mates. When, during the intermission, the patient remains very much debilitated and oppressed, and the feet and legs are oedema- tous, considerable danger may be justly apprehended. Tertians are, in general, more readily removed than quotidians, and quotidians than quartans. Intermittents not unfrequently change into the remittent form; and this conversion is, of course, always an unfavorable occurrence. When such a change is about to happen, the paroxysms of the intermittents are progressively prolonged until they run into each other. Simple tertians always reduplicate their type, before they assume the continued or remittent form. The conversion of intermittents into the remittent form, is particularly favored by whatever is capable of causing or augmenting the gene- ral phlogistic condition of the system, and especially by the acci- dental supervention of some internal inflammation. The unseason- able employment of tonics and stimulants is frequently productive of such changes in the form of the fever. Causes.—The only general cause of intermitting fever is koino- miasmata. Intermittents are the simplest, and in general the least dangerous of all the febrile diseases produced by this variety of mi- asmata. In the vicinity of marshes, we may often trace the various grades of miasmatic fevers from the most violent and fatal to the simplest and mildest varieties, as we progressively remove from the focus of the deleterious exhalations towards the circumference of its influence. On the borders of the soil, whence the miasmata ema- nate, if very copiously engendered, continued and highly fatal cases of bilious fever will prevail; at a greater or less distance from this INTERMITTING FEVER. Ill point, mild remittents will predominate; and at a still more remote situation, intermittents will be most common. From the same cir- cumstance, the first diseases which occur in miasmatifc districts are generally intermitting fevers; as the season advances, remittents occur, and finally prevail with great violence; as the cold weather approaches, and the extrication of miasmata begins to diminish, intermittents again become more common, and the remitting fevers gradually disappear. The tendency of koino-miasmata to produce intermittents, is much enhanced by sudden changes of atmospheric temperature. Intermittents are never more prevalent than when the days are very warm, and the evenings and mornings cool and damp. In some instances, several weeks elapse between the reception or im- pressions of the miasm, and the occurrence of the fever. I have repeatedly known persons to be attacked with intermitting fever in this city, several weeks after they had been exposed to koino-mias- mata in the country.* Persons who have been exposed to mias- mata, should carefully avoid every thing capable of debilitating the system, and particularly the digestive organs, for at least two weeks after exposure. Although koino-miasmata maybe regarded as incomparably the most frequent cause of intermitting fever, yet various other causes may, under favorable circumstances, give rise to this form of fever. Richter observes, that worms and other causes of intestinal irritation have been known to produce intermitting fever. He mentions, also, suppressed catamenia, and haemorrhoidal discharge, as well as the drying up of old ulcers, as occasional causes of intermitting fever. I have seen one instance, in a delicate child, where a distinctly formed ague was manifestly produced by intestinal irritation from too free an indulgence in irritating articles of food. An interesting case is related by Mr. Earle,t in which a regular intermittent was produced by the irritation of a small piece of dead bone in an old wound, and which was at once arrested on removing the irritating * Upon this point Dr. Macculloch differs, so far as I know, from every other writer who has attended to this subject. He maintains that the interval be- tween the application of the miasmata, and the first manifestations of its morbific effects on the system, seldom, if ever, extends beyond twenty-four hours. " I know not," he says, " if physicians have fairly observed that the supervention of intermitting fever may be later than twenty-four hours from the exposure to the cause;" and he asserts that the attack of intermitting, as well as remitting fever, "sometimes instantaneously follows the application of the poison." That the febrific powers of miasmata may be manifested very soon after they are applied, cannot be questioned, but the assertion that the period between the re- ception of the poison, and its obvious effects, does not probably extend beyond twenty-four hours, is undoubtedly contradicted by almost daily experience in our own climates. f Medico-Chir. Review, January, 1827. 112 INTERMITTING FEVER. substance. It would seem that either the generation of miasmata, or their power of producing intermitting and remitting fevers, is greatly controlled by certain occult conditions, wholly unconnected with any appreciable circumstances, with regard to atmospheric tem- perature, or any of the other known requisites for the production of this poison. In certain districts of the temperate latitudes, malari- ous fevers will sometimes disappear, or become extremely rare for a number of successive years; and then gradually become more and more common, until, in the course of a few seasons, they assume the prevalence of an epidemic; and yet, no material difference will be obvious between these periods of exemption from, and prevalence of disease, in relation to what are deemed the necessary concomitants for the production of miasmata. Proximate cause.—In relation to the proximate cause of this form of fever and of its periodicity, we may at once confess our entire ignorance; for all that has hitherto been advanced in relation to these mysterious subjects, amounts to nothing more, at best, than some ingenious conjectures and hypothetical speculations, with a great deal of crude and absurd reasoning and idle suppositions. As to the sentiments of Broussais, which place the proximate cause of this and all other fevers in an inflammation of the mucous membrane of the alimentary canal, it can neither be profitable nor interesting to repeat again what I have already advanced in refutation of its correctness. Treatment.—The treatment of intermittents must be considered under two distinct heads; namely, that which is proper during the paroxysm; and that which is to be employed during the intermis- sions, and upon which the radical cure of the disease depends. In the ordinary regular intermittents of the temperate latitudes, remediate interference during the paroxysm of the disease is ex- tremely uncommon, and is indeed very generally altogether unne- cessary. Nevertheless, where the febrile excitement becomes very violent in the hot stage; or where the system is so enfeebled that dangerous congestions and oppression occur during the cold stage, medicinal aid is not only proper, but sometimes absolutely essential to the safety of the patient. During the cold stage of an intermit- tent, the patient ought to be kept moderately warm; and as the thirst is generally very urgent, bland and warm drinks should be freely allowed. In general, however, stimulating drinks, and the appli- cation of much artificial heat, with the view of moderating the dis- tressing sense of cold, are improper; since they very rarely lessen the feeling of chilliness, and tend often considerably to increase the violence of the succeeding hot stage. These observations apply to the regular disease, occurring in individuals of sufficient vital energy to develop the hot stage, without any artificial support. When the patient is feeble, nervous or exhausted, it will, generally, be beneficial to aid the vital powers during the cold stage, both by external and internal exciting agents, more especially, by the application of ex- INTERMITTING FEVER. 113 ternal heat. Without such aid, the cold stage will probably be greatly prolonged, and the system so oppressed, by internal conges- tions, as to prevent the regular development of the subsequent stages. Various means have been adopted for the purpose of curtailing the cold stage; and of these, emetics and opium appear to be the most efficient. An emetic administered at the beginning of this stage, will frequently put a speedy termination to its progress; and a full dose of opium, taken a short time before the expected occurrence of the chills, will generally have the same good effect. This latter remedy was particularly recommended by Dr. Trotter; and other eminent physicians have given their testimony in its favor. In de- bilitated and relaxed habits the exhibition of a grain or two of this narcotic, just before the accession of the chills, will generally prove decidedly beneficial. 1 have frequently resorted to it in cases of this kind, with obvious advantage. In persons of a full and vigo- rous habit of body, it will rarely do any good, and may readily do mischief by increasing the violence of the reaction and of the deter- mination to the brain, in the hot stage. Compression with the tour- niquet, also, was some years ago, strongly recommended to the pro- fession, from arresting the cold stage of intermittents, by Dr. Kellie.* I have known it to be employed in four cases, and although the effects of it were by no means equal to those which Dr. Kellie as- cribes to it, there was, nevertheless, a manifest impression made on the violence and progress of the chills. Dr. Kellie asserts, that by obstructing the circulation in an upper and in a lower extremity, by means of a tourniquet, we may in general, stop the cold stage in three minutes; and that if the compression be made immediately previous to the accession of the cold stage, it will be entirely pre- vented. The limited experience which I have had in relation to this practice, does not confirm this very favorable account of its effects; although some, and occasionally perhaps considerable advantage may, no doubt, be obtained from it. I should apprehend, however, that in vigorous and plethoric subjects, considerable danger must attend this practice, from the tendency which it must have to favor vascular tur- gescence of the brain; and thereby dangerous oppression or apoplexy. Within the last two years, Dr. Mackintosh has published some highly interesting observations on the utility of blood-letting in the cold stage of agues, which, though contrary to the sentiments uni- versally entertained, concerning the character of this stage of febrile development, and the known tendency of blood-letting, are never- theless too strongly confirmed, by well attested facts, to justify us in rejecting them, without farther experience. "There are few things," says a late writer, "more repugnant to the imagination of a medical man than that of venesection in the cold stage of intermit- tents. Books and lectures all inculcate a diametrically opposite prac- * Medical Commentaries for the years 1794-1797, by Dr. Duncan of Edin- burgh. 10* 114 INTERMITTING FEVER. tice. We see the face and the surface of the body pale and cold; the pulse feeble and quick; the teeth chattering; the whole body shivering; and the suffering patient huddling himself up in all the clothes he can find to keep the spark of life from being extinguished! The very idea of abstracting the vital fluid, which seems almost en- tirely to have vanished, is horrible. But yet, when we come to re- flect that the blood has only shifted its place from the circumference to the centre, and that the internal vessels, and organs must now be gorged with this fluid, and as it were in a state of suffocation, there is nothing very incongruous in the attempt to relieve the suffering organs, by abstracting a portion of blood from the general circula- tion." Moreover when we advert to the circumstance that blood- letting has been strongly recommended and successfully employed, to remove the internal congestions which occur in typhus fevers, where there is generally an actual deficiency or impairment of the vital energies, it does not appear so very extraordinary, that the same means should be adequate to restore the equilibrium of the cir- culation, or to remove the internal congestion in an ague, where the vital powers are not impaired, but only oppressed. Dr. Mackin- tosh states, " that he has seen men in the most severe sufferings from the chills relieved after the abstraction of six, eight, and ten ounces of blood; and he has known three ounces to suffice. The relief, which is the most perfect relief that can be conceived, is so sudden, when a good orifice is made, that it has surprised and delighted every one who has seen this practice." Dr. M. had this practice tried on himself in 1S10; and, although bark and other remedies had entirely failed, he found that before twelve ounces of blood had been drawn, " the rigors ceased with all their unpleasant accompaniments," and neither the hot nor the sweating stage ensued. (t A pleasant sense of heat succeeded the painful one of cold; and, instead of weakness, he was sensible of an acquisition of strength." He afterwards bled many other patients in the cold stage of this malady, and uniformly with the same favorable results. This practice was put in operation in the Royal Ordinance Hospital, of Edinburgh, in the presence of many medical gentlemen, and must, therefore, be regarded as amply attested.* In a single instance I have drawn blood, in the cold stage of this disease; and in this case, it moderated the violence of the chills and curtailed their duration in a manifest degree. I have not since had a favorable opportunity of repeating this practice, but from the result of this case, and the strong testimony of Dr. Mackintosh, I feel inclined to give it a further trial, whenever an opportunity of do- ing so shall present itself. It cannot be presumed, however, that this practice is equally well adapted to all cases. Dr. Zabriskie, of New York, states that he found it,in general, decidedly beneficial in persons " of a plethoric, full habit, with strong pulse, and not enfeebled by in- temperance or by the fever." In patients enfeebled by intemper- * Ed. Med. and Surg. Journ. April, 1827;'and Medico-Chir. Rev. July, 1827, page 186. INTERMITTING FEVER. lis tince, or the long continuance of the fever, with a small and weak pulse, bleeding in the cold stage sometimes gave rise to alarming symptoms.* In the hot stage, it sometimes becomes necessary to moderate the violence of the febrile excitement, especially when delirium or alarm- ing local determinations take place. Blood-letting is of course the most direct and efficient means for this purpose, and where the indi- cations for antiphlogistic measures are strong, it ought to be promptly employed. In agues of a decidedly phlogistic diathesis, blood-letting during the hot stage will often contribute considerably to the suc- cessful employment of the bark in the intermission. I have some- times known the bark promptly efficient in arresting the disease after a copious blood-letting during the paroxysm, where it had previously failed. In cases attended with a very hot and dry skin, and a full and vigorous pulse, cool, bland and acidulated drinks are both grate- ful and salutary. A draught of cold water while the skin remains dry, will often speedily subduct the febrile heat and predispose to perspiration. It may also be proper, in instances of very high general febrile excitement, to exhibit some of the refrigerent dia- phoretics—such as nitre—antimony—the saline effervescing mix- ture.! As soon, however, as the skin begins to be moist, cold drinks must be withheld. During the last or sweating stage, we may allow tepid drinks of a bland character freely. When the stomach is extremely irritable—giving rise to frequent and violent vomiting in the cold or hot stage, tepid diluents should be given, until there is reason to think that the bile is discharged. Opium is, perhaps, our best remedy for checking excessive vomit- ing in this disease. This article does not often aggravate the vio- lence of the reaction, when given in the hot stage, as might be ap- prehended. Indeed, Dr. Lind zealously advocates the propriety of exhibiting a full dose of opium, soon after the hot stage is deve- loped, as a general practice. He asserts, that it takes off the burning heat of the fever, hastens the accession of the sweating stage, and often produces a soft and refreshing sleep, from which the patient awakes free from all complaints, and in full perspiration. He thinks, moreover, that the use of opium in the hot stage tends to obviate dropsy and jaundice. I have given opium in the hot stage to check vomiting, and have always found it to answer this purpose very promptly and completely, without any unpleasant consequences. I cannot,however, think that opium is a proper remedy in the hot stage of ague, unless it be in broken down constitutions, or in such as are * Amer. Jour, of Med. Scien. vol. xiii. page 80. | The following mixture is an excellent remedy for this purpose— R.—Spirit. Minderiri. ^iv. Spirit. Nitr. Dulc. gii. Vin. Antimon. 3L Syrup Limonis, %i.—M. Take a tablespoonful every hour. 116 INTERMITTING FEVER. • feeble and exhausted by previous injurious influences—or unless it: be employed to remove some accidental affection of a distressing or dangerous character. In cases where the reaction of the heart and arteries is incomplete, and where much internal congestion con- tinues to exist through this stage, opium is, without doubt, a valu- able remedy. To put a stop to excessive vomiting in this, as well as in other diseases, not attended with phlogosis of the mucous membrane of the stomach, I know of no medicine which is more promptly and certainly effectual, than a solution of camphor in sul- phuric aether, in the proportion of two scruples of the former to an ounce of the latter; of which twenty or thirty drops may be given with about ten grains of calcined magnesia every half hour until the vomiting is arrested. I have rarely found the second dose necessary. Whatever advantage may result from remediate treatment during the paroxysm, universal opinion concurs in regarding the inter- mission as the proper period for the safe and certain radical treat- ment of intermitting fevers. In prescribing for the radical cure of intermittents, it is of no small consequence to attend to the particu- lar character of the disease in relation to the four modifications or varieties mentioned above; for each of these requires some peculiar modifications of treatment. 1. The inflammatory variety, as has already been stated, is marked by symptoms during the intermission, which indicate an irritated and phlogistic condition of the system, incompatible with the salutary influence of the bark and the other febrifuge remedies of this kind. In this modification of the disease a strictly antiphlogistic treatment must precede the employment of the tonics usually resort- ed to. The patient must be put on an antiphlogistic regimen; one or two cathartics composed of calomel and jalap—or calomel, suc- ceeded in a few hours by an ounce of Epsom or Glauber's salts, will be proper; and where the inflammatory diathesis is very conspicu- ous, blood-letting, nitre, antimonials, &c. are often indispensable. In cases of this character, blood-letting will, in general, prove most effi- cient in reducing the phlogistic habit, when it is practised pretty co- piously during the hot stage. In cases of vernal intermittents, in which the bark or quinine had failed in consequence of the general irritated and phlogistic condition of the system, I have succeeded perfectly with these febrifuges, after the patient had taken one of the following powders,* every two hours during an intermission, and a small bleeding in the hot stage of the succeeding paroxysm. In the congestive and malignant varieties of ague, it will seldom be proper to lose much time in preparing the system for febrifuge tonics. In such cases, the powers of the system must be economised, and tonics early and liberally resorted to. In the gastric modifica * R.—Pulv. nitrat. potassse 3iss. pulv. doveri. gr. yj. calom. gr. vj.—M. In chart. No. yj. dividend. INTERMITTING FEVER. 117 tion, which is most commonly met with in the temperate latitudes, there exists obvious indications of gastric impurities and disorder— such as nausea; bilious vomiting and purging; foul tongue; loss of appetite; pains in the stomach and bowels; bitter or depraved taste, &c. In intermittents of this character, it will be peculiarly proper to attend to the state of the alimentary canal, before the bark or tonic remedies are resorted to. Mild mercurial purgatives are generally decidedly beneficial. In some instances, it may be necessary to repeat them several times before the bowels are brought to a proper state for the employment of febrifuges. Emetics, too, will often contribute much to the success of the bark or quinine. In inter- mittents of a well-formed inflammatory character, there are seldom any unequivocal manifestations of gastric impurities, and hence these evacuations are much less useful or important in them than in the variety I have termed gastric. Among the various articles which have been recommended for the cure of intermittents, the Peruvian bark and its preparations, is, unquestionably, by far the most important. Within the last ten years, the sulphate of quinine has, in a great measure, taken place of the bark in substance, and in many respects, this preparation pos- sesses important advantages over the crude material. It has indeed been said, that the bark itself will sometimes remove the disease where the quinine has failed; but the converse may be said with equal correctness; for I have, in several instances, succeeded with the latter, after the former had been used in large doses without suc- cess. Mr. Valpes, of Naples, in a recent communication to the French Royal Academy of Medicine, states, as the result of his in- quiries, that the sulphate of quinine is preferable to the cinchona, in intermitting fevers, whilst the latter is preferable in the fevers formerly denominated putrid* and which are produced by idio- miasmata.t From my own experience, I have not been led to think that there exists any essential difference in the febrifuge virtues of these two remedies; but as the quinine is much less nauseous, and can be given in sufficient doses in a very small bulk, I should, from these advantages, always prefer it to the bark in substance, unless * Revue Medicale, Mai, 1828, p. 306. ■j- In March, 1825, the number of lunatics brought to the Maison d'Aversa in the kingdom of Naples, was so great, that it was found necessary to lodge them in a convent, which was" not properly prepared to receive them. The most filthy of these unfortunate beings were put into a small dormitory, which was in a state of extreme filthiness. A fever soon broke out among them, which was at first regarded as a petechial fever, and was treated by antiphlogistics. The disease made a rapid progress, and became unusually fatal. The sulphate of quinine was finally employed, but this appeared rather to aggravate the symp- toms, than to afford any advantage. At last, the bark in substance was given, and immediately resulted in the happiest effects.—Revue Medicale, Mai, 1828, p. 306. 118 INTERMITTING FEVER. some idiosyncracy exist against its influence, which can be ascer- tained only by experience. Much difference of opinion has been expressed, both in relation to the period of the disease, and the particular time of the intermission, at which the bark may be most effectually administered in this form of fever. It has been contended, that it will generally be much better to suffer several paroxysms to take place, before any attempt is made to arrest their recurrence. Recamier has recently advocated this practice, as both the most effectual and the safest to the future health of the individual. I do not at all doubt the correctness of this mode of management. Unquestionably, a great majority of our ordinary agues may be immediately arrested, and with perfect safety, by giving the bark, during the first or second intermission; but in this case relapses are much more common than where the disease has been suffered to run on to the fifth or seventh paroxysm. 1 have found agues arrested after the first or second paroxysm, relapse again and again, until they were suffered to run on to the fifth or seventh day, when a few doses of quinine put a permanent stop to their progress. It has long been my practice, when I have met with relapsing agues, to suffer them to run on through five or seven paroxysms, before any attempt was made to arrest them, and I have invariably found this plan permanently successful. In cases which require prepara- tion, especially in inflammatory intermittents, delay is, of course, essential, before the bark can be employed with propriety. I would not, however, lay it down as a general rule, that the disease should be suffered to run on through five or seven paroxysms; for where the apyrexia is very complete, and the patient experience no feelings of illness during the intermissions, the bark may almost always be given with complete success, as soon as the bowels are evacuated by a suitable cathartic* In instances of an opposite character, or such as have shown a tendency to return after a week or two, it will be very difficult to put a final stop to the paroxysms, if the febrifuge be employed during the first or second intermission. A case came under my notice, during the preceding autumn, which had already relapsed four times, and always punctually on the seventh day. After each relapse, the patient took quinine in full doses, which always arrested the disease for the short period mentioned. When he applied to me, I advised him to suffer his disease to go on for some time, without any other medicine than a mild purge every other day. He did so; and on the ninth day, the disease left him spontaneously and permanently. The foregoing observations apply, of course, to the regular in- termittents of the temperate latitudes; for, in that rapid and fatal variety which is termed malignant, no time should be lost by pre- paratory measures, but immediate recourse had to large and frequent doses of the bark, as soon as a favorable intermission occurs. The * R.—Pulv. jalap . . . Calomel aa. gr. x. M. INTERMITTING FEVER. 119 same rule applies to the disease occurring in very feeble, nervous, and exhausted subjects; for unless it be speedily removed, the system may sink under the repeated shocks of the paroxysms. With regard to the particular period of the intermission at which the bark may be most successfully given to arrest the succeeding paroxysm, a diversity of sentiments have been expressed by writers. Some have advised its employment in large doses immediately after the sweating stage has passed off; whilst others recommend it to be given largely, " as near to the time of the expected paroxysm as the condition of the patient's stomach will allow," (Cullen.) There are others, again, who think it best to exhibit the bark in divided and frequent doses, throughout the whole period of the intermission. (Fordyce.) A\ few years ago, Dr. Ridgway published some cases, which go to show, that one large dose of cinchona given as near as possible to the commencement of the approaching paroxysm, will as certainly avert the paroxysm, as when given in repeated doses throughout the intermission.* Since Dr. Ridgway's publication, Dr. Brown, of Boston, has published a small work, in which he ad- duces testimony of a similar purport.t According to Dr. Brown's experience, two or three grains of the quinine taken just as the first symptoms of the approaching paroxysm are experienced, will, when followed up at intervals with a second, third, and sometimes a fourth dose, almost invariably put a stop to the disease. When given just as the cold stage commences, " its influence over the rising symp- toms becomes manifest in a few minutes; the pulse becomes more full and distinct; the respiration more easy; the skin acquires its natural temperature; and, in eleven minutes in his own case, not one unpleasant symptom remained." This state, however, generally continues but a short time, and it becomes necessary to repeat the dose, sometimes three and even four times before the paroxysm is subdued. Dr. Ridgway gave an ounce of the bark at once, as soon as the premonitory symptoms of the paroxysm were felt, and always found it to prevent the attack. There can be no doubt that the dis- ease may be speedily arrested in this way; but it may be reasonably questioned, whether it possesses any real advantage over the plan of exhibiting this febrifuge in efficient doses during the latter period of the intermission. I have generally prescribed the quinine in two grain doses every hour, commencing about six hours before the be- ginning of the approaching paroxysm; and I have had no cause to be dissatisfied with the consequences. Indeed, I have reason to apprehend that a large dose of quinine given during the chills, is calculated to produce very disagreeable effects. In two instances, one a delicate married lady, and the other a lad about twelve years old, a most singular and raving species of maniacal affection ensued, apparently from taking large doses of this medicine after the chills * London Medical and Physical Journal for April, 1825. f A Treatise on repelling the Paroxysm of Intermittent Fevers. Boston, 1836. 120 INTERMITTING FEVER. had commenced. In both instances this alarming mental disturb- ance continued for several hours. I may be wrong in ascribing it to the cause here assigned, but the circumstances strongly favored the suspicion. Whatever views we may adopt, with regard to the time at which it may be best to begin with the bark or quinine, there can be no doubt concerning the propriety of giving large doses,* in such a manner as to make a decisive impression on the system in the latter period of the intermission. I am well satisfied that two or three large doses—three grains of the quinine, given two or three hours before the paroxysm, will do more towards averting it, than a larger quantity exhibited in small doses throughout the whole interval of the apyrexia. In relation to the propriety of employing emetics and cathartics as preparatory measures for the use of the bark, au- thors express contradictory opinions. Unquestionably, where the signs of gastric impurities are conspicuous, and there exists no urgent necessity from the nature of the case, to arrest the disease promptly, it will be proper to evacuate the alimentary canal previous to the employment of the bark. These evacuations will also be useful in cases where the inflammatory habit is so strong as to prevent a com- plete apyrexia. Nevertheless, in the ordinary cases of the disease, where there are no signs of a loaded state of the bowels, and the apy- rexia is very complete, the bark may be successfully employed without either previous purgation or emesis. Upon the whole, however, I should in all instances of this disease, not attended by malignity or great prostration, prefer one or two mild cathartics, before the bark is taken, for the reasons already mentioned. The Peruvian bark has been frequently accused of having a ten- dency to produce visceral indurations and other unpleasant conse- quences, such as rheumatism, dropsy, &c. This accusation is, how- ever, wholly unfounded. No doubt, indeed, can exist that these and other injurious consequences may be produced by the injudi- cious employment of this remedy. When given, for instance, in agues, attended with strong marks of an inflammatory condition of the system, without proper antiphlogistic preparatory measures, we can readily conceive that the bark would favor the natural tendency of such cases to terminate in these disorders. In this respect, how- ever, the bark does not differ from other tonic and stimulating reme- dies; for it is not by any thing peculiar in the bark that these effects are produced, but simply by the power it possesses, in common with the majority of febrifuge remedies, of favoring the phlogistic dia- thesis, and the progress of obscure inflammations. The bark is now generally given by itself. Formerly it was cus- * If the bark in substance be employed, not less than two drachms ought to be administered at each dose. Such doses taken at intervals of an hour, or an hour and a half, within the last five hours of the intermission, will, perhaps, do all that can be effected by bark in this disease. INTERMITTING FEVER. 121 tomary to give it in conjunction with various other remediate arti- cles which were thought to augment its febrifuge powers. It is extremely doubtful, however, whether any combinations can mate- rially improve its virtues; and unless some particular circumstance be present which may render the use of other remedies proper, or unless the bark by itself produce unpleasant or injurious effects on the alimentary canal, it will probably be best to employ it singly. When it causes much constipation, it may be usefully given as follows: R.—Pulv. cinchon. condam. ^j. ----rhei. gss. ----muriat. ammoniae gj.—Misce. In chart. No. iv. dividends. One to be taken every hour or two. When the bark purges, it should be given with small portions of Dover's powder, or opium. The former, especially, acts beneficially in such instances, five grains of which may be given at each dose. Alkaline remedies become necessary in cases where there are signs of much acid in the stomach. The subcarbonate of potash is an ex- cellent adjuvant to the bark in cases of this kind. From ten to twenty grains of the alkali may be given with each dose of the bark; and to prevent this from acting on the bowels, which it is apt to do, it is generally necessary to make a triple compound—viz., bark, sub- carbonate of potash, and opium, or what is better, confectio opii. When the stomach is irritable, the bark will generally be speedily rejected. In this case we may sometimes cause it to be retained by uniting it with some aromatic substance, such as serpentaria, or cloves, or nutmeg, or the calamus aromaticus. The serpentaria is, perhaps, the best aromatic adjuvant to bark, where the stomach is too weak to retain it singly. I have, however, always found small doses of opium to answer better than any other remedy for this pur- pose. The addition of powdered black pepper answers extremely well in cases where the vomiting arises simply from gastric debility. Where, however, this occurrence depends on a highly irritated condition of the mucous membrane, neither this nor any other aro- matic can be proper. In this condition, indeed, the bark itself can- not be employed until the gastric irritation is subdued by leeches, blisters, or cupping over the epigastrium. The employment of the quinine is much less apt to produce the inconveniences just mentioned than the bark in substance; but even this preparation will sometimes produce violent purging or vomiting —several very violent instances of which I have encountered in my practice. Formerly it was custoinary to employ the decoction, or the tincture, or what is better, both in union with each other, where the bark in substance could not be conveniently administered, or where the stomach rejected it. Since the introduction of the qui- nine into practice, however, this mode of exhibiting the cinchona Vol. I—11 122 INTERMITTING FEVER. has been but little employed; nor does it appear probable that any circumstances can occur which may not be as well met with this very convenient and concentrated preparation, as with either the de- coction or the tincture of the bark. The most convenient and ele- gant formula for exhibiting the quinine, is, perhaps, the following: R.—Sulphatis quinae gr. xvj. ' Elixr. vitriol gtt. xvj. Syrup, limonis ^j.—M. Dose, a teaspoonful every hour or two for an adult. < As this mixture, though a very neat and concentrated one, is sometimes much objected to on account of its bitterness, especially by children, I have generally prescribed it according to the follow- ing formula, by which almost all the bitterness is wholly removed: R.—Sulphat. quinae gr. yj. Elixr. vitriol gtt. x. Pub. extract, glycyrrh. sjjss. Aq. fontanae ^ij-—M. Dose, a teaspoonful for a child between two and five years of age. In cases of ague, which, from long continuance, or from some pre- vious malady, are attended with visceral indurations or enlarge- ments, the quinine or bark must be given, either after a gentle mer- curial course, or in conjunction with mercurial remedies. The blue mass will in general answTer best for this purpose, as it is mild, and less apt to pass off by the bowels than calomel. In many instances of this kind, the bark will, in fact, fail entirely in putting a stop to the continuance of the disease; and I have known it to do manifest mischief even when given in conjunction with mercury. In such cases, mercury is the appropriate remedy; and, under careful ma- nagement, will rarely fail to arrest the disease. From three to five grains of the blue mass, taken thrice daily, until the gums become slightly affected, will generally suffice to remove the complaint. Besides bark and its preparations, a vast variety of other reme- dies, drawn both from the mineral and vegetable kingdoms, have been employed with success, in the treatment of intermittents. As nearly all of them are, however, confessedly inferior to the cin- chona, it will be sufficient here, barely to mention them. The most efficient of these articles are the following: viz., the barks of the dog-wood, (cornus florida;) of the American tulip poplar, (Lirio- dendron tulipfera;) of the horse-chestnut, (E. hippocastanum;)of different oaks; of different species of willow; the Virginia snake- root; colomba; gentian; quassia, &c. Coffee is highly recom- mended by Grindel; given in doses of from fifteen to twenty grains every hour, it is said almost invariably to arrest the disease, (Richter.) The black, or cellar spider's web, is highly recommended bv Dr. INTERMITTING FEVER. 123 Robert Jackson,* as a remedy for intermittents. He is of opinion, "that it prevents the recurrence of the intermittent paroxysms more abruptly and more effectually than even bark or arsenic." I have employed this article in six cases; two of these were speedily cured, the others resisted its powers entirely. Shrader speaks of this article as an effectual remedy for agues, in his Dispensatory, published as early as 1644. It certainly possesses very considerable powers in allaying morbid irritability, and in calming the excitement both of body and mind. In my own person, it produces the most delight- ful state of mental and corporeal tranquillity, far exceeding that which is caused by opium.t It is given in five or six grain doses every three or four hours. The muriate of ammonia is favorably men- tioned by Richter as a remedy in this disease.J He considers it especially useful in agues attended with gastric impurities, or a loaded state of the bowels; and in cases connected with visceral indurations. It should be given in union with quinine or cinchona in substance. I have used it myself, in cases attended with induration and enlarge- ment of the spleen, and with the most favorable effects. The mu- riate of ammonia is, perhaps, the most powerful remedy we pos- sess for resolving indurations, when given in very large doses inter- nally. In Germany, it has of late years been much and very suc- cessfully used in enlargements of the prostate gland, and other similar affections. In my own practice, I have had the most satis- factory proofs of its very excellent powers in this respect. I have given it to the extent of three drachms daily. In intermittents, with indurated spleen, it may be given in combination with quinine, in tile proportion of twenty grains of the muriate of ammonia to two grains of the latter. The former ought to be continued after the quinine may no longer be necessary—that is, after the paroxysms have been arrested. Salicia has recently been much extolled for its excellent febrifuge powers. It is given in doses of from twenty to forty grains. M. Miquel has published an account of its use in this disease, from which it would appear, that it is little, if in any degree, inferior to the quinia in intermittents. It has also been used by Dr. Gerardin with marked success. Other physicians in France and Italy have employed it for the cure of intermittents, with satisfactory results. Dr. Berti, the erudite editor of Burserius's posthumous works, speaks very favorably of its febrifuge virtues.§ Among the mineral preparations, arsenic is, undoubtedly, the most efficient, with the exception, perhaps, of the sulphate of zinc. Arsenic was employed in this disease near a century ago, by Jacobi;|| * London Medical and Physical Journal, vol. xxi. f Eberle's Therapeutics, vol. ii. p. 121, first edition. X Specielle Therapie, vol. ii. § North Amer. Med. and Surg. Jour., vol. x. p. 192. || De Arsenico sale alcalico domiti usu interno salutari.—Acta Academ. Elet. Mogunt. torn. i. p. 116. 124 INTERMITTING FEVER. but it was not till Fowler and Brera published their experience, in relation to its medicinal powers, that it was brought into general notice as a remedy in agues. It is, unquestionably, a very efficient remedy in this disease; but, in individuals of a cachectic habit, or where there is a scorbutic tendency, it is apt to cause dropsical effu- sions, as well as great debility and symptoms of general depravation of the system. It appears, moreover, to be improper in phthisical constitutions, and where a strong phlogistic tendency prevails. Of the tendency of arsenic to produce anasarcous effusion, I have had a strong illustration within the present year. I prescribed Fowler's solution to a syphilitic patient, and, although his nodes and nocturnal pains were removed, he became universally anasarcous. Arsenic appears to be best culculated to remove this disease without detri- mental consequences, in individuals of a firm and vigorous constitu- tion. The usual mode of prescribing it is in the form of Fowler's solution, or the liquid arseniate of potash. From eight to twelve drops may be given every four or five hours during the intermission. 1 have generally given it in substance in union with opium, formed into pills in the proportion of one-tenth of the oxyd of arsenic, to one-fourth of a grain of opium every three or four hours during the apyrexia. BietVs arseniate of ammonia is, I think, decidedly the best arsenical preparation for internal use. Since the publication of the first edition of this work, 1 have employed this arseniate, in various affections—particularly in an instance of periodica1 neural- gia, and in several instances of herpes, with peculiar advant ™y dePend>in Part, on the peculiar con- pecullr tvfng u 1S 0' "7" fcat thlS a^ ^ that there exists some KS k i f j hlS P°rtl0n of the resP'™tory passage, during infancy manS; (,,;°°d' "™™«*<*. P™ba%> with mere L'e of aplrture, I manifest from the characteristic voice, at this early period and its remarkab,e ehange during the period of pubescence.^ 'there L another circumstance which may have a large share in the so com- mon occurrence of this malady during infancy, namely the almost universal custom of dressing children so as {o keep {he neck and upper part of the thorax perfectly bare, and thus rendering them more liable to the injurious influence of cold in these parts. Certain exanthematous affections also, often give rise to an increased aptitude for this disease. 1 his is especially the case with scarlatina, measles and miliary fever. Observation would seem to show that florid robust, and fat children, are much more liable to the disease than those who are of an opposite habit. The principal exciting cause ofthis disease, is cold or sudden vi- cissitudes of atmospheric temperature; and hence, its greater preva- lence during the variable, damp, and cold months of autumn and spring, than in the more temperate and uniform season of summer Cynanche tracheal.s is said to have prevailed epidemically; but con- trary to vvhat obtains, in this respect, with epidemic catarrh, these epidemic cynanche are, always, of a very limited sphere, with regard to the extent of country which they embrace. In general, this dis- ease is most apt to prevail after, or during the prevalence of measles or scarlatina. During convalescence from these affections, there ex.s san especial aptitude to cynanche from the influence of cold It would seem too, that the liability to this disease, is often considera- bly increased, by having suffered an attack of it. 1 have known the same individual suffer five or six attacks of the disease, during the period of childhood. & Cynanche trachealis is a phlegmasial disease, consisting essentially of inflammation of the mucous membrane of the superior portion of the respiratory tube. The correctness of this pathology is confirmed not only by the known character of its most common exciting cause, but especially, also, by the more direct evidence of the symptoms of the disease, and the appearances discovered on post mortem ex- amination. r The observations of Bretonneau in France, and of Mackenzie in England, published within a few years pas', go directly to the es- tablishment ofthis view of the nature of the disease. Both these observers assert that the inflammation often commences in the fauces and on the tonsils and descends thence into the trachea; a progress of the disease, which may be verified by ocular inspection. I have myself seen several cases of croup, which commenced by a kind of erysipelatous or superficial inflammation, about the tonsils and soft palate; and in one instance, this inflammation continued for four days, and was the object of medical attention before it extended vol, I.—28 326 CYNANCHE TRACHEALIS. into the trachea and gave rise to the symptoms of croup.* The inflammation which occasions the characteristic phenomena of this disease, rarely remains confined to the larynx and trachea. In many instances, it extends downwards into the bronchia, and sometimes even into the small ramifications, giving rise to the simultaneous existence of acute bronchitis and laryngeal inflammation. The danger, from this disease, is always greater, cseterisparibus, in pro- portion as the inflammation passes down into the bronchial ramifica- tions. Indeed, when bronchitis co-exists extensively, the result must almost inevitably prove unfortunate. In some instances, the laryngo-tracheal inflammation terminates, after a shorter or longer period from its commencement, in the for- mation of a false membrane; which, according to the latest and most accurate observations, appears to consist of a concrete albumenoid secretion.t In other instances, the inflammation terminates in the secretion of a muco-purulent matter of an opaque and yellowish ap- pearance, without the formation of a pseudo-membranous substance. There are other cases again, and these are perhaps much the most common, in which the inflammation produces neither false mem- brane, nor a puruloid matter, but an extremely copious secretion of a very viscid, limpid, and frothy mucus.% M. Blaud, in his excel- * It is surprising that a disease so manifestly phlogistic in its character, should still be viewed by some of the German and French writers as essentially spas- modic in its nature, or at least, as wholly independent either of a local or ge- neral inflammatory condition. Several of the late continential writers on this disease regard the fever and inflammation, which they acknowledge sometimes to exist, as wholly accidental, and as in no manner essential to the perfect con- stitution of the malady. Among the principal antiphlogistic pathologists, in re- lation to this affection, may be mentioned Des-Essartz, Banafox,(a) Ruette,(6) Schneck,(c) Lobstein,(d) Professor Nasse regards impaired or disturbed func- tion of the pneumo-gastric nerves, as the proximate cause of the disease. The symptoms which characterise this disease, he asserts, bear a very strong resem- blance to those which result from the division of the eighth pair of nerves. The inflammation which occurs in the mucous membrane of the respiratory passages, is, according to his views, secondary, and the consequence of the disordered function of the pneumo-gastric nerves. | According to the experiments of Schwilgue, this membranous substance is insoluble both in cold and in boiling water, but perfectly soluble in a solution of the alkalies. By incineration, it yields deuto-carbonate of sodium, proto-phos- phate of lime, &c; corresponding, thus, entirely, with the properties of coagu- lated albumen. X Nouvelles Recherches sur la Laryngo-Tracheite. Par P. Blaud. A Paris, 1824. (a) Jour, de Med. Chir. Pharra. Sec. torn, xxxvii. November, 1816. (A) Traite de l'Asphyxia connue sous le nom de Croup. (c) Bib. Med. torn. xii. p. 256. (d) Mem. de la Societe Med. d'Emulation 8° annee iie. part. p. 538. CYNANCHE TRACHEALIS. 327 lent work on this disease, maintains that these different modes of ter- mination constitute good grounds for dividing the disease into three principal varieties, indicating three different grades of inflammation. The inflammation, he says, is at the highest grade of violence, in those cases which are attended with the formation of false mem- brane. It is less violent in the instances where there is only a muco- purulent fluid formed; and in those cases in which a copious secre- tion of a tenacious, limpid, and frothy mucus occurs, the inflamma- tion is at its lowest grade. In the first and most aggravated variety of the disease, the cough and respiration is always dry, or free from that peculiar rattling sound in the respiratory passages, which occurs, when these contain viscid secretions. This dryness of the cough, usually continues for many hours, after the disease is fully deve- loped. The pain in the larynx is often very considerable, and the febrile reaction is generally violent. The period at which the false membrane is formed, after the commencement of the inflammation, appears to vary considerably. In some cases, M. Blaud found the larynx and trachea lined with such a membranous substance, although the whole course of the disease did not occupy more than twenty hours; in other instances, several days appeared to elapse before it was formed. Occasionally, only a part of the internal surface of the larynx is found coated with this concretion; but in some instances, it has been found to extend into the bronchiae, and even into the smaller divisions. Sometimes, instead of a membranous expansion, we find, on dissection, the upper part of the trachea almost entirely blocked up, by a thick mass of the concreted albumenoid secretion, lodged just within the glottis. In cases in which this membranous substance is not formed, the cough early becomes somewhat humid, and the respiration rattling; and before the disease has continued many hours, the mucus in the larynx and trachea is so copious as lo threaten suffocation by ob- structing the glottis. M. Blaud thinks, that the extremely viscid mucus which is formed in these milder cases, is entirely different in its properties from the secretion which occurs in the former variety —and that it is incapable of being so inspissated as to give rise to a pseudo-membranous substance. Whatever may be thought of M. Blaud's division of this disease, or of his sentiments in relation to the radical distinction between the inflammation and secretion which give rise to membranous structures, and that inflammation and its consequent mucous secre- tion which occurs in cases unattended with the formation of false membrane, it must be admitted, that there exists at least a twofold diversity in relation to the immediate local consequences of the laryngotracheal inflammation—namely, one variety in which false membrane is formed, and in which the cough and respiration are at first dry, or do not indicate the existence of much mucus in the respiratory passages; and another variety in which the cough and respiration are humid, in the early period as well as throughout the 328 CYNANCHE TRACHEALIS. disease, and in which a very copious secretion of transparent and extremely viscid mucus occurs. The former are exceedingly dan- gerous, nay, almost hopeless, unless subdued, by the most prompt and powerful antiphlogistic measures, in their very onset. The lat- ter are much less dangerous, and may generally be cured by more moderate antiphlogistic measures, and the expulsion, from time to time, of the tenacious mucus from the larynx and trachea. In nearly all cases, the mucous membrane of the larynx and trachea is found very manifestly congested on dissection; and the glottis is frequently considerably narrowed by a kind of thickening or tume- faction of its lips. With regard to the ratio symplomatum, it may be observed, that the immediate cause of the distressing difficulty of respiration, and finally of death, consists in an obstruction to the passage of the air into the lungs. The circumstance which causes the exclusion of the air from the lungs, consists either in a spasmodic closure of the glottis, or, in an occlusion of this aperture by tumefaction of its sides, or, by the formation of false membrane or a mass of concrete lymph, or, finally, by an excessive quantity of a very ropy and vis- cid mucus closing up the passage. Death is also, sometimes, the immediate consequence of a copious serous effusion into, and conse- quent choking up of, the bronchial cells, a mode of termination, which, almost always, occurs when the inflammation descends into the bronchial ramifications. Spasmodic contraction and closure of the glottis may be caused, by irritation excited by the upper portion of the false membrane. Prognosis.—Laryngo-tracheitis is always to be regarded as a very dangerous affection. Formerly the majority of cases terminated fatally; but under the present improved pathology and mode of management, the proportion of fatal cases is greatly diminished. Frightful and unmanageable as this disease is, when suffered to pur- sue its course uncontrolled, or when opposed by inadequate means, it is, nevertheless, almost as much under the dominion of a prompt and vigorous antiphlogistic treatment, as any of the more serious phlegmasial affections. The degree of danger appears to be pro- portionate to the violence of the inflammation, and the extent to which it may have passed downwards into the pulmonary pas- sages. It would seem, also, that the more sudden the attack, when attended with strong febrile excitement, the greater, in gene- ral, is the danger. When, however, the disease supervenes sudden- ly without fever, the attack, may be presumed to be purely spasmo- dic,* and may readily yield. The shriller and more sonorous the cough, the more reason is there to apprehend danger. It must be observed, however, that the prognosis in this disease is often exceed- ingly fallacious. Sometimes the symptoms yield, and promise a * Under the head of Asthma, in the second volume, some observations are made on Spasmodic Croup. CYNANCHE TRACHEALIS. 329 speedy convalescence, when a violent exacerbation will suddenly supervene and destroy the patient: and on the other hand, death may appear to be impending, when, on the sudden expulsion of a membrane, or even without such an occurrence, a rapid fthange for the better will ensue, and lead on to full convalescence. Diagnosis.—There is but one disease which may be mistaken for laryngo-tracheitis, namely, spasmodic, or cerebral croup. From this latter form of disease it may be distinguished: by, 1. The attack of cynanche laryngo-trachealis, generally, coming on gradually, with the ordinary initial symptoms of catarrhal af- fections; spasmodic croup always supervenes suddenly, and is rarely preceded by catarrhal symptoms. When the former does come on suddenly, which is sometimes the case, it is so manifestly a febrile affection, that, by this circumstance alone, it may be readily distin- guished from the spasmodic disease. 2. Cynanche is essentially a febrile affection; spasmodic croup is free from fever, except it be accidentally present. 3. Cynanche is often attended with considerable remissions, but not with complete intermissions, except perhaps immediately after vomiting. Spasmodic croup is, often, marked by complete inter- missions, of considerable duration. 4. Cynanche is always attended with a hoarse and sonorous cough, and frequently with a copious secretion of viscid mucus in the tra- chea. Spasmodic croup is rarely accompanied with much cough, frequently none at all, and it is always dry.* 5. The peculiar stridulous sound of the cough and inspiration, so characteristic of cynanche laryngo-trachealis, does not occur in spas- modic croup. 6. In spasmodic croup the pulse is small and contracted, and the skin not above the natural temperature. In cynanche, the pulse is excited and irritated, being generally full, frequent, quick, and tense; and the temperature of the surface is febrile, except towards the fatal conclusion of the disease, when, from the imperfect func- tion of respiration, animal heat ceases to be generated in its normal proportion. Treatment.—From what has been said above, of the nature and character of this disease, it is obvious that the general indications to be kept in view in its treatment are: 1. To subdue the local and ge- neral inflammatory action as speedily as possible; and, 2. To promote the discharge of the viscid and coagulable secretions which are lodged within the superior portions of the respiratory tube. For the fulfilment of the former of these indications, the most prompt and energetic antiphlogistic measures must be adopted. He who * Dr. Rush has published an account of a dissection of a child that had died of spasmodic croup. In this subject, no membrane, nor even mucus was found in the respiratory passages, nor did the lungs exhibit the slightest traces of pre- vious disease. 38* 330 CYNANCHE TRACHEALIS. loses sight of, or neglects this all-important indication, and places his hopes in one or more of the empyrical remedies that have, by different practitioners, been extolled for their supposed specific tendency to counteract the tracheal affection, will, we may be confi- dent, have but little reason to flatter himself for his success in the management ofthis malady.* The remedy upon which we must place our principal reliance for the reduction of the tracheal inflammation is blood-letting, in conjunction with external vesicating or irritating applications to the throat. Here, however, as in most of the other phlegmasial diseases, the good effects of the lancet are confined to the early period of the disease. If bleeding be neglected, or inefficiently employed, in the first stage of the malady, its progress will be extremely perilous, whatever other remediate measures may be adopted. When called to a patient laboring under this disease, in whom the manifesta- tions of high febrile excitement and active tracheal inflammation are conspicuous, a vein should be opened, and the blood suffered to flow until an approach to syncope is induced. As soon as this ef- fect is produced, all the distressing symptoms usually subside. If in the course of an hour or two the difficulty of respiration re-ap- pears, and the pulse be not soft and feeble, more blood should be . drawn, and again to the extent of inducing an approach of syncope. I have been obliged to open a vein three or four times in the course of twelve hours, before a permanent and decisive impression was produced on the disease. Such copious depletion is, however, de- manded only in cases where the local and general inflammatory action is strong—where the pulse is tense, hard, quick, and vigo- rous, attended with a dry and sonorous cough and respiration. Such cases are apt to terminate in the formation of a false membrane in the larynx; and our efforts ought to be prompt and vigorous to re- duce the inflammation below the grade necessary for the formation of pseudo-membranous matter. After the effusion which gives rise to the membrane has taken place, bleeding will afford but moderate and temporary advantage. It must also be observed, that where the disease is attended with but moderate symptoms of febrile excitement; where the pulse is not hard, or tense, though accelerated; and especially where, in ad- * It was owing to physicians not attending to the essentially inflammatory na- ture of this affection, and the consequent indispensableness of prompt and vigo- rous antiphlogistic measures, that this disease was formerly so much more fre- quently fatal than it appears now to be. It is also owing to this error, or rather to the erroneous views which have been so common concerning the pathology of this disease, that so many physicians have objected to the employment of blood- letting, and expressed their willingness to confide in mercury, poly gala senega, carbonate of ammonia, and hepar sulphuris, to the exclusion of the direct and powerful antiphlogistic means, long since so universally and so successfully practised by American physicians. CYNANCHE TRACHEALIS. 331 dition to these manifestations of a moderate febrile excitement, the cough and respiration are attended, early, with a copious, trans- parent, and viscid mucus, blood-letting need very seldom be em- ployed to the extent just mentioned, and may even, in some instances, be wholly dispensed with.* Emetics are important remedies in this disease, and may, indeed, be regarded as indispensable in its remediate management. Assisted by warm pediluvium, mercurial purgatives, and rubefacients to the throat, I have frequently subdued mild attacks of the disease without the aid of direct depletion. In those cases that are early attended with a copious secretion of viscid mucus in the larynx and trachea, emetics are especially useful. They tend not only to expel this tough mucus from the larynx, and thus to give a temporary freedom from the dyspnoea, but also to equalise the circulation and to pro- mote the cutaneous exhalation, as well as to diminish the general arterial excitement by the nausea which precedes and accompanies their operation. In infants affected with this disease, the occasional employment of an emetic is particularly important; for at this early age, no voluntary efforts are made to dislodge and expel the viscid secretion from the larynx, and which, if not removed, may by itself cause suffocation. In those violent cases, which manifest a highly inflammatory character, and in which the cough and respiration are dry during the first stage, there is commonly but little advantage gained from the operation of an emetic, so long as this dryness of the larynx and trachea continues. In such cases, the proper period for the administration of emetics commences with the appearance of the viscid secretions, which always sooner or later occur in the re- spiratory passages, and from which the disease derives its most seri- ous and dangerous character. Without doubt, from the general an- tiphlogistic tendency of nausea and emesis, some benefit may result from the exhibition of emetics before any morbid secretions occur in the larynx; but the peculiar advantages of this class of remedies are most assuredly more conspicuously displayed when the upper portions of the wind-pipe are clogged with a viscid fluid, which re- quires expulsion. In the advanced periods of the disease, there * In no country is blood-letting so actively employed in this, as indeed in all other inflammatory affections, as in America. The value of this evacuation in the present disease has been long understood by American physicians, whilst in Europe it was, until lately, looked upon as an equivocal, if not an injurious mea- sure. Even those who admitted the inflammatory nature of the disease, bled but very sparingly. To this there are indeed some remarkable exceptions. Ferriar recommends bleeding, ad deliquium. (Med. Histories.) " This," says he, " is the essential point, without which no relief can be effected." The same practice is strongly inculcated by Drs. Bayley and Middleton. (Cases of Angina Tra- chealis, with the Cure, in Letters to William Hunter, M. D. 1781.) And in the late medical journals, observations may be found equally favorable to decisive depletory measures in this formidable malady. 332 CYNANCHE TRACHEALIS. exists o'ften so much torpor or insensibility of the system, in conse- quence of the imperfect decarbonisation of the blood and vascular congestion in the brain, that great difficulty is experienced in pro- curing the operation of emetics. To obviate this gastric insensi- bility, and procure emesis, we must endeavor to diminish the sanguineous congestion in the head; and this may, in general, be readily accomplished by putting the patient's feet in warm water, and applying a napkin, wet with very cold water, to the head. The abstraction of blood, too, while the patient is supported in a sitting or erect posture, will rarely fail to ensure the operation of an emetic under the circumstances in question. The articles 1 prefer as an emetic in this disease are calomel in combination with tart, antim. I commonly administer from five to six grains of the former article with one-fourth of a grain of tart, antim. to a child of from two to five years old. I have frequently given from eight to ten grains of calomel alone, and have very generally found it to excite active vomiting in a short time. The peculiar advantages which appear to me to belong to this practice, are the protracted and great degree of nausea which the calomel produces, an effect which has a powerful antiphlogistic tendency; and the alvine evacuations which almost always speedily ensue. Besides these effects, great benefit may be expected from the early constitutional influence of the calomel—an influence which, in the present disease, especially, is very generally acknowledgad to be highly salutary. Be this as it may, universal experience decides in favor of the employment of emetics in this disease. Tart, antim., ipecacuanha, sulph. zinci, squills, sulp. cupri, have all been used and recommended in this affection; and where the object is merely the expulsion of the tracheal mucus, or pseudo- membranous matter, any of these articles may answer our purpose.* In some instances, where the accumulation of the tenacious secretion is very rapid, it becomes necessary to repeat the emetic three, four, or five times in the course of twenty-four hours. M. Jadelot recommends the following mixture as an emetic in croup, after proper depletion has been practised: R.—Infus. polygalas %iv. Syrup ipecac. £i. Oxymel scillae giij. Antimon. tart. gr. iss.—M. Take a spoonful every fifteen minutes, until vomiting is produced. Purgatives are useful auxiliary remedies in the treatment of this disease. In the onset of the complaint, the bowels should be * I have, in a few instances, prescribed an infusion of the lobelia inflata, with the happiest effect. From its known very powerful influence upon the respira- tory function in asthma, independent of its emetic operation, there is some reason for presuming, that in relation to the present disease, it may possess peculiar virtues, and my limited experience with it inclines me to this opinion. CYNANCHE TRACHEALIS. 333 briskly evacuated, and two or three evacuations should be subse- quently procured daily until the inflammation is subdued. After the first purge, which should be energetic, it is best to employ the gentler articles of this class of remedies; for very active catharsis tends to exhaust the resources of the system without procuring any peculiar advantages over milder aperients, and may even do harm. After the first cathartic, it will in general be sufficient to keep the bowels in a loose state by laxative enemata. Calomel, given with a view to its constitutional influence, is a remedy which has been, and by many is still much extolled in the treatment ofthis disease. Many of the continental writers seem to look upon it as decidedly the most valuable means we possess for removing the local tracheal affection. In our own country, too, this article has found some eminent advocates as a remedy in inflam- matory croup. The late Dr. Rush placed great reliance on its pow- ers in this disease; for he asserts, that when given in large doses in the commencement of this disease, and continued afterwards in smaller doses, " it is hardly less efficacious in this complaint than the Peruvian bark is in intermittents." Dr. Hosack also speaks very favorably of the employment of calomel and James's powder in combination, given at short intervals in the second stage of the complaint; and the late Dr. Bard placed much reliance on its pow- ers. That the constitutional influence of mercury is calculated to do good in croup, I am well persuaded from my own experience. It tends in no small degree to reduce the local laryngo-tracheal inflam- mation, and to counteract, as it would appear, the formation of the pseudo-membranous exudation. Its operation in this respect is, however, much too slow to afford particular advantage in the more acute and rapid cases of the disease, many of which run to a fatal termination in less than twenty-four hours. Where the complaint assumes somewhat of a chronic character, we ought not to lose the advantages which may be derived from this remedy. My usual mode of giving this article after the first or second emetic is to ex- hibit one grain every hour or two, with about one-fourth of a grain of ipecacuanha. The warm bath, also, is a very useful auxiliary in the treatment of this disease. Employed along with the remedies already men- tioned, its benefits are often very considerable, more especially where the skin is very dry and hot. Its usefulness is, however, confined to the early periods; for, in the advanced stages, the skin is generally bathed with profuse perspiration, and the pulse weak and soft. Concomitantly with the preceding remediate measures, external rubefacient and vesicating applications to the throat ought, in all in- stances, to be employed. One of the first measures after bleeding should be the application of a blister, or some irritating substance to the throat of the patient. I prefer the application of the spirits of turpentine to blisters or any other similar article. The action of 334 CYNANCHE TRACHEALIS. the turpentine on the skin is prompt and powerful, and if the deriva- tive powers of such applications be proportionate to the degree of irritation and pain they produce, few articles can equal the present one in this respect. A piece of flannel may be imbued with the turpentine and applied round the neck. Children seldom will bear this application for more than twenty or thirty minutes at a time. It must, therefore, be removed and reapplied from time to time, ac- cording to the violence and permanency of its effects on the skin. In general, it has appeared to me that active rubefacients are prefer- able to blisters in this complaint. They generally act with promp- titude and force—a circumstance of no small consideration in a dis- ease which often runs its course in a few hours. A blister requires from four to five hours before its effects on the skin can be of any particular avail. An efficient blood-letting ought always to precede such applications in cases attended with high febrile excitement. The oil of the monarda punctata, with an equal proportion of camphorated liniment, forms also an excellent rubefacient in this affection. Where the disease proceeds slowly, the use of a blister will be preferable to rubefacients. With regard to the local abstraction of blood by means of leeches, general experience does not enable us to ascribe any peculiar advan- tages to it. It has never yet appeared to me to afford any greater advantage than if the same quantity of blood had been drawn with the lancet. Besides the foregoing remediate measures, which may be justly regarded as decidedly the most direct and powerful means for com- bating this malady, a number of other remedies have been recom- mended—some of which have been distinguished by the title of specific. Among these pretended specifics, the poly gala senega and the hepar sulphuris (deuto-sulfure of potassium) have attracted the most attention. The former of these articles is, without doubt, a use- ful medicine in certain states of this disease; but it is, most assuredly, far from possessing the powers which were formerly ascribed to it by Archer and others. In the commencement of the disease, especially in the more violent cases, it is objectionable on account of its stimu- lating properties; but after the complaint has been in some degree subdued, or lost its acute inflammatory character, its influence is often conspicuously beneficial. For the removal of the dry and hoarse cough and slight oppression of the respiration, which in some instances remain after the inflammation has been subdued, we possess no remedy equal in usefulness to the polygala. It is, moreover, a decidedly useful remedy in all instances of chronic croupy afl'ections, and in the catarrhal and pectoral affections which remain as the se- quela of this and other acute affections of the respiratory organs. It is best given in decoction. An ounce of the root to a pint of boiling water suffered to simmer for 15 or 20 minutes and afterwards sweet- ened with honey. The dose of this is about an ounce every hour or two, according to the urgency of the symptoms. CYNANCHE TRACHEALIS. 335 With regard to the hepar sulphuris, a remedy introduced to the notice of the profession about 16 years ago, in a prize essay on this disease presented to the French Ecole de Medecine* little can now be said in commendation of its powers. Its introduction was founded on the erroneous doctrine that croup consists essentially in a morbid coagulability of the tracheal mucus, and which, it was asserted, the sulphuret of potash had the power of preventing or altering. It need scarcely be observed, however, that a remedy which might possess such power, without, at the same time, exerting any influence in subduing inflammation could afford us but little advantage in this affection; and the result of later experience goes to show that this, at first highly lauded remedy, exerts no decided influence over the tracheal inflammation. It would be a waste of time, to pass in re- view the various other remedies of this kind, which have at times been praised, and again abandoned as curative means in this disease. As well might we look for specifics for the cure of pleurisy, phre- nitis, or gastritis, as to expect to find one for laryngo-tracheitis. It has already been stated above, that the exudation of albumenoid fluid, which forms the false membrane, frequently commences on the surface of the tonsils, and thence spreads along the arches of the palate, and at last descending over the internal surface of the pha- rynx and oesophagus, as well as the larynx and trachea. According to the experience of Dr. Mackenzie, the application of a solution of the nitrate of silver to the tonsils, velum palati, and uvula, will in such cases frequently remove the membranous crust completely, and produce speedy and great relief, and ultimately entirely remove all the symptoms. The solution employed by him is of the strength of a scruple of the nitrate of silver to an ounce of distilled water. I have seen one instance in which this application was made, and the result gave me a very favorable impression of this practice. It must of course be confined to those cases in which the fauces are found, on inspection, to present an irritated and inflamed condition. Dr. Laennec has lately published a statement, from which it appears that insufflation of very finely powdered alum generally affords great and speedy relief, not only in this variety of the disease, but alsoin cynanche laryngea and tonsillaris. As cases ofthis kind are not uncommon, the practitioner ought in all instances to examine the fauces; and where the soft-palate and tonsils are found to be inflamed and oedematous, a local application of the kind just men- tioned ought at once to be made. The success of the treatment, must depend materially on the prompt reduction of this primary extra-laryngeal inflammation. With a view of expelling the false membrane, emetics have been recommended in the advanced period of the disease, and the records of medicine are not wanting in instances in which this object was * Rapport sur les ouvrages envoyees au concours sur le croup, par la commis- sion chargee de l'examen et du jugement de ces ouvrages. Paris, 1812. 336 ACUTE BRONCHITIS. effected by such a measure. It offers, however, but an exceedingly slender foundation to build any hopes upon. The same object has in one or two instances been obtained by exciting violent sneezing by blowing snuff into the nostrils through a small tube. As to the proposed operation of tracheotomy in order to detach and remove the membrane, all experience has so far decided against it Sect. IV.—Acute Bronchitis. Peripneumonia Notha. The pathological character of acute bronchitis is very closely allied to common catarrh; and, in truth, the latter affection may be regarded as the lowest grade of mucous inflammation of the bronchia. (Hast- ings.) This form of pneumonic inflammation is most apt to attack old people and infants, or persons of phlegmatic and debilitated habits. It generally commences like ordinary catarrh, with lassi- tude, chilliness, slight cough, and a sense of oppression and tightness about the praecordia. In many instances, the disease seems at first of no very serious character. The patient complains of little or no pain in the breast—a sense of weight and constriction in the thorax being the only uneasiness experienced in that part. In these cases, the febrile symptoms are but moderate. As the disease continues, the oppression at the praecordia increases; the countenance becomes expressive of anxiety; respiration becomes more and more laborious, and is attended with a wheezing rattling sound, as if the air were fosced through a narrow aperture clogged with a viscid fluid. In most instances, there is some degree of hoarseness. In the advanced period of the disease, respiration is much more difficult in the recum- bent than in the erect position; and hence patients generally desire to have the head and shoulders propped up with pillows. At first the cough is dry; but a copious secretion of viscid transparent mucus, resembling the white of eggs, soon takes place, and with it considerable abatement of the violence of the cough occurs. So long as the sputa preserve this appearance, the disease may be re- garded as unchecked in its violence; but when the inflammation is about to terminate in resolution, the matter expectorated loses its transparency, "and becomes mixed with yellowish white or green- ish masses, which are scanty at first, but continue to increase more and more, until at last they compose the whole of the expectora- tion."* In nearly every instance of the disease, severe pain is felt across the forehead, which is always greatly aggravated by cough- ing. When the secretion of mucus into the bronchia is very copious, and respiration much obstructed, considerable drowsiness usually occurs. The tongue is white, and covered with transparent mucus; the skin is dry, and its temperature generally but very little above * Clinique Medicale, &c. Par G. Andral. Deuxieme partie, p. 53. ACUTE BRONCHITIS. 337 the natural standard. The blood is, commonly, buffy, and some- times cupped. Infants are especially liable to this affection. In them the disease manifests itself by a short, quick, oppressed, and wheezing respiration; uneasiness by being placed in the recumbent position; slight cough, somewhat hoarse at first, but humid and rat- tling as the disease advances; a uniformly pale and anxious coun- tenance; pulse frequent and tense; skin above the natural tempera- ture on the trunk—but the hands and feet are commonly cool, or about the regular temperature. Respiration varies greatly: occa- sionally it is easy and free—and then suddenly becomes alarmingly oppressed, threatening instant suffocation. The progress of the disease is usually rapid. If it be not arrested, the breathing becomes more and more oppressed; " the child falls into a comatose state; a slightly livid tinge makes its appearance on the lips, from which the pallid cheeks are not entirely free. But even at this late period, gleams of hope sometimes burst upon us. For a short time the difficulty of respiration may seem to subside, and the child to be better. But these hopes are very seldom realised; for even the next exacerbation may terminate in suffocation." The disease sometimes terminates fatally as early as the third day, though more commonly its course is protracted to the fifth or sixth day. Acute bronchitis is always attended with great muscular debility. In robust plethoric subjects, the febrile reaction in the early period of its course is sometimes as vehement as in pleuritis. In cases of this kind/the inflammation generally passes to the substance of the lungs. Little or no pain, however, is felt in the breast; but the tightness and oppression are extremely distressing, and the breath- ing very laborious. Unless the inflammation be promptly subdued, effusion into the bronchial cells will take place; the lips become pur- ple; the face and extremities cold; the pulse small, laboring, and obstructed; the breathing short and incomplete; and at last drowsi- ness, partial coma, and suffocation, close the scene.* In some instances, acute bronchitis is complicated with hepatic disease; a complication which occurs, not unfrequently, in persons addicted to the intemperate use of spirituous liquors. (Hastings.) Cases ofthis kind, besides the pneumonic symptoms already men- tioned, are attended with tenderness and fulness of the right hypo- chondrium, oppression in the praecordia, nausea, bitter taste, vertigo, headach, dark-colored, and very fetid alvine discharges ; and in some instances symptoms of acute hepatic inflammation attend, more especially when the bronchitis occurs after measles. In children, cynanche trachealis often terminates fatally by the supervention of acute bronchitis. Diagnosis.—The characteristic symptoms of acute bronchitis are: great oppression and tightness in the breast, with little or no pain; * A Treatise on Inflammatiou of the Mucous Membrane of the Lungs. By B. C. Hastings. Vol. I.—29 338 ACUTE BRONCHITIS. severe pain in the forehead, greatly aggravated on coughing; a wheezing rattling respiration; uneasiness in the recumbent position; pallor of the countenance; a very copious secretion of viscid, frothy, and transparent mucus in the bronchia;* and generally a moderate grade of febrile excitement. Post mortem appearances.—In very acute and rapid cases, the lungs do not collapse on opening the thorax, and its whole structure appears to be engorged with a frothy serous fluid. The mucous mem- brane is generally minutely injected—sometimes throughout its whole extent, and occasionally only in patches, the intermediate parts being nearly in a natural state. The smaller branches of the bronchia are usually filled with a tenacious mucus, bloody serum, or purulent matter. In acute bronchitis succeeding pustular exanthe- matous affections, minute ulcerations, with uniform redness of the mucous membrane, frequently occur. In many instances, ihe sub- stance of the lungs exhibits a reddened, hepatised, suppurated, or tuberculated structure; and occasionally even the pleura is found in- flamed with incrustations of false membrane, or effusion into the cavity of the thorax.t The wheezing respiration, and the great difficulty of breathing in this affection, are caused, no doubt, says Dr. Hastings, by the me- chanical impediment to respiration from the redundant viscid mucus lodged in the smaller branches of the bronchial tubes; and the se- vere headach arises probably from " the congestion of the pulmonary blood vessels," interfering with the due return of blood from the head. Deficient decarbonisation of the blood, would seem to be the cause of the great muscular prostration which always attends severe cases of this disease. Although the phenomena just mentioned are very generally pre- sented on dissection, I do not doubt that death sometimes occurs in consequence of the inflamed mucous membrane preventing the at- mospheric air from producing the necessary change in the veinous blood. M. Andral, Jun. has related some cases of mortal dyspnoea from bronchial inflamimtion, where no effusion had taken place, nor any lesion of the parenchymatous structure of the lungs. When the pulmonary mucous membrane is intensely inflamed, the neces- sary influence of the atmospheric air upon the blood, it may reason- ably be presumed, will be more or less diminished; for it can searcely be doubted, that whether the oxygen enter into the blood-vessels, or the carbon be thrown out through the delicate mucous membrane, much impediment will be produced to this process, when this mem- brane is deeply inflamed and thickened. The dyspnoea occurring in the early stage of bronchitis, is, perhaps, mainly attributable to this * M. Andral says, this mucus resembles the white of eggs, and is extremely tenacious. Its tenacity and viscidity increase in proportion as the irritation of the mucous membrane is more considerable. X Hastings, Loc. Citat. p. 186. ACUTE BRONCHITIS. 339 cause, and not to the clogging of the bronchial cells by viscid mucus, as is generally supposed. Patients often die in this disease, it would seem, from asphyxia—the inflamed mucous membrane opposing the transit of the carbon from the blood to the bronchial cells, or of the oxygen of the air into the circulation. The prognosis in this affection is generally attended with much uncertainty; for in cases which appear to be going on without any particular danger, a sudden exacerbation will sometimes occur, and speedily terminate the patient's life. Death, in this disease, is almost always preceded by more or less coma, and occurs, generally, from effusion taking place into the substance of the lungs and bronchial cells. A copious expectoration is always a favorable sign, in this as in the other varieties of pneumonic inflammation. The less thoracic op- pression and dyspnoea there is, the greater will be the chance of re- covery from this disease. Treatment.—Much discrepancy of opinion has been expressed with regard to the value of blood-letting in this affection—some con- sidering this evacuation as attended with much risk, on account of the great tendency to prostration and effusion into the lungs con- nected with the disease; (Richter;) whilst others rely, with much confidence, on prompt and decisive blood-letting. With proper dis- crimination, the abstraction of blood may be as beneficially resorted to in this, as in any other form of pneumonic inflammation. In the acute bronchitis of very old persons, or of worn out and debilitated habits, it is indeed necessary to proceed with much caution in the use of the lancet; but even in cases ofthis kind, moderate bleeding soon after the commencement of the disease, will in most instances prove serviceable. In infants, when I have been called early, I have almost uniformly resorted to one very decisive bleeding; and gene- rally, with unequivocal advantage. In the rapid and violent in- stances which occur in robust, vigorous and plethoric habits, prompt and very efficient bleeding is indispensable. In all cases, however, and particularly in the latter variety, the blood should be taken at an early period—as soon after the development of the inflammation as possible. If delayed until effusion or a copious secretion of bron- chial mucus has taken place, the chance of benefit from it will be greatly diminished, and detriment probably be the consequence. So long as the cough is dry, we may draw blood, with a fair pros- pect of advantage; and a sufficient quantity ought to be taken away, at the first bleeding, to make a manifest impression on the action of the heart and arteries; for a repetition of it will seldom be borne more than once or twice. Cathartics are recommended by some writers, but, except in the very commencement of the complaint, they are of doubtful propriety. The bowels should be kept in a loose state by laxative enemata, or the exhibition of the milder aperients, such as castor oil, or small portions of one of the laxative neutral salts. When, however, the 340 ACUTE BRONCHITIS. disease is complicated with abdominal disease, cathartics may be freely employed with much advantage. Emetics are generally recommended as among the most useful remedies in this affection. They usually procure immediate relief of the oppression in the chest and dyspnoea; and are apt to excite general diaphoresis, as well as more free expectoration. In the bronchitis of infants, they are especially serviceable, by expelling the viscid mucus which clogs the bronchial cells, and thus facilitating respiration, and, thereby, sustaining the powers of the system. Hast- ings observes, that an aqueous solution of tartar emetic is the best medicine for this purpose in adults; and ipecacuanha in children. I have generally preferred using a mixture of vinum antimonii and syrup of squills, in children laboring under this complaint. From 15 to 20 drops of the former, with half a teaspoonful of the latter, may be given every twenty minutes, to a child from one to three or four years of age, until vomiting is produced. Expectorants also are useful remedies in this affection. In the early period of the disease, mucilaginous mixtures, or antimonials, should be employed for this purpose. Thus: R.—Tart. Antimonii gr. ii. Sal. Tartar, ^vi. Aq. fontanae §iiss. Mel. optim. ^iiss.—M. ft. S. A tablespoonful every hour for an adult. But after the general arterial excitement has been moderated, we may resort with much advantage to the stimulating expectorants. R.—G. ammonia? gi. Infusio. polygal. seneg. ^viij. Oxymel. Scill. %i.—M. ft. S. A tablespoonful every two hours for an adult. When the pulse becomes very small and weak, some of the more active stimulants should be exhibited along with the expectorants. For this purpose, camphor and the carbonate of ammonia are valu- able. I have used the following mixtures with much benefit in cases ofthis kind: R.—Pul. camph. 9ii. ---g. arab. ^ii. Syrup Scillae ^i. Triturate them in a mortar, then gradually add, Aq. fontanae §vi. Tinct. opii g. lx.—M. S. Take a tablespoonful every hour or two. Or, R.—Carbon, ammoniae 3ii. Extract, glycyrrh. gss. Aq. fontanae ^ viij. Acid scillae ^ss.—M. S. Take a tablespoonful every hour or two. ACUTE BRONCHITIS. 341 In instances of this kind, Hoffman declares, that the following combination has often, in his hands, afforded complete relief in cases apparently hopeless: R.—Flor. benzoes gr. vi. P. camphor gr. ii. Sacchar. alb. 9i.—M. This dose to be taken every two hours.* Opium cannot in general be given with propriety in this affection, after the bronchial secretion is fully established. By its tendency to suspend for a time the efforts to expectorate, it may readily give rise to dangerous accumulations of mucus in the bronchial tubes. When the cough is dry, however, and the arterial reaction has been mode- rated by depletion, the judicious employment of this narcotic will often procure much relief. " In combination with small doses of ca- lomel, opium may sometimes be beneficially exhibited at an early period of the disease. When conjoined, these remedies not only diminish the cough, and assist expectoration, but seem likewise to regulate the secretion in adults." (Hastings.) In the bronchitis of old people, I have given opium and calomel in the proportion of half a grain of the former to two grains«of the latter, every three or four hours, with much benefit in the early period of the disease. In very young children, however, opium is always to be used with the greatest caution. External irritating applications to the thorax are highly im- portant means in the cure of this disease. Immediately after blood has been efficiently abstracted, a blister should be applied over the anterior surface of the chest, and the surface kept discharging, by some irritating ointment. In children, much benefit usually results from the application of leeches to the chest after general bleeding. Leeching, indeed, constitutes a primary remedy in this affection, and ought always, if possible, to be practised. In many instances, I have known immediate and very great relief obtained from the local ab- straction of blood in this way. A large emollient poultice should be applied after the leeches have been removed; or a blister may be laid over the breast, and suffered to remain until the skin is inflamed, and then replaced by a poultice. The warm bath may also be used with a good effect, where the skin is dry and harsh. A regulated temperature of the atmosphere in the patient's cham- ber is of no small degree of importance in the management of this disease. The air of the room should be kept comfortably and uni- formly warm, so as to favor the action of the cutaneous exhalents.t Low or sudden variations of temperature are extremely apt to have a prejudicial influence in this affection. During the debility, which generally remains after the disease has * Richter's Specielle Therapie, b. i. p. 424. X Broussais, Histoire des Phlegmasies Chroniques, torn. i. p. 149. 29* 342 CHRONIC BRONCHITIS. been subdued, benefit will often be derived from mild and nourish- ing diet, and the use of weak infusions of colomba, gentian, &c. Sect. V.—Chronic Bronchitis.—Bronchial Consumption. Chronic inflammation of the mucous membrane of the bronchia, is an affection of very frequent occurrence in cold and variable cli- mates. In its simplest form it constitutes those protracted catarrhal affections which are common during winter in old persons, and in such as are predisposed to pneumonic irritation. Cases ofthis kind generally commence with the cold weather, and continue to the end of winter. They are characterised by a troublesome cough, attended with copious expectoration of a viscid muco-purulent, or a whitish frothy matter; uneasy and somewhat oppressed respiration, accompa- nied at times with wheezing; more or less weight and uneasiness in the epigastrium; loss of appetite; a slightly furred tongue; irregular action of the bowels; a quick and irritated pulse, particularly to- wards evening; and deep red and scanty urine. The coughing usually occurs in fits of considerable violence, being generally most severe in the morning on arising from bed, or on passing from a warm to a cold air. Sudden atmospheric vicissitudes, also, seldom fail to increase the violence and frequency of the spells of coughing; and the same effect is usually produced by the inhalation of irrita- ting vapors, fine dust, smoke, and occasionally by the act of swal- lowing food. Slight transient pains, are, at times, felt in the chest; frequently, however, no painful sensations whatever are experienced, except immediately after a fifc of coughing, when a general aching pain, is felt for a few moments in the breast. There is another variety of chronic bronchitis, which, in its gene- ral phenomena and effects upon the system, bears so close a resem- blance to tubercular phthisis, that it is not unfrequently mistaken for this latter affection—and which is described by authors, under the name of Catarrhal Consumption. A large proportion of the cases usually regarded as true tubercu- lous consumption, consists of instances of chronic bronchitis; and as a correct diagnosis between these two affections is of much practical consequence, it is especially important that particular attention be paid to the distinctive phenomena, and pathological conditions of the present malady. This, as well as the former variety of bronchitis is the consequence generally of neglected catarrh; and it occurs occa- sionally as the result of an acute attack of bronchial inflammation. At first the symptoms resemble those of ordinary catarrh—the ex- pectoration being viscid, thick, and opaque, but not yellow, contain- ing small lumps, of a firm or viscid, grayish, translucent mucus, CHRONIC BRONCHITIS. 343 which sink in water. Mixed with these sputa, we sometimes find small membranous or flaky substances, which float on the surface of water. (Hastings ) As the disease advances, this viscid mucus be- comes more and more mixed with a yellowish opaque fluid, resem- bling pus, and often slightly streaked with blood. In many instances, the expectoration, at last, acquires a whitish opaque appearance, resembling cream, and sometimes a uniformly greenish yellow color, which readily sinks in water. At first, the pulse becomes slightly accelerated and tense towards evening; and the heat of the surface varies in the course of the day, being sometimes above, and at others below the natural standard. Partial sweats, about the head and breast, occur during the night. The thirst is generally considerably increased; the urine is high-colored, and deposits a copious reddish sediment on cooling. A sense of soreness in the chest, with an occasional transient stitch in the side, is felt in the majority of instances; but there is*rarely any fixed pain in the tho- rax. The cough is usually severe—particularly on rising out of bed in the morning, at which time, the respiration is more or less wheezing, accompanied with a feeling of tightness in the breast. If the disease continue unchecked in its course, the expectoration be- comes at last purulent and extremely copious. Debility and emacia- tion proceed rapidly, and the difficulty of breathing, and sense of weight and tightness across the chest, become more and more dis- tressing. The pulse is now generally very frequent, being seldom under one hundred and twenty in a minute. In the early part of the day the face is usually pale, but a deep flush on one or both cheeks is commonly observed during the evening febrile exacerbations. The tongue becomes clean, and in many instances "it assumes a shining appearance, and is redder than in health." Profuse and exhausting night sweats generally occur at this advanced stage of the disease; and towards the termination of fatal cases, colliquative diarrhoea, and oedema of the ankles, supervene as in tubercular phthisis pulmonalis. Indeed, in the latter stages of the disease, it is generally difficult, if not impossible, to distinguish it with certainty from tubercular consumption; nor is it less fatal in its tendency after it has advanced to this stage, than genuine pulmonary consumption. When chronic bronchitis is complicated with hepatic disease, an occurrence by no means uncommon, it forms what authors have termed <• dyspeptic consumption." In this variety of the disease we have, in addition to the ordinary phenomena of chronic bronchial inflammation, various symptoms indicative of hepatic disorder—such as tenderness and tension in the epigastrium and right hypochon- drium; irregularity of the bowels, with unnatural stools; a sallow hue of the skin, and yellowness of the conjunctiva; flatulency; indi- gestion, with variable appetite; increased dyspnoea, and cough after taking hearty meals; furred and brown tongue; foul breath; and occasional nausea or vomiting. In some instances of this variety of bronchitis, no symptoms indicative of pulmonic affection occur in 344 CHRONIC BRONCHITIS. the commencement of the malady, the only manifestations of dis- ease being such as are usually present in liver affections. A dull pain or tenderness in the right hypochondrium, with increased un- easiness by lying on the left side; irregularity of the bowels; foul tongue, and depressionof spirits, are, in such cases, the first symptoms complained of" by the patient. "The first warnings of disease in the bronchial membrane are slight. There is a dry cough, unat- tended with any pain. By degrees the cough becomes more trou- blesome, and when it continues for some lime, a tenacious mucus is expectorated. The breathing, too, is in some degree affected, and the patient complains of weight and tightness across the chest." The bronchial affection now advances with more or less celerity, until a copious purulent expectoration, and the usual symptoms of hectic, are fully established.* Diagnosis.—The following diagnostic circumstances between chronic bronchitis, in the early period of its course, and tubercular phthisis, will in general enable us to distinguish these two affections from each other. In chronic bronchitis the face is generally pallid, and the lips of a bluish hue. In tubercular phthisis the lips are red, and the cheeks more constantly flushed. " In the beginning of chronic inflammation of the bronchia, the hands and feet are often cold, and the temperature of the surface altogether more variable than in tubercular consumption." More or less inflammation and soreness usually occur in the upper portion of the pharynx, during the early period of chronic bronchitis, which is very rarely the case, in tubercular phthisis. In the former affection the expectoration is free almost from the commencement, and continues to be blended with a large portion of transparent viscid mucus to the end of the disease.t In tubercular consumption, on the other hand, the cough is for a long time short and dry. Chronic bronchitis is attended with much more oppression in the chest, and wheezing respiration, though less pectoral pain, than true pulmonary phthisis.J The paroxysms of hectic fever are much less regular in chronic bronchitis than in tubercular phthisis. Besides these diagnostic indications, the pre- sence or absence of the ordinary signs of a scrofulous habit, as well as the origin and general progress of the disease, will, in general, aid us considerably in discriminating these two affections. In its com- * A Treatise on Inflammation of the Mucous Membrane of the Lungs, &c. By Charles Hastings, M. D. p. 277. ■J- " Early in the disease," says Dr. Hastings, " the absence of pain during in- spiration; the capability of resting on either side in bed, (when there is no abdo- minal disease;) the wheezing noise in respiration; the leaden color of the lips, and the pallidity of the countenance; the appearance of the sputa, consisting almost entirely of mucus, occasionally streaked with blood, are symptoms suffi- ciently well marked to distinguish chronic inflammation of the bronchia from tubercular phthisis."—Loco citat. p. 290. X Dr. Armstrong, on Consumption, &c. CHRONIC BRONCHITIS. 345 mencement and early stage, chronic bronchitis is usually much more distinctly inflammatory than scrofulous phthisis. It should be re- marked, however, that these two forms of pulmonary disease may exist simultaneously; and phthisis pulmonalis is, in fact, not unfre- quently associated in its advanced periods with chronic mucous in- flammation of the bronchia. Post mortem appearances.—On opening the thorax the lungs do not collapse; the capillaries of the mucous membrane are dilated and strongly injected, giving, in some instances, an appearance to this membrane, as if it were composed of a congeries of vessels. (Hast- ings.) This membrane is generally considerably thickened, and in many cases it is found ulcerated in different parts of its extent. The bronchial cells are usually much engorged with purulent matter, mixed with a bloody serous fluid, and a portion of frothy mucus. In some cases the bronchial membrane is covered with numerous mi- nute pimples or eminences, bearing some resemblance to pustules. (Armstrong.) Sometimes the inflammation is found to have extended from the mucous membrane to the surrounding cellular and pulmo- nary structures; and sometimes the submucous cellular texture ex- hibits only a state of redness and vascular congestion; whilst in other instances this structure is condensed and elastic by the deposition of lymph into its interstices. When the inflammation has extended to the substance of the lungs, we usually find it somewhat hard and dense, with loss of its natural elasticity and compressibility. (Bad- ham.) In some cases the pleura is thickly sown with minute tuber- cular depositions, showing that the diseased excitement had extended itself to this membrane. Broussais states, that in the fatal cases of chro- nic bronchitis among the soldiers of the French army, induration of the substance of the lungs was almost a universal pathological phe- nomenon;* and he ascribes the great frequency ofthis disorganised state of the pulmonary structure, to the exposure of the soldiers to wet and inclement weather, while in a state of debility and priva- tion. He states that more or less extensive portions of the paren- chymatous substance of the lungs were almost always found in a state of red hepatisation, interspersed with softened and broken down parts, as if putrefaction had taken place in these points. Causes.—Chronic inflammation of the mucous membrane of the bronchia may occur as the sequel of acute bronchitis. Most com- monly, however, it arises from neglected catarrh. It is the con- sequence sometimes of measles; of hepatic disease; and of protracted disorder primarily located in the digestive organs. It may also proceed directly from the influence of atmospheric inclemency and vicissitudes of temperature; and from the inhalation of irritating vapors or particles of matter floating in the atmosphere—a com- mon source of the disease among stone-cutters, needle-grinders, millers, &c. It occasionally occurs, also, in consequence of hooping * Phlegmasies Chroniques, torn. i. p. 114. 346 CHRONIC BRONCHITIS. cough—particularly from taking cold while under the influence of this affection. Treatment.—The principal indications to be kept in view in the treatment of chronic inflammation of the mucous membrane of the bronchia, are:—1, to diminish the mordid excitability and excite- ment of the sanguiferous system; 2, to lessen the determination to, and derive the circulation from the inflamed mucous structure of the lungs; and 3, to correct the functional derangement of the skin, liver, and alimentary canal. In the early stage of the disease, the activity of the pulse will sometimes call for moderate general bleeding; but this evacuation can seldom be often repeated, even in moderate quantities, without the risk of doing injury by its tendency to increase the general irri- tability and weakness which attend this affection. Where the ge- neral phlogistic excitement indicates the propriety of bleeding, it will always, perhaps, be better to trust to occasional leeching or cupping. After the disease has assumed the character of phthisis, the abstraction of blood may be regarded as very generally alto- gether improper. From the intimate sympathetic relation which subsists between the skin and the lining membrane of the bronchia, it is of great im- portance in the treatment of this affection, to keep up a regular ac- tion of the cutaneous exhalents; for, in proportion as we increase the activity of these emunctories, so do we, in general lessen the afflux of the fluids to the lungs. For this purpose, the patient should be directed to wear flannel next the skin, and to protect himself by proper clothing against the influence of cold and atmospheric vicis- situdes. An equable and mild temperature will generally contri- bute greatly to the successful management of this disease. No reme- diate treatment can procure a permanent advantage in this complaint, when the patient is much exposed to a damp, variable, and incle- ment atmosphere. If the patient's situation or circumstances do not admit of his visiting warm and uniform climates, he should remain in his chamber—the air of which must be kept at a comfortable and regular temperature, during the cold and variable seasons of the year. When the weather is mild, exercise in the open air will, in general, prove salutary in this affection. External irritating applications to the breast, are among our most useful means for combating this disease. Blisters may be employed for this purpose; but pustulation by frictions with tartar emetic, or white precipitate ointment, will produce a more permanent, and, in general, a more efficient counter-irritation. Setons, or caustic issues, are much recommended by some writers; but.their good effects are not equal, I think, to those which may be derived from more exten- sive irritation. Broussais recommends the application of large emollient poultices over the breast. He asserts, that he has cured inveterate casesof catarrhal inflammation by the continued use of poultices of this kind. They are to be preferred to blisters, he says, CHRONIC BRONCHITIS. 347 in nervous, irritable, and plethoric patients. I have myself known great benefit to be derived in delicate and nervous persons affected with this disease, from emollient poultices to the breast. After the skin has been pustulated by tartar emetic ointment, poultices ofthis kind should be kept applied over the breast until the pustules are entirely healed. In the milder variety of chronic bronchitis de- scribed above—that is, in those chronic catarrhal affections which are apt to occur in old persons during the winter, mild emetics have been found useful by dislodging the viscid secretions with which the bronchial cells become engorged; but their beneficial effects are ge- nerally only palliative. To moderate the general irritability of the system, and the velocity of the circulation, digitalis may be advan- tageously employed. In the advanced stages of the disease,- when the expectoration has acquired a purulent character, I have known considerable benefit to be obtained from the use of digitalis and tinct. of the balsam of tolu, according to the following formula: R.—Tinct. digitalis ^ss. -----tolutani gi—M. S. Take a teaspoonful three times daily. At an earlier period of the disease, small doses of digitalis in union with pulvis antimonialis, will sometimes prove serviceable, by lessening the momentum of the circulation, and sustaining the regu- lar action of the cutaneous exhalents. Dr. Hastings speaks very favorably of the effects of squills in the advanced stage of this complaint—more especially in those cases which assume the character of chronic cough. I have used this arti- cle, in combination with the seed of phelandrium aquaticum, with much benefit in a considerable number of cases. I usually order it thus: J R.—Sem. phelandr. aquat. ^iss. Pulv. scillae gr. xii. Pulv. opii gr. ii.—M. Divide into eight equal parts. S. Take one three times daily. The phelandrium is much extolled by some German writers as a remedy in this disease. The use of the tincture of colchicum is recommended by some in the treatment of this affection. Hastings observes that he has found it to allay the cough, promote the expectoration and flow of urine, and keep up a regular action of the bowels. It may be used, he says, where squills from their greater tendency to excite the sangui- ferous system, are inadmissible. From twenty to thirty drops may be given three times daily. I have, in a few instances, known this medicine in union with the tincture of belladonna, to produce excel- lent effects in this disease. Twenty drops of the former may be given with from thirty to forty drops of the latter thrice a day. Some of the vegetable balsams have of late years been particularly recommended in chronic inflammation of the bronchia. Of these, the balsam copaiva is decidedly the most useful. Dr. Armstrong 348 CHRONIC BRONCHITIS. observes, that this article " seems in many cases to exert a specific influence over the mucous membrane of the trachea and its branches; it increases the flow of urine; generally keeps the bowels regularly open, and sometimes excites a peculiar itching in the skin. At first, it should be given in doses of from thirty to forty drops three times a day, and gradually increased afterwards to sixty or eighty drops at each dose." 1 have myself used this article with prominent bene- fit in the advanced periods of the disease; but, in many instances, little or no apparent benefit resulted from its use; and, in a few cases, it was evidently injurious, both by weakening the tone of the digestive organs, and by increasing the general febrile irritation. Morgagni employed this balsam in conjunction with sulphur in chro- nic catarrhal affections; and Armstrong asserts that he has given this combination with unequivocal advantage in the present disease. I have usually given the balsam according to this formula: R.—Sodae supercarbonat. giss. Vitel. ovor. No. iii. Sacch. albi ^ss. Bals. copaib. jvi. Aq. fontanas ^viij. Tinct. opii gtt. lx.—M. S. Take a tablespoonful three times daily. Armstrong has found an emulsion of the spirits of turpentine very efficacious in this disease; but its powers are too irritating to admit of employment in the ordinary cases of the disease. The Peruvian bark has been found a useful remedy in this affec- tion, when the night sweats are profuse and the general debility con- siderable. Given with diluted sulphuric acid in such cases, its bene- fiaial effects, says Dr. Hastings, are sometimes very evident. It tends to restrain the debilitating night sweats, and " to alter the secretion from the mucous membrane of the lungs." In chronic bronchitis succeeding hooping cough, I have used the sulphate of quinine with marked advantage. In several instances ofthis kind, I gave this article in union with the extract of conium, with the hap- piest effect. Opium is often decidedly beneficial in this disease. Given in combination with ipecacuanha, or in the form of Dover's powder, it always procures great temporary relief, and may materially assist other remedies in the reduction of the bronchial inflammation. It is inadmissible, however, so long as there is much febrile irritation; but in the advanced period of the disease, particularly in the chronic bronchial inflammation of old or debilitated subjects,, where the sys- tem is irritable and the cough frequent and troublesome, six to eight grains of Dover's powder, given in the evening, will suspend the cou«h and procure comfortable rest during the night. The extract of conium or hyoscyamus with ipecacuanha, may also be usefully employed, for the purpose of allaying the general irritability and cough, and improving the character of the expectoration. The same CHRONIC BRONCHITIS. 349 intentions will, in general, be answered by full doses of lactucarium. This article is particularly recommended by Dr. Duncan, in the management of pulmonary affections. It may be used with benefit in instances where opium, from its constipating effects, or other dis- agreeable consequences, is inadmissible. The dose is from two to three grains. The prussic acid has been employed with benefit in this affection. From its powerful tendency to reduce the general excitability of the system, it is, without doubt, well calculated to do good in this com- plaint. Its variable and dangerous activity, however, renders it an extremely precarious and hazardous remedy. I have known a few instances in which considerable relief was obtained from this medi- cine; but in the majority of cases no advantage was derived from it, and in two it produced alarming prostration. It may be given ac- cording to this formula.* R.—Acid, hydrocyanici gtt. viij. Mucilag. g. arab. §ss. Sacch. albi^ij. Aq. fontanae 3viij.—M. S. Take a tablespoonful every three or four hours. In the first edition of this work, I omitted, through inadvertence, mentioning the sugar of lead as a remedy in chronic bronchitis attended with hectic. From my own experience with this article, 1 am entirely persuaded, that it will more generally afford relief in this affection, than any other remedy we possess. When the expec- toration is copious, and the night sweats profuse, it rarely fails to moderate and improve the former, and to check the latter evacua- tion. In most instances, too, it exerts a manifest controlling influ- ence over the febrile irritation. Indeed, I am persuaded, that the powers of the sugar of lead as a remedy in this form of consump- tion, are not sufficiently known to the profession in this country. In Germany it has long since been used by many eminent practition- ers, as a favorite remedy in this affection. Osiander speaks in the most favorable terms of its powers in this respect. He asserts that it is not only an excellent and prompt palliative, but the most certain means for effecting a cure we possess.! Hildebrandt, also strongly recommends its use in this disease. There is a very remarkable case of what is called blennorrhcea pulmonum related in Horn's Archives, which was radically cured by the internal use of this remedy.J In France, M. Fouquier has been long in the habit of prescribing this article in consumption, and his confidence in its salutary powers appears to be very great. He asserts that the sugar * The deleterious effects of the prussic acid may be speedily counteracted by a full dose of the aq. ammonia, or of a solution of the carbonate of ammonia. ■J- Osiander, Entwickelungskrankeiten des weiblichen geschlechts. X Archiv. d. pract. Med. B. 4. Hf. 2. s. 287. Vol. I.—30 350 CHRONIC BRONCHITIS. of lead may be regarded as a specific remedy for the profuse night sweats of hectic. It must be observed, that although a valuable means for checking the copious sweats in every variety of consump- tion, the sugar of lead cannot be expected to procure any permanent or radical benefit, or effect a cure in tuberculous phthisis, or in any form ofthis disease attended with structural lesion of the lungs. In that variety of consumptive disease, however, which depends solely on chronic inflammation of the mucous membrane of the lungs— and in which the expectoration of puruloid matter is generally very copious, a well regulated use of this remedy not unfrequently contri- butes very greatly to the complete restoration of health. Within the present year, I succeeded in curing a case of this kind—attended with all the usual symptoms of fully developed phthisis, in a child about five years old, by the use of the sugar of lead. This case was the consequence of hooping cough—a disease which not unfrequently terminates in chronic bronchitis. The best mode of using this arti- cle, in the present affection, is to give it in union with Dover's pow- der, or with the extract of hyoscyamus. One grain of the lead with four grains of Dover's powder, or two grains of the extract of hyos- cyamus, should be given three times daily. The quantity of the lead must be gradually increased, until it amounts to three or four grains at each dose. It is a fact, pretty generally known, that the sugar of lead very rarely produces colic. Osiander declares that in the course of thirty years practice, during which he prescribed it in several hundred cases, it never gave rise to any injurious conse- quences.* The inner bark of the ampelopsis hedra has been employed with great advantage in the advanced stage of chronic bronchitis. It is given in decoction, in the proportion of an ounce of the bark to a pint of boiling water—of which a wineglassful is to be taken four times daily.t In a single instance in which I have lately used this article, I obtained marked benefit from it. The cough gradually declined, the expectoration became improved and diminished, and the general irritation of the vascular system subdued. The bark of the white willow in the form of powder, formed into an electuary with sulphur and honey, was employed with much suc- cess by Dr. Kerckhoff, in the last stage of consumption from chronic inflammation of the mucous membrane of the bronchia.J The root of the actea racemosa has been employed by some American physi- cians in chronic pulmonary affections. I have had some experience with this article in the treatment of chronic inflammation of the mucous membrane of the lungs; and its effects have appeared to me beneficial in several instances. I have found it to diminish the * Casper's Characteristik der Franzosischen Medicin. p. 239. X See Dr. Atkin's paper in the Philadelphia Med. and Surg. Journal, Octo- ber, 1826. X Transact, of Lond. College of Physicians, vol. vi. CHRONIC BRONCHITIS. 351 velocity of the circulation, and to render the expectoration less copious and of a more natural appearance. It is given in decoction in the proportion of an ounce of the root to a pint of water. A table- spoonful of it is to be taken every four hours during the day. Its operation is slow, and requires protracted use to obtain any particu- lar advantage from it. When chronic bronchitis is complicated with hepatic disease, mer- cury must be used in conjunction with the other remedies employed for the bronchial affection. Small doses of blue pill should be given until the gums are very slightly inflamed; and this degree of mer- curial action must be sustained so long as there is any tenderness in the right hypochondriac or hypogastric regions, and the alvine eva- cuations indicate deficient or vitiated biliary secretion. I have used the following pill with peculiar benefit in this modification of the disease. R.—Massae hydrarg. 3L Aloes soccot. Qi. Tart, antimonii gr. iij.—M. Divide into thirty pills. Take one every morning and evening. In some instances, calomel will agree much better with the sto- mach than the blue pill—the latter giving rise to general irritation and more or less gastric disturbance. When calomel is used, it should be given in very small doses, and may be advantageously combined with the extract of conium. Sulphur was formerly much employed in chronic pulmonary af- fections of this kind. In chronic catarrh, attended with a puruloid expectoration, I have known much benefit derived from Englehard's mixture.* Of late years a great deal has been said of the inhalation of the fumes of tar; in the treatment of chronic inflammation of the mu- cous membrane of the lungs. That this remedy has been employed with some success in this complaint, the testimony published by men of eminence and respectability, does not permit us to doubt. It appears to be now generally admitted, however, that its powers are by no means so salutary as was at first asserted. Hastings states " that in chronic bronchitis, the inhalation of tar-fumes seems to as- sist other remedies in restoring the mucous membrane to its healthy secretion; and in some very obstinate cases, the inhalation alone has appeared to remove the diseased action in the mucous membrane of the lungs. In other instances, the inflammation has been aggravated and rendered acute by it. When the habit of the body is irritable, * ]J.—Extract, hyoscyam. Flor. sulph. Extract, glycyrrh, aa 3L—M. Of this mixture eight grains are to be taken three times daily. 352 PHTHISIS PULMONALIS. and the inflammation at all active, the symptoms are increased by its use; but if the disease has been Jong in a chronic state, and the habit of body not irritable, relief may be expected from it." I have employed this remedy in perhaps a dozen cases; in a few instances, I found it particularly beneficial, though generally it failed to do any good whatever. The fumes of resin have also been recommended in the present complaint. A few pieces may be thrown upon hot coals on a shovel, and brought near the patient, so as to cause him to inhale the fumes. The tar is used by placing it in a dish over hot coals, and suffering it to evaporate slowly, until the air of the patient's chamber is well impregnated with the fumes. If the cough and dyspnoea are aggravated by these inhalations, which frequently happens, they must be discontinued. The inhalation of powdered vegetable substances, dispersed in the air breathed by the patient, has been used with marked benefit in the phthisical stage of chronic bronchial inflammation. Dr. Darwin mentions the inhalation of the dust of cinchona as having afforded relief in chronic pulmonary complaints. I have known the inhala- tion of the dust of oak bark effect a complete cure in an instance of chronic bronchitis. Sect. VI.—Phthisis Pulmonalis. Pulmonary Consumption. The assemblage of morbid phenomena, usually designated by the term consumption, may arise from various pathological conditions of the respiratory organs, which, in a practical point of view, it is of much consequence to discriminate from each other. Thus, the symp- toms by which physicians are in the habit of recognising the pre- sence of consumption may depend: 1. On chronic inflammation of the mucous membrane of the bronchia; 2. On ulceration and chronic inflammation of the larynx or trachea; 3. Chronic inflammation of the pleura; 4. Inflammation and the formation of vomica, or ab- scesses in the parenchymatous substance of the lungs; 5. Ulceration of hepatised lungs; 6. Ulceration with melanosis; 7. Infarction of the lungs with morbid cartilaginoid granulations; and, 8. Softening of tuberculous matter in the lungs, with more or less chronic inflam- mation and disorganisation of the pulmonary tissue. Of the first of these varieties of pulmonary disease, I have already treated in the preceding section, under the head of chronic bronchi- tis; and this, the catarrhal or pituitous consumption of authors, con- stitutes, probably, the majority of the reputed cases of phthisis pul- monalis in cold and variable climates. 1. Laryngeal and tracheal Consumption.—Ulceration of the larynx or trachea gives rise to what is termed laryngeal or tracheal consumption, a variety of phthisis, which is generally rapid in its course, and always of a most fatal tendency. PHTHISIS PULMONALIS. 353 Tracheal and laryngeal consumption usually begin with a slight tickling cough; an obscure feeling of uneasiness or pain in some part of the trachea or larynx; occasional oppression of breathing, and slight febrile irritation in the evening. One of the first and most constant symptoms of this variety of the disease is a change of the voice; which becomes indistinct, hoarse, feeble, and whispering. The patient is apt to feel and press the larynx or trachea with his fingers. When the larynx is the seat of the local affection, the first words in the morning are uttered with considerable difficulty. The pain in the larynx or trachea, is always increased by coughing, ex- ternal pressure, and by the inhalation of irritating vapors. When the trachea is the part affected, an increase of the pain is experienced on bending the head backwards, or on turning it round. This is not the case when the larynx is the seat of the disease; here the pain, as well as the cough, is increased by the use of stimulating gargles, and the inspiration of cold and damp air. In laryngeal consumption, the cough is generally violent early in the morning, until something is expectorated; and like spasmodic cough, it often subsides for a consi- derable time, and then returns in sudden and violent paroxysms, the inspiration during the fit of coughing being stridulous, as in croup. A fit of coughing is almost always excited, when the patient begins to swallow; and it seems at first as if the cough were excited only by quick and careless swallowing, yet as the disease advances, the utmost caution in this respect will not prevent this act from exciting the cough. (Armstrong.) The quantity of the sputa is not great in the laryngeal variety of the disease; but, in tracheal phthisis, it is often abundant, consisting chiefly of a viscid, transparent, and frothy mucus, with small masses of purulent matter floating in it. When the disease is once fully established, the usual symptoms of hectic fever occur, the body wastes rapidly, the skin becomes sallow, and the face generally pale, with a transient flush on one or both cheeks in the evening, and a peculiar haggard and anxious expression of the countenance, with an irritable and dejected state of the mind. The ordinary causes of this variety of phthisis are: neglected catarrh; hooping cough; measles, and syphilis. Dr. Armstrong mentions an instance, which was excited by an external tumor pressing on the wind-pipe. 2. Pleural Consumption.—Another variety of consumption, as is stated above, depends on effusion into the cavity of the thorax from chronic inflammation of the pleura. Wliile the effusion into the cavity of the chest is going on, the lung becomes more and more separated from the surface of the thorax, being gradually compressed by the accumulating fluid, until it is reduced to a very small size, and more or less disorganised in its structure. Whilst this is going on, ulceration sometimes takes place in some part of the pulmonary pleura, and the corresponding substance of the lung, and an opening is thus made into the bronchial tubes, through which the effused sero- purulent fluid is discharged by coughing or expectoration. When 354 PHTHISIS PULMONALIS. this takes place, irritative fever, with night sweats, frequent cough, emaciation, and in short, all the ordinary symptoms of phthisis pul- monalis, usually supervene. This form of pneumonic disease is generally the consequence of acute pleuritis. This affection is cha- racterised by a sense of oppression in the chest on lying down; diffi- cult and hurried respiration on ascending stairs, or muscular exertion; short, disturbed sleep; paucity of urine; a short, tickling cough, aggravated on first lying down; spells of hurried and oppressed breathing after speaking; and generally, more or less soreness of the external surface of the affected side of the chest. The patient is easiest when in a sitting posture; and "if requested to take a deep inspiration while in the erect position, he will generally do it with little apparent difficulty; but lay him down flat, and cause him to fetch his breath deeply, he will be almost certain to complain of pain, tightness, soreness, load, or some kind of inconvenience in the chest." (Armstrong.) Death often occurs suddenly, and is almost invariably preceded by considerable oedema of the legs and feet. In some instances, after the effused fluid is discharged through the lungs, the progress of the disease becomes arrested, and the patient recovers a tolerable state of health. When this occurs, the affected side of the thorax contracts to a very manifest degree, forming what Laennec describes under the name of contracted chest. In some instances, where ulceration establishes a communication between the bronchial cells and the cavity of the pleura, more or less of pneumo- thorax occurs; but more generally adhesions take place around the fistulous opening, which prevent the escape of air into the chest from becoming so considerable as to compress the lungs. (Laennec.) 3. Inposthumous Consumption.—Consumption from the for- mation of an abscess in the lungs, is an extremely rare occurrence, although formerly supposed to be one of the most common forms of the disease. Laennec states as the result of his observations, that small abscesses in the pulmonary tissue are not found above four or five times, and large ones not above once in several hundred cases. He regards almost the whole of the reported cases of pulmonary abscesses of the lungs as excavations formed by the softening of tu- bercular masses. It is nevertheless probable, from the observations of others, that abscess of the lungs is not so uncommon as is asserted by Laennec. Armstrong mentions several instances of this kind, and cases are related by Morgagni, Baillie, Foubert, Wright, Heller, Lettsom, and many others. 4. Ulceration with melanosis of the substance of the lungs, is also occasionally met with in phthisis pulmonalis. I have seen one remarkable instance ofthis variety of phthisis, in consultation with Dr. Monges and Dr. M'Clellan. Bayle says that this form of the disease occurs only in adults, and most commonly in persons of ad- vanced age. "The lungs of those who die ofthis affection, present more or less extensive ulcerations, the parietes of which are as black as charcoal, very firm, and several lines in thickness. The parts PHTHISIS PULMONALIS. 355 not in the immediate vicinity of these melanosed ulcers, appear to be perfectly healthy; but if the disease affects the whole lung, it is hard, compact, black, resembling sometimes leather half burned." Phthisis from melanosis is often of long duration, and seldom gives rise to any alarming symptoms until it has continued for a considerable time. The patient usually has a moderate cough, at- tended with a whitish or white puruloid matter, slightly opaque, and usually in roundish masses, swimming in a considerable quan- tity of a thin mucus. These sputa always swim in water. There is little or no pain whatever felt in the chest; and in some cases the patient is entirely free from feelings of indisposition. Never- theless, the body gradually wastes; the pulse is generally somewhat more frequent than natural, and, occasionally, the cough excites vomiting. At last the emaciation usually becomes extremely great, although the patient seldom complains of much illness or uneasy sensations. Very considerable oedema of the legs is a common oc- currence towards the conclusion of the malady. 5. Cancerous Consumption.—The substance of the lungs is lia- ble to a species of cancerous degeneration, giving rise to a slow and most fatal variety of phthisis pulmonalis. Fortunately, however, this is a very rare variety of pulmonary disease. When the cance- rous masses are insulated, there are, in general, many of them throughout the lungs; but the surrounding pulmonary structure is usually in nearly a healthy slate. " When, however, the cancerous masses are not insulated, different portions of the lungs, and, occa- sionally, some of the bronchial glands, are transformed into a white substance, evidently of a cancerods character, belonging, in fact, to that variety of cancer designated by M. Laennec under the name of d6g6n'erescence cerSbriform. The diseased parts are white, some- what shining, sometimes of a firm consistence, and at others already softened, and always traversed by extremely small blood-vessels. When the softened parts are compressed, a liquid matter issues from a great number of points, bearing a strong resemblance to cream. This degeneration pursues the same course that other cancerous af- fections do, and resembles much in its intimate structure the cance- rous masses which are sometimes developed in the liver, as well as the alterations which occur in the mucous membrane of the stomach, when this organ is affected with scirrhus." (Bayle.) The progress of cancerous consumption is very slow. At first, the respiration is somewhat obstructed, attended with a dry cough, which is rarely very troublesome. As the disease advances, the patient begins to feel some pectoral oppression, the cough becomes more troublesome, and the patient experiences, at times, transient pains in the chest. These pains gradually become more frequent and prolonged, until they are constant, at the same time that the cough becomes less dry, and a more or less abundant expectoration of white matter ensues. The skin is usually of a pale yellow color. This affection, says Bayle, seldom if ever occurs in persons under 536 PHTHISIS PULMONALIS. thirty years of age, and the majority of those who labor under it are at the same time affected with cancerous tumors in other parts of the body.* 6. Granular Consumption.—In some cases of phthisis, the lungs contain an immense number of transparent, shining, miliary granulations. These granulations vary in size from that of a millet seed to that of a grain of wheat, and appear to be of a cartilaginous consistence. Mr. Bayle thinks that they differ entirely from mili- ary tubercles, which latter, he says, are always gray, or white and opaque, and terminate by complete softening. The miliary granu- lations, generally, at last, give rise to ulceration of the pulmonary parenchyma, and when this takes place, the ulcerated cavity is al- ways found lined with an albumenoid membraniform substance.t 7. Tubercular or scrofulous Phthisis.—This is a most fatal and unmanageable form of pulmonary consumption. In the commence- ment of the disease, slight aching pains, with a sense of tension or tightness, is experienced in some part of the chest, together with a short and dry cough, which is readily excited by muscular exertions. Respiration is shorter and more frequent, and deep inspiration is usually attended with a feeling of uneasiness and tightness in a par- ticular part of the breast. These symptoms gradually become more conspicuous; and at length slight febrile irritation occurs towards evening, and the pulse and respiration continue to be somewhat ac- celerated throughout the whole day. A fit of coughing usually oc- curs in the morning, and the patient rises out of bed in a relaxed, languid, and feeble condition. An extreme liability to catarrh, on the slightest exposure to cold and damp air, exists. The bowels are usually somewhat torpid; the tongue is moist, often clean and of a pale pink-color, or covered with a thin white fur. By degrees the cough becomes more frequent and troublesome—particularly in the evening and morning, or at night on awaking from sleep. Great sensibility to low temperature is manifested by the patient. As the disease advances, the albuginea acquires a peculiar pearly whiteness; the skin, lips, tongue, and fauces, become dry in the afternoon, slight chills regularly occur about mid-day, followed by distinct febrile exacerbations, during which one or both cheeks are suffused with a circumscribed flush; a dry and burning heat is felt in the palms of the hands and the soles of the feet; the breathing is very quick and short, and the pulse very frequent, small; quick, and tense. These febrile paroxysms contiuue until towards midnight, when they terminate in more or less profuse perspiration, which continues till morning, leaving the patient exhausted, languid, and depressed. Previous to the occurrence of these latter irritative phenomena, the expectoration, which at first was scanty and frothy, becomes thicker and purulent, and occasionally streaked with * Recherches sur la Pbthisie Palmonaire. Par. G. L. Bayle, p. 36. f Loco citat. p. 37. PHTHISIS PULMONALIS. 357 blood. By degrees the sputa assume more and more the character of genuine pus; the evening exacerbations become more distinct, the night sweats more profuse; the burning in the palms of the hands and soles of the feet more distressing; the cough more fre- quent and violent; and emaciation makes evident progress, attended with increasing failure of strength—in short, hectic fever is now completely developed—the pulse being seldom less than 130 during the evening exacerbations, although generally languid, weak, sof£ and not much above its natural frequency in the morning. To- wards the unafavorable termination of the disease, oedema of thefeet, and colliquative diarrhoea, almost invariably come on, accompanied with a weak and hoarse voice, often aphtha? in the fauces, difficulty of swallowing, and sometimes ulcerated throat. The mind gene- rally continues to be unaffected to the last; but in some instances, "a degree of languid delirium occurs for some day*, and occasion- ally total imbecility for a week previous to death." It is a remarkable circumstance, that pulmonary consumption is very generally suspended in its progress by pregnancy. I have met with five or six instances of this kind. As soon as the delivery of the child has taken place, the consumptive symptoms resume their force, and generally advance with rapidity to a fatal termination. It is equally remarkable that the symptoms of pulmonary con- sumption occasionally, though indeed very rarely, alternate with mania. I am at this time attending a young lady in the last stage of phthisis, who has for four months past been in a state of continued mental derangement. She complains of no pectoral uneasiness, and does not appear to be conscious of laboring under this disease; although her body is now extremely.emaciated, and she coughs almost continually, and has a copious purulent expectoration. Dr. Storer* has published some interesting observations on the conversion of phthisis pulmonalis into inflammation of the brain. The cerebral affection usually commences with headach, which gra- dually increases, whilst the consumptive symptoms disappear pari passu, until delirium and finally fatal coma ensue. From one of the cases, which he has published, it would appear, that by subduing the disease of the brain, we may frequently put a permanent stop to the pulmonary affection. Dr. Abercrombie, also, has related several highly interesting cases of mania, and other forms of acute cerebral affection supervening on phthisis pulmonalis, with the speedy cessa- tion of the symptoms of this affection.t Similar instances are men- tioned by Dr. Parry.J Tubercular consumption probably never occurs, except in indivi- * Transactions of the Medico-Chirurg. Society of Edinburgh, vol iii. part 2 p. 613. f See his work on the Brain, &c, cases 29, 45, 55, 56 and 57. X Elements of Pathology and Therapeutics, p. 385 and 388. 358 PHTHISIS PULMONALIS. duals of a strumous diathesis;* and it is doubtful, as Dr. Armstrong observes, whether tubercular matter be ever formed in the lungs, without a constitutional or hereditary predisposition to them. Be this as it may, it appears to be well ascertained, that wherever this predisposition does exist, any cause which is capable of irritating the lungs may give rise to the deposition of tubercular matter into their substance, and lead, consequently, to the development of phthisis pulmonalis. It has, however, been a subject of considerable contro- versy, whether inflammation is capable of causing the deposition of tubercular matter into the lungs. Bayle, Laennec, Rostan, Louis, and Velpeau, are disposed to allow but little or no influence to in- flammation in this respect; whilst Alison, Andral, Cruvilhier, and Broussais maintain that inflammation is frequently intimately con- cerned in the production of tubercular matter. The following obser- vations of Andral, on this subject, are probably correct: "If the dis- position to the formation of tubercles is very strong, then the slightest local congestion of blood, is sufficient to give occasion to it; if this disposition is less strong, it is requisite, for the formation of tuber- cular matter, that the congestion of blood should be so considerable, and so permanent, as to amount to inflammation. But, when there exists no such predisposition, the most intense, and the longest con- tinued inflammation, will not produce a tubercle."* Tubercular matter would seem to be formed by a kind of exudation or secretion into the pulmonary tissue; and as it appears to be unorganised, may be regarded as an extraneous substance, obstructing the pulmonary circulation, and giving rise to more or less local irritation. Tuber- cular depositions in the lungs do not, however, inevitably lead to consumption; for it would seem to be well ascertained, that tuber- cles may exist in the pulmonary structure in a dormant state—that is, without entering into the process of softening, or exciting inflam- mation—and without giving rise either to local inconvenience, or general disturbance of health. (Armstrong, Laennec.) In indivi- * Tubercles are, I believe, never found in the lungs of still-born children, or of such as die soon after birth. Dr. Denis, Eleve Interne, at the Hospital of Enfans Trouves at Paris, declares, " Ou n'a pas encore trouve jusqu' ici de tu- bercules pulmonaires avant le premiers mois que suivent la naissance. Ou com- mence seulment ales rencontrer dans des enfans de 5 ou6 mois."(a) Velpeau, also, states that he has never found any tubercular depositions in new-born infants, though he has long directed his attention to this subject; and Brechet, who is surgeon to the Hospital Enfans Trouves, at Paris, makes the same declaration. Orfila, however, states that he has in a very few instances met with tubercles in still-bom infants. X Clinique Medicale, t. iii. p. 13. (a) Recherches d'Anatomie et de Physiologie Pathologiques sur plusieurs maladies des Enfans noveau nes.—Par M. Denis, M. D. PHTHISIS PULMONALIS. 361 duals of a scrofulous habit, the formation of tubercles is sometimes very rapid, when pulmonary irritation is excited by any accidental irritating cause. In the beginning, tubercles have the appearance of semitransparent grains; and as they gradually increase in size, they become united into regular masses, and assume a yellowish and opaque appearance. M. Laennec asserts, that the conversion of the tubercular matter into a" soft pus-like fluid, is not effected in a man- ner similar to what takes place in suppurative inflammation; but by a peculiar process of softening, wholly distinct from suppuration. The softening commences in the centre of the tubercle, and gra- dually proceeds outwards, until the whole mass is converted into a whitish cream-like matter, which, making its way into the bronchial tubes, is discharged by expectoration, leaving a kind of fistulous ca- vity. These tubercular excavations become lined with "a species of morbid membrane, of a white and opaque appearance, and very soft consistence; external to which, another membrane of a semi-cartila- ginous structure is formed. Bayle thinks, that the pus expectorated in scrofulous consumption is secreted chiefly by the lining membrane of the tubercular cavities; but Laennec asserts, that the greater part of the purulent matter expectorated proceeds from the mucous mem- brane of the bronchia, which alwa)'s suffers irritation and chronic inflammation, to a greater or less extent, in every variety of pulmo- nary consumption. Purulent expectoration from this source occurs in some instances of tubercular lungs, even before the tubercles have undergone the process of softening. Every case of tubercular phthisis, consists therefore of at least two, and sometimes three, simultaneous processes; namely, 1. "the proper tubercular action either in a state of growth or increase, or in that of softening or de- struction; 2. of a degree of chronic inflammation of the mucous membrane of the bronchia; and 3. sometimes of inflammation of the pulmonic tissue, of a chronic character, and tending to hepati- sation." Causes.—As has already been stated, persons may be decidedly predisposed to phthisis, and even affected with a tubercular state of the lungs, and yet escape the disease, if no adequate exciting cause supervene to rouse it into action. In some instances, functional or organic diseases of the liver develop the disease where the predis- position to it exists. Catarrhal affections, however, are by far the most common exciting causes of the disease. The tubercles may also be excited into action by a fixed irritation located in any of the principal viscera, more especially in the alimentary canal. Repelled cutaneous eruptions have a strong tendency to develop the tubercu- lar action, as indeed all other morbid impressions on the skin have in subjects of a phthisical habit. The sympathy between the exter- nal surface and the lungs is intimate and strong, and an irritation seated in the former, seldom fails to manifest itself in the latter organ—more especially when the lungs are in a state of habitual deoility or predisposition to morbid action. It is on this account, 360 PHTHISIS PULMONALIS. that phthisis pulmonalis is so common a disease in cold and variable climates, where the cutaneous function is so liable to sudden and frequent interruptions or variations of activity. Among the ordi- nary exciting causes of this affection, we may also mention the heal- ing up of old discharging sores; atmospheric vicissitudes; the abuse of mercury; intemperance in the use of spirituous liquors; sedentary occupations; excessive venereal indulgence, and onanism; copious losses of blood; the depressing passions; the admission of irritating vapors or fine particles into the lungs—to which latter cause, stone- cutters, glass-grinders, millers, needle-grinders, &c. are particularly exposed. Prognosis.—The different varieties of pulmonary disease men- tioned above, vary very considerably in the degree of sanability, peculiar to them respectively. That form of consumptive disease, which depends upon chronic bronchial inflammation, is by far the most under the control of judicious remediate treatment; and where the mucous tissue remains free from ulceration, or the subjacent pul- monic structure has not become consolidated, recoveries are by no means uncommon. Laryngeal and tracheal consumptions are extremely dangerous affections. I have never known an instance of recovery from this variety of the disease. Cases of recovery have, however, been rela- ted by authors, but the number of such instances is very limited. Consumption from chronic pleuritis, is much more difficult of cure than that which depends on chronic inflammation of the mucous membrane of the lungs; yet in some instances, the disease subsides, and the patient regains a considerable degree of health. When a cure'is effected, the effused fluid is either gradually absorbed while the lung expands, or it is discharged through the lungs by an open- ing into the bronchial tubes from the cavity of the pleura, or it escapes externally by an opening into the cavity of the chest through the intercostal spaces. Tubercular consumption may be regarded as an incurable dis- ease; for tubercular matter, so far as we know, is wholly incapable of being absorbed or otherwise removed. "Previously to the know- ledge of the true character and mode of development of tubercles," says Laennec, "and while consumption was considered as a conse- quence of chronic inflammation, and slow suppuration of the pulmo- nary tissue, medical men did not question the possibility of curing this disease by a suitable mode of treatment, especially if taken in time, and during the first stage. It is now, however, the general opinion of all those who are acquainted with the actual state of our knowledge respecting the pathology of diseases, that the tubercular affection, like cancer, is absolutely incurable, inasmuch as nature's efforts towards effecting a cure are injurious, and those of art use- less." However impossible it may be to remove tubercular matter when once formed, or to cure consumption depending on it, there can exist no doubt that we may occasionally so retard, or even arrest PHTHISIS PULMONALIS. 361 its progress by proper management, as to prolong life to a very con- siderable extent. Nay, it is equally certain, that by carefully avoid- ing those causes which tend to favor the conversion of tubercular matter into a pus-like fluid, persons who are manifestly strumous,or affected with incipient tubercles in the lungs, may pass through a long life without the actual development of consumptive symptoms. Although tubercular consumption may be regarded as incurable by art, yet in some rare cases a spontaneous cure has taken place after the softening of the tubercular matter and the formation of an ulcerous excavation. Laennec, upon whose authority this statement is made, mentions two cases which terminated favorably in this way. Such cures, he says, are effected in two ways; 1. by the cavity becoming invested by a new membrane of a semi-cartilaginous structure, which, when completely formed, constitutes a kind of internal cica- trix, analogous to a fistula, and "is, in many cases, not more inju- rious to health than this species of morbid affection;" 2. the cure may also be effected by a spontaneous obliteration of the cavity by a cicatrix consisting of cellular, fibrous, or cartilaginous structure. Such cures, are, however, extremely rare, and depend in no manner on medical treatment. (Laennec.) Treatment.— Of the treatment appropriate to catarrhal consump- tion, I have already spoken fully, under the head of chronic bron- chitis, and the subsequent therapeutic observations refer chiefly to tubercular phthisis. Notwithstanding the uncontrollable and fatal character of tubercular consumption when once fully developed, patients laboring under this form of disease are not to be abandoned to their fate, without making an effort to arrest, or at least to retard its progress; for although the hope of curing the malady, after its complete establishment, is wholly fallacious, experience has fully demonstrated the fact, that, by judicious management, we may often keep the tubercles in a dormant state, interrupt their progress, or at least greatly retard their passage into an active condition. In consumptive habits, every thing which tends to irritate the system, more especially the respiratory organs, should be carefully avoided. Attention ought, above all, to be directed to the regular maintenance of the perspiratory function; and writh this view, the patient should be directed to wear flannel next his skin; to protect himself by proper clothing against the influence of low temperature; and to avoid, as much as his circumstances may admit, the effects of atmos- pheric vicissitudes. In the incipient stage of every variety of pul- monary consumption, our constant object should be to counteract the inflammatory diathesis of the system, and to remove all sources of irritation. The regimen must be strictly antiphlogistic. In gene- ral, vegetable and farinaceous diet, with milk, is the only proper nourishment for a patient laboring under incipient phthisis. The system in all phthisical habits is peculiarly excitable, and readily thrown into a state of general and injurious irritation by even weak exciting causes. It would be in* vain to expect a reduction of the Vol. I.—31 362 PHTHISIS PULMONALIS. local pulmonary irritation, so long as the system generally is in a state of preternatural excitation. In conjunction with a mild, unir- ritating diet, the wearing of flannel next the skin, and the careful avoidance of inclement and variable weather, gentle exercise, either by walking, riding on horseback, or in an open carriage, when the air is mild and uniform, will tend to invigorate the system, and les- sen its morbid irritability. Bleeding is highly recommended by some in the early period of phthisis pulmonalis; and when cautiously employed in cases attended with an evident inflammatory condition of the general system, its effects are often beneficial. To draw blood copiously, or very fre- quently, however, would, in most instances, prove injurious by in- creasing the debility and morbid excitability of the system. The abstraction of blood by cupping or leeching, in cases which indicate the propriety of direct depletion, will in general answer all the pur- poses, which can be expected from this measure. To expect to effect the permanent reduction of the quickness, tension, and fre- quency of the pulse by venesection, is a fallacious hope. The sys- tem in this disease is preternaturally excitable or irritable; and in order to reduce the velocity and momentum of the circulation, measures must be employed which tend to subdue this morbid irri- tability, an effect which cannot be obtained from venesection. To accomplish this purpose, we possess no remedies which are so safe and so effectual as digitalis, and small doses of tartar emetic. The former of these articles has a powerful tendency to diminish the ex- citability of the heart and arteries, and consequently the velocity of the circulation. Much diversity of opinion has been expressed in relation to the value of this medicine in consumptive affections. My own observations have led me to the conviction, that under careful management, and in conjunction with a well regulated diet, and proper attention to the cutaneous functions, much good may be derived from its employment in incipient phthisis. Its salutary operation would seem to depend on its power of lessening the acti- vity of the heart and arteries, and thereby moderating the momentum of the circulation, and consequently the general and local irritated condition of the disease. Among the most important remedies we possess in the early pe- riods of phthisis, are such as operate through the medium of the skin, or such as establish a regular determination to the external surface of the body. Blisters, issues, or setons, can never be pro- perly omitted in incipient consumption. I have repeatedly known the insertion of a caustic issue or a seton on the ches!, to remove every symptom of approaching consumption. Even in cases com- pletely developed, counter-irritation, in any of these modes, will generally aid very materially in retarding the progress of the malady. 1 am disposed to ascribe more remediate power in this affection to setons and issues than to blistering, and of these two, I generally prefer the latter. PHTHISIS PULMONALIS. 363 Pustulation with tartar emetic, or with the white precipitate oint- ment, is also a very efficient mode of counter-irritation in this dis- ease. I have seen much benefit derived from both these applications in its incipient stage. When the pustules are formed, emollient poultices should be applied to them, and renewed two or three times daily, until they are healed. Whatever counter-irritating measure be adopted, it should be regularly persevered in, until all the threat- ening symptoms have entirely disappeared, or its manifest efficiency be ascertained. To aid the effects of flannel next the skin, and of a warm and equable temperature in maintaining a regular action of the cutaneous exhalents, advantage may be derived from the use of small portions of tartar emetic dissolved in some mild diluent beverage, in the commencement of the disease. A grain or a grain and a half of this antimonial may be dissolved in a pint of gum arabic water, and drank during the day. M. Lenthois of Montpelier, speaks strongly in favor ofthis remedy in phthisis. His mode of employing it is as follows:—A grain of tartar emetic is to be dissolved in eight tablespoonfuls of water; this is to be mixed with four quarts of water, or a tablespoonful to the pint, which the patient is directed to use for his common drink at meals, and at all seasons and hours. Dr. Armstrong directs the use of this article in doses sufficiently large to excite nausea, and occasionally vomiting. " 1 suspect," he says, "that if a regulated temperature and the exhibition of tartarised antimony were more early and perseveringly employed than they usually are, our success in preventing the development of phthisis might be much greater than it commonly is." The account which Lenthois gives of the usefulness of tart, antim. in the present affec- tion is certainly exaggerated; but, although not perhaps of itself sufficient to arrest the progress of incipient phthisis, it deserves, nevertheless, very considerable attention as an auxiliary means. The employment of emetics in this disease was formerly much recommended by some writers. Dr. Maryatt gave the sulphate of copper and tartar emetic in doses of from two to five grains of the former with two grains of the latter twice a week, without allowing the patient any kind of drink for several hours afterwards. Dr. Senter advises to give the blue vitriol in conjunction with ipecacu- anha (seven grains of each) in the morning before receiving anything into the stomach, and withholding all kinds of drink for some time afterwards. Unquestionably, however, the most efficient of all measures for counteracting the tendency to phthisis, or arresting its development or progress, is a removal to, and residence in, a mild genial, uniform, and salubrious climate. The influence of such an atmosphere, aided by proper diet, regular and gentle exercise, and external revulsives, with an attention to the hepatic and intestinal functions, will do all, perhaps, that remediate treatment is capable of effecting towards permanently arresting the progress of the disease in its incipient stage. The climates of Naples, of Nice, of Florence 364 PHTHISIS PULMONALIS. and of Rome, and lately of Egypt, as well as of some of the south- ern parts of France and Spain, have been particularly recommended to consumptive invalids. Nothing, however, is to be expected from the influence of a warm climate after the disease is once fully deve- loped. It is only in the incipient stage of the complaint that any permanent advantages can be obtained from this source, in scrofu- lous phthisis.* Upon the foregoing remediate measures—namely, occasional small bleedings, external irritating applications, antimonials, a regulated temperature, a simple unirritating diet, and exercise by walking or gestation, our hopes must be mainly placed in our efforts to arrest the disease in its incipient stage. A variety of other remedies have, however, been recommended in this affection; and of these, prussic acid has of late years attracted the greatest attention. Could the dose be regulated with any degree of certainty, so as to procure its influence without the risk of dangerous prostration, advantage might, no doubt, be derived from its employment. Possessing, as it does, a direct and most powerful tendency to subdue the irritability and sensibility of the system, it would seem to be peculiarly calculated to do good in the present aflection, in which a particularly excitable condition is so conspicuous. When the disease is once completely established, and purulent ex- pectoration with hectic fever has supervened, we can no longer hope to procure a favorable issue by remediate management; and all our efforts must be directed to the palliation of the symptoms and the prolongation of its course. With the exception of depletion, the remedies already mentioned as most apt to arrest incipient con- sumption or prevent its development, are also among the most useful means in retarding its progress when fully established. When the system is much exhausted in the confirmed stage of the disease, tonics are commonly resorted to, but although I have tried them often in scrofulous phthisis, I do not remember having ever derived any obvious advantage from them—but most commonly they increased the general irritation.! Where it becomes necessary to support the strength of the system, we may allow a more nourishing diet, particularly the more digestible and nourishing kinds of meat —such as tender beef-steak or mutton. To check the profuse and exhausting night sweats which occur in * See Dr. Carter's " Remarks upon the Effects of a Warm Climate in Pulmo- nary Consumption and some other Diseases.—Medico-Chirurg. Transact, vol. vi.—See also, Medical History of the British army in Spain.—Medico-Chirurg. Transact, vol. vi. f The tonics most commonly employed in phthisis pulmonalis, are the mistura feri compos., the quinine, and particularly Dr. Griffith's mixture,—thus: R. Myrrh. 3L terendo mortario cum spirit, piment. gvi. aq. distil, ^viss. dein adde subcarbon. potassaj 3ss. sulphat. ferri. gr. xii. syrup. 3ii.—M. Take %\\. four times daily. PHTHISIS PULMONALIS. 365 the advanced periods of the disease, I know of no remedy which is so effectual as the acetate of lead. I have frequently prescribed this article with unequivocal benefit in this respect. Four or five grains of the acetate may be taken in the evening. I have known some patients who, after having experienced the relief which it frequently procures, would not do without it. The best mode of giving it is in union with opium. Some of the mineral acids are also recom- mended for this purpose. Of these, the diluted sulphuric acid, or elixir of vitriol is the best. Opium is a highly valuable palliative in the advanced stage of phthisis. It generally allays, for a time; the violence and frequency of the cough; tends to diminish the night sweats, as well as the general feelings of distress, illness, and dis- comfort; and at last, assuages the pangs of approaching dissolution by its soothing and oblivious effects on the nervous system. When opium produces disagreeable effects from idiosyncracy, the lactuca- rium may be used in two or three grain doses with excellent effect. We may also employ Dover's powder in union with the extract of hyoscyamus as an anodyne palliative, where opium by itself is ob- jectionable. Six grains of the former, with three grains of the latter, may be given every night. Dr. Bourne, professor of the practice of physic in the university of Oxford, speaks strongly in favor of the employment of uva ursi in consumption. He asserts that he cured nine cases out of sixteen by the use of ten grains of uva ursi with one-third of a grain of opium three times daily. In consumptive symptoms from chronic bronchitis, I have derived much benefit from these two articles given in combination; and the cases related by Mr. Bourne, were probably of this kind.* Expectorants are sometimes useful to palliate the cough. Flax- seed-tea, decoction of the lychen icelandicus, solution of gumarabic, infusion of tussilago or of marshmallows, the camphorated tincture of opium, and syrup of squills in equal proportions, or syrup of pop- pies with tincture of tolutan, may be used for this purpose. Small doses of opium and tartar emetic, as recommended by Pariset, will generally answer very well.t The inhalation of tar-J'umes is not adapted to the treatment of tubercular consumption. In the catarrhal variety of the disease, much benefit may be occasionally derived from this and similar in- halations. Nor is mercury a remedy calculated to do good in the present form of phthisis, although much recommended by some practitioners. The cases of consumption which are reported as * Cases of Consumption, &c. healed by uva ursi, &c. By Dr. Bourne, Lon- don, 1806. X R.—G. opiigr. x. Tart, antim. gr. iv. Conserv. rosar. q. s.—M. Divide into forty pills. S. Take one every four hours. 31* 366 PHTHISIS PULMONALIS. having yielded to ptyalism were, no doubt, dependent on chronic mucous inflammation, unconnected with a strumous habit of tuber- cles in the lungs. Too little discrimination was formerly made between the different varieties of pulmonary disease attended with consumptive symptoms; and it is to this circumstance that we may ascribe the discordant and contradictory statements that have been published in relation to the effects of different remedies and modes of treatment. Laryngeal and tracheal phthisis appear frequently to commence with an obscure inflammation in some part of the lar)rnx or trachea, which may continue for months before ulceration occurs. This in- cipient stage is characterised by more or less hoarseness, change of voice, and disturbed respiration; and it is only during this early pe- riod of the disease, before ulceration has taken place, that any decided and permanent benefit can be derived from remediate treat- ment. Whenever, therefore, we find hoarseness of voice, with cough, disturbed respiration, and a slight prickling pain in the larynx or trachea to continue for some time, particularly when there is no reason to ascribe these symptoms to common cold, we ought imme- diately to adopt the most active measures for the removal of the affection. Should ulceration not have taken place, we may, per- haps, succeed in preventing it, and in saving the life of the patient. (Armstrong.) One of the most indispensable curative means is a mild and uniform temperature. On no account should the patient be suffered to expose himself to a cold or humid atmosphere.— While these precautions are observed, blisters should be applied to the throat, and the blistered surface kept discharging by irritating dressings. Armstrong recommends the use of balsam copaiba in the early stage of this variety of the disease. In several cases which have lately come under my care, the use of the muriate of ammonia, according to the formula mentioned at page 127 of this work, ap- peared to do much good. When the disease arises from syphilis, mercury may be regarded as the principal remedy in conjunction with a regulated temperature and blistering. In consumptive symptoms from chronic pleuritis, our principal reliance must be placed on external irritating applications to the chest, the use of calomel so as to produce gentle ptyalism, and diure- tic medicines. Blisters or tartar emetic ointment should be repeat- edly applied so as to keep up a constant irritation on the external surface of the chest. Internally, we may give calomel and squills in combination, with a view both to a general mercurial impression and the production of diuresis. NEPHRITIS. 367 CHAPTER XIII. OF THE PHLEGMASIA OF THE URINARY AND GENITAL ORGANS. Sect. I.—Nephritis.—Inflammation of the Kidneys. The symptoms which characterise acute inflammation of the kid- neys, are not in general obscure or equivocal—being usually readily distinguished from those of other painful affections seated in the neighborhood of these organs. When this affection is excited by cold, it commences commonly like other diseases from this cause, by slight chills and flushes of heat—the febrile reaction preceding the occurrence of pain in the loins. When the disease proceeds from contusions, strains, and irritation of renal calculi, cantharides, or other irritating substances absorbed into the circulation, or from metastasis of gout and rheumatism, the first intimation of its occur- rence is an acute pressing pain in the right or left lumbar region, or in both. The pain* is deep-seated and of a very severe aching character, and but very little aggravated by external pressure. Any sudden concussive motion of the body, however, always increases the pain considerably. The pain often darts down along the ure- ters—the testicle of the affected side is retracted towards the ab- dominal ring, and a sense of numbness is experienced in the thigh. Nausea and vomiting occur in most cases, and violent cholic pains in some. The bowels are torpid; the urine is very small in quantity, high-colored, sometimes tinged with blood; and the desire to void it is frequent, urgent, and troublesome. When both kidneys are inflamed, the secretion of urine is generally almost entirely sup- pressed;—this, indeed, happens sometimes when the inflammation is seated but in one kidney, the other having its functions disturbed sympathetically.! The patient is easiest when he inclines his body * W. Bouilland asserts, contrary to the general statement of pathologists, that pain does not always attend renal inflammation. f This is always a very unfavorable occurrence. Total or almost entire sup pression of the urinary secretion can never continue long in any affection, with- out adding greatly to the danger of the disease. Complete ischuria renalis, even without the irritation of local inflammation, seldom continues beyond four or five days without producing fatal oppression of the brain.—(Sir H. Halford, Transactions of the College of Physicians of London, vol. vi.) There is a case mentioned, however, by Dr. Laing, in vol. x. of the Edin. Med. and Surg. Jour- nal, where the secretion of urine was suspended for nine days without terminat ing fatally. The great danger of suppression from this secretion in nephritis, 368 NEPHRITIS. towards the affected side, so as to take off the tension of the lumbar muscles. When in bed, he lies either on the affected side or on the back, with the body inclined towards this side. In some instances, a dull heavy pain is at first felt low down, seemingly where the ureters enter the bladdor, and afterwards passes slowly up along the ureter until it reaches the kidney, where it becomes stationary. The pulse in nephritis is full, hard, and frequent, in the early period of the affection; but after the second or third day, it generally becomes smaller and more frequent, particularly where much nausea and vomiting occur. The surface is above the natural standard of tem- perature, and usually very dry and parched. Diagnosis—From inflammation of the psoas muscle, nephritis may be distinguished by the pain in the former affection being always considerably increased on bending the body forwards, where- as, in the latter disease, this position generally lessens the pain. Nephritis is usually attended with more or less nausea and vomiting, and frequent desire to pass off urine, which is not the case in psoas inflammation, unless the kidneys become affected at the same time. From lumbago, nephritis is distinguished by the paucity of the urine, the dysury, the nausea and vomiting, the pain shooting down the ureters in the latter affection; and by the great increase of pain on assuming the erect position, or by any motion of the muscles of the loins in the former, whilst in the latter, little or no increase of pain occurs from these causes. Nephritis is generally rapid in its course. It seldom cootinues beyond the seventh day without terminating in resolution or fending to suppuration. When the disease is about terminating favorably by resolution, the fever and pain decline; the skin becomes uniformly moist; the urine is copious, turbid, or charged with mucus; and the nausea and vomiting cease.* The symptoms which denote occur- rence of suppuration are—frequent chills or shiverings; a dull, heavy throbbing, instead of the preceding acute pain in the kidney; a slight abatement of the febrile symptoms; and a feeling of heaviness or numbness in the affected part. In some instances, the abscess bursts into the pelvis of the kidneys and is then discharged with the urine. This is not so favorable an occurrence as might at first sight appear. 1 have known purulent matter discharged with the urine for upwards of nine months, from a renal abscess. In some instances, more or less pus is discharged with the urine for several years—producing at last hectic and great emaciation, or what has been called tabes renalis. A puruloid sub- stance in the urine must not, however, be too hastily pronounced as was long ago noticed by Aretasus.—De Causis et signis Morborum, acut. lib. ii. cap. ix. p. 22. * Aetius says that a watery and pellucid urine, indicates a slow and difficult declension of the disease—aquosae autem mictiones, et purae ac pellucentes asgre morbum secemi indicant.—Sermo xi. cap. xvi. NEPHRITIS. 369 the result of renal suppuration, or as genuine pus. The irritation of a calculous concretion in the kidneys, will sometimes give rise to a secretion resembling pus; and the same discharge may occur from subacute inflammation of the neck of the bladder. Genuine pus in the urine may generally be distinguished from a puruloid fluid mixed with this secretion, by the former sinking down and forming a thin uniform layer along the bottom of the vessel in which the urine is left standing; whereas, the latter substance remains partly suspended in the urine, and does not settle down into a close layer along the bottom of the vessel.* In some cases, the abscess points externally, and may be evacuated by an incision into the soft fluctuating tumor. Cases are on record which terminated favorably after the matter had obtained exit in this way; but in many instances ofthis kind, a fistulous opening re- mains, which it is always extremely difficult and sometimes impos- sible to heal—the patient gradually sinking under symptoms of hectic.t Authors mention instances of renal abscesses having opened into the intestines; and Richter states, that the matter has found its way into the liver, and even into the cavity of the thorax.J Renal abscess has also been known to burst into the cavity of the abdomen, giving rise to rapid and fatal peritonitis,§ and instances have occur- red in which the matter has passed down along the psoas muscle, and pointed at the upper part of the thigh, like psoas abscess. Inflammation of the kidneys, occasionally, though rarely, termi- nates in gangrene. Scirrhus, or induration of the kidneys, also, sometimes results from this affection. Bonetus relates several exam- ples of this kind.|) M. Bouillaud mentions a change of the paren- chymatous substance of the kidneys into a tuberculous or encepha- loid matter, as the result of renal inflammation; and in several cases he found the structure ofthis organ converted into a yellowish seba- ceous matter. IF Causes.—From the intimate relation which exists between the kidneys and the skin, cold becomes a very frequent cause of this affection. In many instances, it arises from'causes acting directly upon the kidneys—such as irritating diuretics, cantharides, turpen- * Van Swieten observes, when the matter comes from the bladder, there is discharged with the urine a sort of foliaceous fragments; but when it proceeds from suppuration in the kidneys, it is more uniformly mixed with the urine.— Comment, vol. x. p. 38. X Hie autem morbus molestus est ex eoque pluresad renum tabem deveniunt. Hippocrates, De Intern. Affect, cap. xvi. X Specielle Therapie, b. i. p. 615. § Vogel. Handb. t. iv. p. 398.—Richter, Sp. Therap. || Sepulchret. Anat. torn. ii.—as quoted by Morgagni. TT Observations on the Anatomy and Diseases of the Kidneys, &c. By J. Bouil- laud.—Journal Complementaire. 370 NEPHRITIS. tine, renal calculi or gravel, contusions, strains, &c; and in persons subject to gout or rheumatism, the disease sometimes occurs, rapidly and violently, in consequence of metastasis of these affections. Treatment.—As in all other phlegmasial affections, prompt and efficient blood-letting constitutes the primary remedy in this disease. In addition to general bleeding, leeching, or what appears to be bet- ter, cupping over the lumbar region must not be neglected. Active purgatives also assist materially in reducing the local inflammation. Six or eight grains of calomel, followed in three or four hours by a full dose of castor oil, or three or four pills of the formula given below, will generally answer this purpose well.* The bowels must be kept in a loose state by the daily administration of aperients; or by laxative enemata throughout the whole course of the disease. Much relief will sometimes be obtained from anodyne emollient injections, particularly in the evening, after the free operation of a purgative. Indeed, the assiduous employment of soothing emollient enemata, either with or without laudanum, is always a most useful auxiliary in the treatment of this affection. For this purpose we may use an infusion of flaxseed, or simply warm water mixed with a portion of milk; or a thin decoction of barley. Fomentations to the external lumbar region will likewise be proper, particularly in the early period of the disease, immediately after leeching or cup- ping has been practised. A large emollient poultice is a more con- venient, and probably a better application for this purpose. Blisters are very generally regarded as objectionable in this affection, on account of the tendency of cantharides to irritate the urinary organs when absorbed into the circulation. I have nevertheless derived decided benefit from blistering the region of the inflamed kidney, without having ever known any injurious consequences resulting from it. By suffering the vesicatory to remain no longer than is . necessary to inflame the skin—which is seldom more than four or five hours, and then applying an emollient poultice, a full blister will be raised; and I have never known strangury to occur where this mode of vesicating was adopted. I have pursued this practice in ten or twelve cases of nephritis, and generally with evident ad- vantage. Sinapisms may also be used, after adequate depletion, with a prospect of benefit; but they are not equal, in efficacy, to blisters, in this as in other internal inflammations. From the close sympathy which exists between the skin and the kidneys, considerable benefit usually arises from the employment of suitable diaphoretics in this affection. Where the stomach is not too irritable, antimonialst may be employed; but where much nausea * R.—Extract, colocynth. compos, ^i. Calomel gr. xii.—M. Divide into six pills. t R.—Spir. nit. dulc. %i. Vin. antimonii 3ii. NEPHRITIS. 371 and vomiting attend, it will be better to depend on the use of the warm bath, more especially the steam-bath, for the production of diaphoresis. Hot bricks wrapped in flannels previously moistened with vinegar and water, and laid under the bed-coverings near the patient's body, seldom fail to bring on a more or less copious and uniform perspiration. The nitrate of potash cannot be used with propriety in nephritis, on account of its tendency to excite the activity of the kidneys, an effect which could hardly fail to do mis- chief in the inflamed state of these organs. All stimulating diure- tics indeed must be carefully avoided—copious draughts of muci- laginous diluents being the only proper means for promoting the urinary secretions. After the inflammatory condition of the system has been in some degree subdued by the antiphlogistic measures already mentioned, small doses of Dover's powder repeated every three or four hours, will tend to keep up a general diaphoresis, as well as to moderate the local pain and general irritable state of the system. Much relief may also be derived after proper depletion and purging, from the occasional use of anodyne enemata.* A slight sensation of pain and soreness is apt to remain in the affect- ed kidney for several days, and sometimes, weeks, after the disease has been subdued. Here uva ursi, in conjunction with small doses of opium or Dover's powder, is the best remedy. From twenty to thirty grains of the uva ursi, with the fourth of a grain of opium, or three grains of Dover's powder, may be taken four times daily. This remedy is no less useful in cases where the inflammation has terminated in suppuration. I have known the extract of conium, with an infusion of uva ursi, to be employed in suppuration of the kidney with complete success. Three grains of the extract were taken three times daily, and a wine-glassful of the infusion (one ounce of the uva ursi to a pint of water) every four hours. Minute doses of muriate of mercury with this extract,! have also been found beneficial in abscess of the kidneys. The use of lime water, to the Tinct. opii gr. xxx.—M. S. Take a teaspoonful every hour or two. Or,—R.—Spirit mindereri 3|iv. Tart, antimonii gr. i. Spir. nit. dulc. 3ii. Syrup limonis ^ii. Tinct. opii gr. xxx.—M. S. Take a tablespoonful every two hours. * R.—Pulv. opii gr. ii. Mucilag. g. arab. ^ss. Lactis tepefact. £v. Or,— R.—Tinct. opii gi. Infusi. lini %xi.—M. ft. enema. This injection may be repeated two or three times daily. X R.—Muriat. hydrarg. gr. vi. Extract, conii maculat. £iss.—M. Divide into forty-five pills. -S. Take one every morning, noon, and evening. 372 CYSTITIS. extent of from four to six ounces daily, has been recommended in suppuration of the kidneys. (Richter.) Decided benefit has also been derived from the balsam copaiva; but this article must be avoided as long as there is any evidence of inflammatory action pre- sent. Sect. II.—Cystitis.—Inflammation of the Bladder. Symptoms.—Violent burning,-lancinating, or throbbing pain in the region of the bladder—extending to the perinaeum, and in some instances to the testicles and the upper part of the thighs, attended generally with a sense of constriction in the hypogastric region. The pain is greatly increased by pressure made immediately above the pubis, and the perinaeum feels sore to the touch. There are. fre- quent, but often ineffectual efforts to void urine, more or less stran- gury or dysury being usually present. The small portion of urine which passes off is deep, red, and often tinged with blood. In some cases there is a constant stillicidium of urine. Nausea and vomit- ing, with great anxiety in the praecordia, are seldom absent in this affection. The bowels are constipated, and there is often a sensation of tenesmus, from the inflammation extending to the lower part of the rectum. The pulse is full, hard, and frequent; the skin hot and dry; the thirst urgent, and the patient is restless and dejected. If the disease continues unchecked in its course, more or less swelling occurs in the loins, with increased tenderness in the hypogastrium and perinseum. Some diversity occurs in the symptoms, according to the particular part of the bladder in which the inflammation chiefly exists. When the neck of the bladder is inflamed, great pain is felt in the perinaeum, and total retention of urine sometimes oc- curs, or the patient is tormented with dysury or incessant feelings of strangury. In this case, the introduction of a catheter or bou- gie causes extreme suffering. " When the posterior part of the bladder is affected, the rectum suffers more particularly, and the pa- tient is harassed by a most distressing and constant tenesmus. Some- times the inflammation occupies that part of the bladder in which the mouths of the ureters are situated, which thus become involved in the affection, and a suppression of urine, more or less complete, and its consequences, take place; in this case, there is commonly more or less pain and tenderness on pressure in the hypogastric region." (Prout.) Like other inflammations, cystitis terminates either in resolution, suppuration, gangrene, or induration and thickening of the coats of the bladder. Resolution, besides the abatement of the pain and fe- ver, is attended with general and uniform diaphoresis; a turbid and rather copious urine, passed with little or no pain; and ability to bear pressure on the epigastrium, and perinaeum. On dissection, the inner membrane of the bladder is, generally found minutely injected, so as to give a uniform red appearance to the whole surface. In some CYSTITIS. 373 instances, the inflammation is confined entirely to the internal coat; in others, it extends to the muscular tunic; and sometimes even to the peritoneal covering.* Suppuration is not a frequent termination of this affection. (Richter.) Abatement of the violence of the fever and pain accom- panied with chills or rigors, and the sudden appearance of a white matter in the urine, indicate the occurrence of suppuration. In some instances, abscesses are formed in the coats of the bladder, particu- larly near its neck; and in others, the abscess forms in the cellular structure surrounding the neck of the bladder. When suppuration occurs in the mucous membrane, or when the abscess between the tunics of the bladder bursts into its cavity, the matter will be dis- charged with the urine. Sometimes the abscess points externally, and may open into the rectum or vagina, or sink down and infiltrate into the cellular membrane of the pelvis. The abscess has also been known to burst into the cavity of the peritoneum; and the matter has made its way into the labia pudendi, and the loose struc- ture of the scrotum. In some cases, the coats of the bladder are thickened and indurated, particularly the internal one. Sometimes fungoid elevations of the mucous membrane occur; at others, indurations are found in different parts, resembling small scirrhous tumors, and some of these are occasionally ulcerated. Firm adhesions have been noticed between the bladder and rectum, as well as between the bladder and. uterus, in consequence of acute cystitis. It is sometimes very difficult to distinguish some of these results of inflammation of the bladder du- ring life from calculus. Gangrene is a frequent termination of cystitis. The majority of instances that prove fatal within the first six or seven days, terminate in gangrene. The occurrence of gangrene is announced by the sudden cessation of the pain, cold extremities; profuse and clammy perspi- ration; great prostration of strength; a cadaverous expression of the countenance; slight confusion of the mind; a small, frequent, and weak pulse; and hiccough. Causes.—Cystitis may be produced by mechanical irritating sub- stances in the bladder; retained urine; external injuries on the hypo- gastric region; irritation from acrid substances absorbed and con- veyed to the bladder—as cantharides, turpentine, &c.; metastasis of gout and rheumatism; irritating injections forced into the bladder; irritation from the introduction of a bougie, or catheter; gonorrhoea; suppression of haemorrhoidal discharge, and of perspiration; cold ap- plied to the feet or lower portion of the abdomen; injury sustained in parturition, or from the use of obstetrical instruments. Treatment.—Acute cystitis is a rapid and highly dangerous affec- tion, and must be promptly met with the most efficient antiphlogistic measures. Efficient blood-letting must be early practised, until the * Wilson on the Urinary Organs, p. 297. Vol. I.—32 374 CYSTITIS. activity of the pulse is moderated. After general bleeding, leeching is of the utmost importance in this affection. The leeches must be applied to the perinaeum, about the anus, and to the hypogastric re- gion; and, when the pulse admits of it, they should be reapplied. Immediately after leeching, an emollient poultice should be applied over the hypogastrium, pubis, and perinaeum. The bowels must be kept open, by gentle laxatives and mucilaginous enemata. Much relief is commonly obtained from an emollient anodyne enema, im- mediately after the rectum has been emptied by a laxative. Atten- tion must be early paid to the evacuation of the urine, should the bladder be found distended by it Great care, however, is required to avoid all unnecessary irritation from the introduction of the cathe- ter. When the neck of the bladder is inflamed, the pain caused by this operation is generally extremely severe, and it is sometimes im- possible to reach the bladder, from the great irritability and spasmo- dic contraction of its neck. This can, in some degree, be obviated by introducing three or four grains of opium into the rectum an hour before the catheter is used, accompanied with an efficient abstraction of blood, both by venesection and leeching. To promote the action of the cutaneous exhalents, we may employ the warm bath; or, what is better, the steam-bath, as mentioned under the head of nephritis. Some of the milder diaphoretics, such as spiritus mendereri, diluted with barley water or flaxseed tea; or small and frequeut doses of pulvis antimonialis, or of Dover's powders, may be usefully exhi- bited, with a similar view. The hip-bath is particularly recom- mended by Richter as a local application in this affection. After the violence of the local and general inflammatory action has been moderated by the foregoing means, much benefit may sometimes be derived from the internal use of opium and calomel. Richter observes, that opium is a primary remedy in cystitis, par- ticularly when given in union with mercury. Prout also recom- mends the internal use of this combination. A grain of opium, with two grains of calomel, may be given every four hours. In cases of a subacute, character, the employment of opium and calomel, in conjunction with leeching, emollient anodyne injections, and fomen- tations or poultices to the hypogastrium and perinaeum, is particu- larly beneficial. Nitre and blisters are apt to increase the local irri- tation, and cannot, therefore, be resorted to without a considerable risk of doing injury. " If blisters be employed," says Prout, " they should be used with caution and permitted to remain only for a short time, and afterwards such dressings applied as tend to keep them open." The mode of blistering mentioned, when speaking of the treatment of nephritis, may, perhaps, be safely adopted in this affec- tion. Considerable advantage, is said to accrue from the repeated injection of mucilaginous fluids into the bladder, by obtunding the acrimony of the urine, and soothing irritation. CHRONIC CYSTITIS. 375 Sect. III.—Chronic Cystitis. Chronic inflammation of the inner membrane of the bladder is not an uncommon affection, and is generally described under the name of cystirrhoea. In some instances, this affection is the consequence of acute cystitis; but it may arise, at once, from the action of the same causes which produce acute inflammation of the bladder. The symptoms which accompany chronic mucous inflammation of the bladder, are—slight lancinating pains, attended with a sense of heat or burning in the region of the bladder, and a feeling of weight and tenderness in the perinaeum; frequent and harassing desire to pass urine, with occasional spasmodic action of the bladder and urethra. The urine is loaded with more or less of a tenacious mucus. Slow fever generally attends, accompanied with thirst, general debility, " particularly about the back and loins," and, in protracted cases, much emaciation, and exhaustion. There is generally considerable derangement of the digestive functions; loss of appetite; sometimes nausea and vomiting; costiveness; tongue covered with a white or brown fur; and the skin is harsh and dry. "In slight and incipient cases ofthis affection, the urine, when first passed, generally appears of a whitish color, and is more or less opaque and turbid, with the appearance of flocculi floating through it. On standing, however, for some time, it becomes more or less transparent, and the mucus will be found together in a mass at the bottom of the vessel." (Prout.) The writer just quoted states, that in most cases the urine is acid; others assert, that it, commonly, exhales an ammoniacal odor, and that it is rarely acid. In some cases, the quantity of mucus dis- charged, with the urine, "is enormous, amounting occasionally, to several pints in the day; and in this case it not only comes away diffused through the urine, but also in the form of large coagula, which, by blocking up the urethra, give origin to the most distress- ing symptoms—particularly to a sense of severe burning pain along the whole course of the urethra." Sometimes this mucus is easily diffused in water of the urine; but in inveterate and violent cases, it is so extremely tenacious, as to make it very difficult to mix it with the urine. When suffered to cool, the mucus, says Prout, is sometimes so tenacious " that it may be drawn into strings of consi- derable length, and the vessel may be frequently inverted without its falling out." In the worst cases, particularly when ulceration pf the inner surface of the bladder exists, copious discharges of blood, at times, take place. I have known an instance of this disease, which continued for five or six years, and at last terminated fatally, from the supervention of acute inflammation in consequence of irri- tating injections. In this case, more or less haemorrhage occurred from the bladder almost every month. The discharge of mucus was always very considerable. On dissection, two large ulcers of the mucous membrane were found near the neck of the bladder. Dr. 376 CHRONIC cystitis. M'Dowell found, in this affection, the mucous surface of the bladder to present "different degrees of vascularity, from merely a few patches of a dark or bright red color, to an entire vascularity, in some cases so marked, as to appear as if the bladder had been daubed over with blood; the veins in general are turgid; the membrane much thickened; frequently numerous ulcers occur, covered with a tenacious brownish colored lymph; these are sometimes deep and numerous, so as to give a honey-comb appearance to the membrane. The inflammation sometimes ends in complete sphacelus of the interior of the bladder."* " Blood," says Dr. M'D., "is often dis- charged in very large quantity; and, together with the abundant mucus, a white powdery sediment, or sanious matter, is mixed with the urine." This affection is most apt to occur in old and gouty subjects; and persons of an irritable and scrofulous habit are said to be particularly predisposed to it, "more especially if they have been accustomed to free living, or been given to venereal excesses, or have suffered from these affections or gout. Treatment.—In the early stages of the complaint, we must endea- vor to reduce the chronic inflammation by local, depleting, and counter-irritating measures. Cupping along the loins, with the occa- sional application of leeches to the perinaeum, and about the anus, may be accounted our most efficient remedies during the first period of the disease. If the pulse is active, and the pain in the pelvis con- siderable, general blood-letting may be very beneficially resorted to. The bowels must be kept in a relaxed state by the occasional use of gentle purgatives, such as castor oil or magnesia. I have known much benefit to result from a caustic issue on the upper and inner part of the thigh. Advantage would probably be derived also from frictions and pustulation with tartar emetic ointment on the upper part of the thighs, or on the loins. When the inflammatory symp- toms have subsided, either in consequence of the application of the remedies just stated, or by the long continuance of the disease, astringents, with some of the narcotic extracts, may be resorted to with a prospect of advantage. Dr. Prout prefers the uva ursi to all other articles of the astringent kind in this affection. " Given in combination with hyoscyamus, and steadily persevered in for a con- siderable time, the uva ursi seldom fails to diminish the irritation and quantity of mucus, and thus to mitigate the patient's sufferings." Within the last five or six years, the buchu leaves (diosma crenata,) have been strongly recommended to the profession as a valuable remedy in this and other chronic affections of the bladder. Dr. M'Dowell employed it successfully in three cases, according to the following formula: R.—Infus. buchu gvii. Tinct. ejusdem. * Dublin Transactions, vol. iv. CHRONIC CYSTITIS. 377 Tinct. cubebas aa %i.—M. S. Take an ounce of this mixture three times daily. The use of this remedy should be continued for three or four months. I have heard of the successful employment of an infusion of the pipsissewa, (chimaphila umbellata,) in a case of this disease. In se- veral inveterate cases I have prescribed the muriated tincture of iron, with infusion of peach-leaves, with very manifest benefit. In one instance, a perfect cure was effected by the tincture of iron, in conjunction with uva ursi. Frictions over the groins and the hvpo- gastrium with camphorated oil has appeared to me serviceable in some cases. Besides these, a great variety of other remedies have been recommended for the cure of the affection. Balsam copaiva; turpentine; balsam peru; camphor; madder; and many of the ve- getable astringents are mentioned by writers as often beneficial in this complaint. From the known good effects of balsam copaiva in chronic inflammation of mucous membranes, there is some reason to presume that advantage might be obtained from its use in this com- plaint. Experience does not, however, furnish us with much testi- mony in its favor. I have given it in a few cases, but in these it appeared to give additional uneasiness in the bladder, without dimi- nishing the mucous discharge. Different kinds of injections into the bladder have also been re- commended as beneficial in this affection; such as flaxseed tea; infu- sion of marsh-mallows; or barley-water. When retention of the urine occurs from a spasmodic constriction of the neck of the blad- der, relief will often be obtained from seven or eight drops of the muriated tincture of iron given every half hour. The diet should be simple and digestible, and every kind of stimulating beverage carefully avoided. Fatiguing exercise, or riding on horseback, or in a carriage over rough roads, usually aggravates the symptoms. The drink should be bland and mucilaginous. One patient under my care, always felt himself much relieved by drinking the infusion of the malva rotundifolia, a common plant in this country. I have also prescribed the constant use of slippery elm bark tea with beneficial effect. Sect. IV.—Hysteritis.—Inflammation of the Womb. Acute inflammation of the uterus, generally occurs in the puerpe- ral state, and usually within a few days after parturition. Sometimes this affection commences with rigors, succeeded by fever, before any pain is experienced in the uterus; and at others, more or less severe pain in the region of the uterus is the first intimation of its occur- rence. The characteristic symptoms of the disease are: a fixed, con- tinuous, lancinating, or a dull and aching pain in the pelvis, greatly increased by pressure or motion, and accompanied with a sense of weight or bearing down in the perinaeum. The urine is generally 378 HYSTERITIS. passed with much pain and difficulty, and in some cases a total re- tention takes place. This is particularly apt to be the case when the anterior and lower portion of the womb is inflamed. When the in- flammation is chiefly located in the posterior part of the uterus, the pain is particularly severe in the region of the sacrum, and the pa- tient experiences much pain, and often tenesmus, in evacuating the bowels. Sometimes the pains extend to the iliac regions, to the hips, and down the thighs to the knees, and even to the feet. When the pains extend to these parts, the lateral portions of the womb are usually the principal seat of the inflammation. In the early period of the disease, little or no swelling of the ab- domen occurs, but on examining the pubic region externally with the hand, the uterus is always found considerably enlarged, firm, and exceedingly tender to the touch. In those cases that occur soon after deli very, the pain inthepelvisgenerally becomes much increased, at times, in consequence of the occasional contraction of the uterus, and may be mistaken for severe after-pains. To distinguish the in- flammatory pains from the latter, however, it is only necessary to bear in mind that the former are always continuous, though occa- sionally aggravated, whereas the after-pains are intermitting. In the majority of instances, the system generally sympathises strongly with the inflamed organ. In the early period of the dis- ease, nausea with occasional vomiting, occurs;*—the pulse, in some cases, is full, strong, and hard; in other instances, it is small, con- tracted quick, and frequent. Severe headache is a very common at- tendant, and towards evening, and at night, more or less delirium usually occurs. In a great majority of cases, the lochia are entirely suppressed; in some instances a slight lochial discharge continues throughout the disease, and occasionally, though extremely seldom, this evacuation is even profuse. In general, the secretion of milk is somewhat diminished, but it rarely becomes entirely suppressed, as in puerperal peritonitis. In some cases of hysteritis, indeed, the breasts remain full and turgid with milk, during the whole course of the disease. The bowels are generally inactive, and the urine is small in quantity, of a deep red color, and usually passed with much difficulty and pain. The course of hysteritis is generally rapid. If, after four or five days' continuance, it do not tend to resolution, it will most probably terminate in suppuration or gangrene. By a vigorous antiphlogistic treatment, however, the violence of the inflammation may often be broken down in the course of the first twenty-four hours, and reso- lution speedily established. When the inflammation tends to this * Dr. Dewees observes, in his account of the symptoms of this affection, that " the stomach is rarely much affected in the early part of the disease—at least vomiting seldom takes place." This does not accord with my own experience. In all the cases of unequivocal hysteritis I have ever met with, nausea, with oc- casional retching, occurred during the early period of the malady. HYSTERITIS. 379 favorable termination, the pain, tenderness, and swelling of the uterus abate—the pulse becomes slower, soft, and open; the skin re- laxed and moist; the tongue clean and humid; and the headache and general uneasiness gradually disappear. The lochia, also, usually begin to flow more feely, and the urine becomes more copious and natural in its appearance. The occurrence of suppuration in the substance of the uterus, is always attended with great danger. If the abscess bursts into the cavity of the peritoneum, or makes its way between this membrane and the external surface of the womb, into the cellular texture of the lower part of the pelvis, the issue will almost inevitably be fatal. Sometimes the abscess opens into the uterus, and the matter is dis- charged by the vagina. When the pus is evacuated in this way, the probability of a favorable termination will be very considerable. I have seen an instance where the uterine abscess formed adhesions with the peritoneum in the groin, and, after three weeks, the tumor was opened externally, and exit given to the matter. This patient finally recovered her health. Raiman states, that the abscess has, in some instances, burst into the bladder,* and cases are related, in which the matter was evacuated through the rectum. The occur- rence of suppuration may be suspected, when, after an obstinate course of the disease, for five or six days, the pains become less severe, with a feeling of weight in the affected part, at the same time that the pulse becomes more frequent, attended with occasional slight chills; irregular distribution of heat over the body—some parts being cool while others are hot; irregular, partial, and cool sweats; fetid, and more abundant lochia; prostration of the mus- cular power; dry and red tongue, and a livid flush on one or both cheeks. The termination in gangrene is not a frequent event in this affec- tion, unless the peritoneum be implicated in the inflammation. The supervention of gangrene will be readily perceived by the occur- rence of the usual symptoms of mortification. A rapid cessation of the pain; great muscular prostration; dimness of vision: a death-like countenance; a profuse, cold, and clammy sweat; ice- cold extremities; and an extremely small, weak, and rapid pulse, announce the occurrence of gangrene, and the inevitable doom of the patient. The foregoing description applies to hysteritis in its simple or un- mixed form—that is, inflammation of the proper substance of the uterus, without implicating its peritoneal covering in the disease. In many instances, however, the inflammation spreads to the perito- neum, an extension of the local affection frequently met with in the worst forms of what is usually called puerperal fever. Cases ofthis kind almost invariably prove fatal. The extension of the in- flammation from the substance of the uterus to the peritoneum, is * Handbuch der Speciellen Med. Pathologie, &c. B. i. p. 358. 380 HYSTERITIS. attended with an increased frequency of the pulse, tumefaction, and great tenderness of the lower part of the abdomen; entire suppression of the lochia, " or an excessive discharge of them;" (Dewees;) ces- sation of the secretion of milk; great prostration of the muscular powers; frequent muttering delirium; constant recumbence on the back, with the knees drawn up and raised, and the shoulders ele- vated, to take off' the tension of the abdominal muscles; a dry, coated, and brown tongue; and, towards the end, usually, diarrhoea. Cases of this kind are always rapid in their progress, and unless the inflammation be speedily subdued by prompt and energetic mea- sures, collapse of the vital energies generally supervenes in forty- eight hours, and often sooner, from the time the peritoneal inflam- mation commences. Treatment.—The most efficient antiphlogistic means must be promptly and energetically pursued in the treatment of this affec- tion. As soon as possible after the commencement of the inflam- mation, blood should be drawn from a vein to the extent of produc- ing a very decided impression on the circulation, or an approach to syncope. If after the first efficient bleeding, the pulse rises again, and the pain and tenderness of the parts are not materially abated, venesection should be repeated, and again to the extent of causing a very manifest reduction of the momentum of the circulation. When the activity of the heart and arteries has been moderated by general bleeding, and the disease is not adequately subdued, leeches should be applied over the region of the pubes, and to the vulva and peri- naeum. Immediately after leeching, a large emollient poultice should be applied over the lower part of the abdomen and the external organs of generation; and this application should, from time to time, be repeated, until the violence of the local affection is in a great measure subdued. Dr. Dewees objects to the use of fomentations to the abdomen, in this aflection, and asserts that they have done mischief. I have no experience with any applica- tions of this kind, in the present malady, except emollient poultices applied after efficient venesection and leeching; and to me it has always appeared, that very evident advantage was obtained from this application. Purgatives are, in general, highly useful in hysteritis. Calomel, in doses of from eight to twelve grains, followed in the course of four hours by a full dose of Epsom or Glauber's salt, will answer this purpose very well. After the first active purgative, two or three evacuations should be procured daily by the exhibition of small doses of calomel and of the neutral purgative salts. Irritating pur- gative enemata, generally aggravate the patient's sufferings, and should not be employed. I have, however, known unequivocal benefit derived from injecting into the rectum from time to time, warm emollient fluids—such as warm water and milk—decoction of althea—infusion of flaxseed—or simply warm water. In a case which I attended about two years ago, the patient was much relieved by in- HYSTERITIS. 381 jections of this kind. They are particularly beneficial in the declen- sion of the disease. Blisters are much recommended by some writers; but Dr. De- wees thinks their usefulness is very doubtful. From my own ex- perience, I am disposed to ascribe considerable value to vesication in this affection. When employed, after the momentum of the cir- culation has been moderated by general and local bleeding, I am well satisfied that blisters will often do much good in this com- plaint. If after leeching we apply an emollient poultice over the lower part of the abdomen and vulva, and blisters to the upper and internal part of the thighs, much advantage will in general result. Some benefit may also be obtained from the usual antiphlogistic diaphoretic remedies. Nitre, antimony and calomel in combina- tion, form an excellent compound for this purpose. The muri- ate of ammonia, as prescribed under the head of intermitting fever, is a favorite remedy with many of the German physicians, and I am inclined to think that it is very worthy of attention in this respect. Opium, in full and frequent doses, and in union with calomel, is a valuable remedy in this affection. Dr. Dewees, however, " thinks that in this, as well as in all diseases of high inflammatory action, opium is decidedly hurtful." My own experience has led me to a very different opinion. The powers of this narcotic in inflammatory affections are not as yet sufficiently appreciated. That opium is not hurtful, " in all diseases of high inflammatory action," but often highly beneficial, is admitted by many of the ablest practitioners of the present day. When given in active doses, and repeated so as to keep the system constantly under its full influence, it often con- tributes in a powerful degree to the reduction of the local and ge- neral phlogistic actions. By lessening the general irritability and sensibility of the system, the different organs and structures become less susceptible of the stimulus of the local inflammation, and all the sympathetic actions consequently abate in their violence; and, in like manner, by diminishing the morbid sensibility, and pain of the affected part, the inflamed capillaries will be more disposed to resume their healthy functions. Opium does not, generally, in- crease the momentum of the circulation, in fevers depending on local inflammation. I have frequently known, in violent cases of acute rheumatism, a full dose of opium to render the pulse less fre- quent, and much softer than it was before its exhibition. As this article, however, has a strong tendency to cause cephalic congestion, and may do injury in this way, where the system is plethoric, or the action of the heart and arteries very vigorous, it will always be best to delay its exhibition, until blood has been efficiently abstract- ed. When this has been done, and the bowels well evacuated, from one to two grains of opium, with the same quantity of calomel, 382 CHRONIC INFLAMMATION OP THE UTERUS. may be given every three or four hours with the happiest effect in the present disease. Sect. V.—Chronic Inflammation of the Uterus. Chronic inflammation of the uterus, appears to be a very com- mon affection; and, though, frequently productive of very distress- ing consequences, is often misunderstood and consequently mis- managed. This affection is frequently the result of difficult or instrumental labors; and Mr. Guilbert observes, that it often arises from exces- sive venereal indulgence; and from rheumatic and gouty irritation. He mentions, also, translation of erysipelas as a frequent cause of the disease; and it supervenes occasionally, in consequence of the final cessation of the menses, at the critical period of life, and even as the result of temporary amenorrhcea. Chronic inflammation of the womb sometimes occurs in a periodical manner, and this is most apt to be the case when it arises from erysipelas. Mr. Guilbert says, that females who do not. suckle their infants, are more liable to this variety of uterine disease, than those who perform this interest- ing maternal function. Chronic inflammation sometimes affects the whole body of the uterus; but much more frequently, it is seated in the neck or mouth of this organ. Out of a hundred cases, says the author just men- tioned, there will, probably, not be ten in which the inflammation is not almost exclusively seated in the neck and mouth of the womb. Many females affected in this way, either mistake their complaint, or conceal it; or from the slightness of their sufferings neglect to resort to medical aid, until serious, and often irremediable structural disease is established. Some experience only a sense of heat, with slight soreness in the lower part of the pelvis; others complain of dull or lancinating pains in the region of the womb, with occasional intermissions and exacerbations. In some cases a sense of weight is felt, as if the uterus were prolapsed„attended with occasional pains in the upper part of the vagina. In all instances, more or less of a leucorrhceal discharge attends; and when, at times, the inflam- mation is aggravated, this discharge becomes white and opaque, or purulent. Those who are affected in this way are apt to experi- ence considerable pain at the superior part of the vagina, during the venereal embrace; and, in some instances, the tenderness of the os uteri is so great, that the venereal act always causes extreme suffering. On examining per vaginam, the mouth of the womb is found irre- gularly enlarged, one side or lip being usually much swollen, and very tender to the touch. So great is the sensibility of this part, that the patient experiences severe suffering from the slightest touch of the finger on making the examination. In general, the mouth CHRONIC INFLAMMATION OF THE UTERUS. 383 of the uterus is diverted from its regular position in the vagina, and directed to one side, or sometimes to the posterior or anterior part of the pelvis. If the disease has been of long standing, the engorge- ment, or swelling of the neck of the womb, is so great, as to form a large tumor embraced by the vagina. More or less pain in the back and loins occurs in nearly all cases; and the stomach usually sympathises with the uterus, so as to give rise to a train of very harassing dyspeptic and nervous symptoms. In some cases, the inflammation continues for years, without the occurrence of any serious structural disorder of the womb; but in the majority of cases, the neck ofthis organ gradually enlarges, and becomes indurated, or scirrhous, and finally, often terminates in can- cerous ulceration. Many cases, that are usually regarded as simple leucorrhoea, are connected with chronic inflammation of the os uteri; and it is hence especially important, when called to prescribe for morbid vaginal discharges of a leucorrhoeal character, to ascertain, by examination, the state of the neck and mouth of the uterus. The existence of inflammation and tumefaction ma)' be suspected, when with a puru- loid vaginal discharge, the patient complains of heat, weight, sore- ness, or pain in the upper part of the vagina. Treatment.—When the pulse is irritated, or quick, frequent, and somewhat tense, it will, in general, be proper to draw blood from a vein—and this measure is particularly proper when the patient is of a robust and plethoric habit. The diet should be unirritating and digestible, and where the diathesis is manifestly phlogistic, the nou- rishment should be of the lightest kind, until the general irritated condition of the system is removed. When there is reason to be- lieve that the bowels are loaded with feculent matter, a few active purgatives ought to be administered in the beginning of the treat- ment; but after the intestines have been thus thoroughly evacuated, small doses of some of the neutral purgative salts should be given two or three times a week, so as to keep up a gentle and regular action of the bowels. Much benefit is sometimes derived from the application of leeches to the perinaeum, and about the anus and vulva, or even to the region of the pubis. Mr. Guilbert, in the work re- ferred to above, speaks in the most favorable terms of the efficacy of leeches applied to the os uteri.* He has invented a speculum uteri, by which, he says, the application of leeches to this part is very easily effected; and he has given the history of several cases, in which this practice w-as adopted with prompt and complete success. That local depletion, in this way, is likely to do much good, we can- not doubt. In private practice, however, it would be difficult to in- duce patients to submit to this treatment; and there are few prac- * Considerations Pratiques sur les Affections de PUterus. Par. J. N. Guil- bert, M. D. &c. Paris, 1826. 384 PERICARDITIS. titioners, I apprehend, who would be willing even to propose this measure, unless the urgency of the case were extremely great. Cupping above the pubis, and blisters applied to the sacrum, or to the internal surface of the thighs, willsometimes contribute materially to the reduction of the uterine inflammation. Some advantage may also be obtained from warm emollient injections into the vagina, but all astringent and exciting applications ofthis kind ought to be care- fully avoided, with the exception, perhaps of a very weak solution of sugar of lead.* Internally we may employ small doses of balsam copaiva, but its use must be delayed until the measures already mentioned have, in some degree, moderated the local and general irritation. I have, in a few instances, derived considerable benefit from the internal use of the muriate of ammonia, in twenty grain doses, three times daily. When this article is dissolved in water, with a considerable portion of the extract of liquorice, it will, in general, be readily taken by patients; but without the addition of the liquorice, it is so extremely offensive to the taste, that very few are willing to employ it. If after the inflammation, or the pain, tenderness and swelling of the neck or orifice of the womb are removed, a leucorrhoeal discharge continues, it must be treated according to the directions given under the head of leucorrhoea, in the second volume. CHAPTER XIV. OF THE PHLEGMASIA OF THE SANGUIFEROUS SVSTEM. Pericarditis. Inflammation of the pericardium is no very uncommon affection, and from the very important functions assigned to the parts imme- diately implicated, must be regarded as one of the most alarming and dangerous of phlegmasial diseases. The symptoms which usually attend the acute form of the dis- ease, are—sudden severe lancinating pains in the centre or cardiac region of the chest, extending occasionally to the epigastrium, or to the back between the shoulders, attended with more or less oppres- sive dyspnoea, palpitation of the heart, and a sense of weight and con- striction under the sternum and left side of the thorax. Pain in the * The hip-bath—general warm bathing. Mild mercurial course, avoiding ptyalism; a few gr3. of blue pill with two grs. of camphor and one-tenth tart. antimonii. pericarditis. 385 precordial region, obscurity of sound in this region on percussion and irregularity of pulse are the most constant symptoms of this affection. M. Louis asserts that from the concomitance of these symptoms this aflection may be recognised in about half the cases in which it occurs. In most instances the patient isfentirely incapable of lying down, more especially on the left side. He is constrained to re- main almost immoveably, in the sitting posture, leaning the body slightly forwards, and resting his head on the hack of a chair or some other sufficiently elevated support. The slightest varia- tion from this posture, unless very cautiously effected, is apt, in some cases of this kind, to give rise to sudden and most poign- ant pains in the region of the heart. Extreme precordial anxiety, with a dry and short cough usually attend; and in many instan- ces, partial syncope or sudden feelings of great faintness occur, at intervals, during the progress of the disease. Along with these symptoms we have also strong evidence of cardial disturbance in the state of the pulse. In most instances, the pulse is remarkably irregular, intermitting, frequently feeble, and sometimes so small as to be almost imperceptible. A few cases, indeed, have been recorded, in which the p<:lse remained in nearly a natural state. Tacheron relates an instance of- this kind.* The face is generally pale, with an occasional circumscribed flush on one cheek; the prolabia become more or less livid as the disease advances, and a slight puffy swelling is apt to occur about the eyes and temples. The hands and feet usually become slightly oedematous in the latter stage of the disease; and great general weakness almost always en- sues soon after the full development of the inflammation. The speech is commonly faltering, and in some cases the patient is unable to spit out, without giving rise to sudden and extremely severe darting pains in the region of the inflamed organ. Sometimes considerable headach attends, and occasionally much uneasiness and pain is expe- rienced in the stomach, accompanied with tenderness to pressure in the epigastrium. It must not be supposed, however, that pericardial inflammation is invariably attended with the train of symptoms just described. There are few phlegmasial affections so liable to such remarkable variations in the attending symptoms, as the disease under considera- tion. In some cases very little or no pain is experienced in the region of the heart; and the disturbance of the heart's action varies greatly in different cases, or at different stages of the same case. Most commonly the heart palpitates tumultuously, and knocks vio- lently against the ribs; but in some cases, its action is so feeble that its pulsations are scarcely to be felt or heard. Although the majo- rity of patients are obliged to remain in a sitting or semi-recumbent posture, yet some are forced to lie immoveably on their backs, or on the right or left side. " But the strangest anomaly is, that the same * Recherches Anatomico-pathologiques, &c. &c. Vol, I.—33 386 pericarditis. patient who at one period of his disease has fixed himself immove- ably on the left side, will, at another, be forced to turn over and fix himself as immoveably on the right side." (Latham.) Pericarditis is not unfrequently complicated with inflammation of the neighboring structures, as the pleura, lungs, mediastinum, dia- phragm, or stomach; and in some cases the substance of the heart itself participates in the pericardial inflammation. In instances of this kind, the symptoms are, of course, correspondingly complex. Diagnosis.—From the complications just mentioned, the diagno- sis of pericarditis is often attended with much difficulty; and Laen- nec cautions, in all instances, against " too implicit a confidence" in the symptoms mentioned above as manifestations of pericardial in- flammation. Pericarditis, he says, may exist without any of these signs; and on the other hand, all of them may be present, without the slightest inflammation of the pericardium. M. Louis, however, asserts, that from a careful observation of thirty-two cases of this affection, he has been led to believe that the diagnosis is by no means so difficult and uncertain as is supposed by Laennec and others. This, he says, may be asserted, at least, of those cases that are free from complications. Where we find severe lancinating pains in the region of the heart, extending at intervals to the back and epigastrium, attended with palpitation of the heart; great irre- gularity, intermission, and smallness of the pulse; difficult respira- tion; occasional syncope or great faintness; inability to rest in the recumbent position, with more or less oedema of the extremities, we may infer, without much risk of erring, the existence of pericar- dial inflammation. If with these symptoms we find the cardiac region yielding, an obscure or dull sound on percussion, while the other parts of the chest are resonant, the correctness of the diagno- sis will hardly admit of a justifiable doubt. But, although we may, with but little risk of mistake, infer the existence of pericarditis when the foregoing symptoms are present, it is well ascertained that rapid and violent pericardial inflammation sometimes occurs, and proceeds to a fatal termination, without at any period of its course manifesting a single symptom indicative of cardial disease. It is a very remarkable fact also, that cases of this kind occasionally simu- late inflammation of the brain so closely, that no one could for a moment hesitate to regard the disease as an instance of strongly marked encephalic inflammation. Dr. Latham has recorded several highly interesting cases of this kind. "One of the children at Christ's Hospital, had in the opinion of all who saw him the se- verest inflammation of the brain. The attack was sudden, with great heat of the skin and frequency of the pulse. He had delirium and convulsions, and pointed to the head as the seat of his pain." On dissection, not the slightest trace of inflammation within the head was discovered, but the heart and pericardium were intensely in- flamed. M. Andral also relates a case where delirium, general con- vulsions, twitching of the tendons, and finally tetanic spasms, fol- PERICARDITIS. 38V lowed by paralysis of the upper extremities and fatal coma, occurred without the least sign of any particular affection of the head. On dissection, the brain, spinal marrow, and their membranes, did not present the slightest traces of disease. But the pericardium exhibited strong marks of inflammation; its surface was covered with a layer of concreted lymph, and several ounces of a green and flaky serum were effused into its cavity.* Causes.—In general, whatever is capable of causing inflammation of any of the thoracic organs or structures, may give rise to pericar- ditis. Cold; mechanical injuries; the sudden healing up of old ulcers; the suppression of habitual evacuations; repelled cutaneous affections; the influence of the depressing mental emotions; and over exertion of the mind; may produce the disease. Metastasis of rheumatism and gout, is, however, by far the most common cause of this affection. Rheumatic irritation especially, is frequently con- cerned in the production of cardiac affections. Under the head of hypertrophy, its tendency in this way will be particularly noticed. Pleuritis and pneumonia sometimes involve the pericardium. Autopsicphenomena.—In most instances a considerable quantity of serum is found in the pericardium. Louis mentions cases in which more than a pint and a half of reddish or yellowish serum was collected; and Corvisart saw an instance where it amounted to four pounds. The internal surface of the pericardium is generally much injected, and often rough and uneven, or covered with more or less extensive patches of false membrane. In some cases a simi- lar pseudo-membranous formation covers the surface of the heart. M. Louis mentions one where false membrane, nearly half an inch thick in some places, covered the heart, so as to give it the appear- ance of the rind of a pine apple. Laennec asserts that the quantity of serum effused into the pericardium, though considerable in the early stage of the disease, always decreases progressively, by ab- sorption, as the violence of the inflammation declines. In cases of great violence, there is generally very little or no serum effused; but instead of this, a large portion of firmly concreted albumen, usually covers the heart and internal surface of the pericardium, and in some instances, fills the whole cavity of this membrane, unit- ing it more or less firmly with the surface of the heartt In cases that terminate favorably, this albumenoid concrete matter gradually becomes converted into cellular substance, " or rather into laminae of the same nature as the serous membranes." In some cases the pericardium is found very firmly adherent to the heart throughout its whole extent, by means of laminae of cellular structure thus formed. Cases are mentioned by some of the older writers, where * Pathological Essays on some of the Diseases of the Heart. By P M. Latham, M.D. Physician to St. Bartholomew's Hospital. Lond. Med. Gazette, 1829. ■j- Laennec. 388 PERICARDITIS. the pericardium was supposed to be altogether wanting; but these were no doubt instances of firm adhesion of this membrane to the heart. Columbus relates the case of a student at Rome, who after having for a long time suffered frequent attacks of syncope, died suddenly. On dissection, the heart, he says, was found unprotected with a pericardium.* The pericardium has also been found affected with true scirrhous induration; and Dr. Friend asserts that he has found it above half an inch in thickness throughout its whole extent.t Chronic Pericarditis.—The chronic form of pericardial inflam- mation appears to be much more frequent than the acute. It is attended, in most instances, with more or less fixed pain in the region of the heart, subject to occasional exacerbations, particularly from even slight perturbating causes. Some degree of dyspcena and pectoral oppression is seldom wholly absent; and a short dry cough is apt to occur. The pulse, as in the acute form of the com- plaint, is small, and at times irregular and intermitting; and the heart is apt to be thrown into violent paroxysms of palpitation by slight corporeal exertions and mental excitement. Patients labor- ing under this affection, are generallly timid, pusillanimous, and disturbed by apprehensions of evil, or of death. On percussion, the sound elicited over the region of the heart, is peculiarly dull; and when effusion has taken place, some degree of fluctuation may be felt by the patient. In most instances, oedema of the lower extre- mities occurs, and occasionally a puffy swelling appears suddenly in the face, particularly under the eyes, and after a day or two disap- pears again. When the sound on percussion over the cardial region is dull, and the extremities and face become puffy, we may conclude that considerable effusion of serum has taken place in the pericardium; and in this case the danger is always very great. Death from this affection often occurs very suddenly and unexpectedly; but in some instances a slow wasting of the body, and declension of the vital powers, under symptoms of general febrile irritation, gradually lead to a fatal termination. On dissection, the whole internal surface is, usually, found florid; but the pseudo-membranous exudation, so common and conspicuous in acute pericarditis, is but rarely met with in this form of the dis- ease. When albumenoid concretions ofthis kind do occur in chro- nic pericarditis, they are always " thin, soft, friable, and entirely resembling a layer of very thick pus." (Laennec.) The substance of the heart presents a whitish color, " as if it had been macerated, several days, in water;"" and it is sometimes of a much softer con- sistence than natural, whilst in other instances it possesses its normal degree of firmness. Laennec does not agree with those who sup- pose that the loss of color in the muscular substance of the heart, is * De Re Anatomica, lib. xv. p. 267—as quoted by Van Swieten. X History of Physick, p. 2. PERICARDITIS. 389 the consequence of inflammation; but he does not advance any facts which can be deemed sufficient to repudiate this opinion. Treatment—A direct and active antiphlogistic treatment is of course the only mode of management upon which any reasonable hopes of success can be placed. In cases attended with symptoms of pulmonic inflammation, the treatment should, in every respect coincide with that which would be adopted in either pneumonia or pleuritis. Where the pericardial inflammation has supervened sud- denly, soon after the disappearance of external rheumatic inflam- mation, blood-letting cannot, in general, be carried to the extent which is proper in cases arising from other causes. Indeed the ordinary antiphlogistic means usually employed in phlegmasial affections, will rarely subdue rheumatic pericarditis; and copious abstractions of blood are not unfrequently productive of serious mischief. In cases of this kind calomel and opium, given in full and frequent doses, in conjunction with moderate general and local depletion and proper revulsive applications, constitute the most valuable curative means we possess. Dr. Latham speaks in the most favorable terms of the employment of mercury in pericarditis. It is particularly valuable in rheumatic pericarditis, although much advantage may often be obtained from its use in every variety of the disease. "From acute pericarditis," says Dr. Latham, "which has proceeded to the deposition of lymph, nothing, I believe, can effect a perfect recovery, except mercury, given so as to excite moderate salivation." From my own observations, I am entirely convinced that calomel given to the extent of producing a general mercurial impression, is a valuable remedy in this affection. Where the disease is dependent on rheumatism, it will, I think, always be best to give the calomel in union with opium. In a case of rheu- matic pericarditis, which came under my care about six months ago, I prescribed one grain of opium with three grains of calomel, every four hours, with unequivocal benefit. About sixteen ounces of blood were abstracted with the lancet, and thirty leeches applied to the region of the heart, before the calomel and opium were re- sorted to. Blistering on the back between the shoulders, whilst blood is abstracted by leeching or cupping from the anterior cardial region, is a very powerful auxiliary in reducing this affection. The saline hydro- gogue purgatives, are probably better suited to procure advantage in this affection than the other articles of this class of remedies. From vvhat I have myself witnessed in relation to this point, I am led to believe that cremor tartar, with or without a portion of jalap, is the best purgative we can give in this affection. When the disease is of a chronic character, and there is reason to presume that serum has been effused in the pericardial cavity, diuretics will be proper. The squill in union with calomel, may be employed for this purpose. In this form of the disease, a more permanent counter-irritation over 33* 390 ACUTE RHEUMATISM. the region of the heart, than can be well obtained by blisters, should be kept up. Pustulation with the tartar emetic ointment, or a caustic issue, will in general answer this purpose well. CHAPTER XV. OF THE PHLEGMASIA OF THE FIBROUS AND MUSCULAR STRUCTURES. Sect. I.—Acute Rheumatism. Acute rheumatism generally commences with the ordinary initial symptoms of febrile affections from cold or atmospheric vicissitudes. A sense of dullness, alternating with flushes of heat, with general lassitude, loss of appetite, and depression of spirits, are the usual symptoms which attend the development of the disease. In many instances, a general soreness and aching of the body accompany these symptoms. Sometimes the febrile reaction becomes completely established before the local rheumatic inflammation supervenes; in other instances, more or less pain is experienced in one or several joints, or in other fibrous structures, from the commencement of the attack; and occasionally, though rarely, the local affection occurs before any manifest general sympathetic irritation takes place. The parts affected with rheumatic inflammation are swollen, red, and ex- tremely painful—the slightest pressure or motion causing the utmost degree of suffering. When perfectly at rest, the patient often expe- riences some abatement of the gnawing and tearing pain during the day; but at night intense exacerbations usually lake place. Whether the fever precede or rise with the development of the local inflam- mation, it always acquires additional violence as soon as the local aflection is fully established—the pulse becoming full, frequent, and vigorous; the skin hot and dry; the tongue coated with a white fur, changing to a brown color, as the disease advances; the thirst very urgent; the bowels constipated, and the urine scanty, of a deep red color, transparent, and without sediment. In very severe cases, headach, and, occasionally slight delirium, attend during the exacer- bations. Bilious Rheumatism.—Acute rheumatism is sometimes compli- cated with conspicuous derangement of the biliary organs. This is the rheumatismus ucutus gastricus of Richter, and depends, according to Stoll, on gastric irritation from redundant and vitiated bile in the primse viae.* Like bilious pleurisy, it is the result of * Ratio Meden. torn. ii. p. 25. ACUTE RHEUMATISM. 391 the united operation of cold and koino-miasmata on the system. This variety of the disease is met with in miasmatic districts during the cold and variable months of the year, more especially after a warm and sickly autumn. The disease is usually attended with con- siderable pain in the head; a yellowish or icterode hue of the eyes; a thick layer of brown fur on the tongue; occasional nausea and bilious vomiting. The quantity of bile thrown up is sometimes very great; and after each spell of vomiting, an immediate and often almost complete, though but temporary, abatement of the local rheu- matic pains usually occurs. Gonorrhoeal Rheumatism.—Rheumatic pain and swelling of the knees and ankles, is no uncommon consequence of gonorrhoeal irri- tation. In some instances, though rarely, the rheumatic affection becomes more general, very painful, and attended with very consi- derable febrile irritation. Cases of this kind have generally been ascribed to a suppression of the gonorrhoeal discharge. This is the opinion of Brodie, and of Swediaur; but Mr. Bacot thinks this ex- planation of its origin "is to be understood in a very qualified sense." It appears, however, to be pretty well ascertained, that "neither the affection of the joints nor the more general rheumatism, come on until the gonorrhoea is on the decline." Young persons of "stru- mous habits, florid complexions, and not particularly robust," are most liable to this form of rheumatic affection. This form of the disease is characterised by much puffiness and tenderness of the ankles, especially towards evening; the pain is not much increased by pressure—the stomach becomes deranged, and the appetite usu- ally fails altogether. Now and then, "all the symptoms are sud- denly relieved by an eruption of papulae in clusters; or sometimes by pustules in minute patches." This eruption may continue from a few days to several weeks. When it appears, both the pains and constitutional symptoms go off entirely.* The rheumatismus non febrilis recens of the German writers, though diverse from the chronic form of the disease, is not attended with very obvious symptoms of febrile reaction. It shows itself by more or less severe and sharp pain in some one of the muscular or aponeurotic parts of the body, particularly in the muscles of the breast, neck, and about the scapular region, and occasionally in the face and jaws. Sometimes the affected part is swollen and red; at others, neither swelling nor redness occurs. This variety of rheu- matic inflammation generally arises from the local application of cold, such as currents of air directed upon some particular part of the body.t Prognosis.—Although extremely painful, rheumatism is not a dangerous affection, so long as the inflammation remains in the exter- nal parts. When translated to some internal organ or structure— * A Treatise on Syphilis, &c. by John Bacot, Esq. Surgeon, &c. X Richter, Specielle Therapie, vol. ii. p. 36. 392 ACUTE RHEUMATISM. particularly to the heart, meninges of the brain, stomach, or lungs, the most serious consequences are to be apprehended. The duration of an attack of acute rheumatism is extremely va- rious, and depends much on the degree of constitutional predisposi- tion to the disease; and on the remediate management adopted for its removal. When the disease is about terminating, general diapho- resis, with a copious pale-red sediment in the urine occurs; and, in some instances, moderate diarrhoea accompanies the declension of the fever and inflammation. It never terminates in resolution with- out the concomitant occurrence of diaphoresis and a lateritious sedi- ment in the urine. It would appear from some observations of Dr. Chambers and Mr. Wigan, that the sweat in acute rheumatism is almost invariably of an acid quality.* I noticed this fact in a case I attended a few months ago. The patient wore a blue check shirt, the blue stripes of which were changed to a pale-red color during the resolution of the disease. Rheumatism occurs but very rarely during early infancy. Scu- damore asserts that infants are entirely exempt from it; but in this he is certainly wrong. I have met with several instances of acute articular inflammation, attended with the usual phenomena of rheu- matism, in children under two years old. Very aged persons, also, are seldom affected with the acute form of rheumatism, although especially liable to the chronic variety of the disease. From the seventh to the forty-fifth year of age, is the period during which acute rheumatism is most apt to occur. Lean and muscular persons of a sanguineous temperament are, in general, much more liable to this affection than individuals of a fat aud soft habit of body, or of a nervous or lymphatic temperament. Among the most common and powerful accidental predisposing causes of rheumatism are, derange- ment and irritation of the alimentary canal; the inordinate use of spirituous liquors; fatiguing exercise, accompanied with protracted and copious perspiration; and the habitual use of high-seasoned and heating articles of food; and the abuse of mercury. Cause.—Suppressed perspiration from cold or sudden atmosphe- ric vicissitudes is incomparably the most frequent exciting cause of rheumatism. It is on this account that the disease is so much more common during the damp, raw, and variable months of spring and autumn, than in the more mild and equable season of summer. In- deed, rheumatism is almost peculiarly a disease of cold and variable climates—its occurrence in the warm and more uniform latitudes being comparatively rare. Mercury is generally accused as a very frequent cause of rheumatism. It is doubtful, however, if it is ever, of itself the exciting cause of this affection, although its very espe- cial tendency to predispose the system to the morbific influence of low and variable temperature is unquestionable; and it is, probably, by this effect alone, that the use of mercury is so apt to be followed * Medico-Chirurg. Rev. April, 1828, p. 176. ACUTE RHEUMATISM. 393 by rheumatic affections. I have already adverted to gonorrhoeal irritation as an occasional cause of rheumatic affections. It would appear that the occurrence of the arthritic pains is in some way or other connected with the disappearance of the gonorrhoeal discharge but whether the cessation of the discharge is to be regarded as the effect or the cause of the rheumatic affection, is as yet a matter of conjecture. In relation to the proximate cause of rheumatism, authors have expressed a variety of opinions. Formerly it was customary to regard the disease as depending directly on a peculiar morbific or rheumatic matter in the blood, which being thrown or concentrated upon some particular part, was thought to be the immediate exciting cause of the local inflammation. Balfour advanced the opinion of its consisting in a peculiar inflammation of the cellular tissue; and Cullen supposed that an inflammatory state of the blood, in con- nection with a peculiar phlogistic condition of the muscular struc- ture, constitutes the proximate cause of the disease. With Brous- sais, it, of course, is the consequence of the all-embracing gastro- enterite. The opinion of Richter, that rheumatic inflammation is the consequence of irritation from retained perspirable matter (materia perspirabilis retenta,*) though savoring too much of humoral pathology for the prevailing taste of pathologists, is at least as plausible as any other doctrine that has been advanced on this subject, and by no means at variance with the immediate effects of its acknowledged almost invariable exciting cause. Whatever ideas may be entertained in relation to the proximate cause of rheumatic inflammation, it is now generally admitted that the seat of this inflammation is in the fibrous textures—more espe- cially in the aponeurotic and tendinous structures of the body. It is manifest, moreover, that this inflammation differs very materially from the other varieties of inflammation; and the opinion of Scuda- more, that it is, sui generis, of a strictly specific character, is sup- ported by its peculiar character and phenomena. The frequent and often rapid passage of the local affection from one part of the body to another, would seem to indicate something radically distinct, if not in the inflammatory action itself, at least in its immediate or proximate cause. This circumstance, too, favors the opinion that the disease consists in a peculiar diathesis, or general morbid con- dition of the system—the local inflammation being merely one of its effects, or external manifestations. We notice this migratory character in all inflammations which depend on some internal or constitutional affection. It occurs most conspicuously in gout, and n some varieties of erysipelas. Metastasis of rheumatic inflammation to internal organs or struc- tures, and consequent alarming and sometimes fatal consequences, is by no means unfrequent. It may pass upon the heart, diaphragm, * Specielle Therapie, vol. ii. p. 18. 394 ACUTE RHEUMATISM. stomach, bowels, intercostal muscles, and, in short, upon almost every sensible part of the body. When it is translated to the heart, the patient is seized with acute pain and a feeling of great anxiety in the cardiac region, with palpitation, fits of partial syncope, and a pale, contracted, and distressed aspect of the countenance. Metastasis to the meninges of the brain, is attended with a sense of weight, and sometimes acute pain in the head, intolerance of light and sound, a wild and anxious expression of the countenance, occasional delirium, strabismus and impaired vision.* When the stomach becomes the seat of the disease, violent cardialgia, nausea, vomiting, indigestion, "and symptoms imitating cancer or scirrhus of the pylorus" usually supervene. Cazenave says, that in some cases, nothing but a feeling of coldness or pain occurs in the epigastric region.! The same ■writer states, that he has known the bladder to be affected with rheumatism—producing retention of urine, and much pain in the vesicle region. Sometimes the lungs become the seat of the disease, in which case symptoms of peripneumony supervene. When it attacks the intercostal muscles, or the pleura, the phenomena of pleuritis occur. Cazenave states, that he has repeatedly known rheumatic inflammation to fix upon the uterus and its appendices, giving rise to severe pain in this organ. 1 have lately seen an instance of sudden translation of rheumatic inflammation from the wrist to the bowels, in a young lady, which was speedily followed by symptoms of subacute peritonitis. On the fourth day the pain and swelling reappeared in the arm, and the abdominal affection speedily subsided. Dr. Johnson observes in relation to this disease, that though not often fatal as external rheumatism, yet in its con- sequences, he is led, from " long and attentive observation," to regard it as being productive of " a very considerable proportion of those active enlargements or hypertrophiae of the heart, which we now so frequently meet in practice." Dr. Cox also refers to the "numerous cases of organic disease of the heart and pericardium, which he met with during his connection with St. Guy's Hospital, that were referable to, or connected with rheumatitis."J His ob- servations have led him to believe that the " majority of cases of organic disease of the heart in young people, are connected with rheumatism." Diagnosis.—By the ancients, rheumatism and gout were gene- rally described under the common name of arthritis, and it does not appear that they regarded these affections as being diverse from each other. The essential identity of these two diseases has, in- deed, found advocates among modern pathologists, although the general sentiment, at present, is that they are radically distinct from * Observations on Acute Rheumatism and its Metastasis to the heart. By Thos. Cox,M.D. London, 1824. X Memoir on the Treatment of Rheumatism. By Dr. Cazenave. X Loc. citat. preface, viii. ACUTE RHEUMATISM. 395 each other. The principal distinguishing circumstances between these two affections are:—1. The periodical recurrence of gout after it has once invaded the system; whereas, rheumatism does not pos- sess this tendency, the patient often remaining entirely free from the disease during the rest of life, after having suffered an attack of it. 2. The distinct character of their causes; thus, rheumatism is conspicuously and almost invariably, the result of atmospheric in- clemency or vicissitudes causing sudden depression of the cutane- ous exhalation.* It is not produced, like gout, by indolence, in conjunction with the free use of vinous drinks, and rich, high sea- soned, and stimulating articles of diet. An attack of acute rheuma- tism is not usually preceded by uneasy sensations in the stomach, and other gastric disturbances. Gout is very often preceded by dyspeptic symptoms. 3. The predisposition to gout is often trans- mitted from parent to offspring. This is rarely, if ever the case, in relation to acute rheumatism. 4. Gout is most apt to occur in de- bilitated and relaxed habits; its occurrence in lean, muscular, and temperate persons inured to hardships and toil, being extremely un- common; whilst the reverse, in all these respects obtains in rheu- matism. Treatment.—Although of a strongly marked phlogistic charac- ter, rheumatism is not so much under the control of direct depletion as most of the other phlegmasial affections. Blood-letting is un- doubtedly a very important auxiliary in the treatment of this dis- ease; but it is incapable, by itself, of subduing the local inflamma- tion, however copiously practised. Indeed, the very profuse, san- guineous evacuations so frequently resorted to in this complaint, so far from proving beneficial, lead often to very disastrous conse- quences; for experience has fully established the fact, that metasta- sis of the local affection to an internal organ is particularly favored by thus draining the system of its blood, and impairing the vital energies. " We have long been convinced," says Dr. Johnson, "from attentive observation, that the system of detracting large quantities of blood in cases of acute rheumatism, is productive of more frequent metastasis from the extremities to internal or- gans than a more moderate treatment. If we do quell the external inflammation, a retrocession to some weakened organ is too apt to take place. Of this we have seen several instances."t The records of medicine furnish us with many examples illustrative of the correctness of this observation. The case reported by Dr. Kempher is a striking instance of this kind. This was a strongly marked case of inflammatory rheumatism; the fever was violent, * Richter says, rheumatism is always produced by external exciting causes, such as cold, and, therefore, more immediately from a materia perspirabilis reten- ta. Whereas, gout arises from internal causes, giving rise to a peculiar atony and weakness of the system. | Medico-Chirurg. Review, June, 1823, p. 215. oyD ACUTE RHEUMATISM. and "the joints of her limbs, from the elbows and knees downwards, were affected with swelling, redness, and most acute pain." In five days, nearly eleven pints of blood were abstracted from the patient. Metastasis of the disease soon took place, first to the lungs, and then to the head. At last the rheumatic inflammation returned to the extremities and relieved the internal organs.* Dr. Armstrong also, has related a case of this kind.t The inordinate use of the lancet, by debilitating the constitution, is, moreover, apt to prolong the dis- ease in a subacute or chronic state, and to strengthen the predispo- sition to a recurrence of the affection. "In no way," says Scuda- more, " is a degeneracy into chronic symptoms so certainly induced, as by that injudicious employment of general bleeding which enfee- bles the constitution, and still leaves the rheumatic disposition in great force. Nor does the articular disease itself yield to the use of general bleeding in the manner which we might expect.X Blood-letting is, however, not to be entirely neglected in this affection. It is only against the too common abuse of this evacua- tion that these observations are directed. In strong, muscular, and plethoric subjects, general bleeding, until some impression is made on the pulse, is a useful preliminary to the employment of the more efficient remedies in this affection. In general, one or two pretty copious evacuations in the commencement of the disease, will be sufficient to procure all the advantages this measure can afford. The attempt to render the pulse soft and moderate, in its action by blood-letting in this disease, will almost always fail, unless blood be drawn to a very dangerous extent. The usual indication fur- nished by the buffy coat of the blood, for further depletion in inflam- matory affections, is wholly fallacious in rheumatism; for the buffy coat will generally continue in despite of the most copious and re- peated abstractions of blood. "A surer practical indication may be taken from the form of the coagulum and its firmness. When it is exceedingly cupped, and when the inferior part beneath the stratum of fibrine is very firm, it is a presumptive evidence that the heart and arteries are laboring under that morbid contractility which dis- tinguishes the inflammatory diathesis."§ When the disease fixes itself early on some internal organ—par- ticularly the heart, diaphragm, or brain, it will be necessary to re- sort to prompt and decisive bleeding; but even in cases ofthis kind, it will he much better after one or two copious abstractions of blood, to resort to the use of opium and calomel, than to a repetition of the bleeding. Purgatives are always useful in this affection. I have often known the inflammatory condition of the system more effectually reduced * Philadelphia Jour. Med. and Phys. Sciences, No. 12. X Lond. Med. and Phys. Jour. No. 289. X A Treatise on the Nature and Cure of Rheumatism. London, 1827, p. 70- § Scudamore, loc. citat. p. 70. ACUTE RHEUMATISM. 397 by the operation of two or three saline purgatives, than could be effected by several copious abstractions of blood. The more drastic articles of this kind ought to be avoided. These are in some de- gree incompatible with that regular action of the cutaneous exha- lents which seems to be indispensable to the removal of this affection. Laxatives, on the contrary, are of much service by removing the sources of intestinal irritation—equalising the circulation and mode- rating the febrile reaction, without causing injurious irritation by their direct impressions on the mucous membrane of the bowels. As a general rule, the saline purgatives are to be preferred. I have usually directed from six to eight grains of calomel at night, to be followed next morning by a small dose of Epsom or Glauber salts. Scudamore speaks very favorably of an aperient draught composed of small doses of carbonate of magnesia, carbonate of pot- ash, sulphate of magnesia, with tartarised antimony, acetum colchici, and lemon juice sufficient to neutralise the carbonate of potash, and a portion of water and syrup. Two ounces of Epsom salts, with a grain of tartar emetic, dissolved in eight ounces of water, and taken in doses of a tablespoonful every hour, is an excellent aperient in this complaint. Emetics have been much recommended in the treatment of rheu- matism, and my own experience has furnished me with some strik- ing examples of their usefulness. Horn asserts that he has derived more prompt advantage from emetics in this complaint, than from any other remedy.* I attended a gentleman, a few years ago, who was suffering extremely from an attack of acute rheumatism. The principal pain and swelling was in all the joints of the left arm, and in the right knee. He had been freely bled and purged before I saw him, but the pains continued unabated. With a view to excite dia- phoresis, and to moderate the febrile reaction, I prescribed a solution of tart, antim. Contrary to my intentions, the first dose produced pretty free vomiting. Almost immediately his pains were greatly mitigated, and continued so for three or four hours, and then gradu- ally returned, though not to their former state of violence. On the following morning, I gave him an antimonial emetic, which pro- duced full emesis, and again the rheumatic pains subsided, almost entirely, for a few hours; they returned, however, as before, but so greatly diminished, that he was enabled to obtain considerable sleep during the following afternoon and night. On the third day, he took another emetic, after which the disease disappeared rapidly and completely, under the use of a few full doses of opium. I have, since that time, derived signal advantage from emetics in several cases ofthis affection. When rheumatism is complicated with functional disorder of the liver, emetics are particularly useful. In instances of this kind, the * Uber d. heils. wirk. d. brechmittel in hitzigen rheumat. Archiv. b. viii. s. 2. Vol. I.—34 398 ACUTE RHEUMATISM. local pain will often almost entirely disappear for a time; and if full doses of calomel and opium are administered soon after the vomit- ing has ceased, convalescence will sometimes speedily ensue. Diaphoretics may be employed with advantage, although little or no benefit is usually derived from profuse sweating excited by remedies ofthis kind. A gentle and uniform diaphoresis is always serviceable. For this purpose, small doses of tart, antim. in union with calomel and opium;* or with camphor and nitrate of potash;t or Dover's powder with calomel, may be advantageously employed. Scudamore recommends the following diaphoretic and anodyne mixture as particularly beneficial in this respect: R.—Potassae carbonat. gr. cviii. Succi citric, (recentis) Jii. Misturae camph. ^iiiss. Liquoris opii sedativ. giss. ad gii. Syrup, tolutan. ^ss. Antim. tartarisat. gr. i. ad gr. ii.—M. Of this mixture, one, two, or three tablespoonfuls are to be taken every hour or two, until the pain is re- lieved. The diaphoretic tendency of these remedies should be promoted by the use of warm diluents; such as weak infusion of eupatorium perfoliatum, of elder blossoms, &c. Opium, under judicious management, is a valuable remedy in acute rheumatism. When employed in full doses, after proper venesection and purging, in combination with calomel, or with ipe- cacuanha, or tart. antim.J it seldom fails to procure speedy relief, * R.—Tart, antimon. gr. i. Pulv. gum. opii gr. iii. Calomel gr. iv. Pulv. sacch. albi gr. xii.—M. Divide into eight equal parts. S. Take one every two hours. j- R.—Tart, antimon. gr. i. P. g. camph. gr. viii. Calomel gr. iv.—M. Divide into eight equal parts. S. Take one every two or three hours. £ Tartarised antimony and opium have been employed with signal efficacy in rheumatism. Dr. Findlay, of Circleville, Ohio, has published an account of several severe cases of this disease which yielded very promptly to a combina- tion of these remedies. He gave about one grain of the antimony with two- thirds of a grain of opium every hour, (a) I have myself lately employed this remedy in several cases, and with very speedy and entire success. Not more than four doses were required in an extremely severe case of lumbago, to put an entire stop to the pain. M. Lallemand speaks very favorably of grain doses of tart, antimony in rheumatic affections; and it is, in fact, a remedy of excellent powers in this respect. (a) North American Med. and Surg. Jour. vol. x. p. 167. ACUTE RHEUMATISM. 399 and to hasten the resolution of the local and general inflammatory action. When, after copious depletion, or from constitutional fee- bleness, the rheumatic inflammation passes upon some internal or- gan, opium is almost the only remedy upon which any reasonable hope of advantage can be placed. In my own practice, I have had many striking examples of the usefulness of this narcotic in the present affection. It should be given in full doses, and repeated every three or four hours, until relief from the pains is procured. Small doses of opium have a tendency to increase the phlogistic diathesis, whilst large ones, properly repeated, generally produce a contrary effect in acute symptomatic fevers, " It is worthy of con- sideration," says Scudamore, " that so powerfully does pain modify the influence of opium on the nervous system in every kind of dis- ease, that it may be given in the boldest doses without hazard or ill effect, when pain is intense; and in no way except by the active repe- tition of such doses can it be really efficacious when the occasions for it are urgent." Dr. Cazenave very justly observes, that the timidity with which this narcotic is usually administered in acute rheumatism, is the cause of its frequent failure in doing conspicuous good. His mode of using the opium, in this affection, is to give a grain of it every hour, " till a complete calm is established, or an abundant perspiration induced." Most practitioners who are in the habit of employing opium in rheumatism, use it in combination with calomel; and this ha^ ap- peared to me the best mode of using it. After venesection, and the free operation of a cathartic, I generally resort at once to opium and calomel, in the proportion of one grain of the former to two of the latter every three or four hours, until the gums are slightly affected; after which I continue with half a grain of the opium, at first every three hours, and gradually prolonging the intervals in proportion as the disease subsides. I have frequently found, that as soon as the mercurial action was established, the skin became moist and re- laxed, the pulse soft and less frequent, the urine sedimentous, with a rapid declension of the local and general affections. Dr. Arm- strong observes, that after prompt venesection, followed up by pur- gatives with calomel and opium, recovery is often surprisingly rapid. Many highly respectable authorities might be cited in favor of the united employment of these two articles in rheumatism.* "This * Dr. Chambers, of St. George's Hospital, London, gives ten grains of calo- mel, with two of opium, every night, or night and morning, with a daily dose of black draught to evacuate the bowels. He states, that as soon as the mouth be- comes affected, the symptoms usually subside. He does not push the medicine to the extent of producing ptyalism.—Med. Chir. Rev. vol. v. p. 566. Mr. Gosse, of Geneva, has employed calomel and opium to ptyalism with success, in acute rheumatism. From some chemical experiments which he made with the blood of persons under salivation, he found that it contained much less albumen, as well as cruor, and was more liquid than usual; and that it is there- 400 ACUTE RHEUMATISM. treatment of acute, and we may say chronic rheumatism," observes Dr. Johnson, " is employed by many practitioners, and it is that which we have had recourse to for twenty years past."* It is not necessary to continue the calomel to the extent of producing free ptyalism. The slightest evidence of the mercurial action in the gums, is in general sufficient. The cinchona was formerly much recommended in the treatment of this affection. When, after depletion and purging, distinct re- missions of the febrile symptoms occur, particularly in weak and relaxed habits, the powdered bark or quinine may be employed with advantage. But in robust, muscular, and sanguineous habits, it is much more apt to do harm under any mode of management, than benefit. I have known very manifest injury done by the bark in this affection. During convalescence it is a proper and useful re- medy. Colchicum was at first prescribed only in the subacute or chronic forms of rheumatism; but later experience has shown that it may be employed with equal benefit in the acute form of the disease. Mr. Hayden, in his work on the remedial powers of this root, asserts, that it possesses very considerable powers in controlling the action of the heart, and subduing inflammatory excitement. I have exhibited this article in seven or eight cases of acute rheumatism. In one instance it removed the disease completely in the course of three days, although previously very violent, and after calomel and opium, tart. antimon., venesection, and free purgation, had been ineffectually used. In a few instances it appeared to do some good, but in others no advantage whatever resulted from its use. Recently, however, I prescribed it in two instances of a subacute character with the hap- piest effect. Both patients were relieved by it in forty-eight hours, although the disease had for several weeks resisted other modes of treatment. Scudamore recommends the following formula for ad- ministering this remedy, where the inflammatory diathesis is not strong : R.—Liquor, ammon. acetat. ^ss. Vini colchici gtt. xx. ad xxx. Syrupi papaveris ^i. Misturae camph. %i.—M. This draught is to be taken every sixth or eighth hour. The vinous tincture of the colchicum seed may be given to the extent of from 20 or 30 drops, with "about a scruple of calcined magnesia every four hours, until slight nausea or purging is pro- duced. When acute rheumatism continues until it assumes a subacute cha- fore less inflammatory. Similar opinions have been expressed by Dr. Farr and Mr. Travers.—Med. Chir. Rev. vol. i. p. 482. * Med. Chir. Rev. October, 1826, p. 566. CHRONIC RHEUMATISM. 401 ructer—the pulse remaining irritated, small, sharp, and frequent, and the countenance pale, while the affected joints are swollen, painful, and oedematous—great benefit may sometimes be derived from the extract of stramonium, given in quarter grain doses every four hours until vertigo ensues. I have succeeded in removing the disease, in a short time, in several instances of this kind, by means of the stra- monium, after various other modes of treatment had been employed without avail. Very little advantage is in general to be obtained from local treat- ment during the active period of the disease. After the general inflammatory excitement has in a great degree subsided, benefit may be derived from leeching the affected parts. I have also known much good done by blistering the inflamed joints under such cir- cumstances. The treatment by compression, so strongly recommended by Balfour, has not met with much approbation; less I think than it deserves. 1 have in a few cases of subacute rheumatic inflammation, known very considerable relief obtained from a flannel roller applied pretty firmly round the affected joint* The diet should, of course, consist of the mildest liquid farina- ceous articles of food. The drink may be cool and acidulated except when diaphoretics are administered, when tepid diluents should be used. The temperature of the sick chamber should be kept com- fortable and uniform. Sect. II.—Chronic Rheumatism. The symptoms of chronic rheumatism are much less uniform and definite than those which characterise the acute form of the disease. Chronic is often the consequence of acute rheumatism; but it occurs also, frequently, as a direct consequence of exposure to cold and damp air, more especially when the system is under the influence of mercury. The affected parts are commonly neither swollen nor red; nor is there often any manifest fever connected with the chronic variety of the disease; although quickness, tension, and contraction of the pulse are in some instances present in the evening, and during the night. The pain often wanders from one part to another, fixing itself, by turns in the head, shoulders, knees, wrists, fingers, hips, loins, &c.—more especially in those cases which approach the subacute character. Some individuals are hardly ever entirely free from pain; others are affected with it only occasionally, on the occurrence of damp and cold weather. In some instances, the pain is seated in the joints; in others, in the muscles and parts situated between the joints. After remaining at rest for a while, the patient feels stiffness and pain on attempting to move the affected limb; but * Observations on the Pathology and Cure of Rheumatism. By William Balfour, M. D.—Edinburgh Med. and Surg. Journal, April, 1825. 34* 402 CHRONIC RHEUMATISM. on using exercise, until the body becomes warm, both the pain and stiffness are apt to disappear. Those who are subject to this form of the disease, generally feel a dull aching pain in one or more joints, on the approach of stormy or rainy weather. Severe and invete- rate cases of chronic rheumatism are apt to give rise to organic dis- ease of the tendons, bursse mucosas, with wasting and hardening of the muscular structure about the affected parts. The ligaments also, sometimes become rigid, thickened, and the joints stiff A jelly-like effusion into the cavity of the affected joints occurs occasionally. (Scudamore.) When the disease affects the muscles of the loins, it is called lum- bago. Lumbago is distinguished from nephritis by the absence of pain along the ureters, of retraction of the testicles, of the frequent desire to void urine, and of the nausea and vomiting which charac- terise the renal disease. In lumbago too, great difficulty and pain is experienced in bending the body forwards on the hips. In nephri- tis no uneasiness is caused by this movement. When the periosteum of the anterior aspect of the tibiae, or of the ulna, or os frontis, be- comes thickened and tender to the touch, we may presume that the chronic rheumatic affection is syphilitic, or mercurial. Chronic rheumatism sometimes occurs as the sequel of the acute form of the disease; and it arises frequently, also, as a direct conse- quence of suppressed perspiration from cold, damp, and variable weather. It is generally supposed that the action of mercury is particularly apt to give rise to chronic rheumatic pains; but it is extremely doubtful whether it possesses any direct tendency in this way. That the system when under the mercurial influence, is ex- tremely susceptible of the injurious effects of cold and humid air, ils indeed sufficiently ascertained; and it is probable that when rheuma- tism follows the constitutional operation of mercury, it is always the immediate consequence of subsequent influence of cold. Syphilis is apt to give rise to distressing chronic pains of a rheumatic charac- ter, but even where syphilis appears to be its cause, it is probably often the consequence of improper exposure while the system is under the mercurial influence. Mr. Teale has recently published a small work on subinflamma- tion and irritation of the spinal marrow, in which he asserts that not only neuralgic but rheumatic affections frequently depend on irrita- tion, or a slight degree of inflammation, at the origin of the spinal nerves. His observations on this subject appear to me highly im- portant, and from an instance which has quite lately come under my notice, I am satisfied that in some cases at least, chronic pains of a rheumatic character depend on spinal irritation. Dr. J. K. Mitchell, of this city, has, within a short time, published an interesting paper on this subject, in which he has detailed several striking instances of the speedy removal of severe pains of this kind, by cupping over the spinal region. It would appear from the observations of Teale and Mitchell, that in many cases of fixed pains, stimulating rheuma- CHRONIC RHEUMATISM. 403 tism, one or more of the vertebrae of the spine are very tender to pressure, and that, if in such cases leeches or cups be applied over the diseased portion of the spinal marrow, almost immediate removal of the rheumatic pains will be effected. In the case which occurred in my own practice, the patient had complained of constant severe pain in the left foot for several months, and the usual means for the cure of such affection, procured only slight temporary benefit. In- structed by the cases reported by Dr. Mitchell, I at last examined the track of the spine, and found two ofthe lower lumbar vertebrae mor- bidly sensible to pressure. I directed thirty leeches to the part, which afforded great relief, and in a few days afterwards more blood was drawn from the same spot by cupping, and this had the effect of en- tirely removing the disease in the foot. When the pains are situated in the head and upper extremities, the spinal affection, if any exist, will be found in the cervical vertebrae; and when a part about the chest, and upper portion of the abdomen, is the seat of the painful affection, there will probably be spinal irritation in one or more of the dorsal vertebrae. Under the head of neuralgia, I shall again have occasion to speak of this subject; and, in fact, the painful affections which result from this cause, are probably always strictly of a neu- ralgic character, although often mistaken for chronic rheumatic in- flammation. I must again repeat, that the facts developed by Mr. Teale, are highly interesting, and will, no doubt, receive due atten- tion from the profession. Treatment.—Unless the patient be robust, vigorous, and pletho- ric, general blood-letting is not only useless, but often injurious, in the strictly chronic form ofthe disease. Attention should be paid to the state of the digestive functions, and to the bowels. Where the appe- tite is weak and variable, and the bowels inactive, five or six grains of blue mass should occasionally be taken at night, followed in the morning with some gentle aperient—such as the aromatic tincture of rhubarb; or a small dose of the compound infusion of senna. Where there is a general sluggishness or languor of the system, the cinchona bark, or quinine, will sometimes prove decidedly beneficial. Certain diaphoretics of the stimulating kind have been much employed in the treatment of this variety of rheumatism; and of these, gum guai- acum has held by far the highest rank. In individuals of a relaxed and phlegmatic habit of body, and in old persons of a worn-out constitution, it may be used occasionally with much advantage; but in persons of a contrary habit—plethoric, athletic, and phlogistic—it will seldom do good, and is even apt to do harm by its heating and irritating qualities. The usual mode of giving it in the form of a tincture, renders it still more objectionable in habits ofthis kind. In all instances, perhaps, it is best to give it in the form of an aqueous mixture, thus: R.—Pulv. g. guaiaci %i. -----g. arabic 3iii.—Triturate them together in a mortar, and add gra- 404 CHRONIC RHEUMATISM. dually ten ounces of cinnamon water. Of this, three or four tablespoonfuls may be taken daily. In cases partaking of a subacute character, or in such as result from the influence of cold while the system is under the operation of mercury, tart, antimon. will occasionally prove beneficial. In in- stances ofthis kind, I have used this article dissolved in a decoction of the root of burdock, (arctium lappa,) with excellent effects. A grain ofthe tart, antim. should be dissolved in a pint of the decoc- tion (an ounce of the root to a pint of water) and drank in the course ofthe day. In such cases, however, more advantage may in ge- neral be derived from the judicious employment of mercury. In syphilitic and mercurial rheumatism, the production of a gentle mercurial impression on the system, with the concomitant employ- ment ofthe compound decoction of sarsaparilla, will often effectu- ally eradicate the disease. But even in cases which are not con- nected either with a syphilitic taint or with mercurial disease, this remedy will sometimes prove decidedly beneficial. In invete- rate and obstinate cases of chronic rheumatism, says Scudamore, "a well conducted mercurial course, so as to produce and keep up a very moderate ptyalism, will sometimes prove successful after the failure of all other means." Advantage may be obtained from the use of the vapor-bath as an auxiliary to the mercurial course. I hafe used the following decoction, conjointly with mercury, with peculiar advantage: R.—Rad. sarsapariL ^iii. Fol. cymapylla umbelat. ^iss. Rad. mezerion ^iii. Cort. ulmi fulv. £iss. Aqu. fervent. Ibiii—To be boiled down to three half pints; of which a wineglassful is to be taken four times daily. In the same variety of chronic rheumatic pains, I have also admi- nistered the sulphate of zinc, in one grain doses three times daily, with the happiest effects. In one instance, after mercury, sarsapa- rilla, and a variety of other remedies had been fully tried without success, the zinc gave complete relief. The extract of stramonium is highly recommended as a remedy in this affection by Dr. Marcet; and it is unquestionably an article of very valuable powers, in chronic painful affections, unconnected with a phlogistic state of the system. Twenty years ago I em- ployed the tincture ofthe stramonium seed in chronic rheumatism; and I have frequently found it. promptly and completely successful, although often also entirely disappointed in its use. In some parts ofthe United States it has long been used as a domestic remedy in this affection; and it was from having seen it successfully em- ployed by an old female in a case which had foiled all my efforts, that I first learned its remediate powers in this disease. 1 usually CHRONIC RHEUMATISM. 405 give 20 drops of the saturated tincture of the seed three times daily; and direct it to be continued until vertigo, or symptoms of gastric disturbance ensue. I have also employed the extract of stramonium in union with lactucarium, as is recommended by Scudamore, with excellent effect. "In some recent attacks," says this writer, "in which wandering nervous pains have been mixed with lumbago, the effects of this combination have been surprisingly successful. In a few cases, even of long standing, I have derived much satisfac- tion from this remedy." Colchicum is a remedy of considerable powers in chronic rheu- matic afl'ections. I have found it most useful, however, in subacute cases, and in such as are the consequence of the acute form of the disease. In instances of a strictly chronic character, I have never derived any obvious advantage from this article; in such cases, it is I think, inferior in efficacy to the stramonium. In mercurial and syphilitic pains, arsenic will often manifest very excellent powers. It may even be given with occasional advantage in old and obstinate cases arising from other causes—and it is said to be particularly beneficial in such as depend on the repul- sion of some chronic cutaneous affection. In several instances of a mercurial origin, I have prescribed Fowler's solution with com- plete success. After what has already been said above, I need scarcely dwell on the propriety of examining the spinal column, in chronic pains of a rheumatic character. When any portion of it is found unusually tender to pressure, leeches, cups, or a blister, should immediately be applied over the tender part. If the disease be the consequence of spinal irritation, it will frequently speedily disappear under the use of these local remedies. A great variety of other internal remedies have been recom- mended for the cure ofthis form of rheumatism. Of these, savin, nux vomica, phytolacca decandra, dulcamara, hyoscyamus, sul- phur, turpentine, and xanthoxylum fraxineum are the most im- portant. The savin is an old remedy in chronic articular pains;* I knew an empiric, about twenty years ago, who was noted for his success in curing chronic rheumatism. His remedy was an electuary composed of savin, sulphur, and honey. I have prescribed it in a few instances with benefit; but in several cases its effects were mani- festly injurious. In chronic rheumatic pains of the hips (sciatica) and muscles of the loins (lumbago) the spirits of turpentine is among our most efficacious remedies. Home states, that he cured five out of seven cases of sciatica with this article.t Within the present year I suc- ceeded completely in removing a violent and protracted case of this affection by the turpentine, given in doses of twenty drops with a * Rave, Beobachtungen, &c.—Munster, 1796. X Clinical Observations and Experiments. 406 CHRONIC RHEUMATISM. scruple of lac sulphur is three times daily. I have known the infu- sion of capsicum employed with marked advantage in a case of inveterate chronic rheumatism; and the juice of the poke-berries (phytolacca) is a familiar remedy in this affection, and has occasion- ally done considerable good. While practising in Lancaster county, I saw several instances of the successful use of a decoction of xan- thoxylum in chronic rheumatism. Professor Wendt has found an infusion of the clematis recta and vitaba a very useful remedy in this disease. Various external applications have been resorted to with advan- tage in this affection. The application of the tourniquet, so as to cause a temporary interruption in the circulation of the affected part, is said to have done much good.* Lately, the vapor of cam- phor has been used with success in chronic rheumatism by M. Delormel and M. Dupasquier.t The whole surface of the body, with the exception of the head, is to be exposed to the fumes of camphor, in an apparatus similar to the one used for the sulphurous vapor-bath. The camphor is evaporated by throwing it upon a dish of hot coals. Acupuncturation has, of late years, been practised by many physicians in local rheumatic pains unconnected with fever; and the numerous accounts that have been published respecting its effects, are sufficiently favorable to entitle it to considerable attention. Mr. Berlioz observes, that " vague and wandering rheumatism some- times attacks the external muscles subservient to respiration; the patient is obliged to remain motionless; every motion of the trunk compels him to cry out; deep inspiration is very difficult; and cough occasions such intense pains that expectoration is impossible. Acu- puncturation dissipates instantly this state of distress, and renders the muscles their full liberty of action. In the space of one or two minutes, a patient whose sufferings drew from him tears, becomes entirely relieved." This operation has been found particularly effi- cacious in lumbago; and instances of its successful employment in sciatica have been reported. Acupuncturation should, however, never be practised in cases attended with general febrile irritation; or, in inflammations approaching the acute character. Electro-puncturation—that is, inserting two needles, and connect- ing them with the opposite poles of a weak galvanic pile, has suc- ceeded in cases after ordinary acupuncturation repeatedly performed had entirely failed. Dr. Graffe has reported a very severe case of rheumatism, of several years standing, which after having resisted every remedy and mode of treatment that could be suggested, yielded, at last, to the influence of electro-puncturation.—(Graffe 4* Wal- ther's Journal.) * Richter's SpecielleTherapie,b. ii. s. 61__Abhandl. fur Pract. Arzte,b. xx. p. 509.—See also Duncan's Annals for 1801. f Rev. Medicale, Mai, 1829, p. 298. GOUT. 407 Rubefacients are always useful in casesof a strictly local character. Camphor dissolved in aether, as recommended by Ferriar, is an ex- cellent application for this purpose. Ihave generally preferred using the following liniment: R.—Spir. camphor. Aquae ammon. aa ^iss. 01. olivar. %i. Spir vini rect. %iv.—M. The warm bath, in conjunction with mercurial or diaphoretic re- medies, has been useful in this affection. Baths and douches of artificial sulphurous waters have been particularly recommended. In local rheumatic affections, advantage may sometimes be obtained from blistering or cupping the affected part; but the benefits derived from means ofthis kind are seldom more than temporary. Sweat- ing, induced by muscular action, particularly by walking, with an additional quantity of clothing, rarely fails to give temporary relief, and has been known to remove the disease altogether by frequent and regular repetition of the exercise.* Sect. III.—Gout. Gout is a constitutional affection, depending on a peculiar diathesis, and manifesting itself in its regular form by external local inflam- mation of the fibrous structures and fever of the synochal grade. In relation to its symptoms and progress, however, it is subject to certain prominent modifications, which have given rise to its divi- sion into the three following varieties: acute, chronic, and retroce- dent gout. 1. Regular gout.—The acute or regular form of the disease occurs in paroxysms at longer or shorter intervals, leaving the patient in an apparently perfectly healthy condition during the inter- mediate periods. Occasionally the paroxysm comes on suddenly, without any warning of its approach; but, in by far the greater num- ber of instances, it is preceded by various premonitory symptoms: such as disturbed digestive function; a peculiar, uneasy, anxious, and empty feeling in the pit of the stomach; a sense of tension, and weight in the abdomen; an irritable state of the bladder; flatulency and acid eructations; costiveness; a white tongue; giddiness; great lassitude; yawning, and stretching ofthe legs; drowsiness, with dis- turbed sleep, depressed spirits, and debility. In some instances, a disagreeable itching of the skin occurs a few days previous to the attack; and in most cases, the urine acquires a deep-red color. Some persons experience a feeling of numbness and formication in the lower extremities, with coldness of the feet and legs, before the paroxysm comes on. Sometimes the appetite is depraved and vora- * Marcet, Lond. Medico-Chirurg. Transactions, 1812. 408 GOUT. cious, attended with occasional nausea and vomiting. Not unfre- quently blennorrhoeal discharges occur from the bowels or bladder, or a copious secretion of mucus takes place in the bronchia. Some patients experience a sensation as if warm, or more commonly cool air were passing in a gentle stream, up and down the extremity, which is about to become the seat of the disease. According to Van Swieten, the venereal propensity is sometimes particularly urgent just before the accession ofthe attack.* Of all these symptoms, the dyspeptic, or those indicative of gastric disturbance, are the most common precursors of the gouty attack. The duration of this pre- monitory period is very indefinite, and varies from a few hours to many days. The attack generally comes on at night. About two or three o'clock in the morning, the patient is roused from sleep by a severe pain in the ball of the great toe, or in the heel, or instep of one foot. Chills or rigors speedily ensue, terminating, after a short period, in febrile reaction. The pain now becomes more and more severe; the pa- tient is restless, his skin hot and dry, and the pulse frequent, full, and generally hard. About five o'cloek in the morning, some remis- sion in the general and local symptoms usually occurs, with more or less profuse perspiration, and a short interval of imperfect rest is ob- tained. In some instances, the pain and fever continue with una- bated violence, until about the middle of the following night, when they gradually decline, under a moderate flow of sweat—the patient sinking into a quiet sleep towards morning. In very severe attacks, however, no obvious remission of the symptoms takes place, until the third or fourth morning. In all instances, however, the sufferings of the patient are greater during the fore-part of the night than in the day. When the affected part is examined in the morning after the accession of the paroxysm, it is found swollen, red, and the veins of the foot greatly distended with blood. The swelling is of an oedematous character, more especially after the disease has continued a few days. The tenderness of the inflamed joint is so great, that the weight ofthe lightest bed-clothes is often insufferable, and every motion or agitation ofthe limb excites the most torturing pains. In slight attacks, the constitutional symptoms are moderate; but, in the severer cases, the febrile" excitement is always very considerable. The digestive functions are almost invariably conspicuously derang- ed; the tongue is furred, the appetite wholly depressed, the thirst urgent, the bowels constipated, with colic pains, and a sense of un- easy weight in the epigastrium. An unusual degree of nervous irri- tability prevails during the paroxysm, the patient being generally fretful, irritable, and difficult to please. The duration of a first paroxysm of the disease is seldom less than five, or more than nine days; but in subsequent attacks, it is often protracted beyond the second, or to the end of the third week. After * Comment, vol. xiii. p. 44. / GOUT. 409 the disease has subsided in one foot, it occasionally attacks the other, and passes regularly through its course, as in the first instance. The patient is usually left in a much better state of health, after the complete subsidence of the paroxysm, than he enjoyed previous- ly to the occurrence of the attack. His mind and body are, as it were, renovated; his appetite and digestion are good, and his powers, both mental and corporeal, more lively and energetic. Sooner or later, however, according to the degree of constitutional predisposi- tion, and the habit of living, the paroxysm is renewed. At first, the return of the disease is generally at long intervals; in some cases, only after a period of three or four years; though more commonly, its first visits are annual. The intervals of its recurrence gradually become shorter, in proportion as the constitutional energies are en- feebled by its attacks, until at last, "the patient is hardly ever tole- rably free from it, except perhaps for two or three months in the summer." (Cullen.) The periodicity of gout is occasionally very regular. Scudamore mentions an instance where the attack returned regularly on the 12th of April, for three years in succession. Such a strict periodical recurrence of the disease, is nevertheless very rare. At first, the inflammation occurs generally only in the feet, but when by the frequent recurrence of the attacks, the system is weak- ened, and the gouty diathesis strengthened, several joints sometimes become simultaneously affected, or the inflammation passes succes- sively from one external part to another, in the same paroxysm. (Scudamore.) " The external appearances of the disease," says Scu- damore, " vary considerably, according to the situation and particu- lar texture of the part which is affected. The redness of surface, together with the oedematous swellings, are most remarkable on the great toe, on the foot, the back of the hand, and at the elbow; while at the ankle, knee, and wrist, the increased bulk is produced chiefly by the distension of the bursae, and the sheaths ofthe tendons, and takes place often with little change in the natural color of the skin." The sequelae of gout are various, and sometimes of a very distress- ing character. The liver always suffers more or less functional dis- order, and in some instances, undergoes structural derangement. The stomach seldom escapes becoming permanently debilitated from repeated attacks of the disease. The local effects of repeated attacks of gout are sometimes less distressing than the general affections which result from it. The tendons about the affected parts be- come hard and knotty, and in some instances complete anchylosis ensues. Chronic gout.—When, from the repeated attacks of the acute form of the disease the system becomes enfeebled, or where there is an original deficiency of constitutional energy connected with the gouty diathesis, the disease does not manifest itself by paroxysms of acute inflammation, but by chronic wandering, and irregular pains, bearing much resemblance to chronic rheumatism. The pain in chronic gout is usually but moderate during the day, Vol. I.—35 410 GOUT. the patient experiencing onlv a sense of alternate heat and coldness in the affected parts; at night, however, it is generally severe and aching. A feeling of numbness and weight is experienced in the diseased parts, and slight cramps are apt to occur during the fore- part of the night, and the sleep is restless, and interrupted by sud- den startings. The affected joints retain their natural color, or present only a slight purplish hue; but they become oedematous, tender, and more or less stiff; and the neighboring muscles are weakened, and sometimes diminished in size. The inflammation often passes successfully from one joint to another, or it leaves the original seat, and fixes upon some distant joint, and after having re- mained there for a while returns to the part it had left. There is rarely any very conspicuous fever; but the digestive and biliary organs are generally very prominently deranged. The dys- pepsia attending this form of the disease, says Scudamore, is par- ticularly characterised by great oppression, and flatulent distension of the stomach after a full meal, together with heartburn, and occa- sionally a sense of coldness in the stomach. The bowels are usually torpid, or affected with mucous diarrhoea; the urine is turbid; and often charged with mucus; the skin dry, contracted, and sallow; the bilious secretion deficient; and both the animal and vital functions much impaired. The temper in this variety ofthe disease is always very irritable, dissatisfied, morose, irresolute, and sometimes gloomy or hypochondriacal. In some instances, pain is occasionally felt in the kidneys, or neck of the bladder, and gravelly matter is dis- charged with the urine. The local consequences of inveterate or chronic gout are often ex- tremely distressing. The ligaments become thickened; the bursae mucosae indurated and enlarged; and the tendons knotty, rigid, and contracted. In some individuals, strongly predisposed to the dis- ease, earthy matter is deposited in the bursas, sheaths of the ten- dons, under the cuticle, and in the cellular membrane surrounding, the affected joint. Mr. Brodie observes: " the effects of gout on the joints are very remarkable. The cartilages are absorbed; the exposed surfaces of bone are entirely, or partially encrusted with white earthy matter, which I conclude to be urate of soda; and sometimes they have the appearance of being formed into grooves, as if they had been worn from their friction on each other." Retrocedent gout.—When the gouty inflammation, either ofthe acute or chronic form, leaves its external seat, and fixes on some in- ternal organ, it constitutes what is termed retrocedent gout. This retrocession of the disease may depend either on a want of consti- tutional energy; or upon an accidental or habitual weakness of some internal organ; or finally, on cold, repelling, and debilitating appli- cations made to the external gouty inflammation. The disease may be translated to almost every internal organ; but the parts most commonly affected, are the stomach, bowels, brain, heart, and kid- neys. When an acute attack of gout passes to the brain, coma, GOUT. 411 furious delirium, or symptoms of apoplexy, speedily ensue. Paul- mier relates a case where the retrocession of gouty inflammation from the foot to the brain gave rise to peculiar visual illusions; the patient being harassed by a confusion of horrid and ludicrous sights, which were removed in a few hours by epispastics applied to the feet.* When the stomach becomes its seat, violent and often fatal spasm of this organ, or symptoms of acute gastritis supervene. In the intestines, retrocedent gout generally gives rise to enteritis, or violent colic. If the heart becomes its seat, symptoms of an- gina pectoris, or more commonly protracted and generally fatal syn- cope occurs. When the disease passes to the lungs, it gives rise to violent and most painful asthmatic symptoms; in the kidneys it causes nephritis; and when it fixes on the neck of the bladder, the phenomena of vesicle calculus ensue. It has been a subject of considerable controversy whether the in- ternal affection which arises from translated gout be of an inflamma- tory nature, or whether spasmodic. It is probable, I think, that the metastastic affection may assume either character, according to the structure upon which it falls, or the peculiar habit ofthe system. In the stomach, it appears sometimes under the form of violent and rapidly fatal spasm; and in the brain, coma and convulsions; al- though in both organs the ordinary symptoms of inflammation often occur when invaded by the disease. In the atonic and obscure form of the disease, where the gouty affection is, as it were, floating about in the system, with an occa- sional imperfect manifestation of its presence in the joints ofthe ex- tremities, the effects of its attacks on internal parts are not so violent and dangerous as those resulting from metastasis of the acute form of the disease, although often extremely distressing. Indeed, atonic, or irregular chronic gout, often fixes upon internal organs at once, and without the previous or concurrent appearance of external arti- cular inflammation. It sometimes locates itself in the mucous mem- brane of the urethra, giving rise to a blenorrhoeal discharge, resem- bling gonorrhoea. In old and gouty habits, the mucous membrane of the bowels sometimes becomes affected with the gouty irritation, producing muco-purulent discharges from the rectum;! and a simi- lar discharge is still more common from the kidneys and bladders in such individuals. Haemorrhages from the nose, lungs, kidneys, and womb, have been known to arise from gouty irritation; and Richter observes, that haemorrhois are particularly apt to occur in gouty habits.$ Various cutaneous affections depend, sometimes, on a gouty condition of the system. Richter says, "there is a gouty itch, as well as herpes, which latter is apt to appear on the parts in* which * Diet, des Scien. Med. t. xix. p. 112. X Reil's Fiebrlehre, b. iii. p. 596. X Specielle Therap. torn. 6. p. 571. 412 GOUT. the gout is wont to appear, and particularly on the wrists and the ankles." Gilbert relates an instance in which a number of fur- uncles appeared, instead of a regular attack of the disease, in a per- son who had been long subject to hereditary gout* Chronic gouty affection ofthe stomach may show itself by pyro- sis; extreme sensibility of the stomach; bulmia; or total anorexia with gastralgia and flatulency. De Haen mentions a case, where the desire for food recurred at times so violently and suddenly, that if it was not immediately satisfied, severe pain in the stomach, with nausea and violent vomiting, speedily ensued. Stoll relates an in- stance of Spasmodic dysphagia from gouty irritation. Chronic gout, located in the bowels, sometimes gives rise to a colicky affection, with paralysis ofthe lower extremities, strongly resembling colica picto- num. The genital organs are occasionally affected by chronic gout, giving rise to painful and protracted priapism, and pollutions. The uterus, too, often becomes the seat of gouty irritation, particu- larly about the period of the final cessation of the catamenia. " A state of chronic inflammation ofthe uterus ending in a kind of en- largement and induration of this organ, is occasionally the conse- quence of this affection." (Richter.) Chronic pectoral affections are extremely common in old people who have been much afflicted with gout. Cough, dyspnoea, asthma, with copious mucous expectora- tion, or occasional violent and distressing sanguineous engorgements of the lungs, (apoplexia pulmonum) are the usual occurrences in cases of this kind. It would seem, too, that retrocedent gout is not unfrequently the cause of hypertrophy, ossification, and other organic affections of the heart. (Kreysig.) Pott mentions a case of hydro- cele, which disappeared on the occurrence of a regular paroxysm of gout; and it is stated by Musgrave, that chronic gout sometimes assumes the character of scurvy. There is, indeed, scarcely any form of acute and chronic disease which may not arise from gouty irritation, and almost every organ or structure of the system may be the seat of its ravages. Diagnosis.—The only affection with which gout is apt to be con- founded is rheumatism; and there exists, indeed, a very close resem- blance between them, although sufficiently diverse, in several essen- tial circumstances, to justify their being regarded as distinct forms of disease. The principal points of difference between these two affections, have already been mentioned under the head of rheuma- tism, and need not therefore be repeated in this place. Causes.—Gout, unlike rheumatism, requires a peculiar con- stitutional habit or predisposition, before any exciting cause can develop the disease. This predisposition is frequently hereditary, and perhaps still more frequently acquired by certain habits of liv- ing. Where the predisposition is very strong, and this will gene- rally be the case when it is derived from both parents, scarcely any X Diet, des Scien. Med. torn. xix. p. 117. GOUT. 413 precautions in avoiding its usual exciting causes are sufficient entirely to obviate some manifestations of the disease. It is asserted by some writers, that however considerable the gouty predisposition may be, the disease occurs but exceedingly seldom, and some assert never, before the age of puberty. Richter, However, affirms that the dis- ease sometimes, though indeed very rarely, occurs even in child- hood. This predisposition does not manifest itself in early life, by any obvious defect of constitutional vigor or health. The children of gouty parents are as apt to be strong, robust, and to possess appa- rently as vigorous digestive and assimilative powers, as those born from parents of the most healthy habits. Barthez, however/ ob- serves that the hereditary predisposition to this disease is generally attended with a peculiar physiognomical expression, by which an experienced eye may detect its existence.* The age at which gout usually first shows itself, is between the thirtieth and fortieth year. Women are much less subject to this disease than men; and in its regular and acute form, located in the feet, it if almost exclu- sively confined to the latter sex. When gout does occur in females, it is almost always after the period of the final cessation of the menses, and in them it usually assumes somewhat of an atonic or irregular character. Hippocrates observes, that eunuchs are never affected with gout; an observation which is, however, contradicted by Dreysigt and others. The causes which are especially calculated to produce a predispo- sition to gout in habits free from a hereditary diathesis favorable to this disease, are, the habitual and superabundant use of rich, nou- rishing, and strongly seasoned articles of food, particularly animal diet; and the free indulgence in vinous or fermented liquors, in conjunction with an indolent, inactive, and luxurious course of life. Vinous liquors are much more apt to lay the foundation of gout than distilled alcoholic spirits; and of the former it would appear that champagne, claret, and port, have a considerable stronger tendency in this way than Madeira, Lisbon, and Sherry, "because in addition to their equal or greater heating effect, they give rise to more acidity in the primae viae." (Scudamore.) Dr. Rush, in re- ference to the comparative tendency of wine and ardent spirits to produce gout, observes that the effects of the latter are too sudden and violent to admit of their being thrown upon the extremities, and that they appear only in visceral obstructions, and a complicated train of chronic diseases. " The effects of wine," he says, " like tyranny in a well-formed government, are felt first in the extremi- ties; while spirits, like a bold invader, seize at once upon the vitals ofthe constitution." Indolence, or an inactive course of life, con- tributes powerfully to the production of the gouty diathesis. Neither * Barthez. Traite des Maladies Goutteuses. Paris, an. 10. X Anfangsgr. der pract. Arzniew, p. 711, as quoted by Richter—Specielle Therapie, b. vi. p. 605. 35* 414 GOUT. rich and high-seasoned food nor the free indulgence in vinous pota- tions, are apt to produce the predisposition to gout where it is coun- teracted by a laborious or very active course of life. The principal exciting causes of gout are, intemperance in eating and in the use of spirituousdiquors; suppression of habitual evacua- tions; violent or depressing mental affections; cold and humidity; redundancy of acid or bile in the prima? viae; fatigue both of body and mind; intense and protracted study; external injuries; the abuse of mercurial remedies; excessive evacuations, particularly sanguineous discharges; excessive venereal indulgence; and a sudden change from an abundant and nourishing to a spare and innutritious diet. Proximate cause.—In relation to the proximate cause of gout, a very great variety of opinions have been expressed by pathologists. The hypothesis which has obtained most credit, in reference to the pathology of this disease, is that which ascribes it to a peculiar morbific matter in the blood. It has been supposed to depend on an excess of uric acid in the system; since, according to the obser- vations of Wollastan, there always exists a redundancy of this acid in gouty persons. Berthollet thought that an excess of phosphoric acid constitutes the proximate cause of the disease—an opinion to which he was led from having observed that the urine of gouty in- dividuals was much less charged with this acid during the absence of the active state of the disease than in healthy persons; but that it became abundant on the approach and during the continuance of the gouty paroxysm. Some have contended, that instead of a supera- bundance of an animal acid in the system, the materia arthritica is of an alkaline character. It is asserted by Petit, that the perspi- ration of a gouty patient has been known to turn the tincture of violets into green color.* The theory of Herrisant, and in general, the identity of the nature of urinary calculi, and of gouty concre- tions, though apparently confirmed by the experiments of Scheele, has been fully confuted by Wollaston—since, from his experiments, it appears that gouty concretions always contain lithate af soda, which, according to Fourcroy, never enters into the composition of urinary calculi.t Scudamore has entered into an elaborate experi- mental examination of the two former of these doctrines. In rela- tion to Wollaston's hypothesis, he ascertained by experiment, that the appearance and quantity of uric acid is always connected with, and proportionate to the unhealthy state of the chylopoietic func- tion, but neither necessarily nor regularly an attendant on gout. With regard to the opinion of Berthollet, his experiments show that, although an increased secretion of phosphoric acid in the urine occurs in the paroxysm of gout, yet the same takes place in other diseases; as for example, in diseases of the liver, and in some forms * Diet, des Sciences Med. t. xix. p. 162. f Richter's Specielle Therapie, b. vi. p. 634. GOUT. 415 of fever- It is evident, therefore, that the chemical products which occur in gout are various, and that they are to be regarded rather as the effects of a peculiar morbid condition of the organisa- tion, than as the proximate cause of the gouty phenomena—or as furnishing any evidence of a specific gouty matter in the system. (Richter.) Without, however, referring to any other doctrines on this head, it may be observed, that disorder and debility of the digestive functions is one of the most constant precursory, as well as concomitant occurrences of an attack of this disease. From the constant attendance of this gastric disorder, Broussais and some other writers have been led to regard the disease as primarily located in the primae viae, and as depending on a peculiar irritation in the mucous membrane of the alimentary canal. The dynamic doctrines of Stahl, Cullen, Barthez, Sprengle, and others, are even less satis- factory than those which place the proximate cause of the disease in some morbid disposition of the blood. It can nevertheless scarcely be doubted, that some defect or derangement of the reproductive functions lies at the bottom of the evil; and that this primary dynamic disorder, in conjunction with its consequent humoral de- pravation, constitutes the fundamental pathological condition of the system in gout. Treatment.—The treatment of gout divides itself into that which is proper during the paroxysm, and that which is appropriate during the intervals of the fits. To obviate or postpone the re- currrence of the disease after it has once made an attack, an ab- stemious course of digestible diet must be enjoined, and the use of wine and other fermented liquors interdicted. Various reme- dies have been recommended during the premonitory stage, with the view of preventing the development of the approaching pa- roxysm, or of moderating its violence—all of which, however, are much more apt to prove injurious than beneficial, and ought to be rejected as hazardous.* During the attack of the disease, the general treatment must be more or less antiphlogistic, according to the degree of general phlo- gistic excitement present. Unless the system is very plethoric, and the habit vigorous and inflammatory, bleeding may be well dispensed with. Under no circumstances, indeed, can this evacua- tion be regarded in any other light than a doubtful auxiliary; and, when carried to a great extent, may do serious injury by favor- ing metastasis to internal organs. It is true, instances are mentioned * The following means have been advised in the forming stage of the disease, in order to moderate or prevent the paroxysm. Emetics, (Chalmers;) active cathartics, (Musgrave;) vegetable bitters, iron, and high-seasoned food, (Grant;) Dover's powder or antimonial wine with opium, (Fothergill;) large doses of musk or castor, (Williams;) gratiola, (Wolff;) bleeding from the foot, (Gil- bert; the application of very cold water to the feet, (Giannini;) the internal use of iced-water, (Barthez;) &c. 416 GOUT. where the local affection was speedily removed and by prompt copious abstractions of blood, without any immediate evil conse- quences; but the cases where this practice was productive of dan- gerous effects, are sufficiently numerous to demonstrate its danger- ous tendency when very actively employed. I am well aware that there are eminent authorities on the side of decisive blood-letting in this affection. Heberden, Rush, and Hamilton, insist strongly on the propriety of venesection in gout; but the present sentiment of the profession is opposed to this measure as a principal remedy; although, moderately employed, it is generally admitted to be useful under symptoms of high vascular excitement. Cathartics are decidedly beneficial in the attack of regular gout. The alimentary canal is always more or less loaded with dark- colored, vitiated, and irritating matters, which should be as speedily evacuated as possible. Scudamore recommends the following pills —a combination which I have used with very good effect.* He advises the exhibition of cathartics and diuretics conjointly, as particularly useful in the gouty paroxysm. " I have experienced the most remarkable success," he says, " from a draught composed of magnesia gr. xx.; sulphat. magnesiae, 3iss.; vin. colch. 3'iss. with a little sweetened water. This draught should be repeated at in- tervals of four, six, or eight hours, according to the freedom of its operation and the urgency of the symptoms." The bowels should be kept freely moved throughout the paroxysm.t Emetics also have been recommended in the treatment of gout; and where the symptoms of redundancy of acid, or bile, or other of- fending matters in the stomach, are unequivocal in the commence- ment ofthe disease, advantage may, no doubt, be obtained from the administration of an emetic. As a general rule, however, emetics are inappropriate in this affection. They are indicated when there is much nausea, vomiturition, acidity in the stomach, with a furred and foul tongue, or where the disease supervenes soon after a hearty meal. Ipecacuanha should be employed for this purpose in prefer- ence to antimony. For the purpose of keeping up a gentle diaphoresis, we may em- ploy opium in combination with calomel and tartar emetic with much advantage, after the bowels have,been freely evacuated by purgatives. A grain of opium with the same quantity of calomel and one-tenth of a grain of tart, antim. may be given every four or six hours—assisted by copious draughts of infusion of elder flowers, * R.—Extract, colocynth. compos, gss. Calomel gr. xv. Tart, antimon. gr. i.—M. Divide into sixteen pills. S. Two or three to be taken on going to bed. X Boerhaave, Warner, and some other writers, reject purgatives wholly from the list of remedies proper in this disease; but their apprehensions in this respect are without foundation. GOUT. 417 or of eupatorium perfoliatum. I have used the diaphoretic mixture, given at page 176 of this work, with the addition of a drachm of laudanum, with excellent effect. To moderate extreme suffering from the gouty inflammation, and to procure the patient some repose, opium, under proper manage- ment, is both a safe and a highly useful medicine. " On many occasions," says Scudamore, " when the patient has described the pulsatory throbbing of the inflamed part to resemble almost the successive blows of a hammer, when the heart has been in inordinate action, and the inflammatory diathesis has appeared altogether urgent, I have stood by the bed-side and witnessed the happy power of a free administration of opium, in causing an abate- ment of the action of the vessels, and producing universal tranquil- lity in a short time." I have myself employed opium in this affec- tion with the happiest effect. Not only is the extreme pain al- layed, but the sympathetic febrile excitement also is generally con- spicuously moderated by full doses of this narcotic. The bowels should be freely evacuated before recourse is had to this medi- cine. It may be given in doses of one grain, either by itself or as mentioned above, with calomel and.tart. antim. every hour or two until the local pain is allayed. When opium disagrees with the stomach, the black drop, or the liquor opii sedativus of Dr. Battley, should be employed.* A great number of specifics and nostrums have at different times acquired a temporary reputation for their usefulness in this disease; of which, however, a few only need be mentioned. The colchicum autumnale, which would seem to be the hermo- dactyl of the ancients, is now universally admitted to be an article of great powers in removing gouty inflammation. It is not, how- ever, admitted on all hands to be a very safe remedy; for, it is asserted by some, " that it is apt to leave the predisposition to the disease much stronger in the system; to lead to the still more cala- mitous, because still more constant, pains of the chronic form of the disease." fc (Scudamore.) That the objections which have been urged against this article are altogether unfounded, I am not disposed to affirm; but I think it highly probable, that much ofthe harm which has been ascribed to it has arisen from the improper or inordinate use of the remedy. I have used it in about a dozen instances with marked advantage, and so far as I have ascertained, without any pre- judicial consequences whatever. Even Scudamore, whose objection to this article I have just quoted, observes, that under judicious ma- nagement it may be employed with perfect safety, and almost always with decided benefit. He gives it with magnesia and Epsom salts, according to the formula above referred to in page 176. I have * Opium is very favorably mentioned as a remedy in this disease, with the view of moderating the patient's sufferings, by Sydenham, Warner, and Richter. 418 GOUT. usually directed from 30 to 50 drops of the vinous tincture with about 20 grains of magnesia, to be taken every six hours until it acts on the bowels. When it produces nausea, or other unpleasant sen- sations in the stomach, its use must be discontinued. The eau medicinale is a celebrated nostrum, which has been ex- tensively used in France; and its powers of shortening the paroxysm are said to be surprisingly great. It is now generally admitted, however, that in its ultimate consequences it often proves highly injurious. When first used, it rarely fails to remove the gouty in- flammation speedily; but its powers in this way are gradually dimi- nished by repetition—producing at last great derangement of the digestive functions, permanent nervous irritation, giddiness, trem- bling, coldness, and oedema ofthe extremities, and other manifesta- tions of infirm health. The tincture of white hellebore and laudanum has also been found promptly efficient in removing gouty inflamma- tion, but it is said to be as pernicious in its consequences, and even more so, than the eau medicinale. Local remedies.—Various local applications have been employed in the treatment of gouty inflammation; but the majority of them are useless, and indeed often prejudicial. Neither leeching, nor blistering, nor warm pediluvium, appear to be calculated either to relieve the pain, or to promote the resolution of the local affection. Leeching even sometimes increases the pain. Some have advised the application of cold water to the inflamed joint—a measure which will, indeed, often moderate the pain and inflammation, but its par- ticular tendency to cause a retrocession or translation of the dis- ease to internal organs, renders it objectionable.* Scudamore ob- serves, that the best local applications are such as are volatile and stimulating. He strongly recommends a liniment composed of one part of alcohol and three parts of mistura camphorata, which is to be applied to the affected part in a lukewarm state, by means of seve- ral folds of linen strips saturated with it. I have employed this lotion in several instances with decided benefit. Its good effects were manifested by a speedy mitigation of the heat and pain of the affected part. The application of ether will also afford relief by its rapid evaporation, and consequent subduction ofthe heat and local excite- ment of the inflamed joint. Wrapping the part in flannel was formerly regarded as the most safe and beneficial application; but "flannel and patience" have very properly grown out of fashion; for this application tends to protract the paroxysm, and to aggravate the sufferings ofthe patient, without affording any peculiar advantages as to the future health of the patient. Where there is slight or incomplete development of the gouty inflammation in the extremities, with a tendency to retro- * The practice of applying cold water to the inflamed joint in gout is recom- mended by Hippocrates—(Aphor. sect, v.)—Kinglake employed cold poultices. Med. and Phys. Journal, No. 24. GOUT. 419 cession, benefit may, no doubt, be derived from the application of flannel or cotton to the part; but, in the regular and fully developed attack, it is at best useless, and often distressing.* During convalescence after an attack of gout, a temperate and moderately nourishing diet, with regular exercise and the occasional use of mild laxatives, should be enjoined. When the biliary and digestive functions remain disordered, which is very commonly the case after violent and protracted paroxysms, small doses of blue pill in the evening, with an occasional laxative and a weak infusion of colomba or gentian in small but repeated doses during the day, should be used.t To remove the protracted swellings which some- times remain, stimulating liniments may be usefully employed; or, as Scudamore recommends, a flannel roller applied to the affected part. The remedies or prophylactic means that have been recommended during the intervals of the paroxysm, with the view of moderating the gouty diathesis, or of preventing the recurrence of the disease, are very numerous. Little or no dependence, however, is to be placed on any measures in this respect, except on such as are calcu- lated to restore the healthy action ofthe stomach, liver, and skin; and especially on the adoption of proper regulations, with regard to diet and exercise. Abstinence from high-seasoned and very nourishing diet, and from all kinds of fermented liquors, with regu- lar exercise in the open air, a constant attention to the maintenance of the healthy action of the bowels, liver, and skin, by the occasional use of laxatives, blue pill, and weak infusions of some of the tonic vegetable bitters; and the wearing of flannel next to the skin, will perhaps, do all towards resisting the progress of the disease that can be effected by remediate means. According to the experience of Scudamore, the ammoniated tincture of iron, commencing with 20 drops twice daily, and gradually increasing the dose to 60 drops, is an excellent tonic during the intervals ofthe gouty paroxysm. In the treatment ofthe chronic form ofthe disease, the principal attention must be directed to the chylopoietic organs. A light and digestible diet, with an occasional blue pill in the evening, followed in the morning by a gentle laxative, are among the most useful re- mediate measures in this variety of the disease. To relieve the nervous irritation and pain, generally so distressing during the night, we may give one or two grains of opium, or from 15 to 20 drops of * A great variety of other local remedies have been favorably mentioned— namely, the warm steam bath, (Percy;) the split leaves of the cactus crocusf emplast. hyoscyam. spread on oiled silk, (Thilenius;) emplast. opii; cataplasms of conium, belladonna and hyoscyamus, and moxa. X As an aperient during convalescence from gout, Warner's gout cordial is an excellent remedy. The formula for making this tincture is as follows: R.— Rhubarb £i. senna ^ss. saffron gi. liquorice root 3iv. raisins tbi. brandy Ibiii. Digest for a week, and strain. 420 GOUT. black-drop at bed-time. Scudamore recommends lactucarium and stramonium in combination, as a very useful narcotic in such cases. Opium in union with camphor, forms also an excellent anodyne in instances of this kind. The carbonate of ammonia, or from 20 to 30 drops of a solution of camphor in sulphuric, ether (9iii. of camph. to 3i. of ether) or warm ginger tea, may be usefully admi- nistered, to relieve the spasmodic and nervous pains in the stomach, which are so common in the chronic form of gout. A vast variety of remedies have been recommended for the removal of mitigation of chronic arthritic affections. Amongst these, however, there are very few that are worth being mentioned. Gum guaiacum; ol. tere- binth; calamus aromaticus, (Rave, C. L. Hoffman;) and particularly the vegetable bitter tonics; aconitum, (Richter;) the bark of the prunus padus, (Horn's Archiv. 1812;) chalybeates; herba rhodo- dend. chrysanthi; belladonna; mercurial remedies; and the use of sulphurous mineral waters, are the principal articles of this kind. Rave, a German writer, speaks in very favorable terms of savin (juniperis sabina) in chronic gouty inflammation of the joints.* I have known much benefit derived from this article in chronic or subacute arthritic affections, more especially in subacute rheumatic inflammation. Rave recommends the following formula for taking the savin.t In an atonic, torpid, or sluggish state of the system, with chronic gouty symptoms, the following composition, recom- mended by Quarin, will sometimes act very beneficially.% Alka- line remedies have also been supposed peculiarly adapted to coun- teract the gouty diathesis, but they appear to be of little or no value in this respect. Formerly, the liquor antiarthriticus Elleri was much in vogue as a remedy in chronic gouty affections. It consists of equal parts of sulphuric ether and aq. ammon. succinata. The dose is from 30 to 40 drops. When the gouty inflammation leaves its external seat, and fixes on some internal organ, prompt and active remediate measures are necessary to obviate the immediate danger. Cullen recommends heating and stimulating remedies in retrocedent gout; where the * Beobachtungen und Schlusse aus der praktischen Arzneywissenschaft Von Alexander Rave. Munster, 1796. X R.—Herb, sabin. recens. §ii. Tinct. antimon. acris. §vi.—M. Digere per 3 vel 4 dies. Or—R.—Pulv. hb. sabin. recens. £ss. Antim. crud. gr. xii. Flor. sulp. gr. xv. Camphor, gr. iv.—M. f. pulv. pro. dos. This dose is to be taken twice or thrice daily. X R.—Flor. sulph. ^i. Resin, guaiac. ^ss. Antim. crude giii.—M. f. pil. pondere gr. iii. S. Take from six to eight pills, three times daily. CATARRHAL OPHTHALMIA. 421 disease attacks the stomach, this, without doubt, is often the best practice. Laudanum in large doses, (from 80 to 100 drops,) with warm spiced brandy, should be freely administered; and a large sinapism applied over the region of the stomach. Opium, in the form of tincture, is a most valuable medicine in cases of this kind. Even where the translated affection assumes the character of acute gastritis, and where the aromatic and diffusible stimulants are im- proper, the greatest relief will often follow the exhibition of large doses of this narcotic. When the brain becomes the seat of the translated disease, stimulants and opiates are inadmissible. In such cases, our principal reliance must be placed on the speedy and copi- ous abstraction of blood, together with the use of active mercurial cathartics, cold applications to the head, and sinapisms to the feet. In all instances of translated gout, stimulating or rubefacient appli- cations to the feet are decidedly indicated. Irritating purgative enemata also are useful, as well as cupping and leeching over the region of the affected organ. ' CHAPTER XVI. OF THE INFLAMMATORY AFFECTIONS OF THE EYES. 1. Catarrhvl Ophthalmia. This is the most common form of ophthalmia in adults, and pro- ceeds, as its name imports, from the influence of atmospheric vicissi- tudes, and especially from cold and damp night air. The inflamma- tion in this variety of the disease is confined chiefly to the conjunc- tiva and the meibomian glands. The patient complains of pain, into- lerance of light, and a constant sensation of sand in the eye— which latter feeling may, according to Mr. Mackenzie, be regarded as a diagnostic symptom of this variety of ophthalmia.1" In mild cases, the redness of the eye is not very great, and is most conspi- cuous in the conjunctiva lining the eyelids. The flow of tears is always much increased; and in severe cases, the secretion often be- comes opaque and purulent. Chemosis sometimes takes place in very violent instances, and the cornea may burst and destroy vision. The headach in this variety is seldom very severe, and the febrile excite- ment is generally mild, and in slight cases altogether wanting. Treatment.—In mild cases of this variety ofthe disease, general blood-letting is rarely necessary or useful. In instances attended with considerable constitutional irritation, a sufficient quantity of * Med. and Phys. Journal, No. 4. 1826. Vol. I.—36 422 CATARRHAL ophthalmia. blood should undoubtedly be drawn, to moderate the excessive momentum of the circulation. Leeching rarely affords any decided advantage; when local depletion is desired, cupping on the back of the neck and over the temples is preferable. Mr. Travers condemns scarification ofthe conjunctiva, and bleeding from the angular vein, in the acute form of the disease, although highly beneficial in the chrpnic. Nevertheless, when chemois occurs, and the discharge becomes puriform, considerable advantage, will, in general, result from scarifying the conjunctiva of the eyelids. " One or two deep incisions being made along the inner surface of the upper or lower eyelid, a very considerable discharge of blood will immediately take place, and prove a valuable means of cure in cases of this kind. The eyelid, after the incision, ought to be alternately everted and permitted to return to its natural position, by which means the divi- ded vessels are refilled, and thus a continued flow of blood will be pro- duced." (Mackenzie.) In cases of this character, considerable bene- fit often accrues from the use of nauseating doses of tartrate of anti- mony, given at short intervals, so as to keep up a continued and uni- form impression. Cathartics are indispensable in this affection. The bowels must be freely opened by a full dose of calomel and jalap, or by active doses of the neutral purgative salts, and kept in a loose state through- out the course of the disease. The usual astringent lotions do no good in this variety of the dis- ease; indeed, they often prove manifestly prejudicial. The solutions of sulphate of zinc or of acetate of lead, so commonly used in in- flammations of the eye, seldom fail to increase the redness of the conjunctiva and the sensation of sand in the eye. The same obser- vation applies to cold applications; for, although they generally pro- duce temporary ease, " they are followed by reaction, with an in- crease of heat and pain." (Travers.) In the acute stage of the in- flammation, benefit will frequently arise from the use of warm sooth- ing fomentations to the eye. A weak infusion of poppy, or simply warm water and milk, may be used for this purpose. Emollient and soothing warm applications must not, however, be continued too long; for they tend to relax and to produce oedematous elevation of the conjunctiva. When the disease early assumes an atonic, or almost solely congestive character, a few drops of the vinous tinc- ture of opium, or of solutions of zinc, or nitrate of silver, will often afford much relief. The nitrate of silver is decidedly the most effectual local application in this variety of ophthalmia. Four grains of this article dissolved in an ounce of distilled water, forms a solu- tion of a proper strength; " a large drop of which is to be applied to the eye by means of a camel-hair pencil. The instant that it touch- es the eye, the salt is decomposed, and the silver precipitated over the conjunctiva in the state of a muriate."* An abatement of thepecu- * Mackenzie, loc. citat. CATARRHAL OPHTHALMIA. 423 liar sensation of sand and of the inflammation, almost uniformly soon follows the application of this solution. I have myself employed the nitrate of silver in this way with almost uniform advantage. Mackenzie recommends also a solution of one grain of corrosive sublimate in eight ounces of water as acollyrium, to be used, milk- warm, thrice daily, for fomenting the eyelids by means of a fine piece of linen, and allowing a few drops to pass into the eye. In cases of great severity, where the secretion is puriform, he directs " this collyrium to be injected over the whole surface of the conjunc- tiva, and especially into the upper fold of this membrane, by means of a syringe." An ointment made " by levigating twelve grains of red precipitate till they become an orange-colored impalpable powder, to which an ounce of fresh butter is to be added, forms also a very useful appli- cation in this variety of ophthalmic disease." A very small portion of this ointment is to be applied along the edges of the eyelids at night on going to bed. Kopp speaks very favorably of the tincture of galbanum as a local application in ophthalmic inflammation. A compress of linen is to be moistened with this tincture and laid over the closed eyelids. I have used this application with marked benefit in several cases, after the acute stage of the inflammation had in a degree subsided. In some instances of a general irritable habit of body, the ophthal- mia will continue to grow worse under the ordinary depletory mea- sures, " the irritability increasing as the strength fails." In cases of this kind, recourse must be had to calomel and opium in.combina- tion, or opium with small doses of tart, antimon. or ipecacuanha. From three to four grains of Dover's powder with the sixth of a grain of calomel may be given every three or four hours, at the same time that the above exciting applications are made to the eye. Blistering on the back of the neck, particularly after proper deple- tion, will almost always assist materially in the reduction of the in- flammation. In violent and protracted cases of the disease, the inner surface of the upper eyelid sometimes becomes rough, with a species of hard fungoid elevations, resembling a state of sarcoma of the conjunctiva. Where this occurs it should be lightly touched with lunar caustic or a piece of sulphate of copper—the eyelid being held up from the eyeball for a minute or two after the application. Ophthalmia sometimes assumes a strictly periodical form. The attack in such cases is usually attended with intense suffering; and under the usual antiphlogistic plan of treatment is apt to continue a very long time. In instances of this form, leeching, blood-letting, and cooling applications, never fail to do harm. The appropriate means consist of the same remedies that are employed in intermit- ting neuralgia, or in the ordinary intermitting fever; and there can exist but little doubt that all these forms of periodical disease are 424 RHEUMATIC OPHTHALMIA. congeneric affections. Quinine, bark, and arsenic, will, in general, speedily arrest the progress ofthe present variety of ophthalmia.* 2. Rheumatic Ophthalmia. This variety of ophthalmic inflammation is chiefly characterised by violent circumorbital pain, extending to the temples, teeth, lower jaw, and internal ear. The pain is continuous, with occasional fits of aggravation, and is almost always much more severe at night than during the day. The white of the eye is of a yellowish red tinge, terminating abruptly at the cornea—which latter becomes dull, cloudy, and as the disease advances, more opaque in the centre than at the circumference. According to the observations of Travers, "rheumatic ophthalmia presents a zonular arrangement of the ves- sels, more or less cloudiness of the aqueous humor, and a pupil dis- placed or drawn a little to one side." The flow of tears is at first diminished; but in the course of the disease it becomes copious. In most instances, slight abrasions ofthe conjunctiva and cornea occur; but these are generally so minute and superficial as readily to escape observation, unless closely inspected. In violent and protracted cases, the cornea is sometimes destroyed by ulceration, and pus is secreted within the chambers ofthe eye. The inflammation, in this variety of the disease, is confined chiefly to the fibrous structures of the eye and of the surrounding parts; and partakes in this respect of the character of rheumatism. It is excited by the same causes that give rise to the catarrhal variety; and occurs most commonly in persons of an arthritic or rheumatic dia- thesis. It is also particularly apt to occur from the-influence of cold while the system is under the operation of mercury, or soon after the mercurial action has subsided. " It is often seen in company with, or following gonorrhoea, eruptions, or sore throat of a pseudo- syphiltic character, and the pains are allied to those which succeed to the exhibition of mercu^.t Treatment.—Bleeding very rarely affords any obvious advan- tages in this variety of ophthalmia. When the pulse is very active, it should, nevertheless, be modi rated by venesection, in order to lessen the general phlogistic diathesis, and thereby favor the bene- ficial operation of the more appropriate remedies. Much advan- tage may sometimes be derived from one or more antimonial eme- tics in the early stage of the disease; and active purgatives are equally important. After the alimentary canal has been well eva- cuated, we may exhibit a solution of tart, antimon. in nauseating doses, every two or three hours; or antimonial powder in combina- * For an interesting case ofthis kind, see Journal Complement. Jan. 1830. See also Med. Chir. Rev. March, 1830. f Travers—A Synopsis ofthe Diseases ofthe Eye, &c. p. 129, PURULENT OPHTHALMIA. 425 tion with opium and calomel, so as to keep up a uniform, continued, moderate diaphoresis.* I have known much good done in this variety of the disease by repeated small doses of Dover's powders. Cupping or blistering the nape of the neck is a useful auxiliary; and fomentations with an infusion of poppy heads, always mitigates the pain very considerably. One of the most soothing applications to the eye, is a few drops of an aqueous solution of opium put into it several times a day, or a solution of the sulphate of morphia. Punc- turing the cornea, so as to give exit to the aqueous humor, is al- most always soon followed by an abatement of the inflammation and pain. The usual astringent and exciting collyria are wholly inapplicable in the treatment of this affection, and almost uniformly do injury. Mr. Wardrop recommends the internal use of cinchona in very small doses, (from five to eight grains,) if the tongue remains white after the bowels have been freely evacuated. Would not the tincture of colchicum be beneficial in this affection? 3. Purulent Ophthalmia. Acute suppurative inflammation of the conjunctiva is the most dangerous variety of ophthalmia, and generally the most difficult to manage. It occurs, however, under every grade of violence, from a mild and simple to a most severe and rapidly destructive affection. The severer cases come on suddenly, and are from the beginning attended with very severe darting pains through the eye. The eye- lids swell rapidly, and often to an enormous extent—the upper one being often so much enlarged as to rest upon the cheek. The con- junctiva also becomes so much swollen by infiltration and distension of its vessels, as to rise up in an ennular mass of red spongy granu- lations, overlapping the cornea so as almost to conceal this part. A very copious purulent secretion from the inflamed conjunctiva takes place soon after the disease is developed—and which usually issues in large drops from under the swollen lids. The edges ofthe eye- lids are sometimes so closely pressed against each other, as to con- fine the matter until it accumulates and distends the lids into a large round tumor, and at last bursts forth and runs down the cheek. The pain in the head is always extremely severe, and the whole system sympathises strongly with the local affection—the accom- panying fever being of a high synochal grade, suffering conspicuous exacerbations in the evening. Under judicious treatment, this se- vere form ofthe disease usually begins to decline about the third or fourth day, and gradually subsides until the health of the eye is re- stored. Cases of great severity, or where the treatment is inefficient or improper, often terminates rapidly in more or less disorganisation of the eye and consequent loss of vision. Sometimes every part of * R.—Pulv. antimonialis 9i. Calomel gr. iii. Pulv. opii gr. iiss.—M. Divide into nine equal parts. Take one every three hours. 36* 426 PURULENT OPHTHALMIA. the ball of the eye becomes disorganised by suppuration. Much more commonly, however, the consequences are not so destructive— a greater or less degree of opacity and thickening of the cornea^ or ulcerative destruction of this part, being usually the result of the inflammation. In some instances, ulceration ofthe proper substance of the cornea takes place beneath the conjunctiva—this membrane remaining entire. (Travers.) This "interstitial" ulceration of the cornea, says the author just referred to, may be either acute or chronic. The acute variety is often crescent-shaped, and passes nearly across the whole cornea. In consequence of the absorption or abrasion of the conjunctiva, directly over the ulceration of the cornea, great pain is caused by the motions of the upper eyelid. The chronic interstitial ulcer occurs in debilitated subjects remain- ing often a long time like a slight depression or excavation on the surface ofthe cornea, the restorative action ofthe vessels of the part being inadequate to repair the lost structure. Gangrenous destruc- tion of a greater or less extent of the cornea may also take place in suppurative ophthalmia. In the milder variety of purulent ophthalmia, there is little or no danger of destruction ofthe cornea, unless injury be done by stimu- lating applications. Mr. Travers says, "that a very slight haze of the cornea is the worst direct result of the mild form of the disease." In cases of this kind there is neither the intense pain nor the ex- cessive swelling of the lids, which characterise the violent acute form ofthe complaint. There appear to be different varieties of suppurative ophthalmia, in relation to the exciting causes of the affection. The Egyptian ophthalmia, which is the most violent form of this disease, is ascribed to the combined effects of vicissitudes of atmospheric temperature and humidity, a hot wind loaded with fine particles of sand, and a bright and piercing light ofthe sun. A violent form of purulent in- flammation of the conjunctiva, is also excited by the application of gonorrhoeal matter to the eye; and it is said, by metastasis of genorrhceal inflammation from the urethra to the conjunctiva. In- fants also are subject to purulent ophthalmia; but in them the dis- ease is generally much less serious than in adults. Mr. Gutherie states that there are two varieties of infantile suppurative inflamma- tion of the eyes: "one affecting the conjunctiva of the lids only, the other implicating the eyeball." I have repeatedly noticed these distinctions in the ophthalmia of infants; and although little or no permanent injury need be apprehended from the former vari- ety, I have found it even more difficult to subdue than the latter. Some writers attribute this affection in infants to intestinal irritation from bile and sordes in the primae viae; but the opinion of its being almost universally the consequence ofthe direct application of some morbid secretion to the eyes at the time of birth, is, 1 think, by far the most probable. I have never known a single instance of this disease occurring in infants, soon afler birth, where, upon inquiry, I PURULENT OPHTHALMIA. 427 did not learn that the mother had been affected with leucorrhcea, or some other morbid vaginal secretion. The fact too, that the oph- thalmic discharge in cases of this kind, is capable of exciting the same disease when applied to the eyes of others, furnishes a strong argument in favor of this etiology. Mr. Ryall, whose opportunities for observation on this subject have been very extensive, states that he has repeatedly known the ophthalmia excited in nurses, " by the accidental application of the matter from the infant's eyes to their own."* Purulent inflammation of the eyes occurs, no doubt, occa- sionally in infants as in adults, from cold, and various irritating causes, acting directly on the eyes; but this is comparatively, per- haps, but very rarely the case. Treatment.—In mild cases, where the swelling, pain, and puru- lent secretion are not great, general blood-letting is not often ne- cessary. In the severer form of the complaint, however, prompt and very decisive bleeding is indispensable to success. In those vehement cases, where the swelling of the lids is very great, the purulent secretion copious, the pain intense, and the pulse hard and frequent, " the instant relief," says Mr. Travers, « of a large vene- section, is indescribable. The pain is mitigated if not removed, the pulse softened, and the patient sinks into a sound sleep, and per- spires freely. Upon inspection we observe the high scarlet hue and bulk of the swollen and fungoid conjunctiva sensibly reduced, and the cornea has a brighter aspect."! It is frequently necessary to repeat the venesection several times in the course of the first twenty-four hours, before permanent impression is made on the disease. In the disease as it occurs in infants, blood must be abstracted by a few leeches applied to the external angle, or under lid of the eye; and the eye should be frequently fomented with a decoction of poppy heads, a portion of which is to be injected under the lids to wash away the purulent secretion. Minute portions of calomel in union with ipecacuanha, or pulvis antimonialis, with an occasional dose of castor oil, should be given to infants laboring under this affection.J Topical bleeding, after the vigor of the arterial action has been moderated, by a very efficient abstraction of blood from the arm, will generally assist materially in reducing the local inflammation. From 20 to 30 leeches may be applied to each temple and around the eye. Blistering on the nape of the neck, is also a very useful auxiliary; but decisive blood-letting should precede the application of the blister. One ofthe first and most important remediate mea- * Dublin Transactions, vol. iv. X Travers, loc. cit. p. 265. X R.—Calomel gr. ii. Pulv. antimonialis gr. viii.—M. Divide into eight equal parts. Give one every four hours. 428 PURULENT OPHTHALMIA. sures, is the exhibition of an active mercurial purge, and the bowels must be kept freely moved throughout the active stage of the dis- ease, by the daily use of full doses of one of the neutral purgative salts. No nourishment except the simplest mucilaginous fluids, or toast-water, must be allowed; and in very vehement and rapid cases, total abstinence from any nutrient ingesta should be enjoined, dur- ing the first two or three days. Along with blood-letting and active cathartics, nauseating doses of tartar emetic are, in general, deci- dedly beneficial. They should be given in small doses every hour or two, so as to keep up a continued impression on the stomach. During the acute period of the inflammation, emollient fomentations, such as warm water, or infusion of the white poppy heads, will assist in mitigating the pain and promoting resolution; but all astringent and cooling applications are injurious. By the prompt and active employment of these antiphlogistic measures, the pain, irritation, and swelling usually begin to subside about the third or fourth day, and the discharge becomes gleety at the same time that the con- juctiva assumes "a pale and flabby appearance." If, when the in- flammation has thus in part subsided, the cornea appear clear and bright, nothing need be apprehended as to the safety of the eye. Recourse must now be had to the exhibition of tonics and astringent and invigorating collyria. It would appear from the experience of Mr. Varlez, surgeon of the Military Hospital at Brussels, and of Mr. Gutherie, that the chloruret of lime forms the best local as- tringent application we possess in this variety of ophthalmia. The former of these surgeons states that he has employed this article in more than four hundred cases of purulent ophthalmia with uniform success. After the local and general inflammatory condition is moderated by decisive depletion, a solution ofthis salt is to be ap- plied to the inflamed conjunctiva. He usually employed it in the proportipn of a scruple to an ounce of distilled water; but when the inflammation continues, and when the patient bears it without com- plaining, it may be used, he says, to the extent " of three or even four drachms in the same quantity of water."* It has been found equally beneficial in the purulent ophthalmia of infants. In two cases of this variety of the disease, I derived the most signal advan- tage from injecting into the eye a solution of 10 grains of the chlo- ruret of lime to an ounce of water, repeated three times daily. The nitrate of silver, in the proportion of from two to four grains to an ounce of water, forms also an excellent local astringent in this affec- tion. A few drops of this solution should be introduced into the eye twice daily. In the purulent ophthalmia of infants, after leech- ing, emollients, purging, and antimonials, have been employed, a weak solution of this article injected under the eyelids, is generally soon followed by the most favorable effects. Mr. Ryall says, that when the " discharge becomes profuse, assuming a greenish color, * London Med. and Phys. Jour. 1827. SCROFULOUS OPHTHALMIA. 429 all warm fomentations and cataplasms must be laid aside, and a solution ofthe nitrate of silver, in the proportion of two or three grains of the mineral to an ounce of distilled water, should be fre- quently and briskly injected between the lids."* Various other astringent and exciting lotions have been recommended after the acute character of the inflammation has been subdued. A weak solution of alum, one grain to an ounce of water, is recommended by Travers. Others advise the application of alum-curds confined between two folds of thin linen; and Ware speaks favorably ofthe following solution: R.—sulphat. cupri. bo], arm. aa gr. viii. cam- phorae gr. ii. misce et affunde aq. bullient. ^viii. At first a drachm ofthis solution must be mixed with an ounce of water, and injected forcibly under the eyelids; the strength being gradually reduced in proportion as the inflammation subsides. M. Jahn, of Meiner.gen, speaks very favorably of a solution of the chloride of gold, as a col- lyrium in the purulent ophthalmia of children. He says it is equally beneficial in scrofulous, gouty, and rheumatic inflammation of the eyes. He uses it according to the following formula.t Tonics, such as the cinchona or quinine, with the sulphuric or nitric acids, must be employed to sustain the patient's powers, after the inflammation has been reduced, and the conjunctiva appears pale and flaccid. " If, when the lowering practice has been pushed to the extent of arresting acute inflammation, the patient being at the same time sunk and exhausted, the cornea shows a lack-lustre and raggedness of its whole surface, as if shrunk by immersion in an acid, or a gray patch in the centre, or a'line encircling or half encircling its base, assuming a similar appearance, the portion so marked out, will infallibly be detached by a rapid slough unless by a successful rally of the patient's powers we can set up the adhesive action so as to preserve in situ, that which may remain transparent. (Travers.) 4. Scrofulous Ophthalmia. This variety of the disease occurs most commonly in children, and is frequently the first manifestation of the scrofulous diathesis. Its most characteristic symptoms are; extreme sensibility of the retina to the impressions of light; profuse serous secretion or flow of tears; and a muco-purulent secretion from the glands ofthe tarsi, which, during sleep, agglutinates the eyelids. The pain is not often great, unless a bright light is suffered to fall upon the eye; nor is the redness of the conjunctiva generally very conspicuous. In recent and acute cases, effusion of serum sometimes occurs around the cor- * Dublin Transactions, &c. vol. vi. ■j- R.—Chloride of gold gr. ii.; distilled water ^vi. Two or three drops of this solution must be instilled into the eye, and a compress wet with it applied over the eye. Rust's Magazine, vol. xxviii. 430 SCROFULOUS OPHTHALMIA. nea, " elevating the conjunctiva into a circular vesication, about a . line or more in breadth, frequently occupying the entire margin of the cornea, and exhibiting a peculiar reddish brown appearance."* In many instances of this acute character, minute vesicles appear scattered over the cornea and the conjunctiva of the sclerotic coat. " These pustules vary in size, according to the part of the conjunc- tiva on which they appear, being commonly smallest on the cornea, and increasing as they approach the angle where that membrane is reflected over the inner superficies of the lids, and may be considered as a distinguishing symptom of this disease." (Jeffries.) These vesi- cles break, in some cases, and form ulcers; and if the inflammation be not checked, these ulcerations often gradually penetrate deeper into the cornea, until they form an opening into the anterior cham- ber, and give exit to the aqueous humor. The disease, does not, however, often occur in this acute form, the majority of instances met with being of a strictly chronic character, the vessels of the conjunctiva " remaining in a state of passive con- gestion and engorged with red blood," with small indolent ulcera- tions, or nebula of the cornea, attended with a constant profuse flow of tears, and with such distressing intolerance of light, that the patient keeps the eyes constantly closed, and lies with the face downwards or keeps the hands continually applied over the eyes to exclude the light as much as possible. In many instances of this chronic variety of the disease, tinea ciliaris and lippitudo occur; small pustular ulcerations appearing along the roots of the eyelashes, from which a muco-purulent fluid exudes, by which the edges of the eye- lids are glued together; or the edges of the eyelids are red, and exco- riated. Mr. Christian, consulting surgeon of the Liverpool Ophthalmic In- firmary, has described a variety of scrofulous ophthalmia, which he calls porriginous, from the disease being usually preceded, by a por- riginous " eruption of pustules on the face and head." These pus- tules go through the various stages of suppuration, ulceration, and , desquamation; and if the eruption in its pustular form, shall have disappeared before the inflammation of the eyes has commenced still there will almost always be found some traces of the original disease in the form of scabs, or fissures behind the ears, at the com- missures of the palpebrae, or at the junction of thealae nasi with the cheeks."t This appears to be the same variety of scrofulous ophthalmia, that has been described by Mr. Wardrop, under the name of exanthema- tous ophthalmia. Mr. Wardrop considers it as specifically distinct from the scrofulous form of the disease, though he admits that it very frequently occurs in subjects of a scrofulous habit. Neither * Cases of Surgery, &c. &c. By Henry Jeffries, Esq. senior surgeon to St, George's and St. James's Dispensary. Lond. 1820. -j- Glasgow Medical Journal, No. i. SCROFULOUS OPHTHALMIA. 431 the symptoms nor the treatment of this disease, however, differ so materially from those peculiar to scrofulous ophthalmia, as to justify the opinion that they are essentially distinct in their characters. " Eruptions of the scalp and discharges behind the ear, so frequent in children, are the affections with which this ophthalmia is most commonly connected. These diseases alternate with the disease of the eyes, the latter becoming affected when the eruption or discharge disappears; whilst when either of these returns, the eyes recover. This ophthalmia also sometimes succeeds measles, scarlet fever, snd other exanthematous diseases, but usually appears a considerable time after these affections have subsided. The symptoms of the ex- anthematous ophthalmia are very characteristic; for, besides beino- connected with eruptions and confined to young people, the exces^ sive intolerance of light, the enormous secretion of tears, and the relief from forcibly squeezing the eyes, are symptoms quite peculiar. The patient can scarcely hold up his head, and if he is desired to open his eyes, he is affected exactly as if he were looking on a mir- ror, reflecting a bright sunshine, every attempt causing a profuse gush of tears, and being instantly succeeded by a violent and invol- untary squeezing of the eyelids and knitting of the brows. He ex- cludes all light, not only by holding down his head and squeezing the eyelids together, but by pressing a handkerchief firmly on them or by resting his face against a chair in some dark corner of the room. The intolerance of light is always most severe in the morn- ing; but in the afternoon it sometimes remits so much as to allow the patient to open his eyes and see to a very considerable degree for some hours. The tears are of an acrid and irritating quality, so that the cheeks, alae of the nose and lips often become inflamed, swelled, and sometimes covered with pustules and cutaneous ulcera- tions."* Now this very graphic account of the symptoms, answers in every particular to the descriptions given by authors of scrofu- lous ophthalmia, and it certainly describes the disease which I have always considered as the strumous, or scrofulous form of oph- thalmia. Treatment.—General bleeding rarely becomes necessary in stru- mous ophthalmia. In recent and acute cases, however, leeching should be occasionally practised, until the pain, irritation, and in- flammation are moderated. Purgatives are indispensable in this affection, where the abdomen is tumid and tense, and the alvine dis- charges of an unnatural character. Calomel, combined with rhu- barb or jalap, should be given every two or three days, in doses sufficient to cause pretty copious purging; or a few grains of calo- mel may be taken in the evening, and followed next morning by a dose of castor oil, or of senna infusion. This active cause of purga- tion should be continued until the quality of the alvine evacuations * Transact. Med-Chirurg. Society of Edinb. vol. ii. 432 SCROFULOUS OPHTHALMIA. is manifestly improved. After this has been effected it will be suffi- cient, in general, to administer a moderate dose of calomel and rhu- barb every four or five days. In the more chronic form ofthe dis- ease also, active purgation is not in general beneficial. The bowels should be kept in a loose state, however, by small doses of rhubarb or castor oil, or some other mild laxative. In many cases, there is considerable gastric disorder, the appetite being variable and capri- cious—sometimes much depressed, and at others voracious. Where this is the case, emetics may be accounted among our most useful remedies. An aqueous solution of tartar emetic appears to be the best article for this purpose. The emetic may be repeated every third or fourth day, during the active state of the inflammation. To promote the regular performance of the various excretory functions, small doses of calomel with pulvis antimonialis should be given at night, and where the system is very irritable, it will be proper to add a few grains of Dover's powder.* In a few instances I have derived conspicuous benefit from the use of sarsaparilla syrup, with a very minute portion of muriate of mercury, but in many in- stances it failed entirely in doing any good. Where there is con- siderable general irritation, a solution of tartar emetic, given every two or three hours, in doses just sufficient to cause a slight nauseat- ing impression on the stomach, will sometimes prove serviceable. After the alvine discharges have been brought to a healthy state, by the mercurial purgatives, tonics will often afford much benefit. Wardrop recommends the use ofthe carbonates of soda or potass, either singly, or in combinatio/i with small portions of rhubarb and the milder bitter infusions. "In some instances the mineral acids have been very useful, and also the preparations of iron." Quinine, however, is decidedly the most effectual tonic in this species of oph- thalmia, after a proper course of mercurial purgation. In recent and acute cases, the diet should be simple and unirritating; such as liquid farinaceous preparations, or thin animal broths; but in the more chronic variety of the disease, where the system is irritable and feeble, a more nourishing, though plain and digestible diet, must be allowed, in order to support the vigor of the system. Be- sides the general remedies already mentioned, various other articles have been recommended for the treatment ofthis affection; amongst which the muriate of barytes, and iodine, are the most important. HufelanJ, in a small monograph on the use of the former of these articles in scrofula, relates some interesting examples of this variety of ophthalmia, which yielded to its powers.t I have employed this remedy in several cases with manifest advantage, and it appears * R.—Calomel gr. iv. Pulv. antimon. ----Doveri aa gr. viii.—M. Divide into four equal parts. X Darstellung der Medicinischen Krafte, der Salzsauren Schwererde. Von Dr. Christ. W. Hufeland, Berlin, 1794. SCROFULOUS OPHTHALMIA. 433 to be worthy of more attention than it has of late years received. The best mode of exhibiting this substance is in solution. A half a drachm ofthe muriate should be dissolved in an ounce of distilled water; ofthis solution, from thirty to sixty drops may be given three or four times daily to an adult; and for children, from one to two years old, the dose is from ten to twenty drops. Hufeland says, that the best vehicle for administering this remedy, is a ptisan prepared of lig. guiac, rad. gramin., sarsaparilla, and dulcamara. I have, also prescribed the iodine in a few cases, and its use was con- tinued for more than three months, without having in a single in- stance obtained any perceptible advantage from it. Nevertheless, no inconsiderable number of cases have been reported in which this article is alleged to have proved decidedly beneficial, and from its well known influence over strumous glandular enlargements, it is certainly entitled to attention as a remedy in the present aflection. Dr. Mackenzie, of Glasgow, speaks in the most favorable terms of the employment of the sulphate of quina in strumous ophthalmia. "After many years experience," he says, "in the treatment of strumous ophthalmia, and a trial of numerous and various internal remedies, I have found none so useful as quina. In most instances its effects have been very remarkable; and, indeed, although I have met with a few cases which appeared to resist its beneficial influence, in most of the little patients to whom I have administered it, it acted like a charm. The dose which I employ is generally one grain thrice a day; and in very young children, half a grain; and in adults two grains."* The Peruvian bark was strongly recommend- ed by Fothergill and Fordycet in the treatment of this affection, but its powers are vastly inferior, in this respect, to the sulphate of quinine. (Mackenzie.) With regard to the employment of collyria, and other local appli- cations, little of permanent advantage is to be derived from them. As palliatives, however, slightly astringent lotions, such as weak solutions of nitrat. argent, sulph. zinc, or sulphat. cupri., may be beneficially used where the inflammation and pain are considerable; or a decoction of white poppy heads, " with a considerable quantity of extract of conium dissolved in it, (half an ounce to a quart of the decoction,) applied to the eye five or six times daily."J I have found a solution ofthe nitrate of silver, in the proportion of four grains to the ounce of distilled water, to answer better than any other application of this kind. A few drops of this solution is to be instilled into the eye once or twice daily. Mackenzie speaks well * On the Utility of Sulphate of Quina in Strumous Ophthalmia, with Cases. By Wm. Mackenzie, one of the Surgeons ofthe Glasgow Eye Infirmary.—Glas- gow Med. Journal, No. 1. X Lond. Medical Observations and Inquiries, vol. i. X Med. Chir. Rev. Dec. 1822, p. 538. Vol. I.—37 434 IRITIS. of a collyrium composed of one grain of muriat. hydrarg. dissolved in eight ounces of water. When the disease is chiefly confined to the tarsi, (ophthalmia tarsi,) benefit may be obtained from the ap- plication of red precipitate ointment (fifteen grains to an ounce of lard) to the edges of the lids. Mr. Jeffries observes, that the small pustules which occur on the cornea and conjunctiva, should by no means be opened by art, as thejT are then apt to degenerate into ulcers, an occurrence which always greatly aggravates the pain, in- flammation, and intolerance of light, and increases the risk of ulti- mate loss of vision from destruction or opacit)r of the cornea. Blisters very seldom procure any advantage in strumous ophthal- mia. Indeed *they often do harm, by the pustular inflammation which is apt to occur around the blistered part, and the consequent additional source of general and local irritation, which is thus created. The insertion of a seton in the back of the neck is much more useful than vesication in such cases. After the acute character of the disease has subsided, the establishment of such a drain will almost always produce the most favorable effects. In four cases which had resisted for many months the ordinary remedies, the dis- ease gradually disappeared entirely under the influence of a seton in the nape of the neck. 5. Syphilitic and Strumous Iritis. Inflammation of the iris may be produced by various causes, but its occurrence from syphilis is incomparably the most frequent. A vascular zone around the margin of the cornea, attended with cloudiness of the humors; constriction or very limited and slug- gish motion ofthe pupil; great intolerance of light; obscure vision; a continued deep-seated aching pain in the globe of the eye, fore- head, and circumorbital parts; and the appearance of very fine red lines and specks upon the iris, are the principal phenomena charac- teristic of this variety of ophthalmia. In the progress of the dis- ease, adhesion takes place between the fibres of the iris, " the pupil losing its thin flowing edge, and becoming thick, stunted, and gib- bous." In slight cases, no other appearance of inflammation occurs in the eye, the conjunctiva remaining free from redness. In the more acute instances, however, the sclerotica is usually of a rose-red color, shading off gradually towards the circumference. The pain, in instances of this kind, is often fitful, and is particularly severe in the evening or early in the morning. The usual sensation, how- ever, (except during these evening or morning exacerbations,) is a feeling of constant painful pressure in the globe of the eye, with more or less of an aching pain in the temples, bone of the cheek, and forehead. In some instances, the pain in the eye is pulsatile, " mark- ing every injection of the ophthalmic artery." In very acute and violent cases of iritis, lymph is deposited on the iris, appearing in small yellowish-red elevations on its surface; the pupil usually be- iritis. 435 coming angular and misshapen, and sometimes entirely blocked up by a layer of lymph. Mr. Travers divides iritis into primary and secondary. The primary variety is commonly the consequence of syphilis, or of cold while the system is under the influence of mercury, and is distin- guished from the secondary variety by " the more sparing vascularity ofthe conjunctiva, and the consequent more distinct appearance of the vascular corona round the cornea." It usually comes on rather suddenly; is attended with very severe pain in the orbit and head almost as soon as it commences; and " the vision is more quickly and completely dimmed. In the secondary form the inflammation gradually extends from the contiguous tunics to the iris; the conjunc- tiva is vascular and often rose-red; the cornea much clouded; the pupil retains its natural shape, or is but slightly deformed; the pain is confined in a great measure to the eyeball, and is not often very severe, but the intolerance of light is generally very considerable." (Travers.) When the disease is violent, and continues unchecked in its course, the iris projects forwards, and uniting with the cornea, produces corneal staphyloma. If the inflammation extends to the choroid membrane, retina, and vitreous humor, vision will inevitably be lost. Strumous iritis, is most apt to occur in children between the ages of six and eighteen, of a delicate habit, "fair complexion, light hair and blue eyes." The cornea acquires a misty or slightly opaque appearance, with patches of red vessels usually appearing on its edges. A zone of pink vessels is formed around the cornea in various situations. The conjunctiva is but slightly red; and on close inspection the vessels of the sclerotica are found minutely injected, and running in straight lines to the margin of the cornea. Profuse lacrymation occurs, with distressing intolerance of light. The iris is nearly inactive, and vision is obscure. " The eyebrow appears to project considerably before the eye; the muscles (if one eye only be affected) become thicker and stronger than those of the opposite side, from their powerful contraction to exclude the light, and give to the countenance a distorted appearance. The pulse is generally quick and irritable; the appetite uncertain; the secretions unhealthy; the skin dry and harsh, but variable in temperature; the heat ofthe scalp being oppressively great, whilst the extremities are often chilled with cold." Treatment.—Although mercury may be regarded as the princi- pal remedy in this variety of ophthalmic inflammation, yet, general and local depletory measures, free purgation with calomel and jalap, and nauseating doses of antimonials, are essential auxiliaries in the acute stage of the disease. Without mercury, little or nothing can be effected towards arresting the progress of the inflammation. It should be given to the extent of producing ptyalism, except in sub- jects of a debilitated and worn down constitution, where a more moderate merourial action should be established, and the system 436 EXANTHEMATA. supported by a nourishing but unirritating diet. Great care must be had to avoid taking cold while under the mercurial influence in this affection. Belladonna is a highly important remedy in this species of ophthalmia. Without the use of this narcotic, says Mr. Gutherie, "complete success can rarely be obtained." The extract must be thickly smeared on the eyelids and eyebrows every night. After the inflammation has been considerably reduced, and the into- lerance of light removed, a very small portion of weak precipitate ointment introduced into the eyes twice a week, will often aid materially in completingthevcure. Bleeding,cupping, leeching and blistering, are all wholly ineffectual and not unfrequently decidedly injurious. (Gutherie.) Mr. Middlemore, assistant-surgeon of the Birmingham Eye Infirmary, has published a statement which would seem to show that much advantage may be obtained from the use of the spirits of turpentine in this affection.* Mr. Carmichael and Mr. Gutherie, have also given reports illustrative of the usefulness of this remedy. Mr. Middlemore asserts that he gave it with advan- tage to patients, who from delicacy or constitutional idiosyncrasy were unable to use mercury to the extent of producing salivation. Where the acute symptoms had been relieved by mercury, the tur- pentine given in drachm doses, two or three times daily, manifested a peculiarly excellent effect. He insists strongly on the early em- ployment of this remedy in inflammation of the choroid and retina. Strumous iritis is extremely obstinate in its duration. In delicate children very small doses of calomel with prepared chalk, may be given every evening, and a grain of quinine twice during the day. The quinine will often do more good in cases ofthis kind than any other remedy we possess. A seton in the nape of the neck, or a small issue on the arm, will in general contribute considerably to the reduction of the inflammation. Suitable clothing to keep up the regular warmth and action of the skin is an important auxiliary. The patient should also be allowed moderate exercise in the open air; and a simple digestible and nourishing diet is to be enjoined. CHAPTER XVII. OF THE CUTANEOUS PHLEGMASIA. Exanthemata. The term exanthemata is derived from the Greek word ttavOsa, effloresco; and is employed to designate those acute contagious afl'ec- * Medico-Chirug. Rev. July, 1830. • VARIOLA. 437 tions, in which an efflorescence or eruption appears on the surface of the body. The exanthematous fevers are of a strictly specific character:—that is, each affection of this kind has its specific cause, and cannot, so far as we know, be produced by any other cause or combination of causes. In all of them, fever exists as the primary or essential disease—the eruption being a secondary affection, and the immediate consequence of the specific febrile excitement. Un- less interrupted by constitutional idiosyncrasy, or adventitious influ- ences, each of these diseases has its determinate course, both in relation to the duration of its stages and the succession of its charac- teristic phenomena. They are all communicated by contagion; and they possess the power of destroying the susceptibility of the human organisation, to the subsequent morbific influence of their respective contagions, although instances do, occasionally, occur in which this power is, more or less effectively, opposed by the system, and in which, therefore, a second attack is possible. Sect. I.— Variola.—Small-pox. It is not known at what period the small-pox made its first appear- ance. In the writings ofthe Greek and Roman physicians, we find nothing which could lead us to believe that they had any particular knowledge of this devastating malady, although we can scarcely doubt that its origin was of a much earlier date.* The Arabian physicians were the first who gave a distinct description ofthis dis- ease; and it is to the small work of Rhazes, who lived about the be- ginning of the tenth century, that we must look for an account of its early history. It may be collected from the writings of Rhazes and * Rhazes, indeed, refers to some expressions in the writings of Galen, which would seem to show that small-pox, though not described, was known by this Roman writer. " As to those physicians," says Rhazes, " who affirm that the most excellent Galen has made no mention of the small-pox, and therefore that he did not know this distemper, surely they have either never read his works at all, or only very cursorily; nay, most of them do not know, whether what he plainly says of it is to be understood of that disease. For Galen, in a certain treatise, says: this *** does good against the small-pox. And in the be- ginning of the fourteenth book of pulses, he says, that the blood is putrefied in an extraordinary degree, and that the inflammation runs so high that it burns the skin; so that small-pox and pestilent carbuncle are bred by it. And in the ninth trea- tise of the book Of the uses of the Parts, he observes, that the superfluous parts of aliments which are not turned into blood, and remain in the members, putrefy, and in time increasing, do ferment.- whence, at last, are generated the pestilential car- buncle, the small-pox, and confluent inflammations. Lastly, in the fourth part of his commentary upon the Timseus of Plato, he says, that the ancients gave the name of to every thing which produces redness, as the carbuncle and small-pox"—Treatise on the Small-pox and Measles. By Abubecker Rhazes, chap. i. Translated by Thomas Stack, M. D., F. R. S. 438 VARIOLA. others, that small-pox was probably at first brought from Ethiopia into Arabia, and that it was thence conveyed into the Levant, Spain, and Sicily, by the Saracens, during their hostile irruptions into these countries.* In the eleventh and twelfth centuries, it gained vast ground, during the wars waged by the Christian potentates, against the infidel Saracens, for the recovery ofthe Holy Land. From that time forwards, its desolating visitations were frequently renewed, in every part of Europe, and there is, perhaps, no single disease, with which the Almighty has thought it good to afflict mankind, which has carried off so many victims to the grave as the present one.t Small-pox is divided into two varieties—namely, the distinct and confluent. In the former, distinct, elevated, distended, and circular pustules are scattered over the surface ofthe body; in the latter, the pustules are exceedingly numerous, depressed, irregularly circum- scribed, and confluent or coherent. There exists, however, no es- sential difference between these varieties; the division is altogether arbitrary; for, in some instances, the pustules are confluent on the face, while on the rest of the body, they are distinct. The time which elapses between the reception of the variolous virus, and the first manifestations of its influence on the system, is said to vary from about seven to twenty days; although by far the most common period of its inception is between the ninth and four- teenth days. During this period of incubation, no obvious symp- toms of indisposition occur—the individual retaining an apparently good state of health. It is stated by some, that the disease is apt to be most violent when this period is of short duration. Course and symptoms of the distinct variety.—The disease commences with a feeling of languor, weariness, aching pains in the back and lower extremities, slight creeping chills; with flushes of heat and pain in the forehead. More or less nausea and vomiting, attended with great thirst,pain in the epigastrium, and some de- gree of soreness in the fauces, speedily ensue. When the fever is completely developed, the skin and face are dry, the tongue white, and generally red at the point, the bowels torpid, and the urine scanty and of a deep red color. During the first and second days of the fever, slight haemorrhages from the nose are apt to occur; the mind often becomes dejected and confused, and towards the end of * It would appear, that small-pox was known in Europe as early as the seventh century. The word variolx occurs repeatedly, in some manuscripts discovered by Dr. Woodville, in he British Museum, and in the Cottonian col. lections, written about the close of the eighth century; and Marius Aventicensis, bishop of Lausanne, in the seventh century, uses these words: Hoc anno variolas cum profluvio ventris, Galliam, Italiamque valde afflixit.—Gregory''s Practice, vol. i. p. 197. X It has bean estimated, that before the introduction of vaccination, 450,000 individuals died annually of small-pox in Europe.— Richter's Therapie, b. ii. p. 302. VARIOLA. 439 the third day, the tongue usually acquires a bright red color. Shortly before the appearance of the eruption, an unusual tendency to perspiration generally occurs in adults, and frequently much drowsiness, and sometimes coma, supervene at this period. In chil- dren the eruption is sometimes preceded by convulsions; but the tendency to free perspiration very rarely occurs in them. In many cases, the hands and feet are cold throughout the whole course of the disease, more especially in very young children. The coldness of the extremities has by some been considered as the most certain diagnostic symptom of the eruptive variolous fever; but the most frequent and characteristic phenomenon of this fever is the pain and soreness to pressure of the epigastrium, and the vomiting. (Philip. Febrile Diseases.) Both in adults and in children, a considerable increase of the febrile symptoms usually takes place a short time be- fore the eruption begins to appear; and in some instances severe cramps in the legs occur at this period. Towards the end of the third, or the beginning of the fourth day from the commencement of the disease, the eruption begins to make its appearance. The pustules appear first on the forehead, and on the parts about the mouth and nose—next on the fore-arms and upon the breast and abdomen—and last of all on the lower extremities; so that in about twenty-four hours the eruption is completed. The eruption consists at first of red points, which by the middle of the second day present small elevations, with inflamed bases, which as yet discharge no serous fluid when punctured, but " the cuticle appears distended by a sort of semi-transparent plastic lymph." Towards the end of the second day, some of these pustules present central depressions; and on the following day this characteristic de- pression becomes conspicuous in nearly all of them. Where there are but few pustules, they often remain elevated and pointed, with but a very slight central depression; but where they are numerous, they assume an umbilicated form, or flattened with a distinct de- pression in the centre. The fluid appears at first in the central points, and is of a limpid and serous character. The pustules con- tinue gradually to increase in size, at the same time that their umbi- licated form becomes more and more conspicuous. About the fourth day they assume a whitish color, and become surrounded by a pale red areola. When the pustules are very numerous, these areolae run into each other, and give a uniform appearance of redness to the interstitial spaces. The limpid fluid which appears at first in the central part of the pustules, gradually becomes more and more abundant—extends towards the basis of the pustule—and changes from its serous to a purulent character. This change occurs be- tween the fifth and seventh day, and marks the commencement of the stage of Suppuration.—In the distinct variety, the fever which pre- cedes and accompanies the eruption always remits greatly, and frequently disappears entirely, as soon as the eruption is com- 440 VARIOLA. pleted. When suppuration commences, however, the febrile symp- toms usually re-appear. As the process of suppuration goes on, the pustules become distended with pus, and, losing the flattened form, acquire a spherical shape. About the eighth day, when the crop of pustules is pretty numerous, the face begins to swell; the upper eyelids sometimes becoming so tumid and puffy as to close the eyes entirely. Towards the end of the tenth day the swell- ing ofthe face begins to subside, but instead of this, considerable j tumefaction occurs in the hands and feet, and the interstitial spaces over the whole body become more or less swollen, tense and sore. The period of suppuration is almost invariably attended with soreness in the fauces, and where the pustules are numerous, with a copious secretion of viscid saliva. In some instances, the increased flow of saliva occurs with the commencement of the eruption, but its usual time of occurrence is after the suppura- tive stage, has supervened. This secretion generally becomes so thick and viscid, that it is spit out with considerable difficulty, and renders swallowing difficult. On examining the mouth and fauces, they are found swollen and of a bright redness; and from the eustachian tubes becoming closed by the tumefaction, more or less obtuseness of hearing usually occurs. During the latter period of the suppurative stage, a strong and very peculiar odor rises from the patient's body, and this exhalation continues until the process of desiccation is completed. When the tumefaction of the face is very considerable, more or less drowsiness or oppression often occurs, and in some instances diarrhoea supervenes towards the completion of the suppurative process. The secondary or suppurative fever varies in violence and duration, according to the copiousness of the eruption, and the activity of the suppura- tion. In mild cases of the distinct variety of the disease, the se- condary fever rarely continues longer than two or three days, and is seldom attended with symptoms of severity. The suppuration, like the appearance of the eruption generally, begins on the face, and lastly on the hands and feet. As the disease advances, the pustules gradually become yellower and more opaque, and arrive at their full state of maturity about the twelfth day.* After the pustules have acquired their perfect state of development, they sometimes remain stationary for several days; but more commonly a brownish spot makes its appearance an the centre of each pustule as soon as the process of suppuration is completed, acquiring at the same time a rougher and deeper yellow aspect. Soon after the occurrence of this change, the pustules begin to shrink, becoming gradually drier, * If a mature pustule be opened, which had previously presented a well- marked central depression, a yellowish pus will be found below, presenting a small, white, umbilicated disk, perfectly resembling in form and size, the pus- tule before the pus had altered its shape.—Cazenave. Practical Synopsis of Cu- taneous Diseases, p. 142. VARIOLA. 441 browner, and harder, until the matter is converted into a brown crust. Desiccation always commences on the face, " this part be- ing often covered with scabs, when the pustules on the extremi- ties have scarcely arrived at maturity." When the scabs fall off, they leave a vividly red surface, which disappears very gradually. In mild cases of distinct small-pox, the suppuration seldom destroys the skin and subcutaneous cellular tissue, and the skin therefore does not become pitted or marked. In the more severe instances of this variety, however, the cicatrices remain with more or less distinctness —becoming more and more visible, as the redness, which remains 4 after the falling off of the scabs, gradually disappears. Confluent small-pox.—The pain in the back and extremities during the eruptiveffever, is almost always much more severe in the confluent than in the distinct variety of the disease; and, in general, all the febrile phenomena are usually more violent in the former than in the latter. The heat of the skin is very great; the thirst exceedingly urgent; the tongue dry, harsh and sometimes covered with a dark brown or blackish fur and the nervous system is often much affected. In the distinct variety, the eruptive fever is almost invariably of the synochus or synocha grade. In the more aggravated instances of confluent small-pox, it often assumes a typhous character; although in the majority of cases, the eruptive fever is highly synochal. The tendency to copious perspiration, often so conspicuous in the distinct small-pox, is rarely observed in the confluent variety; but profuse diarrhoea sometimes occurs just before the appearance ofthe eruption, and still more commonly dur- ing the suppuration. It has been observed, that the secretion of saliva, commonly so abundant in this affection, is usually very tri- fling, or almost entirely suppressed when diarrhoea attends. In general, the eruption appears at an earlier period in the conflu- ent than in the distinct variety of the disease; and the time of its appearance is altogether much more regular in the former than in the latter. In some instances, the pustules come out as early as the second day, and, occasionally, not until the fourth or fifth day after the commencement of the fever. In many instances of confluent small-pox, a roseolous rash or efflorescence precedes the variolous eruption—a phenomenon which is occasionally observed also in the distinct variety. When the eruption is confluent, the small red papular points which appear at first, run into each other, and form "a large red, tumefied, and somewhat rugose surface." The patient at the same time is very drowsy, and the carotids beat strongly. The pustules of confluent small-pox are commonly irregular in shape, and much less elevated than in the distinct small-pox; and the parts not covered with the eruption are pale and flaccid. The central depression is generally inconspicuous; and about the third day the pustulated surface of the face becomes " covered with a kind of subcuticular whitish pellicle." The tumefaction of the face and hands, as well as the soreness in the fauces and the flow of saliva, are 442 VARIOLA. generally very great in the confluent variety. The reverse, how- ever, is occasionally observed; for, in some instances of confluent small-pox, these symptoms are but very slight. When the suppu- ration is completed, a very manifest aggravation ofthe febrile symp- toms occurs, constituting what is termed the suppurative or secon- dary fever. The matter in the confluent pustules is of a whitish- brown and sometimes of a dark color, and of much less consistence than in the mild form ofthe disease; and in some instances, it ac- quires a corrosive character. About the eighth or ninth day of the eruption, the matter begins to escape from the pustules, and hardens on the surface into extensive brown crusts, which fall off at periods varying from the fifth to the fifteenth day from their formation, and 3re succeeded by desquamations which finally leave deep marks or pits, which are often so united as to form "seams that traverse the face in all directions." Both in the distinct and confluent varieties ofthe disease, great itching attends the period of desiccation. The eruption of small-pox is not confined to the external surface ofthe body. The pustules occur also on the mucous membrane of the mouth, larynx, and trachea, and on the tongue—giving rise to more or less copious ptyalism, hoarseness, painful swallowing, diffi- culty of breathing, cough, viscid expectoration, and perhaps diarrhoea. The disease is sometimes, from the commencement, of a highly inflammatory character. It begins with strong chills, succeeded by intense febrile heat; a frequent, full, and hard pulse; high-colored and scanty urine; flushed countenance; sometimes delirium; and, in children often convulsions. Internal inflammations, particularly of the brain or lungs, are apt to supervene in cases of this kind. When the former organ becomes the seat ofthe inflammation, vio- lent delirium, coma, convulsions, or apoplexy ensue. Thoracic in- flammation is indicated by the occurrence of pneumonia, pleuritis, or effusion into the lungs. The eyes, too, are apt to become inflamed, and the parts not covered with pustules are vividly red and much tumefied. In some instances the attending fever, even in the distinct variety of the disease, is typhoid. The chilly stage is unusually protracted; the pulse remains small, weak, and frequent, and the patient com- plains of much muscular prostration. Various symptoms of nervous disturbance are apt to occur—such as vertigo, faintness, twitching of the tendons, and even convulsions. The urine is colorless and the face pale and sunken. The pustules come out slowly and irregu- larly, appearing simultaneously on every part ofthe body, and some- times first on the extremities, and are often congregated in irregular clusters. The eruption sometimes disappears on some parts without passing into the pustular state; and slight causes, such as cold or mental agitation, may even occasion the whole eruption to recede; in which case, convulsions, or apoplexy, or fatal congestion and effu- sion into the lungs are apt to supervene. Suppuration goes on slowly and often imperfectly, the pustules becoming filled with a VARIOLA. 443 thin watery pus. The intermediate skin is seldom much tumefied, and remains pale. In the advanced period ofthe disease, the swell- ing of the face and extremities sometimes subsides suddenly, and the patient dies apoplectic. Desiccation generally commences seve- ral days earlier than in the ordinary course of the disease; and at this period the fever is apt to become much aggravated.* The disease sometimes manifests a highly malignant or putrid character—more especially the confluent variety. The heat is acrid (calor mordax;) the perspiration clammy and offensive; watery diarrhoea often occurs; the face is bloated and red; the eyes watery and inflamed; the appearance of the eruption and its progress are irregular. The pustules commonly acquire a dark or livid hue; are surrounded with brown or almost black margins; and become filled with a bloody serum instead of pus. Colliquative haemorrhages, particularly from the nose, are common. Desiccation leaves very dark or black crusts, beneath which phagedenic ulcerations are not unfrequently formed.t When the small-pox attacks females in the state of pregnancy, it frequently gives rise to abortion, more especially during the early periods of utero-gestation. Such are the usual course and phenomena ofthe distinct and con- fluent varieties of small-pox. It is subject, however, to considerable irregularity, both in relation to its general progress and the charac- ter of its particular symptoms. But the most remarkable variety of anomalous small-pox is that which has been termed the crystalline, and in which, instead of pustules containing purulent matter, the eruption consists of phlyctenae, or vesicles filled with a colorless transparent serum. The phlyctenae soon become pale, and although not confluent, are never surrounded by inflamed margins. This variety of the disease is of a most dangerous character. In many instances, no tumefaction ofthe face or hands occurs, a circumstance which is particularly indicative of great violence and danger; " for, instead of these swellings, the inflammation generally seizes on the brain." The secondary fever in this variety of the disease usually assumes an evident typhoid character. The sequelae of small-pox are very various, and often extremely distressing. The disease may give rise to slow and wasting fever, dropsy, chronic cutaneous affections, phagedenic ulcerations, necro- sis, chronic ophthalmia, rheumatic pains, deafness, paralysis, struma, phthisis pulmonalis, mania, epilepsy, opacity of the cornea, staphy- loma, dropsy ofthe eye, and cataract. The small pox is sometimes remarkably modified by the influence of the contagion of measles. Sydenham observes, that in 1670-71-72, the small-pox and measles prevailed at the same time in London, and that, during this period, the variolous affection assumed an extremely irregular and violent * Richter's Specielle Therapie, b. ii. p. 297. f Ibid, p. 299. 444 VARIOLA. character. The eruption, at first, resembled measles or erysipelas; in its progress, small vesicles filled with a colorless fluid appeared among the variolous pustules. The scabs formed on the pustules resembled concreted blood, and at last became almost black. The influence of measles on the progress of small-pox, when the two diseases meet in the same individual, is equally remarkable. It has been frequently noticed, that the supervention of measles dur- ing the early periods of small-pox, causes this latter disease to remain nearly stationary until the morbilious affection has run its course, when the small-pox resume their progress and proceed to their regu- lar termination. Thus, if on the second day ofthe small-pox erup- tion, the measles make their appearance, the small-pox will remain stationary until the measles have gone off, after which, the variolous disease will resume its dominion and go on in the usual way. Post mortem appearances.—The morbid appearances on dissec- tion vary, of course, considerably, according to the stage of the dis- ease during which death takes place, the violence of the particular symptoms, and the accidental affections with which it may be com- plicated. Sanguineous congestions in the brain and lungs are gene- rally strongly manifested. Pustules are not unfrequently found in the larynx, trachea, and bronchia, as far as the third division. In the pharynx too, the variolous pustules are sometimes prett)r nume- rous, but they are very rarely found in the oesophagus. Traces of inflammation to a greater or less extent are almost invariably de- tected in the mucous membrane of the alimentary canal, and pustules of a variolous character are sometimes met with in the lower portion of the rectum. It is observed by Cazenave and Schedel, that they had never in any of their dissections found the pustules on the mu- cous membranes distended with pus. It does not appear from the observations of those who have paid particular attention to the post mortem appearances in this disease, that the variolous pustules are ever found on the viscera or in the closed cavities of the body. Some late writers assert, that the internal surface of the aorta almost constantly presents a vividly red appearance, but the frequency of this appearance is denied by Cazenave and Schedel. The pustules on the skin, when anatomically examined before they are distended with pus, or before they have lost their umbilical form, present the following appearances: 1st. " The cuticle preserves its natural thickness, and is easily de- tached, leaving exposed a whitish and smooth surface, elevated at the edges and depressed in the centre. 2d. " A small umbilicated disk of various thickness, formed by a whitish substance, having a certain consistency, and which appears to be a real exudation from the inflamed dermis. This substance occupies the place of the mucous coat, and at first appears to be con- tinuous with the layer which is immediately under the epidermis, but afterwards is easily separated from it. This small body adheres to the dermis by its centre, where it is also much thinner, and often VARIOLA. 445 tears when it is attempted to be raised." If, when the cuticle is elevated by the pus, the pustule be examined with care, it will be found that the bottom of the pustule still presents the same umbili- cated form that it possessed before the cuticle was raised and dis- tended by the purulent fluid. 3d. " Finally, below this small disk, the dermis is of a red color, and sometimes covered with purulent fluid."* The true seat of the small-pox pustule appears to be in the reticu- lar tissue which lies between the cutis vera and the cuticle. In its early stage, the pustule when examined with a lens, exhibits a cel- lular structure, and from the sixth to the ninth day, a thin cir- cular slough of the true skin may be observed at the bottom, which, on being finally cast off, gives rise to a depression or pit in the skin. Cause.—Small-pox, so far as we know, can arise only from one cause—namely, a peculiar contagious substance, which occurs both under the form of a palpable matter and of an imperceptible efflu- vium, but of whose intimate nature and origin we are entirely igno- rant. Observation has made us acquainted, however, with its obvi- ous relations as a morbific agent, and with some of the influences, both vital and extraneous, which tend to modify its operation on the human system. It does not appear that age or sex exerts any con- trolling power over this contagion, and we know that even the foe- tus in the womb is not exempt from its morbific effects. Nor does climate or season, so far as the sensible atmospheric conditions are concerned, appear to exercise any influence either in retarding or favoring its dissemination. One of the most remarkable and mys- terious phenomena of this, as well as of other epidemic contagious diseases, is its recurrence at distant intervals in an epidemic form, depending, no doubt, on certain occult atmospheric constitutions peculiarly favorable to the operation of the variolous contagion. The disease occurs, indeed, also sporadically; but during certain pe- riods, its contagion may thus here and there manifest its presence, without passing from individual to individual, and be speedily extin- guished, like sparks thrown among incombustible materials. What these atmospheric conditions consist in, if in truth the phenomenon in question depend on atmospheric modifications, we know not. Whatever may be the general cause to which these influences be- long, it is probable, that its effects are exerted rather upon the hu- man constitution, by which its susceptibility to the operation of the variolous virus is either increased or diminished, than in modifying the activity of the contagious principle itself. The susceptibility to the operation of the small-pox contagion varies much in different individuals, not only in relation to the liability of becoming affected by it, but also to the degree of vio- lence which the disease, arising from the same source of conta- gion, assumes. Thus, some persons, (though indeed very few) ap- * Cazenave, loc. cit. Vol. I.—38 446 VARIOLA. pear to be naturally insusceptible ofthe disease; others are affected, even by inoculation, with great difficulty; and among a number of individuals exposed to the same c6ntagion, the disease will assume a confluent form in some; in others it will be severe but distinct; in a third, mild and distinct; and in others, again, it will be very mild, and scarcely attended with any eruption. These diversities in the effects of the contagion must be ascribed to original idiosyn- crasy, temperament, and to accidental modifications or conditions of the organisation. One thing is well ascertained in relation to this point—namely, that whatever tends to reduce the general vigor and phlogistic habit of the system, tends also to lessen the violence of the variolous affection; and it is to this circumstance that we owe all the peculiar advantages which are derived from inoculation. The variolous contagion possesses the power of destroying the sus- ceptibility of the system to its subsequent operation, so that a se- sond attack of perfect small-pox in the same individual, though an occasional, is far from being a common occurrence. Instances of a second, and even a greater number of attacks in the same person, have indeed been frequently noticed; and when we take into ac- count those incomplete cases which are termed varioloid, secondary attacks of the disease may be considered as very frequent. Prognosis.—Small-pox varies exceedingly in relation to its vio- lence and the degree of its dangerousness. The distinct and simple form is by no means a dangerous affection; whilst the confluent variety is always attended with great hazard to life. In the more violent cases of the disease, death sometimes takes place as early as the fifth or sixth day; but the greatest fatality occurs during the stages of suppuration and desiccation. The prognosis depends chiefly on the quantity of the eruption; the character of the pus- tules; the nature ofthe attending fever; and on the accidental mor- bid complications. However, regular the progress of the disease may be, the danger is always great when the pustules are very numerous, more espe- cially when they are confluent. It would seem from estimates that have been made in relation to the mortality from small-pox, that nearly three out of five instances die in the confluent variety. The check which a very copious crop of pustules must neces- sarily give to the cutaneous exhalation, and more especially the great irritation caused by so extensive a surface of suppuration, and perhaps the absorption of the pus itself, are the principal causes of the fatal character of the confluent variety of the disease. In re- lation to the form and appearance of the pustules, it may be ob- served, that the more elevated they are, the more distinctly they are surrounded with red areolae; and the more regularly they be- come filled with a thick yellowish pus, the more favorable is the prognosis. When, on the contrary, the pustules are flat or de- pressed, coherent, or congregated in clusters, warty, empty, or filled with a colorless watery fluid, it is a very unfavorable sign. It VARIOLA. 447 is a still worse indication when the pustules become filled with blood.* With regard to the character of the attending fever, the more decidedly phlogistic or typhoid it is, the more danger is there to be apprehended. A moderately active state of fever is favorable, but a tendency to a low grade of reaction is the re- verse. Richter observes, that when the disease is complicated with prominent catarrhal symptoms; or with difficult dentition; or in- testinal irritation from worms, much danger may be apprehended. In general, the prognosis is unfavorable when the disease occurs in old persons of enfeebled constitutions; in plethoric, robust, and vigorous adults; and in very young infants. Pregnancy, or the puerperal condition, also tends to increase the dangerousness of the disease. It has been observed, that the period of life most favorable to a mild and regular course of the disease, is between the third and the tenth year of age. The age of puberty in females, is said to be a particularly dangerous period in relation to this com- plaint.t Convulsions just before the appearance of the eruption, are rarely attended with any serious consequences; but when they occur during the period of suppuration, the danger is always ex- tremely great. Suppression of the urine, or a very frequent desire to void it, is said to be a very unfavorable sign, when it occurs during the sup- purative stage. It is also a particularly dangerous sign when the pustules, about the sixth or seventh day of the stage of suppuration, become collapsed, and the swelling of the face suddenly subsides, at the same time that the areolae disappear, and the intermediate skin becomes pale and flaccid. The sudden recession of the erup- tion, soon after its appearance, is always very dangerous. Of course, the supervention of visceral inflammation, or of sudden violent con- gestions of blood in the brain and lungs, are occurrences of the most alarming character. Treatment.—There is, perhaps, no disease in which false theory has led to such fatal consequences in practice as small-pox. During the general prevalence of the doctrine of morbid humors, it was supposed that the variolous matter was formed by a species of fer- mentation in the blood, and that the more perfectly this matter was separated and cast upon the skin, the greater would be the chance of recovery. Great efforts were accordingly made to assist nature in establishing as copious a crop of pustules as possible; and under this fatal delusion, all kinds of heating medicines and external warmth were diligently applied. When we reflect on the inevitable result of this practice, so long and so universally pursued, we see in it a a frightful drawback on the amount of benefit conferred by the heal- ing art in relation to this disease, although this amount must be re- garded as immense, from the introduction of inoculation, and espe- cially of vaccination. Among the moderns Sydenham appears to * Richter, loc. cit. p. 330, f Ibid. 448 VARIOLA. have been the first who saw the fatal tendency of the heating or exciting plan of treatment in small-pox. He revived the cooling or antiphlogistic treatment of the Arabian physicians,* a mode of man- agement which is now universally acknowledged as the only prac- tice capable of mitigating the violence and dangerous character of the malady. Instead, therefore, of supporting the excitement during the erup- tive fever, that the eruption may be copious, we must endeavor to moderate the febrile reaction, that the pustules may be as few as possible. By an early attention to the fulfilment of this object, the * The general plan of treatment laid down by Rhazes, differs in no essential point from that which was recommended by Sydenham. For the purpose of di- minishing the violence of the disease in those who are exposed to the small- pox contagion, Rhazes advises, that " a vein be opened in those who are four- teen years old. To those who are younger, cupping-glasses must be applied, and their lodgings should be kept cool." The diet, he says, must "consist of yellow lentils, tarts of unripe fruits;" and their drink " should be water cooled with snow, or clear cold spring water, with which also their chamber may be sprinkled." They must frequently eat " acid pomegranates, and the inspissated juices of acid and astringent fruits." The patient must " go into cold water and swim in it, about noon. He must abstain from wine, and meats made by a mix- ture of flesh, onions, oil, butter, and cheese;" as well as from " mutton, beef, shell-fish, and high-seasoned things, and hot seeds; but, if his temperament be hot and dry, and apt to be inflamed, he must eat cooling and moist garden-herbs, purslain, mallows, beets, gourds, cucumbers, sorrel, and small pompions. All acid things are proper to cool the blood and check the ebullition, especially the water called Al-rdib, that is, the sour, bitter water, which swims upon butter- milk, exposed to the surt. When the variolous fever has supervened, care must be taken not to refrigerate too much so as not to extinguish preternatural and natural heat together." Nevertheless, when, during the fever, " you observe great pain in the back, redness of the face and eyes, a violent headache, a full pulse, with a straitness of breath, a red and turbid urine, and such a heat of the body as a man feels who has been for some time in a hot baih; there is then all the reason in the world to take away blood, even till the patient faints away. But, if the symptoms do not run very high, although they are manifest, draw blood but sparingly. In order more perfectly to extinguish the feverish heat, let the patient drink water, made cold in snow, very plentifully; so that he may feel the coldness of it in his bowels. If still the heat return, and the belly be full of water, make him vomit it up, and then give it him again." During the eruption and suppuration, the patient" must be kept in a room not very cold; he should drink frequently, a little at a time, of cold water." " As to the furnaces and baths, they are both destructive, at this time, by overheating and weakening." When the eruption goes on slowly and with difficulty, the cooling and extinguishing remedies " must be absolutely forborne," The drinks " must be warm."(a) (a) Rhazes, loc. cit, VARIOLA. 449 disease will often pursue a mild and simple course, whilst, under the employment of exciting remedies, it would, in all probability, have assumed a confluent and highly dangerous character. It is upon the power which an antiphlogistic treatment exerts in moderating the violence of the disease, or of rendering the eruption scanty, that all the advantages of inoculation depend. When an individual is inocu- lated, the phlogistic state or tendency of his system is diminished by purgatives, simple and cooling diet, and, in plethoric subjects, by bleeding; in consequence of which, a less copious crop of pustules ensues, and the disease, in general, pursues a proportionately milder course. Sydenham resorted to the lancet as the principal means for mode- rating the febrile excitement. There can be no doubt, indeed, that bleeding must often prove very beneficial; but, it seems to be ad- mitted on all hands, that it cannot be employed with great freedom, without considerable risk of mischief, unless the reaction be very violent or the general phlogistic condition great. " It is an obser- vation universally applicable," says Dr. Philip, " that blood-letting is only to be recommended when the effects expected from it cannot be procured by other antiphlogistic remedies." Cathartics of the milder kind are always highly useful during the eruptive fever, in cases requiring a reduction of the general excite- ment. Very active purging—more especially in mild cases, or when the appearance of the eruption is at hand—is improper, as it may readily interfere with the regular progress of the eruption, by the centripetal direction it tends to give to the circulation. Through- out the whole course ofthe disease, however, mild laxatives may be beneficially employed. These observations have a reference to the distinct variety ofthe disease; for in the more violent or confluent form, we may derive advantage from active purging during the eruptive fever. Calomel is one of the best purgatives in small-pox. Its operation is sufficiently mild, and it would seem, that it possesses peculiar powers in moderating the violence of the disease. (Mead, Boerhaave.) The neutral purgative salts, also answer well during the eruptive fever. Some have recommended emetics in the commencement of the disease; and where there are signs of vitiated secretions in the sto- mach, they may no doubt be useful when early administered. When given about the seventh day of the confluent variety, they are said to have no inconsiderable influence in moderating the secondary fever; but in general, they are most useful when given in the onset of the complaint. (Philip.) Diaphoretics of the refrigerant kind will assist in moderating the eruptive fever. Nitre, with small doses of tart, antimony; the saline effervescing draught; spiritus mindereri; sweet spirits of nitre with vin. antim., a solution of muriate of ammonia, &c, may be used for this purpose. But the most grateful, and at the same time the most safe and va- 38* 450 VARIOLA. luable means for moderating the eruptive fever, and thereby lessen- ing the number of pustules, is the cooling regimen. The free ad- mission of cool air into the sick chamber during the eruptive fever, is in all cases, whether the disease be ofthe distinct or the confluent variety, of great importance; and it seldom indeed fails to mitigate the symptoms, in a greater or less degree, throughout the whole course of the disease. The patient should lie on a mattress, with light and cool coverings; and his drinks should consist of cool, aci- dulated beverages. The temperature ofthe sick chamber must of course be regulated according to the season of the year, and the de- gree of febrile excitement present. In warm weather, the external air must be more freely admitted than in cold seasons; and more reduction of temperature is necessary when the excitement runs high, than where it is of a low or feeble kind. There is but one form of small-pox in which the cooling regimen is said to be objec- tionable, namely, the crystalline. The air surrounding the patient ought to be kept uniformly at a temperature just low enough to give the sensation of moderate coolness. If the fever continues after the eruption is completed in the distinct variety of the disease, it will still be proper to go on with the cooling treatment, together with mild laxatives, diaphoretics, and antimonials. It has already been stated that in the confluent variety of the dis- ease, the fever often assumes a low typhoid character; and in in- stances ofthis kind, the diet, instead of being cooling and diluent, should be more or less exciting and supporting. Where the gene- ral excitement is low and sinking, it will even be necessary to resort to the more active stimulating and tonic remedies, such as wine, carbonate of ammonia, camphor, musk, &c. Camphor is a particu- larly valuable article in such cases where delirium attends. The Peruvian bark has also been very favorably mentioned as a remedy in such cases; and where the process of suppuration goes on tardily and imperfectly from want of general energy, large doses of this article, or of quinine, are indeed highly useful. Under similar cir- cumstances—that is, where the pustules are slow in filling up, or the fluid in them remains watery—opium in combination with cam- phor has been found a very useful remedy. (Philip.) When during the progress ofthe disease, internal visceral inflam- mations supervene, local abstractions of blood from the external region of the affected part, blisters, scarifications, and, where the general arterial action is not too low, bleeding from the arm, must be resorted to. In instances attended with cerebral inflammation, much benefit may often be derived from flannel wrung out of hot water applied to the feet, at the same,time that pounded ice is ap- plied to the top ofthe head. The occurrence of profuse diarrhoea during the secondary fever of confluent small-pox, must be counter- acted by astringent and absorbent remedies. From eight to ten grains of prepared chalk, with an equal portion of pulv. ipecac, compositus, will generally answer our purpose in such cases. It is not, however, VACCINA. 451 proper to arrest the discharge wholly in such cases. It should be moderated only. When violent and continued vomiting occurs, we may resort to opium and camphor. One grain of the former with two of the latter may be given every hour or two, according to the violence of the symptoms. To prevent the pustules from affecting the globe of the eye, and injuring the sight, pieces of folded linen wet with cold water should be kept applied to the eyes during the eruptive fever. The appli- cation of camphorated spirits has been used for this purpose; but cold water is more agreeable, and also most effectual in this respect. The use of lunar caustic, as a local application to the pustules, has of late been recommended and successfully practised in France, for the purpose of lessening the number of pustules, and by so doing, rendering the disease milder and less dangerous. In 1825, M. Vel- peau read a memoir before the Royal Academy of Medicine, of Paris, tending to prove, that if the pustules of small-pox are caute- rised during the first two days with lunar caustic, their progress will be arrested. This practice was fully tested some time after, by Dr. Meyreux. According to his report, it appears, that if the variolous pustules are opened with a lancet, and touched with a pointed piece of lunar caustic, on the first or second day of their appearance, they will be wholly destroyed, and leave no marks; but on the third day it will be quite useless. When soon after the eruption has appeared, it is again driven in, (an occurrence which may proceed from the sudden application of cold and damp air, or from the supervention of excessive purging or vomiting, or other rapidly exhausting circumstances, such as sudden terror, or grief, or syncope, or excessive abstractions of blood,) im- mediate recourse should be had to means that have a tendency to determine the circulation to the surface, such as camphor and opium, carbonate of ammonia, warm bathing, sinapisms to the extremities, and gentle frictions with dry flannel or the flesh-brush. Where the retrocession arises from cold, an emetic, with stimulating frictions, will often promptly recall the eruption to the surface. Sect. II.— Vaccina.—Cow-Pox. Long before the the time of Jenner, it was known in some of the dairy counties of England, that cows are subject to a pustular dis- ease, which, when communicated to the hands of milkers, renders them insusceptible of the variolous infection. Although this fact was noticed, and even artificial inoculation with the vaccine matter successfully practised in an instance which was formally communi- cated to Sir George Baker; yet the whole credit of introducing the cow-pox into general notice is due to Dr. Jenner. The benefits which this important discovery has conferred upon mankind are incalcula- ble; and it is not a little consoling to reflect, that as the hand of Providence has in this instance provided a salutary check to one of the most fatal maladies with which man has been afflicted, there 452 VACCINA. may yet be brought to light, at some future period, other antidotal or prophylactic powers against the ravages of diseases, which in the present state of our knowledge, are in a great degree uncontrollable. Although Jenner had made successful experiments with the vac- cine matter as early as the year 1796, he did not publish the result of his investigations until two years after. From that period on, the knowledge of the benefits of vaccination spread rapidly throughout Europe and this country; and there is now no civilised people on earth, amongst whom its blessings have not been largely experienced and gratefully acknowledged. Various opinions have been expressed with regard to the origin of the vaccine disease. Dr. Jenner, at first, ascribed its source to the grease of horses; and this opinion is indeed supported by very strong, though perhaps not absolutely satisfactory evidence. It is asserted by some, for instance, that a pustular disease, in every re- spect similar to the vaccine infection, may be produced both in the human subject and in cows by inoculation with the matter of grease. Friese, Loy, and particularly Sacco,* affirm that they have succeeded fully with this experiment; and Mr. Ring states, that " he succeeded in producing the disease artificially in a cow by removing a scab from the teat, and applying the recent blackish matter of grease to the surface of the sore." The same author has published a letter from Mr. Rankin, relating a case of pustular disease strongly re- sembling the casual cow-pox, accidentally produced on the face and hands of a farmer, by the fluid oozing from the heels of a horse la- boring under grease. It appears, moreover, that persons who have been affected with the pustular disease produced by the matter of grease, are insusceptible of the contagion of small-pox. Dr. Jenner relates a case of this kind. Sheep, also, are subject to a pustular af- fection about the head and mouth, which is said to be communica- ble to the human subject, in whom it produces a disease very simi- lar to that which is caused by the matter of grease, and which it is asserted by Sacco and Richter, renders the human system incapable of receiving the variolous infection. It has also been supposed, that the vaccine disease is essentially the same as small-pox, and that these two affections derive their origin from the same ultimate source. It is conjectured that the small-pox was at first derived from the cow-pox or grease of horses in Arabia, and that in the course of time it gradually degenerated, by passing successfully through the hu- man system, until it acquired the known virulence, and activity of variolous contagion. In confirmation of this supposition, it is asserted that cases have occurred where the variolous matter, inserted into the udder of cows, produced in them a pustular affection not to be distinguished from the cow-pox. Richter makes this observation on the authority of Gassner.t It is also asserted by Dr. Lisa, that * Neue Entdeckungen uber die Kuhpocken, die Mauke u. Schaafpocken. Translated from the Italian, by W. Sprengel, 1813. X Specielle Therapie. VACCINA. 453 sheep are effectually protected from the disease called sheep-pox, by inoculating them with variolous matter. Sheep inoculated in this way are said to become affected with but one pustule at the point of where the variolous matter is inserted.* The original identity of variolous and vaccine matter has recently been incontestibly demon- strated, if we are to place any reliance on the correctness and vera- city of Dr. Ozamann, of Lyons. In a paper which was read at the French/ Academy of Medicine in July, 1830, it is asserted, on the authority of Dr. Ozamann, that the matter of small-pox, if mixed with fresh cow's milk, produces when inserted by inoculation an eruption similar, in all respects, to that of the vaccine virus, and that inoculation with this matter will answer fully for the production of the usual vaccine disease.t Symptoms and progress of the disease.—When the vaccine dis- ease is communicated to the human subject, it proceeds through its course in the following manner. Towards the close of the second day after the insertion of the virus, a small point of inflammation. may, usually, be seen where the puncture was made. On the third day this point is more distinct; on the fourth, it generally assumes the character of a small pimple encircled by a very faint and narrow inflamed basis or areola. This pimple now gradually enlarges, and on the fifth day begins to assume a perfectly regular and circum- scribed form, with a flattened surface, and a small depression at the centre, somewhat darker than the rest of its surface—an appearance which it preserves throughout its whole subsequent course. About this period also, the vaccine pock changes from the pimple to a ve- sicle, containing a limpid fluid. From the fifth to the ninth day, the pock continues to enlarge in its circumference, but not perceptibly in elevation, so that its flattened appearance becomes more and more conspicuous. About the ninth day the pustule is at its full state of maturity, and it is at this period that the constitutional symptoms (if any occur) begin to show themselves. In some instances the glands of the axilla become painful and swelled, and a state of gene- ral languor and drowsiness, with slight creeping chills and alternat- ing flushes of heat occur. Frequently, however, no constitutional symptoms whatever supervene. About the eighth day the slight circle of inflammation which surrounds the pustule in its early pe- riod begins to increase, until by the tenth or eleventh day it forms a broad and beautiful areola round the pock. By the eleventh day, the centre of the pustule, which is slightly depressed, begins to as- sume a darker appearance, and this darkness gradually extends to- wards the circumference, so that by the fourteenth day the surface of the pustule is converted into a brown scab. This scab becomes darker and darker, until it acquires a deep mahogany appearance. In a few days more, the scab begins to separate at the circumference— still, however, retaining its attachment at the centre; and eventually * Mediz. Chirurg. Zeit. 1809. No. xliii. Salzburg. X Rev. Encyclop. Aout, 1830. 454 VACCINA. falls off, generally between the third and fourth week from the time of vaccination, leaving a slight depression in the skin. The areola is usually most perfect about the seventh day after the commencement of the pustule, or on the eleventh day after the vac- cination, and is attended with some degree of tumefaction and hard- ness. The foregoing description answers to the regular progress of the disease but various deviations are occasionally observed in relation to some of the particulars just described. In some cases, for in- stance, the pustule furnishes well-formed vaccine lymph as early as the fourth day of its progress. Much diversity occurs also with re- gard to the time when the disease first manifests itself after the vac- cination is practised; for, in some instances, eight or nine days, and occasionally even a longer period, intervenes between the vaccina- tion and the commencement of the pustule. It often happens, that on the day succeeding the vaccination, con- siderable inflammation and elevation of the cuticle takes place at the point where the pucture was made. When this is observed, we may confidently predict the failure of the operation. This inflam- mation continues for a day or two, and then subsides quickly with- out leaving any local affection. It seldom happens that more than the pustule which rises at the point of vaccination appears on the body. Occasionally one or more smaller pustules appear in the vicinity of the primary one; and in- stances have occurred, in which a pretty numerous crop of pustules came out on different parts of the body. In the report of the cen- tral vaccine committee of France, for 1818-19, it is stated that no inconsiderable number of cases occurred, in which a spontaneous eruption of many pustules appeared after vaccination, and that the matter taken from these pustules produced the disease as perfectly in others, as that taken from the primary pustules. It is a curious and interesting fact, that the vaccine disease occa- sionally counteracts or removes other affections of a chronic charac- ter—particularly chronic cutaneous diseases. In the report of the French committee just referred to, it is stated that " thirteen medi- cal men have seen examples of vaccination proving the means of curing other eruptions, more especially the crustea lactea;" and fully authenticated instances are recorded of the removal of scrofu- lous swellings, ophthalmia, and hooping-cough, by vaccination. Of the power of the vaccine disease to moderate and abridge the course of hooping-cough, I have myself witnessed several examples. Another very important circumstance in relation to the mutual influence of the vaccine disease and other cutaneous affections, is the well-established fact, that important varieties and modifications of the vaccine pustule are caused by herpetic and other eruptive states of the skin. Dr. Jenner, in a paper published in the sixty-sixth number of the London Medical and Physical Journal, points out the fact, that a single serous blotch existing upon the skin during the progress of the vaccine vesicle, may occasion such irregularity VACCINA. 455 and deviation from the genuine course and character of the disease, that it cannot be depended on as a prophylactic against the variolous infection. In a letter addressed by him to the medical profession generally, dated April, 1821, he observes: "I have found abrasions of the cuticle to produce the same effect—such for example, as we find in the nurseries of the opulent, as well as in the cottages of the poor, behind the ears and upon many other parts where the cuticle is tender. We find irregularity in the vaccine vesicle, if the skin is beset with herpetic blotches, or even simple serous oozings from an abraded cuticle. A speck behind the ear, which might be covered with a split pea, is capable of disordering the progress of the vac- cine vesicle." Diagnosis.—An attention to the following circumstances, will enable us to distinguish the genuine from the spurious disease: 1. In the genuine disease little or no inflammation, except what occasionally arises from the mere puncture of the lancet, can be per- ceived until about the third day, and sometimes not until several days later. In the spurious affection, on the contrary, considerable inflammation and elevation ofthe skin at the punctured point, gene- rally appears as early as the second day. 2. In genuine vaccina, the small point of inflammation which ap- pears three or more days after the matter is inserted, increases gra- dually until about the seventh day after its first appearance, at which time it is in its full state of perfection. In the spurious disease, the pustule arrives at maturity and finishes its course in a much shorter time. By the third or fifth day from the first appearance of the inflammation, scabbing commences. 3. In genuine cow-pox, a beautiful circular and circumscribed areola almost always surrounds the pustule, and this areola efflo- rescence is usually in its perfect state about the seventh or eighth day. In spurious affections of this kind, an irregular superficial inflammation occurs on the first or second day after the appearance of the pustule; and the pustule itself appears more like a common festering sore produced by a thorn, than a pustule excited by the vaccine virus. 4. The genuine pustule is perfectly circumscribed, with a flat- tened surface and a slightly depressed centre, and contains a color- less transparent fluid. The spurious pock is more elevated, not de- pressed in the centre, is irregular or angulated in its circumference, and contains an opaque purulent matter. According to Dr. Willan, the vaccine vesicle is to be regarded as imperfect when—1, though perfect in its form and appearances, it is without an areola on the ninth or tenth day. 2, when the vesi- cle is very small, pearl-colored, flattened, with a hard inflamed, and slightly elevated base, a dark-red areola, and without a rounded or prominent margin. 3, when the vesicle is small, pointed, with a very extensive pale-red areola. The spurious disease may be pro- duced— 1, by the genuine vaccine virus acting on a system affected 456 VACCINA. with some cutaneous disease; 2, by vaccinating with matter which has undergone more or less decomposition by long keeping; 3, by vaccinating with matter taken from a spurious pustule; and 4, by the genuine vaccine matter being controlled, or in some way di- verted from its regular operation by idiosyncrasy, or a depraved con- dition of the system. Some difference of opinion has been expressed with regard to the period at which the vaccine lymph should be taken from the pustule, in order to obtain it in its most perfect and active state. Dr. Jen- ner advises that the virus be taken a short time before the areola is completely formed, and consequently soon after the lymph is se- creted in the pustule, or about the sixth or seventh day. To obtain the virus, the edges of the pustule must be gently punctured with a lancet in several parts. The lymph will then ooze out, and may be collected and preserved between two glasses. Of late years, however it has been more customary to vaccinate from the scab. For this purpose, no scab except from the most perfect pustule should be taken. It should be smooth, of a dark-brown or maho- gany color, and rather brittle than tenacious in its texture. When used, the margin, which is of a lighter color, should be removed with a knife, and a portion of the remaining dark, hard, internal part reduced to powder on a glass, and moistened or dissolved with a small portion of cold water. In taking either matter or the scab for vaccination, it is of great consequence to be well assured that the person from whom it is taken was healthy, and particularly that he was not affected with any cutaneous disorder. A want of due care on this point, may give rise to extremely unpleasant and even dan- gerous consequences. I have several times known obstinate and alarming cutaneous affections communicated to children by vaccina- ting with matter taken from unhealthy subjects. It is a common be- lief among persons out of the profession, that the vaccine disease is apt to give rise to disagreeable eruptive affections, and such occur- rences are in fact not very unfrequent. Accidents of this kind proba- bly depend most commonly on the matter having been taken from persons affected with some cutaneous disorder, or with a general ca- chetic or depraved habit of body. It seems, nevertheless, that the vaccine disease, communicated by the purest lymph, will occasion- ally excite pustular and other external inflammatory affections in per- sons of a strumous or scorbutic habit. General remediate treatment is seldom required during the dis- ease. When febrile excitement attends, which is rarely the case, a reduction of the diet, with some mild aperient medicine, diluent drinks, with small doses of spiritus mindereri, or sweet spirits of nitre, should be ordered. In some instances, the inflammation and swelling around the pustule become so great as to demand particular attention. This is most apt to happen when the vesicle is irritated by scratching or rubbing it, at the time when the areola is about making its appearance, more especially when at the same time some VACCINA. 457 other cause supervenes, calculated to produce general febrile irrita- tion. To moderate the violence of the pain and inflammation, a weak solution of sugar of lead, or cold water, or poultices made of lead-water, may be applied to the inflamed part, and laxatives, with some ofthe milder refrigerant diaphoretics given internally. With regard to the prophylactic, or protecting powers of the vac- cine disease against the small-pox, the opinion of the profession has undergone considerable change within the last ten years. It seems to be pretty generally admitted at present, that the vaccine affection, even in its most perfect state, does not so completely protect the system from the variolous infection, as was formerly so confidently believed. From whatever cause it may proceed, it is beyond a doubt, that the failures of vaccination in preventing secondary small- pox, " have been steadily and progressively on the increase for some years past." " This circumstance," says Dr. Gregory, " can- not be met by a reference to the fact, that small pox once gone through, does not always protect the subject from a second attack." Cases of small-pox after vaccination, are far more frequent than second attacks of small-pox. Dr. Gregory has given a table of the total number of admissions into the small-pox hospital in ten differ- ent years, and from this statement, it appears that in the year 1810, the proportion of cases of small-pox after vaccination, to the whole number of admissions, was as 1 to 30; while in 1815, it was as 1 to 17; in 1819, as 1 to 6; in 1821, as 1 to 4; and during the year 1823, as 1 to 3i. Notwithstanding these facts, vaccination must still be regarded as an invaluable means for lessening the amount of mortality, and as deserving all confidence as a protecting power against small-pox. For although it may not, in many cases, render the system wholly insusceptible to the variolous infection, yet the number of instances in which it affords perfect immunity from small-pox, is beyond all comparison greater than that in which it fails to afford complete protection; and even where it does not entirely subdue the suscep- tibility to the small-pox, it almost invariably lessens it to such a de- gree, as to render this latter disease so mild and simple, as in most instances scarcely to require any remediate attention. It is believed by many, that the constitutional influence of the vaccine disease gradually diminishes, until the system, though at first protected by it against the variolous contagion, regains in the course of years its original susceptibility to small-pox; and this opin- ion is in fact strongly countenanced by the results of experience. Some have supposed that the vaccine impression continues only about ten years; others have limited its duration to seven years; and Dr. Leo Woolf, in an interesting memoir on this subject, has adduced facts and reasonings to show that this influence is ef- faced by the constitutional changes which occur at the age of pu- berty. That the prophylactic influence of the disease suffers pro- gressive diminution until it becomes, perhaps, wholly effaced, I Vol. I.—39 458 MODIFIED SMALL-POX. am myself much inclined to believe, from facts which have come under my own observation; but the attempt to set any precise limits within which the gradual subsidence ofthis influence isaccomplished, must necessarily be attended with great uncertainty; since it may well be supposed, that idiosyncrasy, modes of living, and acciden- tal as well as constitutional predispositions, and perhaps habitual ex- traneous influences, may give rise to much variation in this respect. From the general fact (if in truth it be so) that the constitutional impression of vaccination wears out in the progress of time, many physicians have of late recommended re-vaccination, so as to renew its impression on the system; and this practice may be deemed a reasonable, and certainly not a detrimental, precautionary measure. Various modes have been proposed to test the sufficiency of a recent vaccination, as a protective power against the small-pox in- fection. For this purpose, some have advised re-vaccination five or six days after the first operation. If the disease is perfect in its influence, a vesicle will rise at the point of the second vaccina- tion, but it will differ in its progress from the first, by becoming surrounded with a complete areola, as early as the second or third day of its appearance, so that the areola of the first and second vesi- cles commence nearly at the same time, and progress pari passu. Others have proposed to re-vaccinate about the end of twelve days from the first vaccination. If the first has been perfect, the second vaccination will either not succeed at all, or give rise only to a spu- rious or irregular pock. The most certain test, however, is inocu- lation with small-pox matter—a test from which we derive at once our reliance in the general protecting powers of the disease, and in the genuineness of the particular instance. A distinct, circular, radiated, punctulated, and not very large cicatrix, may be regarded as a pretty certain indication, that the vaccine affection was perfect. When, on the other hand, the scar " is large, and bears the marks of having been formed by high local inflammation, and wants the distinctive characters just mentioned," there is much reason to apprehend that the system has not been se- cured against secondary variolous disease. Sect. III.—Modified Small-Pox. I. Varioloid Affections. Soon after the general introduction of vaccination, exanthematous affections, closely resembling small-pox, were occasionally observed in individuals, who had previously undergone the vaccine disease in a regular and satisfactory manner. These varioloid affections be- came more and more common; and within the last fifteen years, they have appeared in various countries in frequent and extensive epidemics. In the earlier periods of vaccination, these eruptions were generally regarded as chicken-pox, but subsequent inquiries MODIFIED SMALL-POX. 459 led to the opinion with many, that they are the product of a. pecu- liar contagion; whilst others were led to ascribe them to the vario- lous contagion acting on systems but partially protected against small- pox by previous vaccination; and this appears now to be the general opinion. From the earliest times of small-pox of which we have any re- cords this disease has indeed been frequently noticed under various modifications, as remarkable and apparently as distinct as the form we now call varioloid. We find various irregular forms of the dis- ease described by the early writers under the names of the vesicular, pustular, and spurious small-pox; swine-pox. sheep-pox, stone-pox, horn-pox, &c. all of which were regarded as having but one origin, namely, variolous contagion. After small-pox inoculation was in- troduced, spurious variola was by no means uncommon; and it has always been observed that genuine and spurious small-pox have in the same epidemics come in and gone out together, in the same man- ner as they have uniformly been observed to do since vaccination has been introduced. It appears, therefore, that various circumstances, either of a con- stitutional or accidental character, may modify small-pox in a variety of ways; and as such modifications were abundantly observed, be- fore vaccination was practised, we need not be surprised that they should be so frequent now, when a new and very extensive modify- ing cause exists in the influence of the vaccine disease. That the present varioloid disease is in fact nothing but a modified form of small-pox, may be regarded as established by an abundance of direct and conclusive evidence. In the course of my practice, I have met with several instances of varioloid disease, which were unequivo- cally of variolous origin. Within the present year I produced a well-characterised varioloid eruption by inoculating with small-pox matter a person who had been satisfactorily vaccinated about ten years before. It is unnecessary, however, to adduce any further evidence on this point. The works of several late writers abound in observations illustrative of the variolous origin of this disease. Dr. Thompson, particularly, has placed this view ofthe subject in a strong light; and to his work on the history of small-pox the reader is referred, for much interesting, and I think conclusive evidence on this point- By viewing the subject in this light, a great deal of that perplex- ity and confusion which have existed in relation to those anomalous pustular and vesicular affections, which usually precede or accom- pany small-pox epidemics, are entirely removed. We perceive that the same morbific agent, modified in its effects on the human system by various causes, lies at the root of all this family of eruptive com- plaints. They are all, it would appear, the offspring of the same parent, and though diverse in their appearance, they possess enough of family likeness to enable an accurate observer to refer them to a common origin. 460 MODIFIED SMALL-POX. -------Facies non omnibus una, Nee diversa tamen, qualem decet esse sororum. As the degree of modifying influence of the different causes which are capable of producing variations in the effects of variolous conta- gion must be extremely various, it is obvious that the irregular or varioloid diseases which result from the combined agency of the modifying causes, and the virus of small-pox, must be correspond- ingly diverse; and we find indeed so great a diversity in this re- spect, that no description can be given of them which can have more than a general application. I confine myself, at present, to the con- sideration of that form of varioloid disease which results from the action of small-pox virus on a system that has previously undergone the vaccine influence. In many instances, as has already been stated, vaccination protects the system completely against infection from small-pox contagion. In other cases, the system is either only partially freed from its apti- tude to variolous infection, or this susceptibility, though for a time entirely subdued by the vaccine influence, gradually returns and regains a greater or less degree of intensity. The disease which results from the action of small-pox contagion on a system thus par- tially deprived of its variolous susceptibility, and which has of late years been so common, deviates more or less conspicuously from re- gular small-pox, and is, in a great measure, divested of the dange- rous character of the latter affection. Symptoms.—In a large proportion of cases of varioloid, the erup- tive fever is so mild and inconspicuous, as scarcely to attract any attention. In some cases, however, the fever is as violent as in the severer instances of small-pox. In point of duration, too, it is very irregular, terminating sometimes as early as the second day, and at others not until the fifth day from its commencement. In all in- stances, whether mild or violent in its symptoms, the eruptive fever ceases suddenly on the appearance of the eruption; so that patients who were confined to bed during the first three or four days, are generally up and about after the eruption has come out. In many cases a transient uniform efflorescence precedes the appearance of the erup- tion; and a rash resembling measles, also, is not an unfrequent pre- cursor of the varioloid eruption. The varioloid exantheme almost always appears at first in the form of small papulae, many of which dry off without becoming either vesicular or pustular. Frequently, however, these small, firm, red papulae are converted into vesicles containing a watery limpid fluid, in the course of the first, and some- times not until the second day. About the third or fourth day these vesicles usually burst, or wither without assuming a pustular charac- ter, the fluid in them acquiring a whey-like appearance. In many instances, the vesicles are surrounded with a small and faint areola. "This variety," says Dr. Thompson, "in the mildness of the erup- tive fever, the strictly vesicular character, short duration, and mode of disappearance of the eruption, corresponded (in the epidemic he MODIFIED SMALL-POX. 461 describes) so exactly with the descriptions usually given of the mild- est varieties of chicken-pox, as not to have been distinguishable from that disease." In many cases these vesicles become filled with a puruloid fluid, are slightly depressed in the centre, and by the third or fourth day, changed into thin, dark scabs, which separate and fall off usually about the sixth or seventh day after the appearance ofthe eruption. Occasionally the scabs do not separate until the tenth or even the twelfth day. Sometimes the vesicles remain distended with a colorless serum for four or five days, and then become pus- tular, containing a pus-like fluid, in which state they usually remain a few days longer before desiccation or scabbing commences. In most cases of varioloid disease after vaccination, papular, vesicular, and pustular eruptions are interspersed through each other at the same time. Not unfrequently the disease assumes so nearly the appearance and character of distinct small-pox, that it is difficult to decide during the first five or six days, whether it should be re- garded as a modified or regular variolous affection; and cases some- times occur, in which the varioloid eruption is so abundant as to resemble confluent, rather than distinct small-pox. Very generally, however, the smallness of the pustules, the whey-like fluid which they contain, and particularly the early period at which they begin to dry and scab, will enable us to distinguish such cases from ge- nuine small-pox. Dr. Thompson observes, that the areola and its pustule sometimes exhibit a remarkable resemblance to the areola and vesicle of the cow-pox—a resemblance which betrays the mixed variolous and vaccine character of the disease. Varioloid pustules very rarely leave any depressions in the skin. When the scabs remain adhering a long time, they occasionally leave slight pits; but much more commonly warty or fungoid elevations remain. From the foregoing account, we perceive how extremely various this affection is both in its general and local phenomena. We see that in some instances it exhibits a striking resemblance to chicken- pox, in others it approaches very near to genuine small-pox, and in some instances it exhibits no small degree of resemblance to the vaccine pustule. Notwithstanding this extreme irregularity of mo- dified small-pox, the following circumstances may be stated as its most common and characteristic features. 1. The eruption appears in successive clusters, occurring at un- certain periods between the second and fifth day. 2. The eruption seldom, if ever, enters into complete suppuration as do the small-pox. 3. The eruption is not attended with fever, except in very violent cases. 4. Desiccation or scabbing invariably occurs much earlier than in regular small-pox;—commencing generally as early as the fifth or sixth day; and the scabs usually separate by the eighth or ninth day, leaving red disks or tuberculous elevations instead of depressions. 39* 462 MODIFIED SMALL-POX. That the system should, in many cases, still remain liable to the morbific effects ofthe small-pox contagion after the process of vac- cination has been undergone, is by no means surprising, when we reflect how often second attacks of genuine small-pox have been known to occur. The greater frequency of a second infection by variolous contagion in those who have suffered vaccination, than in persons who have already had small-pox, may be ascribed, in part at least, to some imperfection or disturbance of the vaccine affection, by which its prophylactic power is more or less weakened or de- stroyed. Dr. Jenner believed, that in all cases where small-pox occurs after vaccination, it is owing to the vaccine vesicle having been disturbed or rendered imperfect by one or more ofthe follow- ing circumstances, viz: 1, preoccupation ofthe skin by some chronic cutaneous affection; 2, the use of spurious vaccine matter; 3, depriv- ing the vaccine vesicle incautiously of its lymph, or otherwise in- juring or irritating it by external violence, so as to give rise to com- mon phlegmonous inflammation. Without doubt, however, modified small-pox, or a second vario- lous infection resulting in a spurious or modified form of the disease, may and often does occur after vaccination apparently the most com- plete and satisfactory. When we see small-pox occurring in the same individual a second time, even after a most severe attack of the disease, we cannot hesitate to believe that the same may happen after perfect vaccination, for it is not reasonable to presume that vac- cination can be a more certain preventive of the small-pox infec- tion, than a severe attack of the small-pox itself. Indeed, facts illus- trative of this truth have been abundantly recorded within the last ten years; and it may now be regarded as established, that vaccina- tion does not in all instances afford immunity from the partial influ- ence of the small-pox contagion. It may be no less true, that a great majority of modified small-pox after vaccination, depends on some accidental imperfection in the vaccine disease, either from con- stitutional idiosyncrasy, or from the causes just mentioned. It would seem from some observations of Dr. Gregory, that the aptitude to variolous infection, after vaccination, prevails in an especial degree in some families. The same writer infers from facts which have come before him, that modified small-pox, subsequent to vaccination, is most apt to occur in persons between the' ages of fifteen and twenty-one. This corresponds with the opinion mentioned before, that the vaccine impression is probably weakened, or partially oblite- rated, during that general constitutional change which takes place at the age of puberty. My own observations, though limited, lead me to the same conclusion expressed by Dr. Gregory, with regard to the age at which the present disease is most apt to occur. By far the greater number of cases of modified small-pox that I have yet seen, were in young people between the ages of fifteen and twenty-one. Modified or spurious small-pox, as has already been intimated, is not, however, confined to those who have been subjected to the MODIFIED SMALL-POX. 463 vaccine influence. It occurs also in persons who have had small- pox; as well as in those who have never had either this or the vac- cine disease. This fact has been adduced in evidence, that the varioloid disease arises from a peculiar contagion radically distinct from that which produces small-pox. It is contended, that if this malady were not a peculiar or specific affection, it could not repro- duce itself in its characteristic form in persons who had not under- gone the modifying influence of small-pox, or of the vaccine disease. In reply to this argument against the identity of these affections, it may be stated, that, on the presumption of their common origin, the varioloid eruption is an imperfect result of the variolous conta- gion; and it is therefore reasonable to infer that the virus of this imperfect form ofthe disease is also modified, or incapable of pro- ducing the genuine affection, unless an extreme degree of suscepti- bility to the disease exists; That the varioloid disease does, how- ever, sometimes produce genuine small-pox in the unprotected, the authority of Thompson and others does not permit us to doubt; and I have myself seen at least two striking examples ofthis kind. As to the production of varioloid affections by the small-pox con- tagion in those who have already had small-pox, there does not appear to exist any difficulty in accounting for it satisfactorily. We know that an attack of small-pox does not always obliterate the con- stitutional predisposition to the variolous contagion. Even after the system has passed through the most perfect form of the disease, a second attack will in some instances occur. Now, between that state of the system produced by small-pox, which affords perfect immunity from a second infection, and that state in which the sus- ceptibility to a subsequent attack is undiminished, a vast variety of grades of susceptibility must, we may reasonably presume, occur, according to individual idiosyncrasy, temperament, accidental con- comitant influences, and perhaps the activity ofthe variolous conta- gion. If,.then, after an attack of small-pox, the predisposition to this disease is not entirely, but only partially destroyed, ought we not to look for an imperfectly developed form of the disease, should a second infection take place ? It is in this way, we believe, that varioloid, or varicellous eruptions occur in persons who have once undergone small-pox. As to the occurrence of varioloid affections in those who have never had either small-pox or the vaccine dis- ease, it may be observed, that the degrees of natural susceptibility to the variolous contagion, are almost infinite in variety in different individuals. We see in the same family, into which this contagion is introduced, one individual affected so slightly as scarcely to re- quire attention; another perhaps only indisposed with variolous fever, without any eruption; a third one seized with a pretty severe attack of the distinct small-pox; and a fourth affected with the most aggravated variety of the confluent form of the disease. We may presume, therefore, that where the small-pox contagion acts on a system which is either naturally or accidentally indisposed to the full influence of its powers, it will produce either an extremely mild 464 VARICELLA. variolous eruption or an irregular or modified one—in other words, a varioloid or varicellous affection. From these and other considerations, I am induced, in common with many others, to regard varioloid as a variety of spurious or modified small-pox, or at least as being referrible, for its ultimate source, to the same contagion which produces this disease. 2. Varicella. As early as the time of Rhazes, exanthematous affections were noticed, which, though they did not appear to protect the system against the small-pox, bore a very strong resemblance to this dis- ease. These varioloid eruptions were described by Vidus under the the name of crystalli; and Senertus observes, that there are varie- ties of small-pox, which, instead of becoming filled with pus, are distended with a watery limpid fluid, which dries off in a few days. Riverius also speaks of these varioloid eruptions as common in his time; and we find them mentioned by the writers of that period under various denominations—as bastard-pox, spurious-pox, lympha- tic-pox. Sydenham speaks of them as a spurious variety of small- pox; and Sauvages has given a description of them under the name of variola lymphatica. Up to the time of Morton, who introduced the term chicken-pox, the general opinion among physicians was, that varicella is an im- perfect variety of small-pox. There were some, however, even at this period, who entertained a different opinion, regarding the dis- ease as a peculiar or radically distinct exanthematous affection. In 1767, Heberden published a memoir,* in which he endeavored to show that varicella is the result of a peculiar contagion, totally dis- tinct from that which gives rise to small-pox. This soon beeame the prevailing opinion on this subject, and continued to be so until its correctness was again called in question by Dr. Thompsont and other recent writers. The principal arguments that have been alleged against the com- mon origin of these affections are: 1. The occurrence of epidemic small-pox without varicella; and the occasional prevalence of varicella without the occurrence of small-pox. So far, however, as my inquiries extend, every epide- mic small-pox that has been particularly described, has been pre- ceded, accompanied, or immediately followed by anomalous or vario- loid affections, bearing the characteristic marks of varicella. Grant- ing, however, that epidemic small-pox may have existed without the concomitant appearance of varicella, it does not follow that these affections are radically distinct. It is quite possible, that from the influence of certain atmospheric constitutions, the human system generally may at one time be so susceptible to the action of the * Transact, of the College of Physicians, vol. i. | An Account ofthe Varioloid Epidemic, &c. By John Thompson, M. D. &c. VARICELLA. 465 variolous contagion, that nothing but the genuine and regular form of the disease can be developed:—or so insusceptible as to enable this contagion to produce only a spurious or varicellous disease. From this or some other occult causes, the small-pox itself assumes the most dissimilar characters. Some epidemics are mild; others severe; and others malignant to a great degree: sometimes the pus- tules become filled with a bloody matter, and at others they are " crystalline." What reason then is there to doubt that the conta- gion may at times be so feeble, or the human system so indisposed to its influence, as to admit only ofthe production of a mild vesicu- lar disease. 2. Varicella is more common now than before vaccination was introduced, when small-pox was more prevalent. This however, only shows that since vaccination is practised, there are more sys- tems insusceptible to the full effects of the variolous contagion than before this epoch, and argues therefore in favor of their identity. 3. Varicella occurs equally in those who have had small-pox, in those who have been vaccinated, and in those who have never had either of these affections. To this argument we may reply, that it is generally admitted, that varicella occurs much more frequently in those who have had small-pox, or the vaccine disease, than in the unprotected. Drs. Bryce and Abercrombie saw but three cases in which varicella took place in persons who had not either of the for- mer affections. 4. Varicella, it is alleged, cannot be communicated by inocula- tion. This is an error. Heim, who is quoted below, asserts that they are very communicable in this way; and Dr. Thompson, in his work on varioloid affections, gives abundant testimony on this point. 5: The occurrence of small-pox does not prevent or modify vari- cella. Dr. Thompson, however, asserts, that out of one hundred and fifty-five persons whom he saw pass through the small-pox, " not one was afterwards affected with vesicular disease, although upon the supposition ofthe co-existence of a varicellous and a vario- lous epidemic, most if not all of this number must have been ex- posed to the influence of both contagions." If, indeed, we adopt this argument as valid, we must conclude the small-pox and the vaccine disease are essentially the same disease; for, as is well known, they mutually prevent or modify each other. Symptoms.—Varicella is seldom attended with much fever. In many cases the febrile symptoms are scarcely obvious, yet in some instances the eruptive fever is almost as violent as in the severer cases of small-pox, and is attended with the same pains in the back, head, and extremities, as in this latter affection. The initial fever continues from one to three days, and terminates in the appearance of a vesicular eruption, which usually .comes out first on the breast and back, next on the face and scalp, and lastly on the extremities. A troublesome tingling or itching in the skin generally accompanies the eruption. The eruption is often preceded, for a few hours, 466 VARICELLA. by a general erythematous rash, as in small-pox, or varioloid after vac- cination. The varicellous vesicles generally come out in succession during three or four days, so that at the same time, some of them will be just appearing: others fully formed and filled with lymph: whilst some will be shrivelling, and others again be already converted into scabs. The vesicles, in different cases, assume different appear- ances; and this has given rise to a division of the disease into three varieties; namely, the lenticular, and the conoidal varicella, and swine-pox. The eruption, in the first of these varieties, comes out very early, and consists, at first, of small, rather oblong, red, flat, and shining elevations, with a minnte vesicle in the centre, which by the end of the second day is somewhat enlarged and distended with a whitish lymph. This fluid assumes a pale yellow color on the succeeding day, and on the following or fourth day, the vesicle be- comes shrivelled, and in two days more is converted into a small brown crust. The scabs fall off about the ninth or tenth day, leav- ing red marks, but no depressions on the skin. In the second or conoidal variety, the vesicles appear suddenly, and are surrounded by a slightly inflamed margin. On the first day they are elevated, pointed, and filled with a limpid serum; on the second day they are more distended, and contain a very pale, yel- lowish fluid. On the third day they wither; and at this time some of them contain a purulent matter; and these vesicles generally leave pits in the skin when the scabs fall off. Scabbing commences on the fourth day, some ofthe scabs acquiring a dark brown, and others a yellowish and semi-transparent appearance. " A fresh eruption of vesicles usually takes place on the second and third day; and as each set has a similar course the whole duration of the eruptive stage in this species of varicella is six days; the last formed scabs, therefore are not separated till the eleventh or twelfth day.* The third variety of varicella, or swine-pox, is characterised by large globose vesicles, with irregularly circumscribed bases, and in- flamed margins. The transparent serum with which they are dis- tended, assumes a whey-like color on the second day after their appearance, and on the succeeding day they begin to shrivel, and some of them contain a purulent fluid. (Bateman.) Varicella may be communicated by inoculation; and it is alleged by Heim, that they are even more communicable than regular small- pox.t Reil states, that small-pox is generally much milder when it occurs after varicella, than where this disease has not been gone through, more especially if the varicellous affection has been se- vere.:}: Varicella, like small-pox, rarely occurs more than once in the same individual. It is never attended with secondary fever, * Bateman, Practical Synopsis of Cutaneous Diseases. f Heim, in Horn's Archiv. fur Medicinische Erfuhrung, bd. vii. heft. 2, Jahrg. 1809. X Ueber die Erkenntniss und cur der Fieber. bd. 5. s. 386. MEASLES. 467 but the scabs, on falling off, not unfrequently leave depressions in the skin. The pits, or cicatrices, left by the varicellous eruption, differ considerably from those which are produced by small-pox; and Heim, who regarded these two affections as essentially distinct from each other, has adduced this circumstance among others in support of his views. The pits of varicella, he asserts, are whiter than the rest of the skin, and quite smooth or even; whilst those left by variolous pustules are the color ofthe surrounding skin, and uneven like the surface of an orange. The margin of the varicel- lous pit is smooth and rounded; in the pits left by small-pox it is generally somewhat indented or angulated. Hairs never grow in the disks ofthe former, in those ofthe latter they do. With regard to the remediate management of varioloid affections, it is only necessary to observe, that where the disease is so severe as to demand any medical attention, the treatment is to be conducted on the same plan that has been mentioned as proper in the milder varieties of small-pox. Varicella, however, very seldom requires any medicinal applications. Gentle aperients, and a mild antiphlo- gistic diet, is commonly all that is necessary. Sect. IV.—Rubeola, morbilli.—Measles. By the American, English, and French physicians, the terms rubeola and morbilli are applied to the same disease—measles. The German writers, on the contrary, universally designate two distinct diseases by these terms—applying the latter only to the present affection, whilst the term rubeola is used by them to desig- nate a different, though somewhat similar disease (rothlen,) de- scribed by Willan, under the name of roseola. Measles, like small-pox, seldom occur more than once in the same individual; and it would seem that a second attack of the former is even less frequent than ofthe latter malady.* I have met with one unequivocal instance only of this kind. Home mentions a singular instance, where an attack of measles was followed by enlargement of some of the lymphatic glands. After a lapse of about six months, the glandular swellings subsided, and the patient became a second time affected with measles.t It does not appear, however, that the morbillious contagion possesses the same degree of activity as that of small-pox. .Many individuals never become affected with the disease, however frequently they may be exposed to its contagion; and it is by no means uncommon to find in the same family some affected by it, whilst others will es- cape infection, though constantly exposed to its miasm. Measles rarely occur sporadically. When they appear, many * See Dr. Baillie's paper, in the transactions of a Society for the Improve- ment of Medical and Clururgical Knowledge, vol. iii. X Medical Facts and Experiments. Richter, Specielle Therapie. 468 MEASLES. individuals usually become affected with them at the same time; and the progress of the disease can never be traced from house to house, or from street to street, as we may frequently do with small- pox or scarlatina. This, among other facts, has been adduced in evidence that the disease is not propagated by contagion; but the fact of its being communicable by inoculation, may be deemed suf- ficient to settle the point of its contagious character. Dr. Home succeeded in communicating the disease in this way in a number of instances; and more recent experience has fully demonstrated the practicability of morbillious inoculation.* In its general course and phenomena, this, like other epidemic diseases, is subject to prominent modifications; and systematic wri- ters have, in consequence, divided it into several varieties, according to the regularity or irregularity of its symptoms, the nature of the attending fever, and the character and violence ofthe local affections. It is evident, too, that this disease is much under the influence of atmospheric constitutions; for at one period it will be marked by symptoms so slight as scarcely to require any medical attention; at another, it will appear under a highly aggravated form; in a third period we may find it to occur under every grade of violence, from the simplest to the most malignant grades; and in a fourth, " it will hold a middle course between the mildest and most dangerous forms of the malady." (Armstrong.) Upon the whole, however, the regular and moderate cases are incomparably more frequent than the instances of a violent or malignant character. In general, measles are apt to be more regular and mild during the warm and equable, than the cold and variable seasons; and con- stitutional habit or idios)'ncrasy appears to have a very decided in- fluence in modifying its character. It is from this latter circum- stance that we sometimes meet with measles in all its grades of vio- lence in children of the same family—several very remarkable instances of which have come under my observation. It would seem, from the observations of some, that the morbil- lious fever sometimes occurs without any exanthematous affection.t Fevers, accompanied with the usual catarrhal symptoms of this dis- * Vogel, Percival, Brown, Monro, and Tissot, recommended inoculation for measles; and Home and Horst practised it with success. More recently, Pro- fessor Sparanza, in an epidemic which prevailed in the territory of Mantua, em- ployed inoculation foT measles with decided advantage. Six boys in the House of Industry, and afterwards he himself, were inoculated. In all, a mild and re- gular morbillious affection was the result. The experiment was afterwards re. peated by himself and others with equal success. " A slight cut was made into one ofthe most vivid ofthe large blotches with a lancet, the point of which was covered with the blood effused. With this, small incised punctures were made on the arm, and a proper bandage applied." Edinb. Med. and Surg. Journ. 1826. See also, Bibliotheca Italiana, Agosto, 1825. X Morton mentions a morbillious fever which was wholly unaccompanied by MEASLES. 469 ease, though without the measly eruption, are by no means uncom- mon during the prevalence of epidemic measles; and Richter ob- serves, that persons who have been thus affected, generally after- wards escape the morbillious disease during the subsequent progress ofthe epidemic. Spmptoms.—The period of incubation, or the time which inter- venes between the first impression of the contagion of measles, and the actual commencement of the disease, varies from a few days to two and even three weeks. In general, however, from five to seven da3^s, may be regarded as the latent period ofthe infection. In the patients which were inoculated by Home, the eruptive fever gene- rally commenced about the seventh day after the insertion ofthe contagion. The initial phenomena of morbillious fever do not differ from those which usually attend the beginning of catarrhal fever. A slight ten- derness and redness of the eyes, with an increased flow of tears, sneezing, cough, and a watery discharge from the nostrils, together with slight creeping chills, and transient flushes of heat, are generally among the first symptoms of the disease. In some instances, the affection of the eyes and mucous membrane of the nose and respira- tory passages does not supervene until about the second or third day ofthe fever. In all cases, however, prominent catarrhal symptoms sooner or later occur, and may be considered as among the specific phenomena of the disease. The cough is at first dry and harsh, and is attended with oppressed breathing, and some degree of soreness in the fauces. Some of the lymphatic glands along the neck and margins of the eyelids often become swollen and tender. About the third day, and occasionally earlier, considerable nausea and vo- miting is apt to occur; and where the febrile symptoms run high, slight delirium sometimes takes place on the evening of this day. In cases of a violent character, more or less coma sometimes pre- cedes for a few hours the appearance of the eruption; and in small children convulsions are by no means uncommon at this period. The fever is generally decidedly synochal; the pulse, in the ordinary forms of the disease, being frequent, hard, and quick, and the skin dry and very hot. Generally between the third and fifth days, the eruption makes its appearance in the form of small red spots, appa- rently papular, first on the forehead, chin, nose, and cheeks, and then successively on the neck, breast, body, and extremities. These red spots, which resemble flea-bites, soon enlarge; and as their num- ber increases, they run into each other, and form larger patches of an irregular or semi-lunar shape,* leaving intermediate spaces in an exantheme; and De Haen asserts, that cases of this kind frequently occur during epidemic measles.(a) * Bateman observes, " that this character of the blotches of the measly erup- (o) Febr. divis. vs. «. 6. See ReiVa Fieberkhre, b. r.p. 216. Vol. I.—40 470 MEASLES. which the skin retains its natural color. During the first day of the eruption, we may often notice a small vesicle in the centre of some of the measles. (Cazenave.) During the second day after its appearance, the eruption in the face is at its highest state of development. On the following day it begins to fade and subside, whilst on the rest of the body it is still vividly red. On the face, the eruption may be felt slightly elevated above the surface of the skin; but on the other parts, the red patches do not appear to be sensibly raised. In severe cases, the whole face becomes considerably swollen; and in some instances the tumefac- tion is so great, as almost to close the eyelids. The fading and sub- sidence ofthe eruption proceeds over the body in the same progres- sive manner that it made its appearance, so that by the eighth day from the commencement of the fever, it begins to disappear on the back of the hands where it is wont to remain longest. About the ninth day, the eruption presents a faint yellowish appearance, and desquamation commences on the face, which by the tenth or ele- venth day is completed over the whole body. The morbillious eruption is not confined to the surface of the body. It appears in red spots on the gums; over the mucous membrane of the mouth; upon the tonsils and uvula; and, according to Frank, on the tongue. Leutaud saw the measly exantheme in the oesophagus, and upon the mucous membrane of the trachea, and even upon the surface of the abdominal and thoracic viscera.* The fever does not remit on the appearance of the eruption; on the contrary, both the febrile and catarrhal symptoms usually be- come sensibly increased when the rash comes out. As soon, how- ever, as the eruption begins to fade, an evident amendment in all the symptoms usually takes place; and in most instances, the fever dis- appears entirely by the time the rash has desquamated. Occasion- ally, indeed, the fever and cough continue, and even become worse after the complete disappearance of the measly exantheme. The coma, Dr. Heberden observes, sometimes returns in violent cases, after the rash has gone off. About the time the eruption begins to decline, more or less diar- rhoea is apt to snpervene, which, if not violent, almost always miti- gates the general and local symptoms. Sometimes copious diar- rhoea takes place just before the rash is about making its appearance. This is to be regarded as an unfavorable occurrence, since it tends to interfere with the regular progress of the eruption, or to cause it to retrocede. Authors generally state that the eruption of measles makes its ap- pearance about the fourth day; and in the majority of instances this tion, (their tendency to assume the irregular crescent shape,) was first noticed by Willan, and is important; for, although entirely overlooked by ordinary observers, it is commonly very manifest, and therefore a valuable diagnostic." ^ * Precis, de Medec. p. 604. MEASLES. 471 will be the case. It is of some importance, however, to bear in mind, that even in cases which go on regularly, the rash often comes out much earlier, and occasionally also later than the period just mentioned. Dr. Armstrong observes, " that the rash does not uni- formly nor generally appear on the fourth day from the first deve- lopment of the reaction. " I have seen," he says, "the eruption come out at all times, between the first and seventh days, though perhaps, the most common period is between the third and fourth day after the occurrence of reaction." Such are the ordinary course and phenomena of measles. In its general character, as well as in the particular phenomena, it is sub- ject, however, to various irregularities and modifications, which often demand especial attention in the treatment ofthe disease. Through- out the whole course of measles there is generally a considerable tendency to inflammation, particularly of the eyes, and the respira- tory organs. Armstrong divides the disease into three varieties or modifications, the simple, inflammatory, and congestive, and to these we may add the typhous and the gastric modifications. 1. The inflammatory variety* is characterised by a high grade of synochal fever; the pulse is vigorous, hard, and frequent; the skin dry and very hot; the cough violent, painful, harsh and dry; the cephalgia severe, attended frequently with considerable deli- rium during the night; the eyes very red; and the respiration much oppressed and often painful. Pleuritis; peripneumonia with bloody expectoration; cynanche trachealis; bronchitis; cerebral inflamma- tion; or gastro-enteritis, are particularly apt to supervene in this modification of the disease. The rash commonly appears early, and is generally vividly red. 2. The congestive modification of the disease, is characterised by the usual phenomena of an internal congestive state of the sys- tem. The reaction takes place slowly and imperfectly, and in some instances remains entirely oppressed. The face is pale, the pulse feeble and laboring, the bowels torpid, the breathing oppress- ed and slow, and the vital energies generally much depressed. If the internal congestions are not removed, coma or stupor, and in many instances, convulsions ensue. The eruption does not make its appearance, or it comes out slowly and imperfectly on some parts of the body. The extremities are cold, and the features sunk and anxious. This form of the disease is most apt to occur in young children, and in persons of a feeble and delicate habit of body. Dr. Armstrong has seen two instances of this kind, in which the patients died comatose and convulsed. In both cases he found the lungs greatly engorged on post mortem examination. 3. The typhous, or, as it has been called, malignant variety of * Strictly speaking, every case of measles is inflammatory; but the general and local phlogistic phenomena often predominate to such a degree, that such cases may with propriety be distinguished by the term inflammatory. 472 MEASLES. measles, is attended with the ordinary characteristic symptoms of a typhous state of the system. The heat of the skin is burning or acrid, (calor mordax;) petechias appear on those parts of the skin not occupied by the measly rash; colliquative haemorrhages, diar- rhoea, and profuse sweats, are apt to occur; the vital energies are greatly depressed; the pulse generally weak and frequent, and some- times nearly natural. This variety of the disease is always fright- fully malignant and fatal. Fortunately, however, its occurrence is not common, although authors have described several epidemics of this kind. Sir William Watson has given an account of a putrid morbillious epidemic; but as he appears to have considered measles and scarlatina, modifications ofthe same disease, it may be doubted whether the affection he describes was the former or the latter ma- lady. Nevertheless, the description he gives of the particular phe- nomena of the disease, answers much more unequivocally to measles than to scarlet fever.* 4. The gastric modification of measles, derives its distinguishing phenomena from gastro-intestinal irritation, which in some instances modifies the general character of the disease very prominently. In cases of this kind, the febrile symptoms are not very conspicuous; the pulse is small, weak, and unusually frequent; the cough is short, almost constant, and distressing. Violent vomiting and purging sometimes occur before, and immediately after the appearance of the eruption. The tongue is brown; the pain in the forehead severe; the measly rash pale and often indistinct; and a sense of tension and fulness is often felt in the epigastrium, or short cutting pains in the bowels. In some instances, great difficulty of breathing, and a sense of pectoral oppression, suddenly comes on, particularly in young and irritable children. Sometimes the patient is extremely restless, with much jactitation, an anxious expression ofthe countenance, and dysp- noea, particularly on assuming the erect position. (Dr. Armstrong.) Several German writerst describe a variety of morbillious disease under the name offalse measles, which corresponds with the ru- beola sine catarrho of Willan, and the rubeola sinefebre of others. This modification of rubeola is characterised by a regular measly rash, without either catarrh, ophthalmia, or fever. It does not protect the system against a subsequent attack of febrile measles. " An interval of many months, even/two years, has been observed, between this variety and the subsequent febrile rubeola; but the latter more fre- quently takes place about three or four days after the non-febrile eruption." (Bateman.) Sequelae.—It has already been observed above, that the tendency to local inflammations is always very considerable in measles, and this tendency is generally particularly conspicuous during the periods * Watson.—Medical Observations and Inquiries, vol. iv. p. 132. f Vogel, Handbuch, Bd. 3, p. 203. Metzger, Vermischte Schriften. Bd. 2, p. 167. MEASLES. 473 of desquamation and convalescence. There are few, if any diseases, which leave the system so susceptible to the injurious influence of cold as measles; and it is, perhaps, chiefly from this circumstance, that inflammatory and other affections are so frequent during conva- lescence from this disease. It is indeed a common observation, that the affections which are apt to supervene on an attack of measles, are more to be dreaded than the disease itself—and in reference to the ordinary or regular form of the disease, the remark is generally correct. The affections most apt to occur after measles, or during the period of desquamation, are pneumonia, croup, rheumatism, chronic ophthalmia, otitis, arachnitis, and bronchitis. In phthisical habits, an attack of measles often develops the tubercular action rapidly. It would seem that the morbillious affection has an especial tendency to develop lymphatic diseases, and to rouse into action the strumous habit. Porriginous eruptions about the head, serous ulcerations be- hind the ears, scrofulous ophthalmia, strumous swellings about the neck, and other scrofulous disorders, are frequent sequelae of the disease. Sometimes induration of the mesenteric glands, and maras- mus, ensue. Herpes, anasarcous swellings, discharges from the ears, and boils on different parts ofthe body, are among the occasional con- sequences of this disease. Diagnosis.—From the earliest records we have of this disease, down to the time of Withering, (1793,) measles were generally con- founded with scarlet fever.* The diagnosis between these two affections, is indeed sometimes attended with considerable difficulty; yet the catarrhal symptoms, and the character of the morbillious eruption, will always enable an experienced observer to distinguish rubeola from scarlatina. The small vividly red spots, like flea-bites, their union into irregular semi-lunar patches, and the natural color, of the intermediate skin, distinguishes the measly rash from the large, irregular, more uniform, and raspberry-colored efflorescence of scarlatina. In the former disease, the rash generally consists of small red spots running into each other, with the central points more vivid than the coalescing margin, so as to give a maculated appearance to the skin. In the latter disease, the redness is more diffused and uniform, consisting of an infinite number of very mi- nute red points united together, resembling much the redness of a boiled lobster. These two affections differ from each other also in their general course or progress. The rash of measles generally comes out about the fourth day from the commencement of the fever. In scarlatina the eruption usually comes out on the second, and not unfrequently on the first day. The coryza, sneezing, hoarse, and * Bateman says, that " the publication of Dr. Withering's Essay on Scarlet Fever—or rather the second edition of that work in 1793, may be considered, perhaps, as the date of the correct diagnosis of this disease."—Synopsis, p. 66. 40* 474 MEASLES. dry cough, inflamed and watery eyes, so rarely absent in measles, can seldom fail to establish a certain diagnosis. Prognosis.—Measles is not, in general, a very dangerous disease, It is only from becoming complicated with internal inflammation, or from having its regular progress interrupted by some accidental cause, that the disease is apt to assume a very dangerous character. However violent the proper morbillious symptoms may be, pro- vided the disease goes on regularly in its course, the danger is not often very great. According to the estimate of Percival, about one out of fifty cases of rubeola terminates fatally; and of this propor- tion one half are in subjects under two years old. Epidemics of this disease, ofthe most fatal character, have indeed been noticed.* Violent internal congestions, so as to prevent the development of febrile reaction, the sudden retrocession of the rash, soon after its appearance, from violent purging, the application of cold, or sponta- neously or from whatever cause, always greatly increases the dan- ger. The occurrence of internal inflammation, particularly of the lungs, brain, or trachea, is a very alarming accident. Great diffi- culty of breathing, with a wheezing sound in the trachea, though not depending on inflammation, is attended with much danger in infants. Colliquative haemorrhages, petechiae, and great muscular prostration, are among the most unfavorable signs. Women in the latter period of pregnancy, or in the puerperal state, are exposed to great risk from an attack of this disease. In general nervous, delicate, and debilitated subjects are more apt to sink under this disease, than persons of healthy and vigorous constitutions. Treatment.—In relation to the treatment of this disease, the practitioner will do well to bear in mind an important truth con- tained in the following observation of Dr. Armstrong. " From an impartial consideration of the facts which have come before me," says this writer, "1 am convinced that our plan of treating measles (in its regular form) is too uniformly active when the eruptive fever is developed; and that we should be more fortunate in the main, if we interfered less with tbe operations of nature in cases of a mild and regular character." Of the importance of this observation I am thoroughly persuaded, both from my own experience and from what I have had occasion to witness in the practice of others. Even where the general febrile excitement is considerable during the eruptive fever, an active antiphlogistic or depletory treatment is not only generally unnecessary, but sometimes decidedly injurious, pro- vided no local inflammations be present. We must view the erup- tion in this, as in other exanthematous affections, as a sort of critical or metastastic deposition on the surface by which the animal economy * It is from the great fatality of such epidemics, that this disease obtained the name morbillus, or little plague. Were these epidemics measles? Both small-pox and scarlatina were formerly confounded with measles. MEASLES. 475 endeavors to relieve itself from some internal morbific irritation. The appearance ofthe rash is essential to the perfect and safe resolu- tion ofthe disease, and whatever greatly interferes with the regular progress of the precursory fever, has a tendency also to interrupt the regular appearance and character of the eruption. When, there- fore, the eruptive fever is regular, not very violent, and unattended with internal inflammations or congestions, the remediate treatment should be gentle. In general, all that is required in such cases, is to keep the bowels open by mild laxatives, and to allow the patient the free use of tepid diluent drinks; and in instances attended with a very moderate degree of febrile reaction, some of the mildly stimulating diaphoretic ptisans, such as infusions of sage, elder blossoms, marjo- ram, balm, or eupatorium, should be ordered. In cases attended with a high grade of fever, moderate abstractions of blood are, with- out doubt, proper, and ought certainly not to be neglected. The re- frigerant diaphoretics, also, are decidedly indicated, and often suf- fice, without bleeding, to procure an adequate reduction of the gene- ral excitement. I have generally preferred the following mixture.* Small doses of antimonial wine, with sweet spirits of nitre, the saline effervescing draught, the ordinary nitrous powders, and par- ticularly the mixture mentioned at page 176, may be usefully em- ployed for this purpose. Although an active treatment is unnecessary, and often prejudi- cial in the regular form of measles, this is by no means the case when the disease becomes complicated with visceral inflammation, oppressive internal congestions, or other irregular and dangerous symptoms. When, after the initial stage of oppression, the febrile reaction does not take place, and the face remains pale and sunk, the pulse feeble, the breathing oppressed, with great prostration, and a torpid state of the sensorial powers, prompt and decisive measures must be adopted to remove the internal congestions, and to excite the reaction of the heart and arteries. If this be not ef- fected, the eruption will not come out, and the patient will sink into a state of fatal stupor or coma. The treatment already given as proper in the congestive form of typhus, must be actively employed in such cases. The warm bath, stimulating frictions of the skin, hot flannel, or bottles filled with hot water applied to the body and extremities, sinapisms to the epigastrium, together with the use of warm and gently stimulating drinks, are the principal means upon which our dependence is to be placed in instances of this kind. Dr. Armstrong recommends moderate bleeding; but although a great advocate of depletion in the congestive state of fevers, he * ]£.—Muriatis ammoniae ^iii. Pulv. extract, glycyrrh. gss. Tart, antimonii gr. i. Aq. fontanae gviii.—-M. Dose—a dessert-spoonful every two hours for a child between two and five years old. 476 MEASLES. thinks that in congestive measles the lancet should be used with particular caution. The observations I have made on this point, when speaking of the treatment of typhus, are equally applicable in this place. In several instances of congestive measles, I have em- ployed camphor suspended in a mucilaginous fluid, with obvious )enefit. I have also used the carbonate of ammonia, in the formula mentioned at page 194, with very good effect in a few instances of this kind. Both these stimulants are, however, more decidedly beneficial, where the rash, after it has come out, suddenly recedes, than in the congestive state which precedes the exantheme. If in cases of this kind great difficulty of breathing, with a short dry cough, an irregular distribution of the animal temperature—"some parts being cool or cold, whilst others are preternaturally warm," and a feeble and quick pulse, with a death-like paleness of the face, occurs, the danger is imminent, and unless prompt relief be obtain- ed, <•' the patient sinks rapidly under an apparent load of phlegm in the bronchia." (Armstrong.) Camphor especially is a valuable medicine where a retrocession of the eruption occurs. Armstrong speaks very favorably of a large dose of calomel, in union with camphor, the pulvis antimonialis, and a few drops of laudanum, in this congestive condition of the disease. When this accident is produced by excessive diarrhoea or vomiting, opium in union with camphor is the appropriate remedy. In conjunction with these remedies, blisters, sinapisms, stimulating frictions, the warm bath, or warmth applied to the surface in a dry way, may be deemed in- dispensable in such cases. It should be observed, however, that moderate diarrhoea, except in very feeble subjects, is rarely attended by any unfavorable effects; and in most instances procures consi- derable relief. In robust and plethoric subjects especially, a mode- rate looseness of the bowels should not be interfered with, unless symptoms of its injurious influence upon the regular appearance and course of the rash supervene. (Armstrong.) In cases complicated with visceral inflammation, a vigorous anti- phlogistic treatment is demanded. Whatever may be thought of the employment of bleeding in simple and regular cases, there can be no question as to the general propriety of resorting to this mea- sure promptly and actively when visceral inflammations supervene. General and local abstractions of blood; blisters applied over the region of the affected part; mild laxatives; antimony; and nauseat- ing doses, are the measures upon which our chief dependence must be placed. When bronchitis or peripneumonia supervenes, much ffood may often be derived from antimonial emetics, more es- pecially in very young children. Whatever organ, in short, may become the seat of the inflammation, it will be necessary to adopt such measures as are proper for the existing inflammation, indepen- dent of the morbillious affection, paying attention only to the grade or character of the accompanying fever. vUreral Measles, attended with pneumonic and other varieties of visceral MEASLES. 477 inflammation, have indeed occasionally occurred, in which bleeding is said to have been not only useless, but often unequivocally detri- mental. Ofthis kind was the very fatal epidemic which prevailed at Paris in 1828; which, though almost always complicated with inflammation of important organs—more especially with pneumonia, was found unmangeable by sanguineous evacuations.* In cases of this kind, opium and calomel would perhaps answer well. I say perhaps: for I have had no experience in instances of this danger- ous and typhoid character; yet, from the excellent effects which I have derived from this combination in pneumonia typhoides, I should without hesitation give it a trial in this modification of measles. Blisters, cupping, and the warm-bath, may be deemed in- dispensable in such cases. It is of great importance, in the remediate management of measles, to guard the patient against the influence of variable temperature. Neither a very cool, nor a warm and confined air, is proper in this disease. An equable temperature, which produces neither a feel- ing of much warmth nor chilliness, is the most suitable. When the eruptive fever is very moderate, and the patient of a feeble and irri- table habit, the temperature of the sick chamber should be such as to communicate a moderate sensation of warmth, and this is more especially proper in congestive cases. 1 have already adverted to the various disagreeable and danger- ous affections which are apt to ensue during convalescence from this disease, and to their frequent dependence on the injurious effects of cold during this period. To obviate such consequences from this source, the patient ought to remain within doors, and to avoid every other exposure to the influence of a cold and damp atmosphere. " Even in summer, convalescents should not be suffered to go out of doors except in the middle of fine days, and not without addi- tional apparel." (Armstrong.) The diet, during the declension of the disease and period of con- valescence, should be mild and unirritating, and all kinds of stimu- lating drinks be carefully avoided. If the skin is dry and the pulse remains irritated after the rash has disappeared, advantage may be obtained from some of the more gentle antiphlogistic diaphoretics, and it will often be proper to continue their use during convalescence. The spiritus mindereri, with a small portion of sweet spirits of nitre, and of vin. antimon. forms an excellent diaphoretic at this stage of the disease. Where the pectoral symptoms continue to be trouble- some during convalescence, the muriate of ammonia, with vine- gar of squills, and antimony, is one of our most useful remedies.t Tonics are almost always injurious during convalescence from * See Biett's Report in the Journal Hebdomadaire, No. xlii. X R.—Muriat. ammoni. giii. P. extract, glycyrrh. ^ss. Aq. fontanae ^vii. 478 SCARLET FEVER. measles. When the system is left exhausted and free from irrita- tion, mild nourishing diet, with a weak infusion of serpentaria, will usually answer to promote the return of vigor and health. I conclude what I have to say on this subject, by the following very interesting observations of Dr. Armstrong: « It is a remarka- ble fact," says this writer, " that when any cutaneous affections arise after measles, the internal organs generally remain free from disease; and even where some internal disorder has existed, I have not un- frequently seen it disappear on the occurrence of some spontaneous eruption of the skin. Indeed there are many cases of this nature already on record. At all times, we should, therefore, be most wary in meddling with vesicles, pustules, boils, and the like when they come out after the measles; for although they may be tempo- rary blemishes on the surface, they are often the occasion of saving the vital works within." Sect. V.—Scarlatina.—Scarlet Fever. Scarlet fever appears under every grade of violence, from the sim- plest and least dangerous to the most severe and malignant forms of disease. Fever—a peculiar exantheme and inflammation in the fauces, terminating rapidly, in some instances, in ulceration and sloughing, constitute the essential phenomena of the disease. In relation to the particular character and violence of these morbid con- ditions, authors have divided the disease into three varieties, namely, s. simplex, s. anginosa, and s. maligna. Symptoms of s. simplex.—After an indefinite period, varying from one to three or four days, of the ordinary premonitory symp- toms of febrile diseases, the patient is seized with slight chills, alter- nating with transient flushes of heat, depression, nausea, pains in the loins, lower extremities, and head, a hot and dry skin, and a frequent and quick pulse. Generally within the first forty-eight hours after the commencement of the fever, a scarlet eruption comes out, first on the face, and then successively on the neck, trunk, and extremi- ties, spreading finally over the surface of the mouth, fauces, and nos- trils, and may even in some cases be seen on the albuginea. This rash consists of innumerable red points, which running into each other, give a diffused blush to the skin, resembling much the shell of a boiled lobster. (Armstrong.) In some cases, the scarlet efflores- cence is uniformly diffused over the whole surface of the body; in others, it appears only in large irregular blotches, leaving the inter- mediate portions of skin of the natural color. The miliary glands and papillae of the skin are usually somewhat enlarged, giving a slight roughness to the surface, more especially on the breast and Acid, scillae §ss. Vin. antimon. gi.—M. S. Dose—a tablespoonful every four hours for an adult. SCARLET FEVER. 479 extremities. When the skin is pressed with the point of a finger, the redness disappears for a moment, leaving a transient white spot. With the commencement of the fever, or soon after its accession, a slight soreness of the fauces, attended with some difficulty of swal- lowing occurs, and the voice, usually, becomes thick and less sono- rous. In most instances the face becomes slightly swelled; the tongue is covered with a thick white fur, through which the enlarged papillae exhibit their scarlet points, and its edges and extremities are generally red; the skin is very hot; and the pulse frequent, quick, and sometimes tense and vigorous. There is seldom much thirst, and the appetite is always much depressed. Considerable restless- ness, and occasionally slight delirium, occurs durmg the evening exacerbations, both of which symptoms, however, generally disap- pear on the approach of morning. On the fourth day, the eruption and fever are generally at their complete state of development, and on the fifth day both usually begin to decline, and continue to diminish, pari passu, until they have gone off entirely; about the end of the seventh day. On the following day, the skin begins to desquamate. When the eruption is about disappearing, the tenderness of the fauces abates; the perspi- ration is free; the urine deposits a copious reddish sediment; and in some cases diarrhoea takes place. Desquamation is usually attended with considerable itching, and frequently leaves a slight tenderness of the skin over the whole body. Occasionally a considerable abate- ment in the febrile symptoms takes place as soon as the eruption makes its appearance. In some instances, indeed, the fever is from beginning to end so slight as scarcely to attract notice; but on the other hand, cases occur in which the general arterial excitement is very strong. The disease sometimes commences and proceeds for a day very mildly, and then suddenly assumes all the violence cha- racteristic of the anginose variety.* S. Anginosa.—In this form of the disease, the fever and the angi- nose affection are much more violent than in the former variety. The forming stage of s. anginosa is almost always attended with * In reference to cases of this kind, Dr. Armstrong makes the following ob- servations. " Simple excitement, may readily produce inflammation, and in fact is the most frequent cause of it; for if there be a latent weakness in any organ, the simple excitement, if not timely moderated, is sure to give rise to inflamma- tion there. It is on this account, that many diseases merely marked by simple excitement at the beginning, are complicated with inflammation in their progress; and hence it is, that apparently benign seizures of scarlatina may eventually be- come the causes and concomitants of serious affections of some of the viscera. It is, indeed, only in subjects of the soundest constitutions that we ever see simple excitement uncombinedly exist throughout the disease; and the reason why it so frequently occasions inflammation is, that some tissue or other had been secretly in fault before its occurrence.—On Measles, Scarlatina, fyc. p. 157. 480 SCARLET FEVER. considerable headach, praecordial oppression, nausea, sometimes vo- miting, and general muscular prostration. The fever is accompa- nied, from its commencement, with a feeling of stiffness and dull pain in the muscles of the neck and under the ears and angles of the jaw. Frequently, indeed, these local symptoms precede the occur- rence ofthe fever; and on examining the fauces, the palate, tonsils and uvula present a red and slightly tumid appearance. The voice soon becomes hoarse, deglutition painful and difficult, and respira- tion is attended with a disagreeable sense of constriction in the throat. The febrile symptoms rise rapidly to their acme; the pulse acquires great frequency and quickness, but it is rarely either so vigorous, tense, and full, as in the simple variety ofthe disease. The thirst is generally urgent, and the heat of the skin more intense than in any other febrile affection. Currie and Willan have found the temperature of the surface as high as 108 and even 112 degrees of Fahrenheit's thermometer. The tongue soon becomes dry, and very florid, along the edges, with the inflamed papillae projecting from its surface. Considerable uneasiness or pain is felt in the head, and much restlessness, languor, and prostration prevail throughout the whole course of the disease. The eruption does not generally come out as early in this, as in the simple variety. It usually makes its appearance on the third day ofthe fever, and is seldom diffused over the whole surface, com- ing out in irregular and not very large patches on different parts of the body, particularly about the elbows. In some instances, the efflorescence disappears the day after it has come out, and " reap- pears partially at uncertain times, but without any corresponding changes in the general disorder; and the whole duration ofthe com- plaint is thus lengthened, and the desquamation is less regular." (Bateman.) When the fever declines as early as the fourth or fifth day, the tonsils and palate seldom become ulcerated, the swelling and inflam- mation in the fauces passing off with the fever and the eruption without ulceration; but, when the fever is protracted beyond this period, or when it is violent during the first three or four days, small ulcers form about these parts, which are rapidly converted into ash- colored superficial sloughs. There is always a considerable quan- tity of ,viscid mucus secreted in the fauces, which often concretes into white flakes upon the inflamed parts, and presents the appear- ance of ulcers where in reality none exist. The parts should, therefore, be carefully examined before an opinion is expressed as to the existence of ulcers. (Armstrong.) As the fever declines, the sloughs in the throat begin to separate, and leave red ulcerated sur- faces, which generally cicatrise without difficulty. Sometimes, how- ever, instead of separating about the eighth day, the sloughs enlarge, become brown, and discharge an acrid sanious fluid; and in such cases the glands about the neck are generally swollen, hard, and painful; and the patient is harassed with painful diarrhoea and tenesmus. The SCARLET FEVER. 481 inflammation occasionally extends into the trachea, and the patient dies under symptoms of acute bronchitis. The brain often becomes prominently affected during the eruptive stage, giving rise to deep and fatal coma. Abdominal inflammations may likewise supervene. "At first there are only slight pain and soreness in some part ofthe abdomen, with a quickened pulse and hurried respiration; but the pain and soreness gradually increase, and at length are attended with vomiting, eructation, fulness of the belly, and general restlessness. In six, seven, or eight days, the abdominal soreness and pain abate or disappear, while the pulse grows rapid and feeble, the breathing more anxious, and the vomiting more urgent. Cold clammy sweats, and an universal collapse, now speedily supervene, and are the im- mediate precursors of death." (Armstrong.) S. Maligna.—Although this form of the disease usually com- mences like the preceding variety, it soon betrays its violent and dangerous character. The eruption comes out at uncertain periods from the second to the fourth day; and is usually pale when it first makes its appearance, acquiring, in most instances, a dark or livid hue in the progress of the disease. It is also very irregular in its duration, and often suddenly disappears soon after it has come out, and reappears on some parts of the body two or three days after- wards. The temperature of the skin is variable, and not generally very intense; and the pulse, though in the commencement active, becomes small and feeble in the course of the second day. Delirium generally occurs at an early period, and often continues with occa- sional intermissions, and exacerbations, throughout the subsequent course of the disease. In nearly all cases the sensorial functions suffer very considerable disturbance; and, in aggravated instances, the eyes are dull and inflamed, and the cheeks suffused with a livid flush. The tongue is dry, and covered with a brown or dark fur; the breath fetid. On examining the fauces, gray-colored sloughs are seen on the soft palate and tonsils, which soon acquire a brown, and at last a dark color. The disease, however, sometimes terminates fatally under symptoms of cerebral oppression, before the ulcers in the throat become extensive, or acquire a very bad appearance. " In general," says Dr. Armstrong, " it is only when the fever is protracted beyond the fourth day that the ulcers are converted into ill-conditioned, black, and fetid sloughs." There is generally a large quantity of very viscid mucus secreted and lodged in the fauces, giving rise to difficulty of respiration and a rattling noise in the throat. When the sloughs are foul and extensive, a thin acrid fluid is usually discharged from the nose, occasioning irritation and exco- riation ofthe parts with which it comes in contact. In cases of a particularly violent character, collapse supervenes towards the mid- dle or end of the second week of the disease. When this occurs, the heat of the surface sinks; the pulse becomes very frequent and feeble, the tongue dark, brown, or black, the animal powers greatly prostrated; painful diarrhoea often ensues, and in some instances Vol. I.—41 482 SCARLET FEVER. petechia? and haemorrhages from various parts occur towards the fatal termination of the disease. The fever and ulcerous affection of the throat frequently exist without an eruption at any period of the disease. Death sometimes takes place as early as the second or third day, and Bateman observes, that occasionally the symptoms continue to be moderate until an advanced period, when they suddenly as- sume a malignant and rapidly fatal character. Dr. Armstrong has described three modifications of malignant scarlet fever—namely, the inflammatory, the congestive, and the mixed; the latter being attended, he says, at once with much inter- nal congestion, and a moderate reaction of the heart and arteries. The first of these modifications (inflammatory) corresponds with the putrid variety of Richter.* It commences with violent fever; the pulse is full, strong, and hard; the heat of the surface intense; delirium occurs early; in short, all the symptoms indicate a high grade of inflammatory excitement. The eruption comes out early, and is at first vividly red, assuming a darker or purple hue as the disease advances. In its commencement, and for a day or two, it resembles s. anginosa, differing from this variety in the early su- pervention of a typhus state or collapse, and in the affection of the throat assuming, in a few days, the gangrenous condition mentioned above. At an early period of the disease the animal powers sink; the pulse becomes small, feeble and frequent; the heat of the sur- face acrid and burning; the rash purplish, colliquative diarrhoea and haemorrhages, and occasionally petechiae, or a miliary eruption, ensue. The most characteristic circumstance of this modification, however, is the extremely violent degree of the anginose affection, and its decided and early tendency to terminate in extensive gan- grenous ulceration. It is this modification of the disease that was formerly commonly described under the name of putrid sore-throat. In the congestive modification, the reaction does not ensue. The patient becomes pale, faint, and oppressed; he complains of deep- seated pain and sense of weight in the head, attended with giddi- ness, nausea, much anxiety and oppression in the praecordia, and great muscular prostration. Respiration is quick, short, or slow and impeded, "and there is often a mixture of lividity and paleness in the face, and the eyes are usually dull, acquiring a fatuous or inebriated expression in the course of the disease. The mind, at first alarmed and confused, or dejected, soon becomes disordered with delirium; or an indifference to surrounding objects, and a stupor succeeds, under which patients frequently expire." The pulse is slow, irregular, and weak; at first the tongue is covered with a white fur, which becomes rough and brown in the progress of the disease. The bowels are torpid in the beginning, but towards the termination of the disease, diarrhoea almost always occurs in fatal cases. This modification of the complaint seldom runs a pro- * Specielle Therapie, bd. ii. p. 466; SCARLET FEVER. 483 tracted course, and frequently proves fatal as early as the second, third, or fourth day. Colliquative haemorrhages from the nose mouth, and bowels; petechiae and gangrenous spots, are by no means uncommon towards the fatal conclusion of the disease. In this mo- dification, the rash, from the commencement of its appearance, is pale or of a copperish hue, acquiring at last a purple aspect. The anginose affection is seldom very violent. Dr. Armstrong thinks that the affection of the throat is rarely the cause of death —its fatal tendency depending chiefly on the " venous congestions of the brain, liver, spleen, lungs, and of the vessels of the heart, giving rise to universal collapse and visceral disorganisation," and perhaps to a change in the constitution of the blood itself. Sequela.—Scarlatina, like measles, is frequently followed by va- rious troublesome and often dangerous disorders; amongst which, anasarca is by far the most common. There is, indeed, no acute disease which is so apt to be succeeded by dropsical effusions us scarlet fever; and this is especially the case with the anginose va- riety. These swellings seldom occur before the ninth or tenth day after the eruption has gone off, and continue usually two or three weeks. Bateman observes, that " when the anasarca becomes pretty general, a sudden effusion occasionally takes place into the cavity of the chest, or into the ventricles of the brain, occasioning the death of the patient in a few hours." In general, however, the dropsical effusions which occur after scarlatina, are not attended with much inconvenience or danger. The malignant and anginose varieties are sometimes followed by abscess ofthe tonsils, enlargement ofthe parotids, inflammation of the testicles, ophthalmia, deafness, and in- flammation of the mucous membrane of the alimentary canal, otitis, suppuration of the glands about the neck, chronic cough, excoria- tions about the nates, and bronchitis, or other slow suppurative in- flammations, with hectic fever and its consequences. It is observed by Dr. Armstrong and others, that the hair is very apt to come out on the abatement of scarlatina, and that it often never looks or grows well afterwards. Various nervous affections have also been known to occur as sequela of this disease:—such as hysteria, spasmo- dic asthma, chorea, epilepsy,* and neuralgic pains in the extremities. Strumous affections, chronic cutaneous eruptions, gutta serena, herpes, and rheumatic pains, are occasionally the consequence of the dis- ease. The more perfectly and obviously the cuticle desquamates, the less apt are secondary diseases to supervene during convalescence. Diagnosis.—The only diseases with which scarlatina is liable to be confounded, are measles and miliary fever; and in the simple and anginose varieties, the diagnosis is indeed sometimes attended with very considerable difficulty. There is not a single symptom which can be regarded as absolutely peculiar and characteristic of * Kreysig. Abhandlung uber das Scharlachfieber, &c. p. 59. See also Cappel. Abhand. von Scharlachsauschlage, p. 90. Reil. Fieberlehre. Bd. 5. p. 122. 484 SCARLET FEVER. scarlet fever. The eruption is sometimes wholly or nearly absent, is diffused or in blotches, and occasionally papular; and the angina varies from only a slight redness to much tumefaction, with or without ulceration and sloughing. Nevertheless, the following cir- cumstances will almost always enable us to distinguish scarlatina from measles. In the former the eruption generally comes out within the first forty-eight hours of the fever; whereas in measles the rash rarely appears until the third, and most commonly not un- til the fourth day. The eruption in scarlatina appears like a diffused erythematous blush of the skin, with innumerable points inter- mixed with small papulae, dispersed over the cuticle. The rash of measles, on the contrary, consists of small circular dots, like flea- bites, of a deeper red in the centre than at the circumference, so that, in running into each other, the skin presents a less uniform blush than in scarlatina. These red and slightly elevated dots gene- rally appear in clusters or patches, assuming an irregular crescent shape. "The crescent-like form of the patches of measles," says Bateman, " and the more diffuse and irregular shape of those of scarlatina, will be a material diagnostic guide." The color of the eruption of scarlatina usually resembles that of a boiled lobster shell. In measles it is generally of darker red, inclining slightly to brown. The most prominent diagnostic symptoms between these two affec- tions, however, are the catarrhal phenomena, which are almost in- variably very conspicuous in measles, whilst in scarlatina they are either altogether, absent, or extremely slight and partial. The in- flamed eyes, profuse discharge of tears, sneezing, coryza, strong, harsh, and hoarse cough, intolerance of light, and red and swollen edges of the eyelids, so seldom absent in measles, are but very rarely noticed in scarlet fever. In the malignant and anginose varieties of scarlatina, the ulceration and sloughs which appear in the fauces are sufficiently characteristic to distinguish this affection from measles. In some instances, simple scarlatina assumes so much the general appearance of miliary fever, that on slight examination it might be readily mistaken for this latter affection. They may be distin- guished by the miliary eruption being almost universally attended with considerable perspiration, which is not the case on the appear- ance ofthe efflorescence of scarlatina. The little points or miliary papillae of the rash of scarlet fever, rise out of a uniformly erythe- matous blush of the skin, whereas those of miliary fever appear to be seated on a sk*in possessing its natural color. The coming out of the miliary eruption is generally attended with great anxiety in the praecordia; and when it is about declining, a second eruption, similar to the first, sometimes comes out; and in some instances a third crop of papulae supervenes. Prognosis.—The prognosis in scarlatina must of course be ex- tremely various, since the disease assumes every grade from the mildest to the most fatal degrees of violence. In the simple variety, little or nothing in general need be apprehended for the safety of SCARLET FEVER. 485 the patient, unless dangerous secondary affections supervene during the declension or period of convalescence, from cold or other acci- dental causes. But the prognosis ought to be cautious, even in cases which appear at first under mild symptoms; for the disease will sometimes go on for a few days in a regular and simple form, and then, all at once, assume a highly dangerous grade of violence; and this is more especially apt to be the case when the epidemic gene- rally is of a severe character. The anginose variety of the disease can never be regarded as free from particular danger; and the ma- lignant variety is to be accounted among the most fatal maladies. It is generally, and perhaps justly, considered that the danger in scarlatina is to be estimated by the character and violence of the affection of the throat. Dr. Armstrong, however, seems to be of a different opinion; at least, the affection of the throat abstractedly considered, he thinks, is rarely the cause of death—a termination which he refers rather to violent internal venous congestions and visceral disorganisations, so common in the more violent grades of this disease. When the eruption is bright red, and uniformly dif- fused over the whole or the greater part of the body, the prognosis is better than when it is pale, or purple, or brownish, and appears only here and there in large patches. (Armstrong, Reil.) A vari- able eruption, being by turns red, pale, and brownish; appearing now principally in one part, and then in another; going off for a time, and again making its appearance, or finally suddenly, and at an early period, vanishing entirely, are unfavorable indications. A white streak passing down on both sides of the nose and encircling it below, is said to be a fatal symptom. (Reil.) If on a sudden a strong inclination to pass urine occurs, and a copious flow of crude watery urine takes place, the danger may be considered great. (Richter.) When the inflamed fauces are of a bright red color, considerably tumefied and attended with painful swallowing, the prognosis is better than when the inflamed parts are dark-red or livid, and without swelling and difficult deglutition. White sloughs in the fauces are more favorable than ash-gray or brown ones. The occurrence of gangrenous ulceration is of course of very alarming import. It is scarcely necessary to say that the grade and character of the attending fever has an important bearing on the prognosis. A mo- derately active state of the reaction is favorable; a typhus grade is the reverse; and when the fever is extremely violent at first, with much angina, there is great reason to apprehend early and danger- ous collapse. Violent internal venous congestions, by which the de- velopment of febrile reaction is prevented or much impeded, is al- ways indicative ofthe utmost danger. The supervention of visceral inflammation is no less alarming. These are generally soon followed by collapse, and if death does not take place early, great prostration ensues, with the fatal symptoms of coma, constant delirium, cold ex- tremities, and if to these are added petechiae, colliquative haemor- 41* 486 SCARLET FEVER. rhages, and involuntary evacuation of feces, a speedy dissolution may be predicted with certainty. In general, scarlatina is apt to be more mild in children than in adults, except when the former are suffering from painful dentition. The disease is said to be most dangerous when it occurs in persons between the ages of fifteen and twenty-five.* It is also attended with particular danger when it attacks pregnant women, and espe- cially in the puerperal state. In general, robust and healthy indi- viduals bear the disease much better than persons of a weak, lym- phatic and nervous temperament. A regular abatement of the heat and efflorescence of the skin, ac- companied with a lateritious sediment in the urine; a subsidence of the swelling, and of the frequency of the pulse; with separation of the sloughs and healthy granulation of the ulcers; and finally, de- squamation of the cuticle, are indicative of a favorable termination of the disease. Cause.—Scarlatina arises from a specific contagious miasm or principle, which like most other febrile contagions, appears to be much under the influence of certain occult atmospheric tempera- ments, as is manifest from its occasional epidemic prevalence, as well as from the various grades of violence and diversity of character which different epidemics have been known to assume. It agrees, moreover, with the contagion of small-pox and measles, in destroy- ing the susceptibility of the system to its subsequent morbific influ- ence; although exceptions to this rule have been noticed, the disease having in some instances, though extremely rarely, occurred a second time in the same individual. There has been much controversy in relation to this latter point. Withering and Willan assert that they never witnessed a second attack of the disease, and they deny the possibility of this occurrence; and Bateman observes, " that this fact is now fully ascertained." Cases of second attacks have neverthe- less been adduced by authorities equally respectable, and the reality of this occurrence, though rare, appears to me sufficiently esta- blished. Bicker,t Neuman,J Binns, and others, mention instances of this kind; and Richter observes, that cases of a second, nay even a third attack of scarlatina have been noticed.§ Some individuals are wholly insusceptible to the operation of this contagion, and never become affected with the disease, however, frequently they may be exposed to its cause. Accidental predisposition, age, and idiosyncrasy of constitution, have of course as great influence on the activity of this as of other contagions. The period which intervenes between the * Reil. loc. cit. vol. v. p. 138. X Beschreibung eines Scharlachfiebers.—Rotterdam, in 1778 and 1779, p. 162. X Aufsatzeand Beobachtungen fur Aertze, p. 284, as quoted by Reil. loc. cit. t. v. p. 136. § Specielle Therapie, bd. ii. p. 440. SCARLET FEVER. 487 first impressions of the contagion and the manifest commencement of the disease, varies from three to five or six days. It is asserted that the contagion emanating from an individual affected with the disease, is most active during the period of desquamation. (Caze- nave.) Although unequivocally depending on a peculiar contagion, yet "there is abundant evidence that fever attended with scarlet eruption, and possessing all the other characters of this disease, does occasionally arise from exposure to cold."* Scarlatina occurs at all seasons, but it has been observed that warm and damp weather, and the air of low and marshy districts, have a tendency to promote the dissemination as well as the vio- lence of the disease. It is also said, (Reil, Richter, Steiglitz,) that this disease is more apt to affect females than males; and general observation goes to show that nurslings and old persons are much less subject to the influence of its contagion than individuals during the intermediate ages. Some epidemics affect scarcely any but children; others seize almost exclusively on adolescence and adults. Reil says that he has seen malignant epidemic scarlatina which was almost entirely confined to persons between the ages of fifteen and twenty-five. The progress of epidemic scarlet fever is sometimes very irregular. The disease, though very violent and general, some- times suddenly abates so as almost to disappear, and after a while resumes its power and rages with still greater malignity. Occa- sionally the contagion appears to linger for several years in a cer- tain district, a few patients only becoming, from time to time, affect- ed with the disease. Treatment.—From what has been said of the various symptoms and characters which scarlatina may present, it is at once obvious, that the remediate management of the disease must be greatly modi- fied in the different varieties which it is wont to assume. In the simple form of the disease, nothing but the mildest antiphlogistic treatment is necessary. One or two gentle aperients, or enemata; a mild unirritating liquid diet; cool or tepid drinks, such as barley- water; toast-water, acidulated with lemon-juice, or muriatic acid, or lemonade; confinement in a moderate and equable temperature; with the use of slightly astringent and emollient gargles—such as sage- tea, with a small portion of alum, and sweetened with honey; or an infusion of green tea, is all that is, in general, necessary to resort to in cases of this kind. But even the simple form of the disease oc- curs, occasionally, under symptoms of very considerable febrile irritation, and may, by the continuance of the high excitement, as- sume the severer character of scarlatina anginosa. No regard should, therefore, be paid to the mere decision of its being a simple form of the disease; but where the general excitement runs high, it will be prudent to adopt a more active antiphlogistic treatment, and to regu- late it in such a manner as to restrain the phlogistic tendency with- * Gregory's Elements of the Theory and Practice of Physic, vol. i. p. 244. 488 SCARLET FEVER. out interfering too much with the regular, and we may presume, necessary excitement of the heart and arteries. Although it may be true, nay, most assuredly is true, that the "nimia diligentia medici," has done more harm in simple scarlatina than the disease itself, yet the intelligent and experienced practitioner has a safe and a sure guide in the grade of the existing symptoms, to direct him in the application of antiphlogistic measures. It is moreover to be observed, that in the onset of the disease, it is not always in our power to decide satisfactorily whether its sub- sequent course will be simple or complicated, or severe and danger- ous. However mild, therefore, the general character of the prevail- ing epidemic may be, it will be proper, whenever we are called to a case during the forming stage, attended with considerable lassitude and oppression, paleness of the face and skin, some headach and nausea, to commence the treatment as if the disease were about assuming an aggravated character. An emetic will under such cir- cumstances frequently do much good by removing internal venous congestions; and after its operation, a brisk mercurial purge may be given with advantage. In cases attended with considerable affec- tion of the head during the forming stage, Dr. Armstrong advises the use of the warm bath strongly impregnated with salt. " This practice," he says, "assisted by a brisk purgative, will in general give immediate relief, and contribute powerfully to moderate the subsequent reaction. When the subsequent febrile excitement be- comes strongly developed, it should be moderated by purgatives, tepid affusions, cooling drinks, rest, ventilation, and some of the milder diaphoretic remedies—such as spiritus mindereri, sweet spi- rits of nitre, or small doses of nitre and antimony.* In the anginose form of the disease, a much more energetic course of treatment is requisite. Almost all writers agree in recom- mending the use of emetics in the beginning of this, as well indeed as in the other varieties of scarlatina. The earlier they are resorted to, the more beneficial, in general, will be their effects; and it is particularly in the forming stage, or at the very onset of the febrile excitement, that they may be employed with decided usefulness.t When given at this early period, they frequently moderate the whole subsequent course of the disease, and in some instances almost completely break up the train of morbid actions. They have in- * Armstrong. Treatise on Scarlatina, Measles, &cs X Numerous authorities, of great weight, might be quoted in evidence ofthe good effects of emetics in this disease. They are recommended by Tissot, (Avis au Peuple;) Stoll, (Ratio Medend. torn. ii. p. 248;) Withering, (Account of Scarlet Fever and Sore Throat, &c. as it appeared at Birmingham in 1773, and London in 1799, p. 300;) Steiglitz, (Versuch einer pruning und verbesse- rung der yezt gewohnlichen behandlungsart des scharlachfiebers, p. 241;) Rich- ter, (Specielle Therapie, Bd. ii. p. 480;) Reil, (Fieberlehre, torn. v. p. 166;) Armstrong, (on Scarlet Fever, &c.;) Rush, (Medical Inquiries.) SCARLET FEVER. 489 deed been recommended throughout the whole course of the disease, (Withering,) but general experience goes to show that the com- mencement of the disease is the only proper period for their em- ployment. The good effects of an emetic in the beginning ofthe disease depend, probably, chiefly on the centrifugal direction which active vomiting communicates to the circulation, and thereby obvi- ating internal congestions and secondary inflammations; and per- haps, also, by weakening the morbid sympathies established by the cause of the disease. Purgatives have of late years been strongly recommended in this affection, and they are, without doubt, often highly useful, al- though there formerly existed much prejudice against their employ- ment. The utility of this-class of remedies in scarlatina, is particu- larly insisted on by Dr. Hamilton;* and all modern writers speak favorably of this practice. My own experience, though limited in this variety of the disease, has strongly impressed me with the utility of moderate purgation in this affection, and with the excep- tion of an antimonial emetic in the commencement, I have in most instances confined myself almost entirely to the employment of aperients, with cooling applications to the surface, an antiphlogistic regimen, and the local applications to be mentioned hereafter. The judicious employment of laxatives in the early periods ofthe dis- ease, is the most effectual measure for preventing the occurrence of colliquative diarrhoea in the latter stage—an occurrence which is always attended with danger. It is by no means necessary, or as a general rule, even proper, to use active purges. From three to four evacuations in the course of twenty-four hours are suffi- cient to procure all the advantages which purgatives can afford,t unless cerebral congestion exists, when active catharsis will be very proper.:): With regard to the employment of antimonials and the usual dia- phoretic antiphlogistics, experience does not furnish us with any satisfactory evidence of their usefulness. " In truth," says Dr. Bate- man, "the temperature is too high to admit of a diaphoresis; and the only safe and effectual method of producing this effect, consists in reducing the heat ofthe surface by the application of external cold. Richter, nevertheless, speaks favorably of the internal em- ployment of the muriate of ammonia, when the fever is strong, af- * Treatise on Purgatives. X Bateman, Gregory, Richter, Reil, Willan. Dr. Armstrong, however, recom- mends active purges in preference to the milder articles of this class, in the an- ginose variety of the disease. X Rhubarb and calomel; rhubarb and soda in equal parts; calomel with small portions of antimonial powder, (Willan;) calomel, followed by a small dose of magnesia; small portions of the sulphate of soda or magnesia; an occasional dose of two or three grains of calomel, with the daily use of a dose of castor oil, or the administration of laxative enemata, may be used for this purpose. 490 SCARLET FEVER. ter the bowels have been regularly evacuated.* It should be given in union with tart, antimon. in the way directed at page 127. If notwithstanding the use of purgatives, and the other remedies al- ready mentioned, the inflammatory condition increases, and the pa- tient becomes anxious and very restless, the use of diluted sulphuric acid, in large and frequent doses, is, according to the experience of Steiglitz, a valuable remedy. (Abhandl. fur Pract. Arzte. B. xxii. p. 307.) The application of cold water to the surface of the body, cannot be too strongly recommended in the higher grades of this affection. " We are possessed of no physical agent," says Bateman, " as far as my experience has taught me, (not excepting even the use of blood-letting in acute inflammation,) by which the functions of the animal economy are controlled with so much certainty, safety, and promptitude as by the application of cold water to the skin, under the augmented heat of scarlatina and of some other fevers. This expedient combines in itself all the medicinal properties which are indicated in this state of disease, and which we should scarcely a priori expect it to possess, for it is not only the most effectual fe- brifuge (the ' febrifugum magnum/ as a reverend author—Dr. Han- coke—long ago called it,) but it is in fact the only sudorific or ano- dyne which will not disappoint the expectation of the practitioner under these circumstances. I have had the satisfaction, in numerous instances, of witnessing the immediate improvement of the symp- toms, and the rapid change in the countenance of the patient, pro- duced by washing the skin. Invariably, in the course of a few minutes, the pulse has been diminished in frequency, the thirst abated, the tongue has become moist, a general free perspiration has broken forth, the skin has become soft and cool, and the eyes have brightened; and these indications of relief have been speedily fol- lowed by a calm and refreshing sleep." The only precaution that it is necessary to observe in the application of cold water to the sur- face in this and other febrile diseases, is to see that the skin is above the natural temperature, and dry, and that no feeling- of chilliness be present. When the arterial excitement is vehement, and the tem- perature of the surface intense, the water should be applied by pour- ing or dashing it over the body; but where this mode of using it is impracticable, or objected to on the part of the patient or his friends, we may obtain our object by washing or sponging the skin with cold water, or vinegar and water, and this should be repeated every hour or two, until the desired reduction of the heat and arterial excite- ment is effected. Dr. Armstrong observes, that as the disease ad- vances, instead of cold tepid affusions are to be used; and, as a general rule, he thinks it most prudent to resort to the latter after the third day of the stage of excitement. In this, however, we must be governed by the degree of arterial excitement, and of the heat of the surface present; for cold water may be safely and beneficially * Specielle Therapie, B. ii. p. 490. SCARLET FEVER. 491 applied at any period of the disease, provided the skin be very hot and dry.* (Dr. Stranger.) Purgatives and cold affusions may be employed conjointly. Armstrong, indeed, asserts that when thus used they do more good than when employed separately, more es- pecially during the first three days of the stage of excitement; and several instances have come under my own observation which strongly favor this opinion. Blisters may sometimes be benefi- cially used during the first two or three days of the stage of excite- ment. When the tonsils are much inflamed and swollen, so as to render swallowing difficult, the application of a blister to the throat will often afford considerable relief. This practice is particularly recommended by Willan, Heberden, and Rush. When the disease is complicated with visceral inflammation, little or no relief will be obtained from the application either of cold or tepid water to the surface; and Armstrong observes, that where these measures in conjunction with purgatives do not afford any ad- vantage, the practitioner may be sure that there is some latent in- flammation present. When this is the case, and collapse is not ap- proaching, recourse must be had to sinapisms, blisters, small general or topical abstractions of blood. Should there be manifestations of much vascular irritation, or of incipient inflammation of the brain— that is, should the face become flushed and turgid, with severe pul- sating pain in the head, more or less delirium, intolerance of light, and a disposition to somnolency, the patient must be kept in a cool situation, with his head elevated, and blood drawn according to the state ofthepulse,X an active purgative administered, warm fo- mentations, or sinapisms applied to the feet, and cold water to the head, and cups applied to the temples, or blisters to the back of the neck, provided always that collapse is not at hand. Unfortunately, however, the supervention of internal visceral inflammations in this affection is almost always speedily followed by collapse; and in this state sanguineous and other evacuations are entirely out ofthe ques- tion. Dr. Armstrong observes, that " in such examples the question is simply this—whether is there greater danger to be apprehended from the inflammation or from the depletion?" Visceral inflamma- tion, he says, almost invariably terminates fatally, but depletion pro- duces debility only, and debility is rarely the cause of death. He is, therefore, of opinion, that an attempt ought to be made to arrest the inflammation by depletion, even in the stage of collapse, where- ever it may be seated. It is true, that debility is perhaps rarely the cause of death; but it may be asked, why is visceral inflammation so * Willan on Cutaneous Diseases—note at page 360. X Armstrong; Marcus, (Specielle Therapie, torn. iii. p. 272;) Lorry, (Hist. de la Soc. Roy. de Med. t. ii.;) P. Frank, (de Curand. Homin. Morbis;) Rush, Burserius, (Institut. Med. Pract. vol. ii. p. 72;) Heim, (Horn's Archiv. fur Medic. Erfahr. fvol. iv. h. 1. p. 150.) Richter and other eminent authorities may be adduced in favor of prompt blood-letting in such cases. 492 SCARLET FEVER. fatal in such cases? The answer would seem to be:—because it is connected with universal debility; and the clear inference is, that whatever tends to augment this debility or prostration, must tend also to hasten its fatal termination. Before we adopt so desperate a practice, we should reflect that a small bleeding cannot materially influence or reduce the internal inflammation, and a large one must inevitably precipitate the patient into fatal prostration. Such cases are indeed exceedingly perplexing, for the remedies which are best, and almost alone calculated to remove the inflammation, are also the most certain to increase the prostration. When the brain is the seat ofthe inflammation, we may apply fomentations to. the feet, dry cups to the temples and shaven scalp, and exhibit active purgatives conjointly with carbonate of ammonia or camphor. In other visce- ral inflammations attended with collapse, I should be disposed to resort to calomel and opium, with dry cupping and large fomenting cataplasms over the region of the affected part. Blisters in such cases are almost as hazardous as bleeding. They produce much general irritation, and the blistered part often becomes gangrenous. Malignant scarlatina, though generally strongly phlogistic in its commencement, passes so rapidly into a low and typhus state, that formerly physicians placed almost their entire dependence in its treatment, on the active and early employment of bark, wine, and other stimulating and tonic remedies. " These remedies," says Armstrong, " so forcibly, so indiscriminately, and so fatally recom- mended by numerous authors, were once the means upon which, unfortunately, I relied for the cure of this modification of scarlet fever; and from repeated trials of them, I can truly affirm that they are the most pernicious in the first stage, and the most destructive in the second." However rapidly this form of the disease may pass into a low and malignant state, its onset is often characterised by highly inflammatory symptoms. The attack is vehement, and the febrile excitement at first tumultuous, tending rapidly to consume the vital energies; and in proportion to the violence of this excited, though transient stage, will be the tendency of the disease to assume a putrid character. It is therefore of the utmost importance to break down promptly, by energetic measures, the initial febrile commo- tion. I have already stated that the exhibition of an emetic, followed by a brisk purgative, in the chilly or forming stage, is often as bene- ficial in this as in the other modifications of the disease; and the treatment should always commence with these remedies, if we are called at a sufficiently early period. If, after the operation of these evacuants, the stage of excitement begins with violent symptoms— such as intense heat of the skin; severe headach; delirium; and a frequent, quick, and tense pulse; blood should be promptly and effi- ciently abstracted. (Burserius, Lorry, Armstrong.) As this stage is generally but short, it is of great importance to draw blood at once in its onset, to the extent of producing a very decided impres- sion on the system; or, as Armstrong advises, until syncope ap- SCARLET FEVER. 493 proaches. By one such bleeding, and the brisk operation of a pur- gative, the violence of the disease is often broken down, and its sub- sequent course rendered milder and more manageable. It must not be forgotten, however, that these active depletory measures must be entirely restricted to the early period of the stage of excitement; for when collapse is approaching, bleeding is wholly out of the ques- tion. (Armstrong.) Purgatives are always proper during the stage of excitement in every variety of scarlatina. Calomel has been particularly recommended for this purpose, both in the mild and the malignant forms of the disesse.* Dr. Rush gave this article through- out the whole course of the disease. Seeligt speaks in high terms of a combination of calomel, precipitated sulphuret of antimony, and tart, antimony, according to the formula below,;): a combination which is said to be particularly useful as a gentle laxative, and anti- phlogistic alterative in the present variety of the disease. In con- junction with purgatives we may use the warm bath with a pros- pect of advantage, more especially in cases attended with*internal inflammation. When a prompt and energetic antiphlogistic treatment is employed in the onset of the inflammatory form of malignant scarlatina, the system seldom sinks into a very low state of collapse; and when this stage supervenes, after such a treatment in the commencement ofthe disease, we may, in general, give sufficient support to the vital powers by wine-whey, weak solutions of ammonia, infusion of ser- pentaria, a milk diet, quietness, and proper ventilation. (Arm- strong.) When from an inefficient or improper treatment in the beginning, or from a peculiar violence of the disease, great and uni- versal collapse ensues, (which is indeed but too frequently the re- sult, both in the inflammatory and congestive modifications of malig- nant scarlatina,) recourse must be had to a more active stimulating, and tonic treatment. The carbonate of ammonia in frequent and active doses;§ wine; camphor and opium where the brain is not par- ticularly affected; infusion of serpentaria, with strong doses of elixir * " It is somewhat remarkable," says Armstrong, " that calomel, though, given in large and frequent doses, will hardly ever produce ptyalism in scarla- tina." He states that he has frequently given from six to eight grains of this article, to children, twice, thrice, and even four times daily, without having in a single instance known it to produce salivation. He considers it the best purga- tive in every modification of this disease. X Hufeland's Journal, bd. 16. 1 st. Reil's Fieberlehre, vol. v. p. 177. X R__Calomel Qi. Sulphuret. antimon. praecipit. gr. ii. Tart, antimon. gr. i.—M. Divide into twenty equal parts. Dose- one part to be taken every three or four hours by adults. § Peart asserts that he has been so successful with the use of carbonate of ammonia, that out of three hundred cases in which he employed it, he lost but three patients. This, however, may well be deemed, ultra rem tendere, in com- VoL. I.—42 494 SCARLET FEVER. of vitriol; quinine and capsicum are the remedies upon which our dependence must be placed. The capsicum appears to be a parti- cularly valuable exciting remedy in this variety ofthe disease. This article was first employed in malignant scarlatina by Dr. Stephens* in a very fatal epidemic which prevailed at St. Christopher's (West Indies) in 1787, and it has since received the decided appro- bation of many eminent practitioners.t The manner of employ- ing it is as follows: take two table spoonfuls of small red-pepper, or three tea spoonfuls of common Cayenne pepper, and two tea- spoonfuls of fine salt; beat them into a paste, and pour upon them half a pint of boiling water; this is to be strained, and half a pint of good vinegar added to it. Of this liquor, when cold, a table- spoonful is to be taken every half hour by an adult, and the throat should be frequently gargled with it. Stephens asserts that he em- ployed this remedy in about four hundred cases, and with surprising success. The ulcers in the fauces soon cast off their sloughs and commenced to heal, a general pleasant warmth was diffused through- out the system, and the vital powers speedily resumed a more active condition. MalfattiX speaks very favorably of the flowers of arnica; and Stieglitz employed them with much advantage in the sinking stage of the complaint. Reil strongly recommends large doses of musk, particularly where much restlessness and nervous irritation exist. Stimulating frictions with brandy, camphorated spirits, or tincture of capsicum, have also been found useful in the collapse of this disease. (Riel, Stieglitz.) In the stage of excitement, cooling drinks acidulated with lemon-juice, or the sulphuric or muriatic acids, should be freely allowed; but during the subsequent stages, infu- sions of sage, balm, or catnep, with sulphuric acid, are more appro- priate. In relation to the congestive modification of the disease, it is not necessary to say much in this place, for the principles of treatment are always the same in all congestive states of febrile dis- eases, and what has already been said of the treatment of congestive typhus, applies in all respects to the present malady when it assumes this modification. When the disease commences and proceeds under symptoms of oppressive internal venous congestions, our first efforts must be to recall the circulation to the surface, and to relieve the in- ternal organs; and for this purpose, our reliance must be placed on the assiduous use of frictions, and warm and stimulating applications to the surface; large doses of calomel, (20 grains;) stimulating ene- mata; warm and gently stimulating ptisans, and small doses of cam- mendation of this remedy; although, unquestionably, a highly useful medicine in the stage of collapse, not only of this but of all forms of disease.—Practical Information on the Malignant Scarlet Fever, &c. by E. Peart, London, 1802. * Edinburgh Medical Commentaries, Dec. 2. vol. ii. p. 75. X Cappel, loc. cit. p. 276, Kreisig, loc. cit. p. 113, and Seibert, archiv. fur die Volksarzneikunde, p. 129.—As quoted by Reil, loc. cit. vol. v. p. 175. X Hufeland's Journal, Bd. 12, st. 120. SCARLET FEVER. 495 phor where the stomach is irritable. Having elicited a moderate degree of febrile reaction by these means, it will in general be most prudent to commence at once with the use of some of the milder stimulating remedies, such as infusions of serpentaria, calamus, wine- whey, or small doses of the carbonate of ammonia; and as the dis- ease advances and the signs of prostration increase, the more active exciting remedies already mentioned must be employed, with an energy corresponding to the degree of prostration present. Local treatment.—Various local applications have been recom- mended for the purpose of moderating the tendency to ulceration in the fauces, or of checking the progress ofthe ulcers, favoring the separation of the sloughs, and disposing them to heal. Willan strongly recommends fumigation with nitrous gas; others speak favorably of the application of a weak solution of nitrate of silver to the sores; and some recommend the sulphate of copper—all of which may, no doubt, be used with benefit. Various gargles also have been employed, and of these the infusion of Cayenne pepper, mentioned above, is perhaps the best. I have seen much good done in putrid sore throat by a strong infusion of the root of baptisia tinctoria (indigo plant,) and I have also employed the black-wash, (calomel gr. xx. lime-water §viii.) with excellent effect in several cases ofthis kind. Barley-water, acidulated with sulphuric or muri- atic acid, forms an excellent gargle for washing off the acrid matter from the inflamed and ulcerated fauces. Dr. Barth has employed the pyroligneous acid, for this purpose, with signal advantage. He uses half an ounce of the acid with five ounces of water and an ounce of syrup; with which the throat is to be gargled every half hour.* Where there is no visceral inflammation, or collapse has not supervened in the anginose variety, a gentle emetic will often have an excellent effect in cleansing the sores and clearing the fauces from viscid and offensive matter. "Emetics," says Armstrong, "are the best gargles, where the throat is much obstructed from an accumula- tion of tenacious mucus; their operation effectually dislodges that morbid secretion for a time; often greatly relieves the respiration; improves the appearance of the ulcers; and they may be repeated where no abdominal inflammation exists, at any time, during the con- tinuance of the fever, whenever the respiration and deglutition be- come much impeded by an accumulation of phlegm." During convalescence from scarlatina, which is generally very te- dious, a light and nourishing diet should be enjoined, and the patient carefully guarded against the influence of cold and variable weather. When there isconsiderable debility and relaxation present, mild tonic and cordial remedies should be prescribed, such as weak infusions of serpentaria, colomba, gentian, or calamus aromaticus, with some ofthe mineral acids, particularly the sulphuric. In some cases, more or less general irritation remains during the early part of this period. * Rust's Magazine, vol. xxvii. No. 1, 1828. 496 SCARLET FEVER. The pulse is quick and frequent, the skin pale and dry, the bowels inactive, the appetite weak, and the sleep disturbed. Here tonics and cordials are entirely out of place. Recourse must be had to mild aperients, diaphoretics, warm bathing, and a simple and unirritating diet. Small doses of calomel in union with ipecacuanha, (one grain ofthe former to two ofthe latter) three or four times daily; the mu- riate of ammonia; digitalis with the nitrate of potash; spiritus min- dereri with minute portions of tartar emetic; infusion of eupatorium perfoliatum, or of elder blossoms; acidulated diluents, &c. will gene- rally answer well in cases of this kind. In all instances, the patient should be particularly careful to avoid taking cold; and as the suscep- tibility to the injurious effects of low and variable temperature is always especially great immediately after an attack of this disease, he should remain within doors during the whole period of conva- lescence, unless the weather be mild or warm. I have already mentioned dropsy as a very common consequence of every modification of scarlatina. This tendency to anasarcous effusion is generally ascribed to improper treatment during the fe- brile stage ofthe disease, or to errors in diet, or imprudent exposure to cold during the periods of desquamation or convalescence. That these causes have a particular influence in this respect cannot be doubted; but as dropsy sometimes occurs after the most judicious and careful management in all these respects, it would seem that the original disease itself tends ultimately to effusions of this kind, per- haps from not having passed regularly and completely through its specific train of morbid actions—the dropsy or some other disorder appearing afterwards as a complimental affection.* These dropsical affections are seldom either obstinate in their course or dangerous. In most instances of dropsy from this cause, the general state of the system is manifestly phlogistic. The pulse is quick, sharp, tense, frequent, and sometimes full; the skin dry, harsh, and preternaturally warm; the urine small in quantity, high-colored, and charged with coagulable serum; and the bowels generally torpid. Here an anti- phlogistic treatment is evidently indicated. Richter strongly recom- mends blood-letting and other eminent writers (and amongst these several recent ones) insist with equal emphasis on the propriety of this measure. Burserius gives an account of an epidemic scarlatina which prevailed at Florence in 1717. The disease yielded readily under the plan of treatment recommended by Sydenham. After the twentieth day from the commencement of convalescence, many be- came affected with a sense of weight in the chest, cough, oedema of the face and on the fore-part of the neck. Fever soon followed; the dropsical efiusion increased until it became general; the breast felt sore; the abdomen distended and painful; the urine very small in quantity, and in some instances almost entirely suppressed. All who took diuretics died. On dissection, the lungs, kidneys, and intestines were found inflamed. Blood-letting was now freely re- * Reil, loc. cit. vol. v. p. 186. SCARLET FEVER. 497 sorted to in the cases which occurred, and the result was uniformly favorable.* Gregory seems to hesitate concerning the propriety of venesec- tion in hydropic affections after scarlatina. He stales that he has " met with several cases which appeared to indicate bleeding and purging, but which resisted both, and ultimately yielded to bark and aromatic confection." My own experience leads me to place confi- dence in this measure, where the diathesis is evidently inflammatory; not indeed as a sole or even a principal curative means, but as an im- portant preparatory step to the employment of diuretics, purgatives, and diaphoretics. The best diuretic in cases of this kind is digita- lis, either alone or in union with small portions of calomel and ni- trate of potash. As a purgative and diuretic, I have derived much advantage in this and other varieties of phlogistic dropsy from the following combination.! Small doses of tart, antimon. dissolved in a large portion of some mucilaginous diluent, may also be used with advantage. Richter recommends large doses of calomel, from five to ten grains daily to children. The occasional use of the tepid bath will often prove beneficial, and the mildest farinaceous diet, with cooling acidulated drinks, and quietude, should be enjoined. Some- times these dropsical effusions are entirely without any febrile irri- tation, the system being relaxed, torpid, and leucophlegmatic;—the hydrops frigidus of the German writers (Reil.) According to Richter, " the principal remedy in cases of this kind, is calomel in doses sufficiently large to evacuate the bowels freely."J The cin- chona bark, and the various medicinal preparations of iron, particu- larly the black sulphuret, are often decidedly beneficial in this form of the disease. Among the diuretics, squill, spirits of turpentine,§ and the tincture of cantharides, have been especially recommended. (Hufeland, Bucholz.) The following mixture is said to have done much good in such cases.|| * Burserius, Institutiones Med. Pract. vol. ii. p. 81. f R.—Crem. tart. 3L P. Sulphat. potassae ^iii. P. scillae ^ii. Tart, antimon. gr. iss.—M. S. Give from twenty to thirty grains four or five times daily to an adult. X Kreisig speaks equally favorably of calomel in this and other morbid con- sequences of scarlet fever. " Against the sequela of scarlatina," he says," the powers of calomel are great, and cannot be too highly praised."—Abhandl. iiher das Sharlachsfeber, &c. p. 107. § R—Spir. terebinth, %i. Tinct. opii gtt. L.—M. S. From ten to twenty drops may be given three times daily to children from five to ten years old. || J$.—P. cinchon. gss. Aq. fervent. §xii. coque ad reman, ^vi. dein adde, Rad. polygal. seneg. 3H. 42* 498 ERYSIPELAS. Prophylactic measures.—In Germany, and in France, many statements have been published which would seem to prove that the belladonna, when regularly taken by those who are exposed to the contagion of the disease, will effectually protect them from the in- fection. Hannemann, the author of the homoepathic doctrine, first introduced this narcotic as a preventive of scarlatina, and in con- formity to his views, he prescribes it in what may be called infini- tesimal doses. He gives but forty drops in seventy-two hours, of a solution of which one drop contains no more than the twenty-mil- lionth part of a grain of the extract! However incredulous we may be in relation to the efficacy of such doses, we are not without re- spectable authorities in favor of the prophylactic powers of this ar- ticle when given in small doses. Berndt asserts, that he gave it with unequivocal advantage in this respect. Dr. Koreff of Berlin, found it to protect persons completely against this disease, when taken for eight or ten days before they were exposed to its conta- gion. Three grains of the extract are to be dissolved in an ounce of cinnamon water, and given in doses of from two to three drops to children under one year old, and one drop more for every year above this age.* Seclusion of the sick, free ventilation, frequent changes of the linen, and other similar precautions, have been found completely effectual in preventing the communication of the disease to other members of the family. It does not appear that the contagious miasm of this disease is capable of attaching itself to clothes like some of the other exanthematous contagions. The breath of patients in the malignant form of the disease is said to be powerfully infec- tious; and the same has been observed with regard to matter dis- charged from the fauces. Sect. VI.—Erysipelas.—St. Anthony's Fire. Erysipelas is a febrile disease, attended with diffusive cutaneous inflammation on some part of the body, characterised by redness, burning heat, swelling, and vesication. In the majority of instances, various symptoms of deranged health precede the appearance of the erysipelatous inflammation—such as lassitude; slight headach; loss of appetite; nausea; general depres- sion; furred tongue; and a disagreeable feeling of weight in the epi- gastrium. These symptoms usually terminate in febrile reaction before the cutaneous inflammation commences; but in some instances the local and general affections come on simultaneously; and occa- sionally the inflammation appears before the febrile irritation is de- Fol. digitalis, J)i. cola, dein adde, Spir. nitri. dulc. 3U. Syrup, cort. aurant. £ss.—M. S. Take from a tea, to a tablespoonful every two hours, according to the age of the patient. * Ed. Med. and Surg. Journ. Jan. 1825. ERYSIPELAS. 499 veloped. Sydenham speaks of an erysipelas, in which the affection of the face preceded the fever. The inflammation comes out in the form of an irregularly circum- scribed stain or blotch, which soon spreads over a greater or less ex- tent of the contiguous surface. When the inflammation is very su- perficial, the redness ofthe skin disappears, for a moment, on pres- sure being made with the point of the finger; but where the inflam- mation extends deeper, no white spot is left after pressure. Consi- derable burning and stinging pain, but neither pulsation nor tension, is felt in the inflamed part. Some degree of tumefaction always attends from the beginning, and increases, often to a very consider- able extent, in the progress of the disease. After the inflammation has continued for an uncertain time, though usually about the third day, small vesicles, or blisters of various sizes, filled with a limpid or yellowish serum, make their appearance. On the succeeding day, and sometimes not until two or three days after, these vesicles break, and discharge a viscid fluid, which occasionally forms crusts or large scabs. When the inflammation is about terminating in resolution, which usually occurs between the fourth and sixth days, the redness of the affected part diminishes, and assumes a pale or brownish yel- low color; the swelling also begins to subside; the skin acquires a rough and rugose appearance; and, on the following day, desqua- mation takes place. The general or febrile symptoms commonly follow the progress of the local erysipelatous affection, both increas- ing and declining together; yet, in their respective grades of vio- lence, there is often no direct proportion between them; the fever being sometimes severe, with but a moderate local inflammation, and vice versa. In some instances, the inflammation gradually travels along the skin, without increasing much in the extent of its surface, disappear- ing from the parts first affected, in proportion as it encroaches on the adjoining sound skin. La Motte gives the history of a case which commenced on the scalp, and in the course of three weeks gradually- travelled over the whole surface of the body.* Similar cases are related by other observers.t (Reil.) Occasionally, whilst it retains possession of the part first seized, it spreads more and more, until a large extent of skin, and in some rare instances the whole surface of the body, is erysipelatous. Salmuth, (cent. i. obser. 3,) relates a case of universal erysipelas. Sometimes the inflammation disappears from its original seat, and comes out on some other, and often remote, part of the body. Such are the general phenomena of erysipelas. It is subject, how- ever, to several prominent modifications, exhibiting important pecu- liarities, both in relation to the character of the local affection, and the nature of the attending fever. * Chirurg. t. i. observ. p. 92. f Ephem. Nat. Curios. Dec. ii. Ann. iii. ob. p. 171. 500 ERYSIPELAS. The true seat of erysipelatous inflammation, appears to be in the cutis, or the dermoid system generally; and in its simple and regu- lar form, it is, in a great measure, if not wholly, confined to this structure. When the inflammation is very active, and extends itself to the subcutaneous and intermuscular cellular structure, it assumes somewhat of the character of common phlegmonous inflammation, constituting the erysipelas phlegmonodes of authors. This state of the disease is characterised by a decidedly synochal grade of fever; the pulse being hard, tense, and frequent; a vividly red appearance, and an extremely distressing burning heat and prickling pain of the inflamed part; a dry tongue, with urgent thirst; and a tendency to profuse sweats. The swelling usually commences about the second day of the fever; and in a few days more, small vesicles appear on the inflamed skin. When the disease tends to resolution, these vesi- cles break or subside about the fifth or sixth day; the redness assumes a yellowish hue; the tumefaction and fever gradually decline, and by the eighth day, the old cuticle begins to desquamate. Frequently, however, instead of taking a turn to resolution, the pain becomes throbbing, at the same time that the redness diminishes, and more or less extensive suppuration ofthe ordinary phlegmonous character takes place. Sometimes the inflammation extends deeply into the cellular tis- sue, and appears to commence simultaneously with the external or dermoid affection. In cases of this kind, the pain is always ex- tremely severe; the skin tense, and exceedingly painful on the slightest pressure; and the general phlogistic irritation vehement. " The termination, except from energetic treatment, is seldom in resolution; the suppuration, which takes place from the fifth to the seventh day, though sometimes sooner, is accompanied with irregu- lar chills; the redness of the skin and the pain diminish, but the swelling increases; there is much doughiness, and the part remains in that state for some time. In some cases, the pus remains for a long time before an opening is formed in the skin to give it vent, but in general it escapes either by a natural or artificial orifice, mingled with shreds of gangrenous cellular tissue. In these cases the course of the disease is ordinarily tedious; sinuses are formed; sometimes sloughing of the skin takes place to a considerable extent, and colliquative diarrhoea often carries off the patient, exhausted by the slow fever and great suppuration." (Cazenave.) In some in- stances where cellular inflammation and suppuration take place be- neath aponeurotic membranes, the symptoms become still more vio- lent and distressing. In cases of this kind, "violet spots appear on the inflamed skin about the second or third day; these spots increase rapidly, and become covered with vesications; finally, small eschars are formed, which gradually fall off, and convalescence takes place under a greater or less degree of suppuration." This variety of the disease is sometimes attended with strong symptoms of disorder of the biliary system, constituting the erysi- ERYSIPELAS. 501 pelas phlegmonodes biliosum of some of the continental writers. Although not an uncommon modification, it has been but little no- ticed by the English writers. Mr. Copeland Hutchinson is, I believe, the only one who has given a particular account of it in the English language. There is, generally, much bilious vomiting in the com- mencement of this variety of the disease, and throughout its whole course the symptoms of biliary disorder are very conspicuous; the tongue is covered with a brown fur; the tunica albuginea is tinged with bile; and the skin generally exhibits a more or less icterode hue. The fever is of the synochus grade, and suffers very distinct evening exacerbations and morning remissions. The urine is small in quantity, and highly charged with bile; and in many instances bilious diarrhoea attends. Phlegmonous erysipelas may occur on any part of the body, but it most commonly appears on the extremities and face. Bateman says that it most frequently occurs in the face; but Cazenave states that it is most frequently observed on the extremities, and this accords en- tirely with my own observations. In some cases, the erysipelatous inflammation is early accompa- nied by an oedematous state of the affected part; and this is more par- ticularly apt to be the case, when the disease attacks persons of a relaxed and leucophlegmatic habit, or in such as have suffered much from chronic disorders, or are habitually intemperate. It would seem that in cases of this kind, the capillary vessels of the cellular tissue are, at first, in a highly congested, but not inflamed condition, and that these vessels soon relieve themselves by pouring out serum into the cellular structure. This modification makes its attack more mildly, and is, upon the whole, less dangerous and distressing than the preceding variety; although sometimes attended with considera- ble danger when it attacks the face. The inflamed skin is pale-red, or yellowish-brown, and is attended with but a moderate degree of heat and burning pain. The tumefaction does not increase so rapidly as in the phlegmonous state of the disease, and exhibits a smooth and polished surface, and pits when pressure is made with the finger. The vesicles are very minute, numerous, and but little elevated. On the second or third day after their appearance, they break, and give rise to thin dark-colored scabs. When the disease attacks the face, the swelling often becomes so great as to close the eyes, and render the whole face exceedingly bloated, giving it the appearance, as Wilan observes, "of a bladder distended with water." In this case, too, considerable vomiting sometimes'occurs at an early period, and in the height of the inflammation, delirium and coma occasion- ally supervene, and death takes place under symptoms of cerebral oppression. This modification of the disease is usually denominated erysipelas ozdematodes. When the disease occurs in weak and nervous individuals, it is apt to assume a typhoid character, and is generally accompanied with low delirium throughout the greater part of its course. In instances 502 ERYSIPELAS. of this kind, the inflamed part is of a dark or livid color; the vesicles are not numerous but large, and frequently terminate in gangrenous ulceration. Suppuration and sloughing of the cellular tissue usually take place, " producing little caverns and sinuses, which contain an ill-conditioned pus." This constitutes what is termed by authors erysipelas gangrenosum. In the year 1716, gangrenous erysipe- las prevailed epidemically at Toulouse; and a similar epidemic is said to have prevailed in France in 1130. (Reil.) Infants are subject to a modification of erysipelas (E. neanatorum) of a very obstinate and dangerous character. It usually occurs soon after birth, and instances are related of children having been born with blotches of erysipelatous inflammation, so far advanced as to exhibit vesication and spots of gangrene. (Richter; Bateman.) The inflammation almost always commences on the lower part of the body—particularly about the genitals, nates, and umbilicus, and gradually spreads over the abdomen, and along the back and inside ofthe thighs. In some instances, several parts are affected at the same time, without a confluence of the inflamed blotches. The in- flammation begins by a small red spot, which rapidly spreads irregu- larly over a greater or less extent of the skin. The inflamed part swells considerably; is firm and extremely painful to the touch, and of a dark red or purplish color. Large but thinly scattered vesi- cles appear, having inflamed livid bases, tending often rapidly to sphacelus. The disposition to gangrene is indeed always very con- siderable in this variety of erysipelas, particularly on the abdomen; when it affects the extremities, ulcerative suppuration is apt to ensue. Symptoms of intestinal and hepatic disorder are scarcely ever wholly absent. The alvine discharges are usually frequent, painful, and grass-green; in some cases there is constipation, with colicky affections. A jaundiced appearance of the skin, aphtha in the mouth, and acid ejections from the stomach, are very common in this disease. Its course varies from about seven days to three weeks. When deep incisions are made into the affected parts after death, a large portion of thin serous fluid issues,* and the skin exhibits a firmer and thicker structure than in the natural state. Meckel found the umbilical vein, together with the peritoneum, inflamed, and he was led, by this fact, to believe, that inflammation of this vein, oc- casioned by rude management in cutting and tying the umbilical cord, constituted the primary disease. This opinion has since been adopted by many, but its correctness as yet is by no means estab- lished. (Reil, Fieberlehre, b. ii. kap. 5, s. 329.) Richter observes, that this disease in its general character is never purely inflamma- tory, but always manifestly gastric and irritative. There is another affection which appears to be very closely allied to the present one, if not in reality the same disease, and which is * Osiander. Denkwurdigkeiten, b. ii. st. 2, s. 370.—Neue Denkwurdigk. b. i. 6. 56. ERYSIPELAS. 503 equally confined to new-born infants. This is the induratio telae cellularis, an affection characterised by a peculiar hardening, con- solidation, or induration of the cellular tissue. It is not often met with in private practice, but in some of the foundling hospitals of Europe it has been abundantly observed. The affected part becomes hard, incompressible, and tense; the skin so firmly adherent to the subjacent parts, that it cannot be pinched up, or in any way moved from its fixed position. Its color is violet, pale red, yellowish red, or yellow. It generally commences on the trunk, and gradually ex- tends its circle, until, in some instances, the whole body becomes affected. The little patient cannot cry out; deglutition is often diffi- cult, spasmodic, and occasionally impossible; the jaws are sometimes closed as in trismus; and in most cases, convulsive or tetanic spasms ultimately come on. Its course is always rapid—terminating often by the third day, and seldom continuing beyond the seventh. It is a most fatal malady. I have seen five or six cases, but no recovery. There is also an habitual and non-febrile form of erysipelas. It oc- curs in cachectic persons, in women of a leucophlegmatic habit labor- ing under menstrual irregularities, and especially in individuals affected with chronic visceral disease, more particularly of the liver. Habitual drunkards also are very liable to this form of the disease, no doubt from the hepatic disorder which is almost always ultimately produced by habitual intemperance. Although erysipelatous inflammation most commonly terminates in resolution, yet suppuration and gangrene frequently occur in the more violent grades of the disease. There is something very pecu- liar, however, in erysipelatous suppuration, both with regard to the seat of this process and the character of the pus which is formed. It always commences in the subcutaneous cellular tissue, and the pus generated is very rarely thick, and yellowish like that in common phlegmonous suppuration, but thin, grayish or whitish, somewhat acrid and sanious. The matter is never collected in circumscribed cavities; it travels along the cellular tissue, under the skin, and be- tween the muscles until this structure (cellular) is almost entirely destroyed in the affected part. Small openings finally ulcerate through the skin, and the matter, mixed with shreds of sphacelated cellular membrane, is discharged. Through these orifices large portions of deadened cellular structure may be drawn, " resembling pieces of wet tow." I have, in two instances, known this tissue so completely destroyed in the fore-arm, that the skin hung loose like a bag round the muscles, and the muscles themselves were completely separated, as if they had been dissected from each other. Both cases termi- nated fatally. In instances of this kind, that finally get well, the skin grows fast to the muscles, and even the muscles themselves ad- here to each other, rendering their action very difficult, and some- times destroying the free use of the limb entirely. Erysipelas, of whatever variety it may be, is always more dan- gerous when it attacks the head than when it occurs on the body or 504 ERYSIPELAS. the extremities. This arises chiefly from the brain being apt to be- come oppressed or inflamed in severe cases of the face. Instances occur, in which the inflammation passes down into the fauces and along the alimentary canal, giving rise to severe and exhausting di- arrhoea. Visceral inflammations of various kinds, have been known to supervene during the progress of severe erysipelatous affections. I have seen a case in which pneumonia came on during the height of the disease; and instances are related, in which the inflammation extended along the vagina into the uterus, as well as along the uri- nary passages to the kidneys. * (Frank.) The brain, however, is by far the most frequently affected in this disease. Does this arise from metastasis of the external inflammation? This point has been much disputed. Cullen ascribes the cerebral affection to the mere exten- sion of the inflammation from the external part to the brain. This I believe to be correct. I have seen at least half a dozen cases in which symptoms of cerebral inflammation came on; but in no in- stance was the external inflammation in the smallest degree lessened by this occurrence. It is from the state of the brain, when the dis- ease attacks the face, that we chiefly collect the prognosis. When neither delirium nor coma supervene, either before or during the presence of the inflammation, there is generally no cause to appre- hend particular danger; but when these symptoms come on, the hazard is always great. I am by no means disposed to deny that ery- sipelas sometimes passes, by metastasis, from the external to internal parts—or perhaps more correctly speaking, that visceral inflamma- tion sometimes supervenes at the same time that the erysipelatous affection disappears. I have myself recently seen an instance of this kind. A lady became affected with erysipelas on both arms, occu- pying the whole surface from the hands to the elbows. On the third day the inflammation rapidly subsided, and on the following morn- ing she was seized with alarming haemoptysis. Richter observes that the oedematous, and what he calls nervous,X modifications of ery- sipelas, are the most liable to pass upon internal organs. What I have hitherto said, has a reference chiefly to the local erysipelatous affection. In relation to the character ofthe attending fever, important diversities occur, which it may be proper to notice more particularly than has already been done. The most common grade of erysipelatous fever is the synochal, or strictly inflammatory. In some instances, the fever, in its onset, manifests a typhoid tendency, but as soon as the inflammation ap- pears, its synochal character becomes developed. More commonly, however, the fever begins at once in the character of a well charac- terised synocha; and this is more particularly apt to be the case in * Reil, loc. cit. vol. ii. p. 372. X He designates those cases by the term nervous, that are attended with a ty- phoid or tyyhus grade of fever. They are generally connected with manifest gastric derangements. ERYSIPELAS. 505 the phlegmonoid variety of the disease. In nearly all instances in which the inflammation attacks the face, the attending fever is of this grade; and it is of course always more apt to assume this grade in the young, plethoric, and robust, than in aged, infirm, and relaxed individuals. When the fever is synochal, it always increases in violence when the inflammation appears. Not unfrequently the attending fever is typhoid, ab initio, and throughout. This is most apt to be the case in weak, nervous, and irritable subjects, and particularly in those who are affected with derangement of the digestive organs. Cases of this kind are always much more dangerous than where the fever is of a more active grade; for they are equally liable to the supervention of internal inflammations, and the occurrence of gangrenous suppuration is much more common in the former than in the latter, and of course, the system less capable of sustaining the effects of the disease. Typhus, or, as it has been called, malignant erysipelas, has occa- sionally prevailed epidemically. De Haen and Bartholini mention epidemics of this kind, and I have already referred to the epidemic which prevailed at Toulouse in 1716, which is said to have been but little less fatal than the plague.* Cause.—In relation to the cause of erysipelas, nothing very defi- nite can be said. Some individuals appear to be constitutionally predisposed to this affection; and Richter supposes that this predis- position depends on a peculiarly irritable and delicate condition of the dermoid system. In some persons, bruises, wounds, and other local irritating causes, are particularly apt to give rise to erysipela- tous inflammation, and this is more especially the case in injuries of the scalp. The inflammation which is produced by the 'recent leaves of the rhus toxicodendron, is strictly of an erysipelatous character. Individuals of a cachectic habit; the habitually intem- perate in diet and spirituous drinks; the leucophlegmatic; and per- sons laboring under chronic visceral affections, particularly indura- tion of the liver or spleen, or mesenteric glands, are most liable to this disease. Strong and sudden mental emotion has been known to produce erysipelas. Richter observes that he has known indi- viduals who always became affected with erysipelas of the face, after they had been thrown into a violent fit of anger. (Therapie, bd. ii. p. 210. In some individuals, erysipelas returns periodically. (Reil.) These cases are generally slight, and soon go off; and are usually dependent on some disorder of the liver or alimentary canal. Erysipelas seems at times to depend on some peculiar atmospheric constitution or miasm, for it is only to a cause of this general cha- * Hippocrates mentions an erysipelas which spread among the people, and proved exceedingly fatal. The whole arm, leg, &e. had their soft parts in some instances almost entirely destroyed by gangrenous ulceration.—Van Swieten's Comment, vol. v. p. 181. Vol. I.—43 506 ERYSIPELAS. racter that we can ascribe its occasional epidemic prevalence. Some writers of eminence assert, that the disease is sometimes propagated by contagion; and there are many facts recorded, which strongly favor this opinion. The disease has, for instance, been known to prevail to a great degree in certain wards of hospitals;* and Dr. Wells has brought forward some examples which occurred in pri- vate families, that appear to demonstrate its occasional contagious character.! Dr. Stevenson, also, has recorded some facts of a similar import.^ Its occasional apparent contagious character in hospitals may depend, however, merely on a general depraved habit of body, produced by the foul air to which the inmates of hospitals are at times exposed from deficient cleanliness and ventilation. Bateman states that this disease has been banished from the Royal Infirmary of Edinburgh, by ventilation and other means of purification. Erysipelas occurs sometimes in the course of fevers, apparently from a critical effort of the system to relieve itself from some inter- nal irritation. I have lately witnessed an interesting example of this kind. A person was seized with fever of a remitting synochus form. The disease was attended with symptoms of much gastric and biliary derangement. It continued without any amendment for nearly two weeks. At last a violent erysipelatous inflammation oc- curred on the face, which in the course of six days subsided regu- larly, and left the patient in a state of convalescence. This disease appears also at times on the suppression of some habitual evacuation. I know a gentleman in this city, who has been affected, for thirty years past, with an extensive superficial ulceration on one of his legs. Whenever the ulcer becomes dry, which generally occurs several times during the year, either an erysipelatous inflammation occurs on the face or the fore-arms, or he is seized with a violent fit of asthma. On the application of a blister to the leg, these affections speedily go off. Treatment.—With regard to the general treatment of this dis- ease, it is obvious that it must be modified according to the cha- racter of the attending fever; and that a course of remediate ma- nagement, which might be very proper in one modification of the malady, would probably be very injurious in another. When the fever is of a high grade of reaction, the treatment should be anti- phlogistic. It is not, however, often necessary, even in cases of this kind, to make frequent and copious abstractions of blood— unless symptoms of cerebral inflammation supervene, with an active * " The occasional contagious character which erysipelas assumes, is well known to all who have paid any attention to the complaint in the wards of hos- pitals."—Dr. Johnson, Med. Chir. Rev. October, 1826, p. 404. X Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, vol. ii. 1800. (Bateman.) X Transact, ofthe Med. Chir. Soc of Edinburgh, vol. ii, art. ix. ERYSIPELAS. 507 state of the circulation. Under such circumstances, blood should be promptly and freely drawn, in order to relieve the brain. It does not appear, however, that any particular impression is often made on the progress of the erysipelatous affection itself—at least not on its obvious condition—by venesection; although unquestion- ably frequently very useful in obviating some of the unfavorable consequences of the inflammation. When the pulse is frequent, tense, and hard, bleeding ought by all means to be practised, and carried to the extent that may be indicated by the state ofthe circu- lation, without any regard to the appearances or character of the local affection. With regard to the propriety of local bleeding by leeches, very discrepant sentiments are expressed by authors. Willan, Thompson, Richter, and others, speak decidedly against this practice; and from what I have myself seen of it, there appears to me much foundation for rejecting it. In the only case in which I have employed leeches, several very obstinate ulcerations occurred, apparently in conse- quence of the leech-bites. Cazenave speaks favorably of this mode of depletion; but he very properly cautions against applying the leeches to the inflamed surface. It must be observed, however, that although some advantage may be derived from the application of leeches a small distance from the eruption, yet as the inflamma- tion is apt to spread, this will not always obviate the evil conse- quences which are apt to result when they are applied to the inflamed part. Purgatives are useful in every variety of the disease. When the disease attacks the face, they are particularly serviceable. In the ordinary phlegmonoid form, the saline purgatives are in general the best; but where symptoms of gastric derangement attend, calomel, in small and repeated doses, assisted by an occasional saline aperi- ent, is preferable. In the bilious modification, the exhibition of an emetic will often prove very useful. After the operation of the emetic, large doses of calomel should be given, until the bowels are freely moved. Reil says, that in cases attended with fever of a sy- nochus, inclining to the typhoid grade, emetics are highly service- able. " If the disease has continued for some days, and the more direct antiphlogistic remedies may no longer be deemed proper, and the inflamed part assumes a pale yellowish hue, and is somewhat oedematous, with but a moderate degree of heat and pain, emetics will generally arrest the progress of the disease effectively."* The regular action of the cutaneous exhalents should be supported by diaphoretics of the refrigerant kind. The saline mixture, with a small portion of tart, emetic; spiritus mindereri, according to the formula mentioned at page 176; or the sal ammoniac mixture men- tioned at page 127, will answer well for this purpose. Small por- tions of calomel and ipecacuanha in union, are peculiarly beneficial in * Fieberlehre, bd. ii. p. 398. 508 ERYSIPELAS. this disease,* more especially in the erysipelas of infants. Through- out the whole course of infantile erysipelas, our principal aim should be to restore the regular actions of the liver, alimentary canal, and of the skin; and hence calomel and ipecacuanha, in the proportions just mentioned, with an occasional dose of magnesia or castor oil, and warm bathing, constitute, so far as my own experience enables me to judge, the most useful course of internal treatment in this va- riety of the disease. When the attending fever is typhoid, direct depletion will of course be improper. In cases ofthis kind, bark and wine have been much recommended; and where the symptoms of prostration are great, it will be* necessary to employ them actively. I have used cinchona in conjunction with the carbonate of ammonia, with much advantage, in a few cases of this kind. The quinine, however, would appear to be the best tonic in this modification of the disease. I have had occasion to prescribe it in but one instance of this kind, and its effects in this case were highly gratifying. But although tonics and stimulants are essential in cases of a low grade of reaction, mild laxatives are almost equally necessary. The bowels are almost invariably loaded with irritating matters, which, if not removed, tend strongly to oppress and prostrate the powers of the system. In instances of this character, it will be pro- per to exhibit laxatives conjointly with stimulants, and to continue the use of the latter, during, as well as after the operation of the former. In what is called the gangrenose modification of the dis- ease, the fever always assumes a low grade in its progress, however active it may have been in its early stage. Where manifestations of approaching gangrene come on, or where this process has already commenced, wine, opium, camphor, quinine,X and the mineral acids, are the remedies upon which our reliance must be placed. Free purging, with active doses of calomel, in the early period ofthe dis- ease will, however, very generally render the necessity of tonics and stimulants in the latter stages, much less urgent than when this evacuation has not been sufficiently effected. It should always be recollected, in prescribing for febrile diseases, that intestinal irrita- tion, from whatever cause it may proceed, has a powerful tendency to oppress or prostrate the vital powers; and that,under due precau- *. R.—Calomel gr. ii. Pulv. ipecac, gr. iii. Sacch. albi gr. xii.—M. Divide into twelve equal parts. S. One to be taken every four hours by an infant. X This article has of late years been much recommended, and deservedly so, in erysipelas of a typhoid tendency. Sir Astley Cooper, in his Lectures, gives the following, as, in general, the most successful mode of remediate manage- ment. " At first, give calomel, for the purpose of restoring the secretions of the liver and intestines, and the liquor ammoniae acetatis, with antimony, to act upon the secretion ofthe skin, and then give the sulphate of quinine." ERYSIPELAS. 509 tions, the debilitating effects of purgatives are greatly exceeded by the increased energy imparted by the removal or diminution of such sources of the irritation. Should the inflammation terminate in suppuration and sloughing, opium and camphor, with quinine or cinchona, are indispensable in all cases. Opium is particularly valuble under circumstances of this kind, by allaying general irritation, and supporting the action of the heart and arteries. Opium may be given advantageously in combination with quinine; and in several instances of extensive sup- purative ulceration in this disease, I have known much benefit de- rived from the extract of conium, in union with camphor, given at short intervals, in full doses. Upon the whole, however, bark or quinine in large doses, and opium, may be regarded as the most use- ful supporters in such cases. Where the pain and irritation are great, opium, after proper eva- cuations, seldom fails to procure much relief. It should be given in full doses, at the same time that cold applications are made to the scalp and forehead. When secondary inflammation occurs in some internal organ, recourse must be had to local and general bleeding, if the pulse re- main sufficiently active; and in all such cases, cupping, sinapisms, blisters, and the other usual revulsives, are indispensable. In cases attended with prominent cerebral disorder, such as de- lirium, coma, or insensibility, active purgatives and stimulating ene- mata are highly important means. For this purpose, the ol. tere- binth, has been found especially efficacious. Mr. Cox has given an account of a case of erysipelas of the scalp, face, and breast, which was attended with delirium, succeeded by coma and insensibility, with other symptoms portending a fatal termination; and which was successfully treated by the daily use of the turpentine combined with castor oil, both by the mouth and per anum. This medicine brought away large offensive stools, and from the first dose the symptoms gradually subsided.* Some diversity of opinion exists with regard to the propriety or usefulness of local applications to the affected part. Bateman ob- serves, " that with respect to external applications in the early stages of erysipelas, experience seems to have decided that they are generally unnecessary, if not prejudicial;" and the same observation is made by Cazenave and Schedel. My own experience has led me to a different conclusion. I have certainly never seen the least in- jury done by suitable applications ofthis kind; but, on the contrary, often the most decided benefit. Formerly, physicians were much in the habit of applying cooling or relaxing remedies to the inflamed surface—such as lead-water, cold water, emollient poultices, fomenta- tions, &c. That such applications should prove useless, and often injurious, may be readily admitted. There exists a close analogy * Lond. Med. Repository, April, 1825. 43* 510 ERYSIPELAS. between the inflammation of erysipelas and that produced by a scald or slight burn. In both, the capillaries of the inflamed part are debilitated, congested, and passively distended, and in both, there- fore, the best applications are such as are capable of exciting or sti- mulating these vessels to increased tone and activity. For many years I was in the habit of using a solution of corrosive sublimate, in the proportion of about four grains to the ounce of water, and ge- nerally with a satisfactory result* Pieces of linen or flannel moist- ened with this solution, should be laid over the inflamed part, and renewed until the inflammation begins to subside. During the last four years, however, I have invariably used the nitrate of silver in solution, in the proportion of five or six grains to the ounce of wa- ter, and almost always with prompt and complete success. This so- lution is to be applied in the manner just mentioned for the subli- mate wash. The mercurial ointment has been a good deal used in this country^ as an application to erysipelatous inflammation.t I have myself employed it in several cases; in one, it proved very useful, but in the others, it afforded little or no advantage. It is to be applied by spreading it on pieces of linen, and laying them on the inflamed part. Dr. Brodie, of London, from some experiments he made with this ointment, came to the conclusion that its good effects depended more on the adipose substance, than on the mercurial oxide combined with it, and in subsequent trials, he used only simple oint- ment, which in some instances, he says, proved quite as useful as the mercurial unguent. Lard has also been used in this city, and it is said with considerable benefit. Brodie objects, and with justice, to the mercurial ointment, on account of its tendency to produce salivation; for in other respects, " its utility seemed unquestiona- ble." Dr. Dewees also speaks favorably of this ointment, but makes the same objection to its use. Some of the English surgeons speak very favorably of an ointment, composed of equal parts of ceratum calaminae, ceratum saponis, and unguentum plumbi acetatis. In St. George's Hospital, it has been used with evident benefit in traumatic erysipelas ofthe scalp. Blisters applied to the inflamed surface, will often promptly arrest the progress of the inflammation. Dupuytren speaks favorably of this practice, and it has long since been a favorite remedy with many practitioners both in this country and in France. My own experience enables me to say very little of this application. I have resorted to it only in two cases; one of these terminated in extensive suppurative ulceration; the other was benefitted by it. Blistering * I learned the use of this remedy in erysipelas from Dr. Schott of this city. f This remedy was first introduced to the notice of the profession of Dr. Dean of Harrisburg, although I have learned, that in the interior of this state, it was long before used in this affection by several respectable practitioners. Drs. M'Lellan and Lewis employed it before Dr. Dean became acquainted with its use. ERYSIPELAS. 511 is said to be most useful where there is but a moderate degree of febrile reaction, with a moist and slightly red tongue, and a some- what hot and tense skin. The blister must be laid directly over the inflamed part, and be large enough to extend a small distance on the sound skin. Velpeau and Bretonneau recommend compression by bandages in phlegmonous erysipelas; and their statements do not permit us to doubt, that, in some instances at least, much benefit may be derived from this practice. When the disease affects one of the extremities, compression may be easily made; but in the face it is impracticable. It is only in the early stage of the complaint, before vesication oc- curs, that this practice can ba advantageously or safely adopted. In a case which I have attended within the last eight days, I had a satis- factory illustration ofthe usefulness ofthis measure. Nevertheless, statements have been published unfavorable to this practice; and Cazenave apprehends, though apparently not from any experience, much mischief from it. Several late English writers recommend making incisions through the inflamed skin and subjacent adipose and cellular textures. Mr. Lawrence, who strongly recommends this practice, asserts, that " these incisions are followed, very quickly, and sometimes almost instantaneously, by relief, and cessation of the pain and tension;" and a corresponding declension of the inflammation almost always takes place. Mr. Lawrence confines this practice to cases of the phlegmonous kind. Mr. Hutchinson also speaks decidedly in favor of making incisions into the erysipelatous surface. Mr. Lawrence recommends making one free incision, extending from one boundary to the other, through the centre of the inflamed part. Mr. Hutch- inson, on the contrary, considers it better to make a number of smaller incisions, about an inch or an inch and a half in length, through the skin and cellular structure. Mr. Dobson, who likewise advocates this practice in a modified form, advises a great number of punctures to be made, a short distance from each other, over the whole disk of the affected part. The experience of Mr. Plymsol, of the Glasgow Royal Infirmary, may also be cited in favor of this practice. " The practice of making incisions in erysipelas phlegmonodes," says Mr. P., " has been established in this infirmary for the last four or five years, and has invariably proved successful; long incisions are generally pre- ferred." That this practice is calculated to afford much relief in phlegmo- noid erysipelas attended with a due degree of constitutional energy, cannot be doubted. The incisions or punctures give exit to the blood congested in the vessels of the inflamed part, and thus contri- bute directly and strongly to the reduction of the inflammation and its attending affections. In the other varieties of erysipelas—and even in the phlegmonoid form, attended with weak powers of vital resistance or a tendency to a typhoid condition, this practice is con- 512 HERPES. nected with considerable risk, from the tendency of the wounds to assume a gangrenous state. Some have indeed expressed much doubt as to the value or general propriety of this practice, even under apparently favorable circumstances; and several respectable writers speak decidedly against its employment. Mr. James states, that in the cases in which he tried incisions, he did not obtain all the advantage which he was led to expect from Mr. Hutchinson's report of this practice. Several writers strongly protest against this measure, affirming that the wounds are apt to run into mortification. Mr. James did not find this tendency to mortifi- cation so great as some appear to apprehend. CHAPTER XVII. MINOR EXANTHEMATA. Sect. I.—Herpes. The term herpes was formerly applied in a very vague manner; and the German writers still include under its head various chronic affections of the skin, which by the late English and French writers, are regarded as wholly diverse from each other.* Willan first em- ployed it in a different manner, and restricted its application to a distinct class of cutaneous affections, characterised by an eruption of vesicles, appearing in groups or clusters on an inflamed sur- face, " so as to present one or more distinct spots separated from each other by intervals of sound skin." In most instances, mani- fest constitutional disorder, such as languor, loss of appetite, restless- ness, and occasionally febrile symptoms, with a burning or stinging sensation, or deep-seated aching pain in the affected parts, precede the appearance of the eruption. There is a regular increase, matu- ration, and decline, in the progress ofthe eruption, but the duration * Richter arranges ptyriasis, psoriasis, ecthyma, and various species of impeti- go with the herpetic affections. His fourth species, herpes pustulosus, compre- hends the five varieties of herpes of Willan. The minute splitting of diseases, so common of late, may be regarded as of very doubtful advantage, both in a scientific and practical point of view. A careful comparison of many of these species—their variable character, and their frequent conversion into each other —shows at once the little foundation there exists for at least some of these sub- divisions. The affections arranged under the term herpes, by Willan, and others, are however sufficiently distinct in their character, and diverse from other analo- gous disorders, to require separate consideration; and it is of little consequence what name they bear, provided they are properly described and understood. herpes phylctenodes. 513 of its course varies from one to three weeks. The fluid in the vesi- cles is at first limpid, becoming opaque or whey-like and more vis- cid as the disease advances, and at last either concretes into brown crusts, or the vesicles break, and suffer it to escape, giving rise often to disagreeable and unmanageable ulcerations. The diagnosis of herpes is founded on t\ie assemblage of the ve- sicles in separate clusters, the red or inflamed state of the skin upon which they are seated, and the natural color of the intermediate spaces of skin. These characteristics distinguish it sufficiently from erysipelas. From tetter (impetigo,) eczema, and other forms of chronic eruptions, it differs in its purely vesicular form, its more acute character, and particularly in the regular progress of the vesi- cles from their incipient transparent state to maturation, and finally scabbing. Herpes admits of being divided into different varieties, according to the particular form of the vesicular clusters, and the part of the body upon which they appear. 1. Herpes Phlyctenodes. This variety of herpes may occur on all parts of the body, having no determined form or seat. The appearance of the eruption is usually preceded, for several days, by slight febrile symptoms, and these sometimes continue after the vesicles have come out. On the part which is about to be the seat of the eruption, we may at first notice a multitude of very minute red points. In the course of twenty or twenty-four hours more, the skin upon which these points appear, becomes uniformly red, and small transparent vesicles make their appearance. The cutaneous efflorescence extends a few lines beyond the margin of the vesicular group; and the vesicles them- selves are firm and resisting to the touch during the first day. A sense of smarting, and occasionally a dull and severe pain, accompa- nies the appearance of the eruption.—(Cazenave.) The eruption most commonly occurs on the upper parts of the body, particularly on the neck, breast, arms, and cheeks. It con- sists of small transparent vesicles, aggregated into irregular clusters of various sizes, from a few to nine or ten inches in circumference. These vesicles are sometimes very minute, and at others they are as large as a small cherry. In some instances they come out at first on the neck or breast, "and gradually extend over the trunk to the lower extremities, new clusters successively appearing for nearly the space of a week." This gradual extension of the eruption oc- curs very rarely, however, except in cases where the vesicles are very minute. In general, the eruption is confined to one or two groups when the vesicles are pretty large. About the fourth or fifth day the vesicles either burst and give exit to the included fluid, or they begin to wither and concrete into yellowish scabs, which usu- ally fall off'about the eighth or tenth day, and leave a red and irrita- 514 HERPES zoster. ble surface. When the eruption appears in successive groups on different parts, the disease will of course be proportionably pro- longed; for each, cluster passes regularly through its stages of matu- ration and scabbing. However contiguous the groups of vesicles may be to each other, the intervening skin always retains its healthy appearance.—(Bateman.) Diagnosis.—The only .affection with which the present form of herpes is particularly liable to be confounded is pemphigus; but an attention to the circumstance that the vesicles in pemphigus are usu- ally large, and always isolated—or at least not aggregated in clus- ters; and that they are very rarely attended with a red or inflamed basis, (unless where the bullae are nearly in contact with each other,) will enable us without difficulty to distinguish these affections. Causes.—Children, and young and robust persons, appear to be most liable to this affection; but of its predisposing and exciting cau- ses we have no definite knowledge. Cold, improper nourishment, or an excess of food, grief, watching, and irritation in the primae viae, have been supposed to exercise an agency in its development. 2. Herpes Zoster.—Shingles, Zona. This disease bears a very close resemblance to erysipelas, and was generally regarded as a mere variety ofthis affection, until Willan pointed out its distinctive characters, and placed it with the herpetic eruptions. This form of herpes is characterised by a band of vesi- cles, seated on a red or inflamed surface, commencing usually either in the right hypochondrium or lumbar region, and extending like a belt towards the fore part of the abdomen, without however crossing the median line. In some instances this band of vesicles passes down to the groin; in others it passes upwards to the inferior angle of the scapula, and sometimes extends to the internal part of the arm, "running down occasionally to the cubital border of the hand." This eruption does not often occur on the left side ofthe body; in- deed I have seen but very few instances, of its location on this side. Velpeau,* and Brendel, however, assert the contrary. The former saw but one instance of its occurrence on the right side, out of thirty cases. The majority of writers, nevertheless, affirm that it gene- rally makes its appearance on the right side, and my own experi- ence is strongly in favor of this observation. It has never been found to occur on both sides at the same time. These vesicular zones are composed of irregular groups, from one to two or three inches in diameter; and where the clusters are not very close to each other, the intermediate skin retains its healthy color. The extension ofthe band does not occur by a regular succession of vesi- cles, but by successive new clusters coming out nearly in a line with the first. This, like the preceding variety of herpes, is gene- * Revue Medicale, December, 1828. herpes zoster. 515 rally preceded for a few days with loss of appetite, lassitude, slight headach, nausea, more or less febrile irritation, "together with a scalding heat and tingling in the skin, and shooting pains through the chest and epigastrium." In some instances, however, little or no constitutional symptoms can be perceived.* At first vividly red blotches appear arranged into an irregular belt, a short distance from each other. Upon these inflamed surfaces, a number of small whit- ish points appear, which soon increase in size, and become distinct transparent vesicles "ofthe size and appearance of-small pearls." These vesicles increase in magnitude until the third or fourth day, when they acquire a yellowish or milky appearance, and on the fol- lowing day-begin to shrivel, at the same time that their bases acquire a darker red, or bluish color. The vesicles about this time break and discharge a viscid serous fluid which dries into brownish crusts, which fall off about the tenth or twelfth day. Sometimes excoria- tions and occasionally superficial ulcerations occur, leaving strongly marked cicatrices. The disease does not, however, always pursue this regular course. In some instances the vesicles dry up about the fifth or sixth day— the fluid in them being absorbed—and terminate without scabbing, by desquamation. In old and enfeebled subjects, the eruption has been known to terminate in gangrenous ulceration ofthe skin. Causes.—Zona is most apt to attack young persons;t and it is said to occur more frequently in males than females. (Bateman, Cazenave.) Reil asserts that this affection has never been observed in children under three years old. It seems occasionally to arise from the influence of cold; and some have ascribed its occurrence to irritation of the urinary organs. (Reil.) Disorder or irritation of the primae viae, and perhaps of the biliary organs, has appeared * Cazenave and Schedel observe, " we have seen a great number of instances of zona in the Hospital St. Louis, and have never seen it accompanied with those general symptoms, and particularly of a gastric nature, with which it has been asserted it is always attended; a state of uneasiness, in some rare cases a slight excitement of pulse, heat ofthe skin, a sensation of tension, which is generally painful about the seat of the eruption, acute pain in those parts where the dis- ease terminates in ulceration, aud finally a slight local pain, remaining some time after the eruption has disappeared, (not acute as has been said,) are the only phenomena, which, in a majority of cases at least, accompany this variety of herpes."—Practical Synopsis, p. 104. ■j- We often meet with perplexing discrepancies in the statements of different writers, on points,'too, which are matters of mere observation. Thus in the present instance, Reil's observations are directly opposed to those of Willan, Bateman, Cazenave, and others. " Of the causes of zona, we know at least that those who are most subject to it are old and cachectic persons, with a relaxed skin and visceral disorders." Fieberlehre, bd. v. p. 399. My own observations, however, lead me to the opinion expressed in the text upon this point. 516 HERPES ZOSTER. to me in some instances to be at the root of the disease. It is said to have prevailed epidemically. (Cazenave.) Prognosis.—This form of herpes is but rarely attended with severe symptoms. When it terminates in ulceration it may be- come troublesome; and the occurrence of gangrene, which, how- ever, is very uncommon, will of course be attended with more or less danger, according to its extent and the patient's constitutional vigor.* Treatment.'—The treatment of herpes phlyctenodes and zona, is to be conducted on the same principles. Gentle aperients, a simple and unirritating diet, and rest, will, in general, suffice for the con- stitutional treatment. When there is considerable restlessness, and some degree of febrile irritation, we may prescribe mild diaphore- tics and cooling acidulated diluents. Where there is reason to suspect gastric or biliary irritation, minute portions of calomel and ipecacuanha will be proper. The warm bath will also be useful to allay restlessness and dispose to a regular action of the skin. Occa- sionally the arterial excitement is such as to warrant small abstrac- tions of blood by venesection or leeching. Reil recommends par- ticular attention to the renal functions, and advises diuretics where the urinary secretion is scanty. Where there is much deep-seated pain, we may use full doses of Dover's powder with benefit. Bateman considers external applications unnecessary during its vesicular state; and Cazenave asserts that "they are useless." My own experience has led me to a different conclusion. It is indeed true, that " saturnine and other similar astringent lotions" are of little or no service. I have, however, uniformly found the applica- tion of a solution of lunar caustic, in the proportion of six or eight grains to an ounce of water, when employed soon after the vesicles appear, to arrest the progress of the eruption, and cause desquama- tion in the course of three, or four days at furthest; and sometimes much earlier. I have never known the slightest inconvenience to result from this practice. I keep this solution constantly applied to the affected part, by strips of linen or flannel saturated with it.t M. Velpeau, also, has expressed the most favorable opinion of the powers of this application, in zona. He affirms that when applied before ulceration has taken place, it never fails to arrest the progress of the malady, and so far as he has observed, always without unfa- vorable consequences.^ * In relation to the prognosis of this affection, we find very different sentiments expressed by the old writers. Pliny, Lannge, Dr. Hoffman, and Shulze, con- sidered it as a dangerous disease; whereas Burserius, Vogel, Lorry, and Diel assert the contrary opinion.—Reil, loc. cit. vol. v. p. 400. X The lunar caustic was, I believe, first used as a local application in this af- fection* by M. Geoffroy.—Revue Medicale, April, 1820. X Loc. citat. p. 435. HERPES CIRCINATUS. 517 3. Herpes Circinatus.—Ringworm. This form of herpes is easily recognised by the annular arrange- ment of its small vesicles. It commences with slight redness and itching, succeeded by a circle of minute globular vesicles closely set together, which, when closely examined, are found to contain a colorless fluid. These coronae of vesicles vary from an eighth of an inch to two inches and upwards in diameter, and the larger ones leave the central portion of the skin apparently in a natural state. The vesicles break'in four or five days after their appearance, and are succeeded by little prominent, brownish, and thin crusts or scales, which in the majority of cases fall off about the eighth or ninth day, leaving a red surface which gradually disappears. Occa- sionally the whole disk of the circle is somewhat inflamed, "and a slight desquamation occurs without the formation of vesicles." When the circles are very small, the eruption withers, and gradu- ally exfoliates without the formation of crusts or scales. Although the eruption is seldom protracted beyond the tenth day, yet in many instances new circles of vesicles appear, in succession, so as to pro- long the whole course of the disease for several weeks. The erup- tion is always attended with a troublesome itching and tingling sen- sation. This variety of herpes is most frequently met with in children, and occurs generally on the arms, shoulders, breast, and especially on the neck and face. This disease must not be confounded with a somewhat similar affection which occurs only on the scalp, (porrigo scutulata,) and which is familiarly known by the term hair-worm. This disease is contagious, destroys the hair, and is pustular. Its duration is in- definite and long, and it gives rise to the formation of thick adherent scabs. There is a variety of ring-worm, not noticed in the work of Caze- nave, though described by Bateman, which is by no means uncom- mon in this country, and which often continues for many months, and at last takes up a large extent of surface. It commences with a small circle of vesicles, like the form just described. This circle, however, gradually enlarges its circumference, by the successive appearance of new vesicles around the external margin of the ring, whilst those situated on its internal margin heal and desquamate. Treatment.—The treatment is almost exclusively local. Alka- line washes, such as a lotion of from one to two drachms of subcar- bonate of potash or soda to a pint of water; or solutions of nitrate of silver, sulphate of zinc, or of copper. One of the best applications 1 have met with in this affection, is an ointment made ofthe root of the common narrow-leafed dock, (rhumex crispa,) by boiling the grated root in lard. Mild laxatives should be used if the eruption is extensive. Vol. I.—44 518 HERPES PREPUTIALS. 4. Herpes Labialis. This is a vesicular eruption which occurs on the upper and under lips, and particularly at the outer angle of the lips, extending some- times nearly round the mouth, and occasionally to the cheeks, alae nasi, and chin. In some instances this eruption appears almost sud- denly, without any previous redness or disagreeable sensation in the part; and at others it is preceded by a slight tenderness or pain, inflammation and swelling of the skin, for three or four hours. The lip generally becomes somewhat swollen, hard, stiff, and tender. The vesicles sometimes "attain the size of a small pea, and are filled with a transparent fluid," which soon becomes opaque, acquiring a straw-color, or sero-purulent appearance, during the third or fourth day. In the course of a day more they shrivel, and are succeeded by light-brown scabs, which usually separate on the seventh or eighth day. This eruption is always attended with very consider- able heat and smarting, and great soreness to the touch. This variety of herpes does not often occur as an idiopathic affec- tion. It generally appears on the subsidence of slight febrile affec- tions from cold/ as well as on the declension of other acute diseases, more especially such as are connected with visceral affections. It may in fact be considered, in cases of this kind, as a phenomenon of crisis, for it is a common, and in general not an incorrect observa- tion, that the occurrence of this eruption indicates the near approach of convalescence. In many instances it is accompanied by coryza, and pain or tenderness in the fauces. It may be produced by irri- tating applications to the lips. The only remediate applications necessary in this affection, are such as palliate the burning heat and pain, when these are trouble- some. For this purpose, fomentations, with a decoction of white poppy heads; or cold water, with a small portion of acetate of lead dissolved in it, may be used. 5. Herpes Preputialis. This variety of herpetic disease, occurs on the prepuce, and may readily be mistaken for chancre, to which indeed it sometimes bears a very close resemblance. It begins with one or more red spots, attended by itching, and a sense of slight heat in the part. Small vesicular elevations soon appear on these inflamed surfaces. WThen the eruption occurs on the external surface of the prepuce, the vesicles dry up about the sixth day, and are converted into small, firm scabs, which usually fall off by the end of the ninth or tenth day, and leave the skin underneath sound. When the eruptions occur on the internal surface of the prepuce, they generally break out about the third or fourth day, and form small scales, which soon separate, and leave excoriations, passing PEMPHIGUS. 519 sometimes into superficial ulcerations, with white bases, and slightly elevated edges. If left to themselves, or not irritated, these sores continue nine or ten days before they begin to heal, but when they once commence this process, they usually cicatrise rapidly. This affection may arise from the prepuce being chafed by woollen clothing; from the irritation of morbid vaginal discharges; and par- ticularly from suffering the natural secretions of the part to remain between the glands and prepuce. Treatment.—I have generally employed a solution of borax with much advantage in this affection. When the excoriations are slow in healing, a very weak solution of the nitrate of silver is perhaps the best application. I have used this solution in a number of cases with prompt benefit. The chloride of soda in solution is likewise a very efficacious application in cases ofthis kind. I have lately em- ployed this lotion in two obstinate cases with marked success. It was first recommended by Lisfranc. 1 used this article in the pro- portion of twenty grains to an ounce of water, and applied it five or six times daily. Sect. II.—Pemphigus* The term pemphigus is used to designate a peculiar exanthema- tous affection, characterised by fever, followed in the course of from one to three days with large transparent vesicles, having red and in- flamed bases. The occurrence of such a disease, as an independent or idiopathic affection, has been much doubted by many writers, and some have even denied its existence altogether. Willan, Bateman, Plumbe, Reil, and a number of other writers, contend that the cases which are described by the earlier writers, as acute idiopathic pemphigus, were—typhus, pestilential, or other milder forms of fever, attended by bullae, as mere casual symptomatic and unessen- tial eruptions. Gilbert,! and Biett,J on the other hand, admit the occasional appearance of acute pemphigus, as an idiopathic malady. There can exist but little doubt that many of the cases described by authors as pemphigus, were, in relation to their vesicular character, purely symptomatic; for bullae entirely similar to those which are ascribed to this affection, have been known to occur in diseases ob- viously diverse in their general essential characters. They have * The first distinct account that was given of this disease, is to be found in the writings of Piso (observ. 149) and Morton (tract, de morb. acut.) It has since been described under a great variety of names—such as, febris catarrhalis vesicularis, (Delius. amcenitat. Med. dec. 1;) febris vesicularis, (Macbride and Selle, prax. medic, t. 11. c 18;) febrispemphygodes, (Seeliger, Ephemer. N. C. dec. 1, ann. viii- ob. 56;) febris phlyctenodes, (Burserius;) hydatides, (de morbis a colluvie serosa orta;) febris bullosa, (Bmgmann.) j- Monographic sur le Pemphigus. X Cazenave and Schedel. Pract. Synop. of Cutan. Diseases. 520 PEMPHIGUS. occurred in intermitting fever;* in bilious remittentsjt in dysen- tery;J in typhus;§ in various modifications of malignant as well as in arthritic fevers;|| in hysteric affections;^ and in the ordinary catarrhal fevers, as well as in various other forms of febrile disease. Cazenave states that he saw a case in the Hospital of St. Louis, in which "this eruption was attended not only with gastro-intestinal irritation, but also with a pulmonary catarrh, an ophthalmia, and a very acute inflammation ofthe urethra. All these symptoms, together with the eruption, disappeared in the course of a month." It is difficult to conceive upon what grounds he regards this as a case of idiopathic pemphigus; for in its general course and phenomena it is greatly at variance with his previous description of this affection. Most assuredly, if this case deserves to be regarded as an instance of pemphigus, we may with little hesitation admit the many supposed examples of this disease, which have been reported by different writers (but rejected by Cullen, Willan, Bateman, and Reil) as genu- ine, though modified instances of this affection. Under this per- plexing contrariety of statements and opinions, it is no easy matter to come to any satisfactory conclusion on this head. That the ap- pearance of bullae, or large distinct vesicles, in febrile affections, is often casual or symptomatic, and sometimes apparently critical, is unquestionable;** but it is nevertheless difficult to deny, merely from this general fact, that they may appear in an acute form as an idiopathic or independent malady. Whether, however, this erup- tion be always, or only generally symptomatic, 1 shall now describe it, as it has been observed and recognised for genuine acute pemphi- gus, by several recent writers, who must have been fully acquainted with the doubts expressed on this subject by Cullen, Willan, and others, and who, we may therefore presume, were better prepared to estimate the character of the disease than the early writers. Pemphigus appears under two distinct forms: the acute and the chronic. The latter form is described by Willan, Bateman, and other late writers, under the name ofpompholix. Symptoms of acute pemphigus.—The disease commences with symptoms of general indisposition, or more or less febrile irritation. In some cases, the precursory symptoms amount only to a feeling of general languor and uneasiness, with slight acceleration of the pulse, * Braune. Versuch iiber den Pemphigus, &c. Leipzig, 1795. X Salabert. Abhandl. fur pract. arzte, vol. xiii. X Bontius. De Medic. -Egyptiorum. Rengger. Museum der Heilkunde Zurich, 1794. § Medecine Experimentale. || Hufeland's Journal, \ol. xi. p. 138. % Frank. Epitome, torn. iii. p. 269. ** Frank saw an instance of inflammatory fever, in which, after the fifteenth venesection, a critical pemphigus broke out.—De Curandis, Horn. Morb. L. Ill, p. 265. PEMPHIGUS. 521 and itching ofthe skin. In others, nausea, loss of appetite, slight chills, increased thirst, and great frequency of the pulse, with a hot and burning skin, precede the eruption. At an indefinite period from the commencement of these symptoms—varying from one to four days—the eruption makes its appearance. At first, small red circular spots come out, which speedily increase in size, each one be- coming covered with a transparent vesicle. These vesicles or bullae are of a circular form, and vary from the size of a pea to that of a large hazelnut. Sometimes the bullae are much smaller than the red spots upon which they are seated, leaving a considerable inflamed margin around their bases; at others, they cover nearly the whole surface of the circular spots, with only a very narrow line of red border. Cazenave and Schedel seem to regard these red areolae or bases as invariably present and strongly characteristic of acute pem- phigus. Richter, however, observes, that the bullae sometimes ap- pear to rise out of a sound skin, without the least redness around their bases. Some spots occasionally appear on the skin which do not vesicate; but to the touch they will be found slightly elevated, "and when they are rubbed for a short time, the cuticle becomes detached, and a slight exudation of serous fluid takes place under it." The bullae increase in size during the first twenty-four hours, and the contained fluid, at first limpid, becomes yellowish, and finally turbid.* They sometimes break on the second day; but much more commonly they remain in a turgid state to the end ofthe third or beginning of the fourth day, when the fluid begins to be absorbed, and the vesicles shrivel, leaving either thin brownish crusts, or only " small dry white epidermic lamellae," which in a few days longer separate, exposing pale red surfaces.! If the bullae are broken at an early period, they sometimes rise again, but more frequently super- ficial suppurative ulcerations ensue. (Richter.) The occurrence of the eruption has no manifest influence on the general symptoms, the fever continuing usually without any obvious change until the bullae begin to wither. (Kichter.) The eruption may come out on any part of the body, and either occupy only a particular region, or appear scattered over the greater part, or the whole surface ofthe body. In most instances, however, the bullae are confined, at first to a single part; when these begin to disappear, another crop comes out on some other portion ofthe body; and in * This fluid has been noticed acrid or irritating, like the tears in violent catarrh. Occasionally it is reddish, as if a small portion of blood were mixed with it. Very generally, however, it is perfectly bland and unirritating, at least in the early period of the eruption.—Richter, Specielle Therapie, bd. ii. p. 604. j- The spots left by this eruption are said to be peculiar. " We have several times seen M. Biett draw a diagnosis from them as to the previous existence of bullar eruption, which had been cured some time before. They are of a dull red color, separated from each other, of an irregular form, of variable size, and form slight exfoliations from time to time."—Cazenave and Schedel, I. c. p. 129. 44* 522 PEMPHIGUS. this way, two or three successive eruptions may take place, so as to protract the whole course of the disease, sometimes to a period of between two and three weeks. The internal mucous surfaces, also, are liable to become affected, particularly the mouth, fauces, and oesophagus, and probably the mucous membrane of the alimentary canal. The pompholix solitarius of Willan, is, according to Cazenave and Schedel, a mere variety of acute pemphigus. This is an ex- tremely uncommon form of the disease, and may assume a more or less chronic character, although its usual duration is from eight to ten days.* Willan says that it seems to be entirely confined to females. A sensation of tingling of some portion of the skin is at first felt; this is succeeded by one large vesication, (appearing usu- ally at night,) which is rapidly filled with a transparent colorless lymph. This large bulla breaks in the course of forty-eight hours, and leaves a superficial ulceration. In a day or two a second vesica- tion occurs near the first one, which runs through the same course; and a third or even a fourth one may rise in succession, so as to protract the disease to the ninth or tenth day. (Bateman.) Chronic pemphigus.—Willan and others who deny the existence of acute idiopathic pemphigus, describe the present variety of the disease as a distinct affection, under the term pompholix. They assert that the bullae appear " without any inflammation around them, and without fever." This, says Richter, is not entirely incorrect. In many cases the disease commences with distinct febrile symptoms, which continue occasionally until the first eruption is completed; and in some instances the slight fever reappears afterwards, when- ever a new and numerous eruption of bullae is about to take place.t In almost all cases, the patient experiences a slight degree of lassi- tude, pain in the limbs, and languor, for several days previous to the appearance of the eruption. Nor does the observation that the bullae are always " without any inflammation around them," appear to be correct for in some instances " the secondary eruptions have erythematous areolae." (Cazenave.) The bullae begin by small red elevated points, on the centre of which the epidermis becomes speedily raised. These rapidly enlarge " into irregular vesications, acquiring often in a few hours the size of a hazelnut or even a wal- nut." If they do not break, they begin to shrivel about the third or fourth day, the fluid contained acquiring a reddish and opaque ap- pearance. In a few more, the withered and macerated cuticle dries into thin brownish crusts. If the bullae break at an early period, " the cuticle shrivels, or becoming partly detached, rolls up and lays * Cazenave, Synopsis, &c. p. 124. X Specielle Therapie, bd. ii. p. 613. Reil says that in some cases the febrile symptoms are conspicuous in the commencement, but that these gradually sub- side, leaving only a chronic bullar eruption, which continues often for many months and even years. Loc. cit. p. 428. PEMPHIGUS. 523 bare a portion of the inflamed surface," or separates entirely, and exposes a painful superficial ulceration. (Cazenave.) This affection is generally very tedious in its course, and may con- tinue for several years. A continual succession of bullae occurs on different parts of the body, sometimes in successive crops, and at others in such a manner, that, at the same time, some will be just appearing, others will be large, and distended with a straw-colored lymph, and others again shrivelling, or already converted into small crusts. Occasionally the bullae are so numerous that many of them run into each other, and in this case some of them usually become purulent, and on drying up leave thin yellowish crusts extending over a considerable portion of the body. When the eruption is moderate, the patient does not in general experience much inconvenience from the disease; but in cases at- tended with numerous vesications, and particularly where the lymph is somewhat irritating, a burning and extremely distressing itching is experienced, which in violent cases sometimes obliges the patient to keep to his bed. In some instances the vesicles are early attended with severe burning pain, become filled with a red acrid humor, and terminate in superficial suppurative ulcers, which heal very slowly. Reil ob- serves, that bullae, containing bloody lymph, occur only about the ears, where previous vesicles have already occurred.* Wichmann relates a case, in which, nine months after the commencement of the disease, he found the patient extremely tormented and debilitated by a great number of large ill-conditioned ulcerations on the lower extremities and sacral region. The ulcers appeared red, and the surrounding skin as if it had been scalded with hot water.! A some- what similar case is mentioned by Cazenave and Schedel. This affection may occur simultaneously on every part ofthe body; but in most instances the vesications are confined to a particular space. In the palms of the hands and soles of the feet they occur but very rarely. They have been observed on the internal surface of the mouth, the fauces, oesophagus, and the alimentary canal; in these situations they soon assume the appearance of aphthae. The tongue and fauces occasionally become excoriated in cases of this kind. Colic; constipation; bloody and mucous alvine discharges; nausea; vomiting, or haematemesis, have been known to supervene in cases where the disease affected the alimentary canal. (Wich- mann, Reil.) " At times, it would seem as if the eruption on the external and internal surfaces alternated—the symptoms of the latter increasing as those of the former decrease, and vice versa."\ Both Wichmann and Braune relate cases in which the mucous membrane * Fieberlehre, Bd. v. p. 418. j- Beitrag zur Kenntmiss des Pemphigus. ± Braune. Versuch uber den Pemphigus und das Blasenfieber. Reil, 1. c. p. 420. 524 PEMPHIGUS. of the bronchiae became affected during the progress of this malady. Several instances are mentioned in which cough and purulent expec- toration came on. Cause.—Of the etiology of pemphigus there is as yet but little known of a satisfactory or definite character. It is said to be more common in old than in very young individuals, and in women than in men.* Braune supposes that this affection is frequently depend- ent on deficient or disordered urinary secretion; (1. c. p. 59.) Ha- bitual deficiency of this secretion, and obstinate chronic cutaneous disorders, are indeed not unfrequently associated affections. In one ofthe instances of chronic pemphigus mentioned by Braune, the in- timate connection between the action ofthe kidneys and the cutane- ous affections was manifested in the clearest manner. Whenever the urine flowed freely, the bullae disappeared; but they invariably re- appeared when this secretion became scanty, watery, and muddy. Renal calculi were discharged from time to time with the urine. Richter, Wichmann, and Reil, also admit the frequent occurrence of renal disorder in pemphigus. It would seem also that disorder of the liver is a frequent attendant on this disease—whether as cause or effect, is not known. Biett, in his dissections in the Hospital St. Louis, several times met with structural disease of the liver, in per- sons who had died under this disease. (Cazenave.) The irritation of dentition; neglect of personal cleanliness; a defi- cient and coarse diet; habitual exposure to a damp atmosphere; and chronic visceral affections, would seem sometimes to favor the de- velopment of the disease. It arises, however, often, without any perceptible cause, either predisposing or exciting. It is said to have occurred endemically. The same individual may be affected with it several times, at distant intervals. This disease in not contagious. Hall inoculated with lymph taken from the bullae without effect.t Diagnosis.—Acute pemphigus is liable to be confounded with rupia simplex, ecthyma and herpes phlyctenodes. From the first of these affections it differs, by the bullae in rupia being few in num- ber, and followed by ulcerations, upon which thick and projecting scabs are formed. It is distinguished from the second by the bullae in ecthyma being less elevated, and filled with a purulent fluid, having a brownish spot in the centre of each. From the last disease it may be distinguished by the vesicles in herpes always appearing in clusters seated on a diffused red and inflamed surface. Although several bullae in pemphigus are occasionally found collected in one or more groups, yet distinct bullae appear elsewhere on the body, which is not the case in herpes. Prognosis.—The acute form never terminates fatally unless dan- * This at least is in conformity with the observations of Reil and others. Ca- zenave, on the contrary, says that the chronic form of the disease " rarely occurs in women." X Duncan's Annals of Medicine, for the year 1799. PEMPHIGUS. 525 gerous secondary affections supervene. In relation to the probable duration, ultimate violence, and obstinacy ofthe chronic form ofthe disease, the prognosis is in general very uncertain. Some cases con- tinue moderately for eight or ten weeks, and then disappear; others, apparently equally mild during the first four or five weeks, gradually acquire more and more severity, and continue for many months in an aggravated and very distressing form, and may even terminate fatally. The degree of danger depends, of course, in a great mea- sure, on the extent of the eruption, the obstinacy of its progress, the nature of the visceral affections with which it may be complicated, and the degree of constitutional vigor of the patient. When the vesications assume a livid or bluish appearance, there is much reason to apprehend unfavorable consequences. (Reil.) Old, worn down, relaxed, arthritic, and nephritic subjects, are most apt to suffer se- verely from this aflection. Treatment.—In the acute form of the disease, it will in general be sufficient to put the patient on a simple and unirritating diet; to prescribe an occasional mild laxative; cool acidulated diluents; rest; and to avoid a humid and variable atmosphere. If inflammatory symptoms supervene, or the eruption is very extensive, a more active antiphlogistic treatment is required. Gentle purgatives; the ordinary saline diaphoretics, particularly the alkaline effervescing draught (potio Riverii); tepid bathing; and venesection, must be used with an energy corresponding to the degree ofthe general and local inflammatory excitement present. Richter recommends calomel in such cases above all other aperients. He also advises the use of diuretics, if the disease manifests a disposition to continue beyond its ordinary course—and of these, he says, digitalis is the best, squills being, according to his experience, objectionable. All local applications must be avoided, nor should the vesicles be disturbed or opened. Cazenave recommends the application of leeches to the anus. In chronic pemphigus, (pompholix,) we should in the first place endeavor to ascertain whether any visceral or other general disor- ders co-exist, or preceded the eruption. Should there be grounds for presuming the presence of a syphilitic taint, or of an arthritic or calculous diathesis, or finally of hepatic or some other visceral affec- tion, recourse should be had to remedies suited to counteract the lurking affection. (Richter.) In general, a moderately antiphlogis- tic treatment—such as acidulated diluents, mild aperients, and tepid baths, will be proper in the commencement. The German writers speak very favorably of the employment of diuretics in this variety of the disease. They are particularly indicated where the urinary secretion is scanty or unnatural. Richter says that he cured an in- veterate case in a short time by the following mixture,* in conjunc- * R.—Extract, digital, purpur. gr. iii.—iv.—vi. Submuriat. hydrarg. mitis gr. i. 526 URTICARIA. tion with the free use of an infusion of juniper berries. The same writer recommends dulcamara, in union with antimony* Lime- water in large portions: infusions of herba jacea; sarsaparilla, preci- pitated milk of sulphur; belladonna; and opium, have all been men- tioned as remedies in this affection. I have met with but one case of chronic pemphigus. It continued for six months, under various modes of treatment, and at last disappeared under the use of Fowler's arsenical solution. When diarrhoea, with more or less obtuse ab- dominal pain, supervenes, opium is particularly serviceable. When pulmonary irritation occurs, attended with frequent and violent cough, spitting of blood, and oppressed respiration, local and general bleeding becomes necessary, after which opium and calomel may be administered with benefit. When, by the long continuance and severity of the disease, the strength of the patient is exhausted, or when the disease occurs violently in old, relaxed, and worn down subjects, quinine, with the sulphuric acid; a nourishing diet; occa- sional opiates; chalybeate preparations; and other supporting reme- dies, should be employed. Cazenave and Schedel state that they have observed several examples in the Hospital St. Louis, of the very good effects of tonic remedies even in young subjects, where the eruption was of long continuance. Sect. III.— Urticaria.—Nettle-rash. The nettle-rash, a very common cutaneous affection, is character- ised by hard elevations of the cuticle, of irregular forms, with a pale or whitish centre, and generally a diffuse redness around their mar- gins, attended with intolerable itching, and a stinging or smarting pain. Its course is often very rapid, the eruption appearing suddenly, and vanishing again in the course of a few hours; although in such cases it usually reappears for several days in succession. It may also assume a chronic character, and continue with occasional tran- sient intermissions or remissions for many months, or even years. Urticariafebrilis.—Symptoms of general indisposition, such as nausea, languor, drowsiness, slight chills, headache, anorexia, pain and anxiety in the epigastrium, with an accelerated pulse, precede the appearance of the eruption. At first, a general itching with a Opii puriss. gr. ss. Sacch. albi gr. xv.—M. Divide into twelve equal parts. S. Take one three times daily. The proportion of digitalis should be gradually increased. If the gums become affected, the use of the medicine must be suspended for a while.—Loc. cit. p. 615. * R.—Antimon. crud. nigri. Pulv. stipit. dulcamar. aa ^i. Extract, trifol. aquat. 3H.—M. Divide into two grain pills. S. Take ten three times daily URTICARIA. 527 feeling of tingling heat is felt over the whole body; to relieve which, the patient is apt to rub or scratch the skin, which never fails to bring out, almost instantaneously, large patches of red elevations or wheals, with whitish central disks and irregular crimson areolae, attended with an extreme degree of itching and tingling. The erup- tion speedily becomes more or less extensively diffused over the surface, particularly on the palmar aspect of the fore-arms, around the knees, along the loins, on the inner part of the thighs, and on the shoulders. The eruption vanishes irregularly on different parts of the body, but is almost immediately recalled " on any part of the skin, by strong friction or scratching." During the day the erup- tion subsides, but as the evening approaches, it returns, together with slight febrile irritation; and in, this manner the disease is usu- ally protracted to the sixth or seventh day, before it finally subsides. The parts principally affected become swollen and uniformly red; but the swelling always soon subsides after the eruption disappears. More or less languor and febrile irritation accompany the disease throughout; " the disorder of the stomach, however, is relieved by the appearance of the eruption, but returns whenever the eruption reappears." (Bateman.) Urticaria evanida.—This variety of the disease is unattended by fever, and often continues for many months under a succession of transient wheals, appearing here and there on the body, and vanish- ing again in a few hours, at short and irregular intervals. An erup- tion will perhaps appear on one arm in the morning, and disappear again in a few hours; in the afternoon, the wheals may come out on the legs and remain for a short time; and after a short interval, or only on the following morning, they may appear on the body. In this way the disease may go on to a very protracted period—the eruption appearing and disappearing frequently, "according to the temperature of the air or the exposure of the patient, and the degrees and kind of exercise which he uses." The slightest friction or scratching will almost immediately bring out the wheals on any part of the body; but when thus excited, they usually recede again in a very short time. The eruption consists of irregular patches slightly raised and firm to the touch, or of elongated wheels, " like those produced by the stroke of the whip, or they are round, resembling the firm, elevated tumors produced by the bite of a mosquito." Thesewheals arenot surrounded by an erythematous areola, although sometimes encircled by a very narrow and faint streak of red. They are always attended with violent itching, and a sensation of tingling or stinging pain, more particularly " on undressing and get- ting into bed." Languor, headache, transient pains, and derange- ment of the digestive functions, are apt to occur during the course of the disease; but in some instances scarcely any symptoms of con- stitutional or sympathetic disorder, except the cutaneous affection, attend. " Its course varies from a few days to many months, and even years." (Bateman.) 528 URTICARIA. Urticaria tuberosa.—This rare variety of the disease is charac- terised by hard, prominent wheals, or tuberosities, attended with deep-seated pain, tension, and difficulty of motion. The eruption occurs chiefly on the loins and on the extremities. It generally comes out at night, and disappears before morning, leaving the pa- tient " weak, languid, and sore, as if he had been bruised or much fatigued." Cazenave and Schedel state that they saw at the Hospital St. Louis, an instance accompanying a quotidian fever which, after having lasted for four years, finally terminated " in swellings, great distension, ecchymosis, ruptures and ulcerations." Some paroxysms were attended with so much general tumefaction, as to produce op- pressed and hurried respiration, a livid and puffed face, weak and intermitting pulsation of the heart, and other very alarming symp- toms. Urticaria subcutanea.—In this variety the wheals seem, as it were, to lurk beneath the skin, and make their appearance only at distant intervals. An almost constant tingling sensation, however, is felt in the skin, with occasional severe pricking sensations, as if needles were thrust into the surface, limited at first to a single part, but extending afterwards to others. Individuals affected with this variety of the disease, are apt to suffer frequent pain in the stomach, and cramps in the muscles ofthe legs. (Bateman.) Causes.—Urticaria is most commonly met with in children, young females, and in persons of a sanguine and nervous temperament. The seasons most favorable to its occurrence are spring and sum- mer. Some individuals are so strongly predisposed to the disease, that the least friction or scratching almost immediately brings out large wheals. The irritation of dentition, mental excitement, and various articles of food, such as strawberries, raspberries, mush- rooms, honey, oatmeal, green cucumbers, almonds, dried or smoked fish, lobsters, shrimps, crabs, and particularly ?nuscles, are apt to produce febrile urticaria in some individuals. The internal use of valerian and balsam copaiba produce extensive urticaria in some persons. Chronic urticaria is frequently connected with an irritable and deranged state of the digestive functions. The tuberous variety " seems to be excited by excess in diet, overheating by exercise, and the too free use of spirits." Urticaria is also produced by direct irritating applications to the skin, particularly by the leaves of the common nettle (urtica dioica) and by the contact of certain caterpillars, as the phalsenaprocessionacea. It occurs sometimes in the course of various febrile diseases, and is often speedily produced by taking a draught of cold water after the body has been excited or heated by exercise. In many instances, however, the disease makes its appearance without any manifest exciting cause; and its occa- sional dependence on peculiar idiosyncrasy or constitutional habit is unquestionable. In children it often occurs during the process of dentition, or apparently from acidity in the primae viae, and is in them usually called hives. URTICARIA. 529 Prognosis.—Although often an extremely tormenting affection, from the intolerable itching and stinging pain which attend, urticaria is almost universally wholly devoid of dangerous consequences. Werlholf, indeed, observes, that it has in few instances terminated fatally; but death probably occurs only where the eruption is secon- dary, and associated with some other more serious malady. Richter says that in children the disease is sometimes accompanied with great difficulty of breathing. The sudden recession of the eruption does not appear to give rise to any unfavorable consequences. Treatment.—In the febrile variety of the disease, advantage may sometimes be obtained from an emetic of ipecacuanha. Richter states that the operation of an emetic will occasionally put a speedy stop to the progress of the disease. In general, however, one or two mild laxatives, rest, simple diet, cooling drinks, and the occa- sional use of the tepid bath, will be sufficient. Where there are symptoms of acidity in the primae viae, magnesia or alkaline reme- dies, particularly lime-water, will be proper. When the disease occurs in irritable and debilitated subjects, or in persons of weak and disordered digestive powers, benefit may be derived from moderate doses of quinine, sulphuric acid, and the usual preparations of- iron, after the alimentary canal has been evacuated by emetic and laxative remedies. Reil says, copious draughts of cold water often produce a very good effect. In the chronic variety of urticaria, particular attention should be paid to the diet; for, in some instances, it would seem to depend on some article of food rendered oppressive or irritating to the stomach by constitutional habit or idiosyncrasy. "I have," says Willan, " desired several persons affected with chronic urticaria, to omit first one, and then another article of food or drink, and have thus been frequently able to trace the cause of the symptoms. This appeared to be different in different persons. In some, it was malt liquor; in others, spirit or spirit and water; in some, white wine; in others, vinegar; in some, fruit; in others, sugar; in some, fish; in others, unprepared vegetables." Almost all the useful diaphoretic alterative remedies, such as sarsaparilla, the root of burdock, the golden sul- phuret of antimony, dulcamara, Lisbon diet drink, &c, have been at times recommended, but they rarely appear to afford any particular advantage. Fowler's solution, however, is a very efficacious remedy in the chronic form of the disease. It is mentioned by Cazenave as having been successfully used in a very obstinate and distressing case of this kind. Dr. Dewees has used it frequently with success, and I have myself employed it in a few obstinate cases with the hap- piest effect. To relieve the extreme itching, various external applications have been recommended. Vinegar and water, or lemon juice diluted with water, will sometimes procure considerable relief. The tepid bath, also, may be used as a palliative for this purpose. Sea-bathing, or washing with salt water, has been used with good effect, both as a Vol. I.—45 530 MILIARIA. palliative and a curative means. Dusting the affected part with rye- meal or hair powder, gives some relief from the itching and ting- ling. Sect. IV.—Miliaria.—Miliary Fever. This is a febrile affection, characterised by an eruption of acu- minated vesicles, of the shape and size of millet seed, more or less thickly scattered over the surface ofthe body. These minute vesicles are at first red, and surrounded with erythematous areolae, which run into each other when the eruption is copious, and give a uniform vivid redness to the surface, (milaria rubra.) In the course of from twenty-four to forty-eight hours, they enlarge, and the contained fluid becomes whey-like, giving them a white or pearly appearance, (miliaria alba.) When the vesicles are very numerous, some of them unite, and form here and there vesicles of the size of a pea; and on some parts they are closely grouped into irregular patches of various sizes. In a few instances, some of these confluent vesicles become filled with a purulent fluid, (miliariapurulenta.) In some cases the eruption retains its red color throughout; and occasionally the vesicles are white from the commencement. The miliary eruption appears in general as a symptomatic exan- theme in various forms of fever; " in continued, remittent, inflamma- tory, and contagious, as well as other diseases;" and it has been much doubted whether it ever occurs as an idiopathic or independent malady. Bateman says, that "it is perhaps invariably symptoma- tic;" and this would seem to be the general sentiment at the present day. Cazenave, nevertheless, asserts," that there are instances where it is idiopathic, as when it occurs in persons in good health after violent exercise during the heat of the summer;" and Richter ex- presses the same opinion. The appearance of the eruption is almost always preceded by pre- monitory symptoms; such as a sense of anxiety in the epigastrium; weight and oppression in the breast, accompanied with a short dry cough; pains in the loins and extremities; a benumbed prickling sen- sation in the fingers; stinging, itching, and burning pain in the skin; a small, frequent, contracted, and tense pulse; cephalalgia; vertigo; ringing in the ears; and a feeling of heaviness in the head, creeping chills; disposition to syncope; palpitation; twitching of the tendons; delirium. The most characteristic phenomenon, however, is the pro- fuse sour rank sweat, which is said almost invariably to occur just before and during the appearance of eruption. Sometimes, however, the miliary veiscles come out without any precursory symptoms whatever.* The eruption always appears first on the neck, breast, and on the inner surface of the arms; and then successively on the abdomen, back, and inferior extremities. The duration of the erup- * Richter, Specielle Therapie, Bd, ii. p. 541. MILIARIA. 531 tion is very variable. In some instances it disappears as early as the fifth or sixth day; but in the majority of cases desquamation does not take place until the ninth or tenth day, and occasionally not until a still later period. Not unfrequently the eruption of vesicles is re- peated twice, thrice,1 and even a fourth time, so as to protract the whole course of the disease to the sixth or seventh week. In most instances new vesicles appear daily for five or six days, and longer. This eruption appears to be peculiarly liable to recede from the slightest causes; and the consequences of a sudden retrocession are often extremely alarming. Great anxiety in the precordial region; extreme restlessness; increased febrile irritation; violent delirium; coma; or strong pulmonary congestion with distressing dyspnoea, are among the consequences which are apt to result from this accident. If under these symptoms the eruption do not reappear, or copious diarrhoea, or some other evacuation, do not ensue, a fatal termination will be almost inevitable. (Richter.) This eruption does not appear to be the effect of critical effort in the system, or in any degree to diminish the general symptoms, if we except those miliary vesicles which sometimes occur towards the termination of rheumatic fever and gout.* Causes.—That the miliary eruption is, generally, an artificial dis- ease, has been long ago fully established. In the latter part of the seventeenth, and the commencement of the eighteenth century, when the alexipharmic or heating and sweating plan of treatment was so much in vogue on the Continent, miliary fevers of the most fatal character were among the most frequent diseases. As soon as the antiphlogistic and cooling method of treating febrile affections, be- came more universally adopted, the miliary disease was but rarely observed; and it is now almost an unknown affection, except in its mildest form. By a stimulating, sweating, and heating treatment miliary vesicles may be produced in every variety of febrile disease; and as such a plan of treatment is peculiarly apt to render even mild and manageable fevers dangerous and malignant, we may readily conceive how fatal the diseases must have been which were thus fo- mented into the miliary eruption. Sometimes, however, miliary vesicles make their appearance in acute diseases under the best regu- lated antiphlogistic treatment; and there can, I think, exist but little doubt, that an eruption of this kind appears at times as an idiopathic disease. I have seen but few instances of this kind; but one case which came under my notice within the present year, was apparently of this nature. The patient, a child, complained a few days of slight indisposition, which was followed by an eruption of innumerable red points or vesicles. On the second day they became more dis- tinctly vesicular and whitish, and continued until the fourth day before desquamation began. There was throughout the disease a constant moderate perspiration. * Stoerk, Barretta, Dissert, de Miliaris Natura, &c. as quoted by Richter. 532 LICHEN. Cazenave and Schedel observe, that " in certain cases of violent en- tero-colitis, accompanied with general debility, the miliary eruptions, which often occur at night during the paroxysms, present the next day a complete vesicular appearance, and the portion of skin which they cover, is destitute of redness, and appears as if a multitude of minute drops of limpid water had been sprinkled over its surface." The affections in which the miliary eruption is most apt to occur, are: puerperal fever; gastro-intestinal irritation or inflammation; in- flammation ofthe serous membranes; rheumatism; and Richter says that females affected with severe leucorrhoea are particularly liable to this affection on the occurrence of febrile irritation. The occur- rence ofthis eruption is said to be favored by a confined and damp atmosphere; excessive sanguineous and mucous discharges; insuffi- cient and innutritious diet; acid and other irritating substances in the alimentary canal; and intemperance. Treatment.—The attending fever must be treated according to its character and symptoms, without any regard to the miliary exan- theme. In general the febrile irritation is sthenic, and requires an antiphlogistic treatment, and cooling regimen. In short, where the eruption is symptomatic, we must prescribe for the original malady, and not for the cutaneous aflection. The idiopathic cases are mild, and require little more than gentle aperients, cooling drinks, and free ventilation, without, however, exposing the patient to a cold or hu- mid air. The diet, of course, must be mild and unirritating; and in instances which manifest much gastric derangement, a gentle ipecacuanha emetic may be given with advantage. When the eruption recedes, and unfavorable symptoms ensue, we should endeavor to recall it to the surface by warm bathing and mild diaphoretics—such as Dover's powder; and where the arterial action is low, by the inter- nal use of carbonate of ammonia, infusion of serpentaria, camphor, and opiates. Sect. V.—Lichen. This affection is characterised by minute firm elevations or pim- ples, (papulae,) generally appearing in clusters, usually of a white color, sometimes red, and attended with considerable itching. Sys- tematic writers describe many varieties of the disease. Lichen simplex.—The disease almost invariably commences with transient flushes of heat in the face; lassitude; a slightly accelerated pulse and occasionally severe headache; weakness; painful sensations in the stomach, and general febrile irritation. The eruption consists of red and inflamed miliary pimples, attended with heat and itching. In three or four days the redness begins to fade, and on the follow- ing day desquamation commences, which is usually completed in three or four days more, unless successive crops of papulae appear, which sometimes occurs. In the chronic variety of simple lichen, LICHEN. 533 the pimples are usually white, and but slightly or not at all inflamed. The eruption is preceded by,moderate itching. The papulae are seldom very perceptible, but in passing the hand over the skin it receives the sensation of a slight roughness from the small firm ele- vations on the surface. Its course is tedious, and of uncertain dura- tion, lasting often several months. The skin becomes thickened, and at last exfoliates in large scales. Acute lichen occurs most com- monly on the face and body; the chronic, on the extremities, more especially on the back ofthe hands. In irritable habits it sometimes returns every summer. Persons subject to gastric pains and headache, are sometimes affected with this eruption, as if by crisis, when these affections go off*. (Bateman.) Sometimes the pimples occupy the roots of the hairs of the skin. (L. pilaris.) And in this case the disease generally continues long. In some instances the papulae appear in patches or groups, well de- fined, and approaching to the circular form. (L. circurnscriptus.) These spread at the same time that the central part heals and exfoli- ates, remaining, however, slightly red and scurfy. Occasionally the patches are livid, the pimples being soft and flat. (L. lividus.) These are sometimes mixed with dark red or purple maculae from sanguineous extravasation, occurring most commonly on the lower extremities of relaxed debilitated subjects. The eruption is some- times disposed into the form of a long stripe or band, extending in a spiral manner round an extremity. (L. gyratus, Biett, Cazenave.) At times the eruption consists of larger pimples than the usual size. (L. urticatus.) They are inflamed, prominent, large, confluent, " and resemble the stings of a nettle." They come out suddenly on the face or neck, particularly in young persons and females in the summer. A burning pain and considerable itching attends. They usually disappear in a short time, but often return at irregular intervals. (Cazenave and Schedel.) Infants at the breast are sub- ject to a modification of this eruption, (L. Strophulus,) in which the papulae are "either redder or whiter than the skin, and attended with great itching, which is much increased by the heat of the bed." It is acute in its character, and subject to distinct exacerbations. (Cazenave.) Lichen agrius.—This is conspicuously febrile; the eruption con- sists of a multitude of vividly red miliary pimples, aggregated into large patches, seated on a diffused erythematous surface. Itching, heat, and a sense of painful tingling, greatly increased by the heat of the bed, by active exercise, and stimulating ingesta, are experienced. Morning remissions and evening exacerbations occur. The skin around the patches are generally painful and somewhet swollen. The eruption and general symptoms usually increase until about the fourth or fifth day, when small ulcerations appear on the summit of the pimples, discharging a sero-purulent fluid, which concretes into small, yellow, prominent crusts. These finally fall off, and are suc- ceeded by thin scales. The disease usually continues from twelve to 534 LICHEN. fifteen days. The itching and stinging sensation in this variety of the disease is often extremely violent. In many instances the erup- tion appears and disappears several times before it finally goes off". The skin of the affected parts generally, at last, becomes harsh, chappy, and extremely painful when rubbed. This variety may ter- minate in impetigo, a chronic pustular affection. (Bateman.) When the eruption recedes, from exposure to cold, it is apt to be followed by an increase of fever, headache, vomiting, and colic pains. Simple lichen may assume this form of the disease. L. agrius is most apt to occur in young persons of vigorous and sanguineous habits. (Caze- nave.) Lichen may also acquire a chronic character. In this case the cuticle becomes harsh, hard, full of fissures, dry, and rough, par- ticularly in the hollow of the articulations. Causes.—Lichen occurs in persons of all ages, and in both sexes. Summer and spring are the seasons most favorable to its occur- rence. High temperature, particularly the heat of the sun, is apt to excite it. Mental affections, stimulating potations habitually in- dulged in, gastro-intestinal irritation, and internal inflammations, are mentioned among its most obvious causes. Diagnosis.—Simple lichen may be distinguished from eczema by its acuminated, solid, and very prurient pimples; the eruption of eczema consisting of transparent vesicles, attended only with slight smarting pain. From scabies, lichen may be known by the distinct vesicular character of the former, and its usual location on the bends of the joints and between the fingers. The vesicles of lichen are aggregated in clusters. From prurigo, lichen is distinguished by the flat, irregular appearance of the papulae in the former, and their being usually lacerated, and covered with small blackish crusts. The itching and burning of prurigo is always extremely distressing; in simple lichen it is generally slight. (Cazenave.) Lichen circum- scripta sometimes resembles herpes circinatus; but may be known from it by the red, or more strongly inflamed state of the skin sur- rounding the margin of the latter; and the distinct papular character of the former, both in the centre and at the border of the patches; whilst in herpes the central disk is free from vesicles. Lichen ur- ticatus may be mistaken for erythema papulatum, or syphilitic lichen. The diagnosis between them consists in the large size of the erythematous patches, their pale-red color, the almost entire absence of itching, the less prominence, and their not appearing and disappearing several times in succession. The copper color of the papulae of syphilitic lichen, their freedom from inflammation and much itching, and their slow progress and long continuance, distinguish it from L. urticatus. From chronic eczema lichen agrius is often not easily distinguished. The presence of lichen, however, may be known by the great itching, roughness and thickening of the skin, and the appearance here and there of distinct pimples. Prognosis.—Lichen is never a dangerous, but sometimes an ex- tremely troublesome and disagreeable affection. The precursory LICHEN. 535 fever is seldom so great as to keep the patient confined, and in the majority of instances it is wholly absent. By violent friction and scratching, and sometimes spontaneously, severe excoriations and burning pain occasionally occur, which are almost always difficult to remove. When the eruption is repelled by improper applications, or by other injurious influences, as cold, severe fever, internal in- flammations, great heat, thirst, fixed pains in the abdomen, vomiting, &c. sometimes ensue. Treatment.—In the simple variety, tepid bathing; mild aperi- ents; diluent acidulated drinks; abstinence from heating drinks, food and exercise; are all that is necessary to prescribe. Dry, irri- tating applications are improper—particularly sulphur, and the me- tallic oxydes. To relieve the severe itching and burning in the affected parts, we may apply cream, or wash the part with flaxseed tea, or some other mucilaginous fluid. When the affected parts be- come very red and irritated, attended with constant stinging pain and itching, a laxative dose of calomel may be given occasionally, and fresh, unsalted butter applied. In the chronic forms ofthe dis- ease, alkaline and sulphurous baths, mild laxatives,* tepid bathing, at first with the water of scalded bran, "and afterwards with water rendered alkaline by adding subcarbonate of potash, in the propor- tion of half an ounce or an ounce to four or five pounds of water.'' Cazenave advises, in severe cases of this kind, anointing the erup- tion with one of the following ointments.t During desquamation, the internal use of the diluted sulphuric acid is often beneficial. The treatment must be more active, however, in lichen agrius. Here sanguineous evacuations, both topical and general, are often necessary in the beginning of the complaint; but when blood is drawn by topical means, it must be taken from a sound part of the skin. (Cazenave.) Low diet, laxatives, diluted nitric or sulphuric acid taken internally, laxative doses of calomel, alkaline sulphurous baths in the decline of the malady, the internal use of Fowler's solu- tion, with a gradual increase of*the dose, until it produces gastric disturbance, are the means generally relied on in cases of this kind. * R.—Calomel gr. xii. Hydrarg. sulphur, nigr. gr. xxxvi.—M. Divide into 12 equal parts. S. Give one every other evening to a child of from 2 to 7 years old, with a small dose of ol. ricine on the following morning. | R.—Calomel ^ss. P. camph. gr. xii. Axungiae %i.—M. f. Or— J$.—Protoioduret hydrarg. gr. xii. to 3i. Axungiae §i.—M. f. 536 ECZEMA. Sect. VI.— Eczema. Eczema is a vesicular eruption, which occurs both in an acute and chronic form. Cazenave and Scbedel divide acute eczema into three varieties, namely, E. simplex, E. rubrum, and E. impetiginodes. 1. E. simplex.—The eruption consists of innumerable small, closely approximated, transparent vesicles, without any surrounding inflammation, distributed over a greater or less extent of the surface —the skin every where retaining its natural color. No premonitory symptoms, but only a slight itching, precede the eruption. The fluid in the vesicles soon becomes opaque, and after a short period is ab- sorbed; the vesicles then shrivel, and the cuticle desquamates slowly. It never spontaneously gives rise to inflamed surfaces. This eruption is usually local, or confined to certain parts—commonly the arms and between the fingers, and being attended with severe pruritus, may be mistaken for the itch. Heating and irritating applications to the skin often produce this affection. " It often appears between the fingers of women in child-bed;" and in persons who are much exposed to the heat of a fire. It is sometimes associated with itch, and appears to be excited by the irritating remedies usually employed for the cure of that affection. 2. Eczema rubrum.—Heat, stiffness, and some tingling in the skin, precede the eruption in this variety. The affected surface is inflamed and vividly red, covered with very minute acuminated pimples, of a shining white or pearly hue. After some time, vesicles of the size of a pin's head, surrounded with distinct red areolae, appear on the af- fected parts. In the course of six or seven days, the contained fluid is absorbed, the vesicles shrivel and desquamate, leaving a pale red surface, sprinkled with minute rounded papulae, each rising from a small whitish disk. In some instances the cutaneous inflammation increases, and continues beyond its ordinary duration; the vesicles become confluent, break, and discharge an irritating fluid, which causes superficial excoriations; and at last, concrete into large, thin, pliant scales, leaving inflamed surfaces on falling off. 3. Eczema impetiginodes.—Violent inflammation, swelling ofthe affected parts, and vesicles generally congregated or confluent, filled with a sero-purulent fluid, are the principal characteristics of this variety of the disease. These purulent vesicles soon break, and the fluid concretes into soft, yellowish, and often extensive scales, or thin crusts. When these fall off, they leave red surfaces, exuding a red- dish fluid, which dries into thin laminae. The eruption is commonly confined to a particular part, or even a single spot. Occasionally, however, it occurs over the whole body, and is attended with con- siderable fever. The disease may continue from ten to twenty days, and upwards. The vesicles are generally transparent at first, and be- come pustular afterwards. This variety al>o sometimes assumes a chronic character, resembling then the chronicstateof eczema rubrum. ECZEMA. 537 4. Chronic eczema.—When acute eczema is very severe, it often terminates in chronic excoriations and fissures ofthe skin on differ- ent parts of the body, particularly in the bends of the knees and elbows, and about the axillae. The parts thus irritated and inflamed, exude an abundance of serous fluid, which causes the linen to adhere to them. In this state it usually remains for several months, the dis- charge continuing undiminished. In some instances, the exuded se- rum dries into soft, yellowish, and thin crusts, leaving an inflamed and nearly dry surface when they fall off. " These crusts form at greater intervals; they become drier, and the disease seems on the point of disappearing, when on a sudden, and without any assignable cause, the inflammation acquires greater intensity." New vesicles arise which, like the former, soon break and discharge their fluid; "and the affection goes through the same course, and the disease may thus last for years." (Cazenave.) Sometimes, the thickened, red, fissured skin, remains dry, and the crusts are drier, more firmly attached, and of a brownish yellow hue; leaving but a slightly red surface when they separate. Occasionally, indeed, the skin for a long time remains vividly red, cracked, with dry scales of altered cuticle thinly scattered over the surface. Chronic eczema commences on a limited portion of the skin, often not above a few inches in diameter, and spreads afterwards over a greater or less extent ofthe surface. The itching is always very great, and returns,by spells, causing an irresistible desire to scratch. The parts furnished with hair, the region ofthe pubis, the arm-pits, groin, scrotum, pudendum, and the bends of the joints, are most apt to become the seat of eczema, although every part of the body may become affected with it. Causes.—Though not contagious, yet instances do occasionally occur, in which this disease is communicated from one to another by protracted contact. (Biett, Cazenave.) It occurs more frequently in women than in men, and in the warm than the cold seasons. Its general cause is unknown. It may be excited by direct irritating applications to the skin, as a blister, sinapisms, turpentine valerian root, the rays ofthe sun,* dry frictions, and irritating ointments, lime, and sugar.t The use of mercury, when long continued, sometimes produces a very severe variety of eczema. Diagnosis.—Simple eczema often greatly resembles itch. They may be distinguished by the following circumstances. In eczema, the vesicles are flat or rounded; in itch, pointed; in the former they are nearly or entirely in contact with each other; in the latter, they are single and considerably separated. The itching of eczema is at- * The prickly-heat or heat-spots are classed with this variety of eruptions. (Willan.) + Persons who are in the habit of handling or working in sugar are liable to an eruption of this kind on the hands, called the grocers' itch. (Bateman.) And bricklayers are subject to a similar affection from the irritation of lime. 538 ECZEMA. tended with smarting pain; in itch, the pruritus "is rather agreeable than painful." The impetiginode variety of eczema has been confounded with impetigo. The former, however, occupies large spaces, the latter usually small ones. The eruption in impetigo is strictly pustular from the beginning. In eczema impetiginodes, it is vesicular at first, the vesicles being generally transparent, and never contain genuine pus, as they do in impetigo. In the latter, desiccation gives rise to thick, yellowish, uneven scabs; in eczema, only thin pliant scales are formed. Vesicles of eczema rubrum surround the latter, but they never appear in impetigo. Chronic eczema is very liable to be confounded with lichen and psoriasis. Lichen agrius, the variety most apt to be mistaken for chronic eczema, differs from this affection, in the thick, small, and yellow appearance ofthe scales or scabs, and the papular appearance of the surface which they leave on falling off; whereas, the surfaces left by the separation of the thin lamina in eczema, are smooth, red, often shining, and generally slightly excoriated. In lichen, small hard papillae may be seen around the eruption; jn eczema, vesicles only appear in the neighborhood ofthe eruption. Treatment.—Diluents, acidulated with sulphuric, or nitric acid; a light and simple diet; occasional tepid bathing; gentle laxatives; and where the eruption is extensive, alkaline and sulphurous baths,* with some of the milder vegetable tonics, such as infusions of cin- chona, serpentaria, or colomba when languor or debility exists, are the principal useful measures in this variety of the complaint. When the eruption continues long, advantage may be obtained from rub- bing the affected parts with sulphur ointment. In eczema rubrum and impetiginodes, frequent bathing, or emol lient fomentations of the affected parts, will generally moderate very considerably the itching pain and tenderness of the eruption.t Emol- lient poultices also often answer well as a palliative application. After exfoliation, the following ointment may be beneficially applied to the tender and half-excoriated surface;}: by means of linen rollers renewed twice daily. Mild laxatives should be regularly given; and a simple, unirritating diet, as well as total abstinence from all * The alkaline bath is made by dissolving five or six ounces, or more, of the subcarbonate of potash or soda in a bath. The sulphurous bath is made by add- ing about four ounces of sulphuret of potash to a bath. (Cazenave.) f The French are in the habit of using a decoction of bran, or the water of scalded bran, for this purpose. Cazenave and Schedel recommend cataplasms made of potatoes and some emollient decoction. X R.—Emplast. plumbi ^ii. Ceras flavae §ss. Olei amygdal. dulc. ^iss.—Melt the plaster with the wax, then add the oil, and stir the mixture until it has entirely cooled. This ointment is particu- larly recommended by Dr. Pearson.—See Bateman's Synopsis, &c. p. 12. ECZEMA. 539 kinds of stimulating drinks, enjoined. It will also be useful to ad- minister refrigerant diaphoretics, such as sweet spirits of nitre, small portions of nitrate of potash with tart, emetic, spiritus mindereri, and to allay nervous irritation and procure rest at night, full doses of Dover's powder with a few grains of calomel in the evening. The diluted mineral acids with tonic bitter infusions will at times be proper during the subsidence of the disease. All kinds of irritating applications must be avoided. When the exciting cause is obvious, and of such a nature as to enable us to remove it, the first step in the treatment must of course be to obviate its influence. In chronic eczema, emollient baths of about the temperature of 90°Fahr.; the internal use of nitric or sulphuric acid; occasional laxatives; alkaline solutions internally, and when the itching is great, externally,* are among the principal remedies in this form of the disease. One or two of Plummer's pillst given twice daily, have been found very useful in chronic eczema. Benefit may also be derived from laxative doses of calomel and pulvis antimonialis, with an occasional dose of sulphate of magnesia or soda. Sulphu- rous waters, employed both externally and internally, will, in gene- ral, contribute materially towards the removal of the disease. In- fusions of sarsaparilla, chimaphila, or of the slippery-elm bark, with small portions of antimony, may also be usefully employed. In a very severe and inveterate case of chronic eczema, I prescribed the following pills, in conjunction with sarsaparilla syrup, with complete success.^ In the dry, scaly, cracked form of local eczema, "as it occurs in the hands," Cazenave recommends frictions on the part, with an ointment made by mixing half a drachm of proto-nitrate of mercury with an ounce of lard; or of twenty grains of proto-ioduret of mercury rubbed up with an ounce of axunge. I have known a case of this kind cured by the following application,§ first recom * " Half a drachm of the subcarbonate of potash dissolved in a pint of infusion of chicory may be given internally." Washing the affected parts with a solu- tion of the subcarbonate of potash or soda, before going to bed, will generally afford much relief. (Cazenave.) f B— Calomel. Antimon. sulph. praecipitat. aa £ii. Pulv. g. guaiac. giv. Sapo. venet. 3ii. Mf. pi. aa gr. iii. X R.—Muriat. hydrar. corrosiv. gr. iii. G. opii gr. x. G. camphor, gr. xx. Conserv. rosar. q. s.—M. Divide into 40 pills. Take one every morning, noon, and evening. § R.—Axunge gviii. Melt it, then gradually add, nitric acid %i. and stir until it is cold. 540 ERYTHEMA. mended, I believe, by Alyon. (Essai sur les Proprietes Med. de V Oxygene.) Washing the affected parts with an infusion of stramonium leaves, or of solanum nigrum, or hyoscyamus, will generally greatly allay the itching and painful irritation. When the eruption is confined to a limited surface, solutions of borax; lime-water and milk, or an ointment made by mixing half a drachm of calomel with an ounce of lard, may be occasionally applied with benefit. The best local ap- plication, according to my own experience, however, is stramonium ointment intimately mixed with a portion of calomel, in the propor- tion of thirty grains of the latter to an ounce of the former. The tincture of cantharides is sometimes very efficacious in obstinate cases of this affection. Cazenave states that it is particularly useful in the eczema of women.* Arsenic also has been used with complete success in inveterate instances of chronic eczema. (Biett, Cazenave.) The Asiatic pills appear to be the best arsenical preparation in this affection. One of these should be taken daily, and continued for several months. I have employed Fowler's solution in several cases with marked advantage. Sect. VII.—Erythema. The term erythema, is applied by Willan and other late writers, to a cutaneous affection, characterised by a slight superficial irregu- larly circumscribed redness of some portion of the skin, attended with symptoms of constitutional disorder. It is most commonly seated on the face, breast, and extremities, and continues usually from one to two weeks. It appears generally as a symptomatic affection—although in many instances it occurs without being pre- ceded by any obvious constitutional symptoms. Superficial spots of a vividly red color, variable in size, and attended usually with very slight heat and pain, come out on a greater or less extent ofthe surface. When these spots are pressed with the finger, the redness disappears for a moment, as in erysipelas. In some instances, not the slightest tumefaction attends; but in others, the spots become swollen and firm to the touch. Sometimes the bright red patches are irregularly rounded, and present on their first appearance a slightly elevated rough or papulated surface. In a few days the redness becomes more vivid, and afterwards changes to a violet hue, particularly on the central parts of the patches. The slight swelling * Cantharides have been successfully employed in various chronic cutaneous affections. Keir relates several very obstinate instances of impetiginode affections which^flelded to a protracted course ofthis remedy, (VoigteVs Arzneimittell, bd. ii. z0fT\\. s. 15.) Home also gave it successfully in herpatic affections, (Clini- cal Experiments, <^"c.) Tilenius, (uber die Flechtenart. Hautauschl. 1802,) and Simons, (Med. Comment, vol. i.) relate instances of its successful employment in similar cases. ERYTHEMA. 541 subsides in the course of the second day, but the redness continues from about ten to fourteen days. This variety of the disease (the E.papulatum of Willan) is most frequently met with in females and young persons, and is usually seated on the neck, breast, and arms. It is sometimes attended with much general disorder—such as anorexia; a small and frequent pulse; great depression of strength and spirits; and acute pain in the limbs. In most instances, how- ever, the constitutional symptoms are slight. (Bateman.) In some cases " small slightly elevated tumors are interspersed through the patches," which continue six or seven days before they disappear__ the redness going on for a about week longer. (E. tuberculatum.) This eruption frequently appears also in the form of red oval spots, usually seated on the anterior part of the legs, and sometimes, though rarely, on other parts—as the chin and arms. The spots become elevated towards the centre, and are firm and painful to the touch, presenting the appearance of slight nodes when seated on the tibia. These protuberances rise slowly, and subside about the eighth or ninth day, at the same time that their color becomes bluish, as from a bruise. This variety of the disease is preceded for four or five days by moderate fever, general uneasiness, and depression of strength. Bateman says that it seems to occur only in females; but Cazenave and Schedel state that it is met with also " in infants, and in young persons of a weak constitution and lymphatic tempera- ment." This variety constitutes the E. nodosum of Willan. The erythematous spots which sometimes occur in acute diseases as symp- tomatic eruptions, (E.fugax) are usually of short duration, and re- semble the redness produced by pressure or friction. They occur also in chronic affections, "especially those in which the primae viae are deranged." Causes.—Erythema may be produced by the direct action of irri- tating agents on the skin, such as the direct rays of the sun; acrid secretions or discharges remaining long in contact with the skin; and by the chafing of two contiguous surfaces, as between the breasts, in the arm-pits, groin, and on the buttocks and internal parts of the thighs from riding on horseback. It occurs symptomatically from intestinal irritation, dentition, menstrual irregularities, particularly about the decline of the menses, from irritation in the stomach, and in almost every form of acute disease. It is sometimes associated in oedema, or anasarca of the legs. Diagnosis.—From erysipelas, erythema is distinguished by the limited extent of the spots; the absence of pain, of vesication, and of tumefaction; and the mild nature of the disease. From roseola it differs in its vivid redness, and in the less distinctly defined circum- ference of its spots or patches. The spots of roseola are never raised above the surrounding skin; those of erythema nodosum are. Ery- thema papulatum may be known from urticaria by the greater ele- vation of the latter, and the great itching which always attends, as well as by its " irregular and often rapid course." The absence of Vol. I.—46 542 KOSEOLA. itching in erythema distinguishes it also from lichen urticatus. (Ca- zenave.) Treatment.—Light diet, gentle diaphoretics, the internal use of the mineral acids, laxatives, warm baths, tepid ablutions, and sooth- ing applications when it occurs from the friction of surfaces, such as aqueous solutions of borax, opium, acetate of lead, or pulverised starch, or the powder of lycopodium, comprise all that is necessary in idiopathic erythema.* Sect. VIII.—Roseola. This affection consists of rose-colored spots, of various forms, without swelling or elevation of the skin or papulae, and is usually preceded and accompanied by febrile symptoms. These efflo- rescences may occur over the whole surface of the body, but they are usually confined to one or more parts. Its course varies in dura- tion from one to about six or seven days. Sometimes the rose-red spots are nearly circular, contiguous to each other, and not above three or four lines in diameter. They are usually connected with disorder of the stomach and bowels, and occur almost exclusively in infants; and they seldom last longer than thirty-six hours. During dentition these spots are apt to assume an irregular and nearly con- fluent appearance, and generally succeed violent symptoms of gastro- intestinal disorder, such as vomiting, diarrhoea, and fever. There is a variety of. this eruption which has been mistaken for measles, and which is most apt to occur in children during summer. (R. assliva.) It commences with chills, languor, headach, followed by febrile reaction, and occasionally delirium, and even convulsions. The skin is hot and dry, the bowels are constipated or affected with diarrhoea, and the appetite wholly depressed. From the third to the seventh day after the commencement of these symptoms, the erup- tion makes its appearance, first on the face and neck, and then gra- dually spreads over a greater or less extent of the surface of the body. The spots are usually from one to three lines in diameter, resem- bling the spots produced by touching bibulous paper with the point of a pen dipped in red ink. When the eruption is very copious, the spots run into each other on some parts of the body, but the roseolous points may still be distinguished on the red surface. These spots are not in the slightest degree elevated, yet when the patient has been kept too warm, or when heating diaphoretics are used, a papular eruption is apt to appear along with the roseolous spots. The eruption is attended with troublesome itching, and the febrile * To relieve the inflammation and tenderness pruduced by chafing, the follow- ing ointment, applied by strips of soft linen, is often promptly effectual: R.—Ungt. stramonii ^i. Pulv. lythargyri 3L Pub. opii Jss.—M. PURPURA. 543 irritation continues until it disappears with the eruption. It is often attended with sore throat, or painful deglutition, but not with coryza, inflamed eyes, and cough, like measles. The spots may continue from three to ten days; they disappear without desquamation. Oc- casionally a second eruption occurs after the first has gone off. In some rare cases, the rosy spots assume an annular shape, the central parts retaining the natural color ofthe skin. (R. annulata. Willan.) V Roseola occurs most frequently in women and children, and is not contagious. It occasionally prevails epidemically, and some- times precedes the eruption of small-pox, or it follows the vaccine affection. Dentition, and a draught of cold water when the body is heated by exercise, may give rise to this eruption; and it is often associated with gastric disorder, particularly in children. Diagnosis.—Measles and scarlet fever are the affections with which roseola is most liable to be confounded. The more distinct catarrhal character of measles, the irregular semilunar grouping of its small red points, and the vivid redness of its eruption; contrast- ed with the larger, more circular, well defined, and rose red spots of roseola, will generally enable us, without difficulty, to form a cor- rect diagnosis. The small vesicular elevations, the irregularly dif- fused raspberry efflorescence, and the tumefaction of scarlatina, are usually sufficient to distinguish this affection from roseola. Roseola is not contagious; measles and scarlatina are. Prognosis.—This disease is almost always wholly free from dan- ger. Heim,* Selle,t and Formey,J however, mention the occurrence of very violent and fatal epidemics of this kind. But in these the eruption was probably purely symptomatic of typhus fever. Hilde- brandt refers to an exantheme, somewhat similar to this one, as a very constant, though transient, symptom, in the stage of excitement of contagious typhus. Treatment.—Rest, mild aperients, acidulated cooling diluents, a simple and unirritating diet, an equable and moderate temperature; and where the temperature of the skin is elevated, refrigerant dia- phoretics, are, in general, all that is required in the treatment of this affection. When internal inflammations occur, a more vigorous and appropaiate course will be demanded. Sect. IX.—Purpura. Hemorrhcea Petechialis, Ecchymome, Hemacelenose. This affection is characterised by spots or patches of a vivid red, inclining sometimes to a purple hue, varying in size from a line to * Bemerk, uber die Verschieden. des Sharlachs, der Roethelund der Masern. j- Neue Beitrage zur natur-und Arzneiwissenschaft, tem. i. X Topographie von Berlin, Richter, Specielle Therapie, Bd. ii. p. 524. 544 PURPURA. several inches in diameter, and retaining their color under pressure. These maculae appear often without any perceptible febrile pheno- mena whatever; but they occur also in the latter stage of malignant fevers, (petechiae,) and in this case are always of the most fatal im- port. Willan has divided purpura into five species: purpura sim- plex; purpura hasmorrhagica;purpura urticans;purpura senilis; and purpura contagiosa. Simple purpura consists in small bright red patches, appearing usually on the extremities in a successive manner, preceded com- monly with slight restlessness, nausea, headach, languor, and want of appetite, but without any obvious irritation of the circulatory system. The duration of this affection is almost always tedious, and varies from a few weeks to many months. The individual spots, however, do not often continue for more than seven or eight days—the whole course ofthe malady being made up either by a continuous succes- sion of the eruption, or a succession of eruptions, with short inter- vening periods. This variety ofthe disease occurs usually in young subjects, and appears equally liable to attack vigorous, sanguineous, and robust, as well as feeble, relaxed, and delicate individuals. It is said to appear more frequently during warm and dry weather, than in the cold seasons. Its diagnosis is not difficult. The persistence of the redness when pressed with the finger, is alone sufficient to distin- guish it from all other similar affections. Simple purpura is always a mild aflection, and though sometimes very prolonged in its course, can never be regarded as dangerous. P. haemorrhagica.—The variety of purpura, however, which has attracted the most attention, and which indeed is always a very seri- ous and alarming affection, is the purpura haemorrhagica—or mor- bus maculosus hxmorrhagicus of Werlholf. The spots in this va- riety are generally numerous, and of a dark-red color^ with here and there irregular livid patches, resembling recent bruises. They usu- ally appear first on the. legs, then on the arms, and lastly on the body; the hands almost invariably remaining free from them. In some instances the cuticle over these maculae becomes slightly elevated, with a small portion of bloody serum underneath.* These spots occur also on the mucous surfaces, particularly in the mouth, nostrils, rectum, or vagina, giving rise to haemorrhages, sometimes so copious as to cause speedy death. In general, however, the haemorrhage is moderate, returning at intervals, and either ceases spontaneously, or recurs again and again until the system is exhausted, and a fatal ter- mination occurs; sometimes a slight, but uninterrupted, discharge takes place. The constitutional symptoms vary exceedingly in this affection. Some cases commence with wandering and vague pains, lassitude, restlessness, and exhaustion; others are not preceded by any symptoms of general indisposition. In general, however, the disease, * I. G. Arcel, (C. Zetterstrom) Diss, de Haemorrhcea. Upsal, 1797. PURPURA. 545 when once developed, is accompanied with a state of depression and languor; yet in relation to the activity of the pulse, the greatest di- versity occurs in different cases. In some instances it is feeble, soft, and moderately full; in others it is contracted, firm, and very fre- quent; and in others again, active, full, and resisting. The skin is sometimes above the natural temperature;* though generally it is cool and pale. Cough, pain in the chest, and slight oppression of respiration, frequently precede and accompany the cutaneous and haemorrhagic affections. Dr. Fairbairn relates a case attended with deep-seated pain in the left breast, increased on coughing and deep inspiration, laborious breathing, and flushed countenance. Dark, venous blood oozed from the gums, cavity of the mouth, and appa- rently from the mucous membrane ofthe bronchiae, and numerous petechiae or purple spots appeared on the arms, neck, and trunk.t Uneasiness in the stomach, with abdominal pain, or tension and weight in the hypochondria, sometimes precede the appearance of the spots. When the disease becomes protracted, more or less ana- sarcous tumefaction of the legs and face, emaciation, and great weak- ness and languor, supervene. The duration of this malady is as va- rious as the general phenomena which accompany it. It may termi- nate either in health or in death, within a few days from its com- mencement, or run a tedious course of many months. The fatal ter- mination of this affection is frequently the immediate consequence of profuse haemorrhage from some internal organ. Cazenave states that he has " seen patients suddenly expire from copious haemoptysis, as well as from haematemesis and intestinal haemorrhage." The spots or maculae are caused by the extravasation of blood under the cuticle. Concerning the etiology and pathological character of this re- markable affection, we know, as yet, but little that is satisfactory. Dr. Parry regarded the disease as being decidedly phlogistic, whilst most other writers ascribe it to an opposite character. It is certain, that notwithstanding the extraordinary tendency to haemorrhage— apparently of the passive kind—the blood drawn with the lancet sometimes coagulates strongly, and exhibits a sizy, and even a cup- ped and buffy surface. J It is equally ascertained that extensive in- ternal inflammations are sometimes connected with this malady. In the case reported by Dr. Chambers, (Med. and Phys. Jour. Nov. 1826,) "the convolutions of the small intestines were found agglu- tinated by adhesive inflammation, and the whole arachnoid mem- brane on the upper part of both hemispheres was covered with lamina of coagulated lymph." More commonly, however, the blood taken * See Dr. Gardiner's case—Edinburgh Med. Chir. Transact, vol. i.'p. 671. Also, Dr. Fairbairn's case, quoted below. + Transact. Med. Chir. Society of Edinburgh, vol. ii. art. 1. X Dr. Stocker, Pathological Observations, &c. part I. p. 36. Parry's Posthu- mous Works, vol. i. p. 220. See also Dr. Chambers's case.—Med. Chir. Rev. Jan. 1827, p. 201. 46* 546 PURPURA. by venesection presents none of the appearances indicative of a phlo- gistic condition. " In many persons who were examined after death in the hospital St. Louis," says Cazenave, "the blood was found in a state of remarkable fluidity." In Dr. Fairbairn's case, the blood coagulated " into a soft and tremulous mass," and in the case re- ported by Dr. Gardiner, the first blood drawn coagulated imperfectly, and on the following day resembled a tremulous jelly, with a green- ish surface interspersed with brownish spots. What was discharged afterwards " was more like turbid lymph, or a fluid in which some reddish coloring matter was suspended." In the majority of instances, marks of violent venous congestion,* with copious extravasation of bloody serum or dark liquid blood into the internal cavities, are detected on post mortem examination. Petechiae, too, are often met with on the internal surfaces, particu- larly on the mucous membrane of the lungs, intestines, stomach, (Fairbrain, loc. cit.) and fauces. In some instances almost the whole capillary system takes on the haemorrhagic action—every structure, whether membranous or parenchymatous, presenting marks of san- guineous extravasation. Under all this perplexing contrariety of phenomena, our reason- ings and conclusions respecting the fundamental pathological charac- ter of this affection, must necessarily be vague and unsatisfactory. That it is not essentially an inflammatory disease, though often connected with local inflammation and an active state of the circula- tion, appears, I think extremely probable. It is indeed true, that in some of the most violent forms of inflammatory fever, colliqua- tive haemorrhages and subcutaneous extravasations of blood occur; but these do not supervene until the general powers are prostrated, or a state of collapse is induced by the previous excessive excitement. In purpura, however, the petechiae and sanguineous discharges are sometimes among the first signs of indisposition; and are but yery rarely preceded by symptoms of strong vascular or phlogistic action. Dr. Stocker thinks that this affection is attended with an altered and unhealthy state of the blood, " either from want of due preparation of the fluid at the two chief sources of supply, and of the subsequent changes these fluids should undergo in their passage through the pulmonary, sanguiferous, and hepatic systems, or from the injurious effects of diseased functions in the organs of sanguifica- tion."t That a dyscrasy of the blood exists in this disease, is indeed not at all improbable; but whether this condition of the blood has a direct and principal agency in the production of the characteristic phenomena petechiae and haemorrhage; or whether it is only one of * The lungs are sometimes greatly engorged with sanguineous extravasation and congestion. M. Biett saw an instance of violent venous congestion of the tongue. It was of a deep livid color, and double its natural size. (Cazenave and Schedel.) X Loco cit p. 40. PURPURA. 547 the ultimate consequences of the primary and essential disease, is altogether uncertain. To me it seems probable that this affection has a considerable latent period before it manifests itself by external symptoms; that primary disorder of the assimilating functions de- ranges the healthy constitution of the blood; and finally, that the blood thus deteriorated or changed, being no longer possessed of its healthy relations with the organic sensibility of the capillary ves- sels, causes these to suffer its ready transmission and extravasation. Treatment.—The uncertainty which exists in relation to the pathology of this disease, leaves us of course in an equally unsettled state with regard to the principles of its remediate management. The most opposite plans of treatment have been recommended, and practised too, with occasional success. It would seem even that the existing symptoms are often a very fallacious guide; for in some cases marked with all the usual symptoms of general debility, relaxa- tion, and asthenia, the use of tonic and other invigorating means have almost immediately aggravated the disease. Nevertheless, where the disease occurs in old persons or children, enfeebled by previous diseases, privations, or other debilitating influences, a mode- rate tonic and exciting plan of treatment, with an invigorating regi- men, has been found most beneficial. Decoctions of cinchona, ser- pentaria, or rathany; the ferruginous preparations; mineral acids, particularly the sulphuric; wine, and a nourishing diet, may be em- ployed in cases of this kind. The only instance of this disease which has come under my notice, was in a child about seven years old. In this case I employed the nitrate of silver, in quarter grain doses every six hours, together with from fifteen to twenty drops of the spirit of turpentine, with complete success. The case continued for nearly three weeks before it yielded to this treatment. When the disease appears in adults of good and sanguineous con- stitutions, and who have not been previously subjected to the influ- ence of enervating causes, tonics and exciting remedies almost inva- riably do great mischief. In all instances in which there are mani- festations of strong visceral congestions, or of inflammation; where there is pain in the chest, in the epigastrium, hypochondria, or the abdomen; where there are evidences of intestinal irritation, or con- stipation exists; where the pulse is firm, corded, or tense, antiphlo- gistic measures should be adopted. Bleeding is recommended by Parry, and cases have beeen reported illustrative of its occasional be- neficial effects. A case is reported as having occurred in Bartholo- mew's Hospital, which strikingly illustrates the occasional usefulness of blood-letting in this affection. The whole surface of the body was sprinkled over with purple spots. The gums were spongy, livid and bloody. " The whole tongue also, was livid, and half of it presented the appearance of a large, black, bleeding fungus, shoot- ing from its surface." Nothing but blood passed by stool. The pa- tient nevertheless felt strong, and had a good appetite, Dr. Latham drew fifteen ounces of blood, which was very buffy, enjoined water 548 PURPURA. gruel, and administered mercurial purges. The patient under this management gradually recovered.* Where the disease is attended with an active state of the circula- tion, or with symptoms of visceral congestion or inflammation, bleed- ing may be practised with a prospect of advantage. It is a measure, however, which requires cautious employment even where it seems to be most clearly indicated; for the natural tendency ofthe disease to exhaustion and prostration is always great, and may readily be injuriously promoted by incautious abstractions of blood. Whatever may be thought of blood-letting, almost all writers agree in recommending purgatives in this affection. Dr. Harty states, that after he had failed in one case by tonic remedies and a nour- ishing diet, he resorted to the free administration of purgatives in upwards of a dozen cases, and he avers, with uniform success. (Bate- man.) He gave active doses of calomel and jalap daily. Of late years the oil of turpentine, in purgative doses, has been strongly recommended as a remedy in purpura. Dr. Whitlock Nicholl has reported three cases in which this article was administered with the most satisfactory result.t To a child only two years old he gave half a drachm of the oil with some syrup and water, thrice daily, for ten days in succession. Under this remedy, the disease, though very violent, gradually yielded. Cinchona was, at the same time, freely used. Dr. E. Thompson also gave small doses of turpentine and castor oil with complete success. % Dr. Belcher used turpentine enemata, with manifest advantage.§ The turpentine with castor oil generally causes large, unnatural, and very fetid alvine discharges; and if the system is, at the same time, supported by tonic infusions, generous wine, and the mineral acids, nothing need be apprehended from the exhausting effects of daily purging with this mixture. According to the report of Cazenave and Schedel, the treatment usually adopted in the management of this disease by M. Biett, consists in the employment of acidulated drinks and laxatives; and in cases attended with much feebleness and exhaustion, the extract of rathany, (in doses varying from a scruple to a drachm daily,) mixed with ice. This treatment is also recommended by other emi- nent French practitioners. (Dr. Brachet, of Lyons.)|| Local applications have been recommended to restrain the haemor- rhages, but these rarely afford any other than very temporary advan- tages. Upon the whole, therefore, moderate blood-letting, where there are strong congestions, or an active pulse; purgatives freely and almost daily employed, together with cinchona, rathany, tinct. cinnamon,^ wine, beverages acidulated with sulphuric acid, and a * Med. Chir. Rev. May, 1828. f Lond. Med. Repository, July, 1821.—Ibid. No. VI. X Ibid. No. CXIX. § Med. and Phys. Jour. March, 1825. || Cazenave, &c, Synopsis, p. 379. T Jahn. Klinik der Chron. Krank. Bd. p. 308. HEMORRHAGES. 549 nourishing diet, constitute the means which experience has found most apt to afford relief in this affection. Advantage might perhaps be obtained from bathing the body in a decoction of oak bark or cin- chona, or water strongly impregnated with salt. CHAPTER XIX. VASCULAR IRRITATIONS WITH A FLOW OF BLOOD. Haemorrhages. Spontaneous Hemorrhage may be defined a disordered state of the vital properties of a greater or less extent of the capillary system, manifesting itself by sanguineous effusion or extravasation.* It was formerly supposed that haemorrhages depend invariably on rupture of a blood-vessel; and this opinion is, indeed, still entertained by some pathologists. Dr. Gregory seems to take it for granted that actual rupture of a vessel takes place in all haemorrhagic effusions.t That this may sometimes occur, cannot be doubted; but this is proba- bly so seldom the case, as to form but a very limited exception to the general fact, that the effusions of this kind depend on a sort of sanguineous exudation, without rupture, or structural lesion of the vessels. In what manner, or through what particular openings, the blood is suffered to escape from its proper vessels, is, however, still a matter of conjecture, or at best of uncertainty. According to Bichat, the blood is discharged through the exhalents; and Reil supposes that it transudes through the coats of the vascular extremities, (per dia- paedesin,) from deficient vital power in these structures, just as we sometimes find the bile percolated through the cystic coats on post mortem examination, or by what Dutrochete calls exosmos, through the agency of animal galvanism. When we take into view the results of some late physiological experiments, which go to show that the veins imbibe fluids into their cavities apparently through the insen- sible pores of their coats; it does not appear extravagant to suppose, that, under particular circumstances, they may also give exit to their contents through the same channels. It is nevertheless most probable that the effusion occurs, (per anastomosing) through the exhalents, in the manner so ingeniously explained by Bichat. In consequence of a morbid change in the activity of the sanguineous capillaries, as well as in the specific sensibility of the serous exhalents, the blood * Bichat, General Anatomy, vol. ii. Reil, Fieberlehre. Bd. iii. p. 23. + Elements of the Theory and Practice of Medicine, vol. i. p. 517. Second American edition. 550 HEMORRHAGES. passes from the former to the latter, and by these is suffered to escape externally. Whatever doubts and exceptions may have been expressed by some recent physiologists, with regard to the agency of what this eminent writer terms organic sensibility in the deve- lopment of diseases, there is much foundation for believing that this pathological principle lies at the root of many of the morbid phenomena of the capillary system. It would be foreign, however, to the scope ofthis work, to enter into a particular discussion on this head. Those who may desire to obtain a full view of the facts and arguments that may be adduced in support of this pathology of haemorrhages, may consult the chapters on the capillary and exhalent systems in Bichat's General Anatomy. Pathologists have divided haemorrhages into active and passive. A haemorrhage is said to be active when there is a preternatural flow of blood to the part, attended with an increased vascular excite- ment. In many cases, the whole circulatory system is in a state of increased activity; but the local vascular excitement often approaches, and indeed actually rises to the grade of inflammation, as in the spitting of blood in pneumonia, or the sanguineous discharges in dysentery. The local haemorrhagic irritation is, however, not always accompanied with an increased momentum of the general circulation. On the contrary, strong local determinations, and an active haemor- rhagic excitement, often exist in an organ, whilst the activity of the heart and arteries is depressed, and the general powers of the system languid. Thus active haemoptysis and uterine haemorrhage often occur in persons of weak and irritable habits, with a small, weak, and frequent pulse. Active haemorrhages occur most frequently in young, plethoric, and irritable persons, and in those who are constitutionally predis- posed to strong irregular determinations of the blood to particular organs, as the head, the lungs, or the abdominal viscera. They occur in inflammatory fevers, either as accidental or critical evacuations; and in this case, they are always to be regarded as favorable. In many instances, the eruption of the blood is preceded by various premonitory symptoms; but in others, the haemorrhage comes on suddenly without any manifestations of its approach whatever. Among the symptoms which announce the approach of active haemor- rhages, may be mentioned, a full, frequent, rebounding (dic^otus; bisferiens) pulse; alternate flushes of heat and chills; redness, ten- sion, and fulness of the skin; increased sensibility of the sensorial or- gans; restlessness; anxiety; watchfulness; slight aberrations of the mind; a feeling of heaviness, pressure, heat, and pain in the part; and in some instances, a turgid state of the veins, redness, aud swelling in external parts remote from the organ from which the blood is about to flow. Haemorrhages are called passive when there is neither sanguineous congestion, nor a sense of heat and fulness, but a decreased instead of an increased vascular activity, both of the general system and of the HEMORRHAGES. 551 part from which the haemorrhage occurs—the exhalents suffering the blood to escape passively from want of vital activity to resist its en- trance and transmission. Some have contended that all haemorrhages are necessarily active; that the blood is always thrown out by an action of the exhalents, and not merely forced through them, as through passive tubes by the vis a tergo. This may be true; and yet when we find some chronic haemorrhages, connected with great feebleness and relaxa- tion, speedily arrested by remedies whigh all physicians are accus- tomed to regard as the most energetic means we have for stimulat- ing or exciting these very vessels to increased activity, we cannot be much out ofthe way if we call such discharges passive. In that variety of chronic haemorrhage which occurs in relaxed and debili- tated females at the critical period of life, we possess no medicine which so promptly and safely arrests the discharge, as small doses of aloes and savin in combination—the very remedies, too, which we often find most successful to excite the menstrual evacuation; in other words, the uterine vessels. This variety of haemorrhage depends either on mere relaxation and inactivity of the vessels, without any morbid changes in the constitution ofthe blood, in consequence of previous diseases, exces- sive discharges of all kinds, and other exhausting influences; or it is connected, and probably in a great degree dependent on a thin, watery, or dissolved state of the blood, and therefore incapable of communicating healthy impressions and activity to the general and capillary systems of vessels. This state is always attended with a variety of symptoms besides the haemorrhage, indicative of a relax- ed, exhausted, and sometimes irritable condition ofthe system.* Of this kind of haemorrhage (passive) are those which occur in some chronic affections, attended with great relaxation, exhaustion, and morbid irritability, such as scurvy; and in the stage of collapse of malignant and other typhous forms of febrile diseases. In some instances, the haemorrhage partakes of both the active and passive characters just mentioned. The vessels of some particu- lar part may be habitually debilitated, inactive and relaxed, and con- sequently especially predisposed to congestion. If in this state, some accidental circumstance supervenes, which increases the general momentum of the circulation, or particularly favors the determina- tion of blood to the debilitated vessels, a haemorrhage may occur, attended both with general vascular activity, and local torpor and relaxation. This occurs sometimes in hasmorrhois. The effects of sanguineous discharges on the system, are of course various, according to the suddenness and quantity of the evacuation, their duration, and the constitutional habit of the patient. The immediate effects of a considerable loss of blood on the heart and arteries, need not be particularly enumerated. When the hae- * Jahn. Klinik der Chron. Krankheiten, Bd. iii. p. 272. 553 HEMORRHAGES. morrhage is excessive, the respiration becomes quick and difficult, the skin pale and cool; tremors of the extremities, chills, ringing in the ears, dimness of sight, and finally syncope, ensue. When faint- ing occurs, the bleeding usually ceases. In violent cases, the syn- cope may terminate in immediate death; but such a termination is by no means common in spontaneous haemorrhages. More or less reaction usually soon returns, and the bleeding either remains per- manently arrested, or reappears with diminished activity, con- tinuing, in some instances, with occasional intermissions, until the whole system becomes greatly relaxed and exhausted. The secondary effects of profuse or long-continued discharges of blood are often very alarming, obstinate, and even fatal. These remote consequences of haemorrhage are indeed among the most important circumstances connected with sanguineous discharges, whether they be considered in a pathological or practical point of view, and deserve the greatest attention. After the immediate exhaustion of a profuse or protracted haemor- rhage has in some degree gone off, the whole system is sometimes left in an extremely excitable state. The pulse becomes very fre- quent, throbbing, sharp, moderately full, and compressible; the least corporeal exertion or mental excitement produces agitation, strong beating of the carotids, palpitation ofthe heart, hurried respiration, and throbbing along the course of the abdominal aorta. In some instances of this kind, the arterial reaction becomes still more vehe- ment. A pulsating, deep seated pain in the head, and a high degree of morbid sensibility of the brain occur—manifested by great into- lerance of light and sound and occasionally more or less delirium, with other manifestations of cerebral irritation. This state of tumult- uous reaction and general irritability sometimes gradually subsides, and health slowly returns. In individuals, however, of weak powers of constitutional resistance, this secondary excitement is apt to ter- minate in a state of great feebleness and exhaustion. The patient becomes sluggish both in mind and body; he is disposed to dose, and is inattentive to surrounding objects; the face acquires a pecu- liarly pale and slightly tumid appearance; the pulse is frequent, irregular, and though often large, feels as if the artery were filled with wind. The muscular powers are greatly prostrated; respira- tion is difficult; interrupted by deep sighs, and attended with a pecu- liar crepitus, changing finally to a slight, rattling sound in the trachea and bronchia. In cases of this kind death sometimes supervenes, apparently from infusion into the lungs; in other cases cerebral op- pression, coma, and insensibility, precede for several hours the fatal termination.* In many instances, however, the morbid consequences of haemor- rhages are of a much more chronic character. When the blood- vessels are much drained by copious or protracted sanguineous dis- * Dr. Marshall Hall. Medical Essays, p. 41. HEMORRHAGES. 553 charges, absorption always goes on very actively.* They soon become replenished, therefore, with a crude and watery fluid; the blood is greatly attenuated—containing often but a few ounces of cruor in a pound of the fluid. In consequence of this state of the blood, the heart and arteries are irritated; all the animal and organic functions become enfeebled and sluggish; the face and inferior ex- tremities become more or less oedematous; and the whole surface acquires a peculiarly pale, exsanguious, leucophlegmatic appearance; the mind is torpid; the countenance anxious, or vacant and apathetic; the heart palpitates strongly on the slightest exertion; the hands and feet are cold; the thirst usually very considerable; and the appe- tite variable, and attended with gastric pain or uneasiness, flatulency, sour eructations, and other dyspeptic symptoms. If the urinary secretion is small, general anasarca, or other forms of dropsy ensue; or colliquative haemorrhage may return, and finally extinguish life. Causes.—The degree of constitutional predisposition to haemor- rhagic discharges varies much in different individuals. Some per- sons appear to be particularly indisposed to spontaneous haemorrhage; whilst others, on the contrary, are naturally very prone to discharges ofthis kind, although in other respects of vigorous and healthy con- stitutions. In some individuals, there exists so great a constitutional haemorrhagic predisposition, that the slightest wound of the skin is apt to cause the most alarming discharges of blood, and which no applications are, in some instances, able to arrest. It appears, more- over, that this extraordinary tendency to haemorrhage is sometimes hereditary. Fordyce relates the case of a man who bled almost daily from the nose. All his children were extremely subject to epistaxis, and one of them died of this affection. Several very re- markable instances of this kind are reported in the second number of the American Medical Review. It appears also that the predisposition to the different varieties of haemorrhage varies with the age ofthe individual. During childhood, haemorrhages are most apt to occur from the nose; between puberty and the thirtieth year of age, haemoptysis would seem to be most common; in middle life, haemorrhage from the rectum occurs most frequently; and in very old people, haematuria is not uncommon.t * The experiments of Magendie and others have fully demonstrated this fact. Under the head of dropsy, I have entered more fully into the pathological cir- cumstances which result from this principle. f Cullen's First Lines, vol. ii. The explanation of these circumstances, as given by Cullen, though ingenious and plausible, is far from being satisfactory. It rests too much on the mere mechanical or hydraulic character of the blood- vessels. The intimate relation subsisting between the nervous and vascular sys-. tems as vital structures, and the various sympathetic relations between the dif- ferent organs themselves, subject to variations according to age, are probably much more concerned in the development of these and other predispositions, varying by age, than the circumstances mentioned by Cullen. Vol. I.—47 554 HEMORRHAGES. With regard to the occasional or exciting causes of haemorrhages, it may be observed, that whatever, is capable of producing strong local determinations to soft and very vascular structures, particularly the mucous membranes, may give rise to effusions of blood. The following are the principal causes of this kind. High atmospheric temperature suddenly succeeding cool and damp weather; sudden diminution of atmospheric pressure—hence the aptitude to haemop- tysis and epistaxis on ascending high mountains. Various causes tending to obstruct the free return ofthe blood to the heart; such as ligatures, tumors pressing upon large venous trunks, tight cravats, visceral indurations, and tightly laced corsets; cold repelling the blood from the surface to the internal vessels. Causes that suddenly and greatly increase the momentum of the general circulation, as violent exercise, lifting heavy weights, stimulating ingesta, and vio- lent mental excitement. Exertions that agitate, or over-exercise particular organs, as loud-singing, long-continued speaking, vehe- ment laughing, blowing wind instruments. Substances irritating particular organs, such as cantharides and turpentine acting on the kidneys, sternutatories, or acrid and stimulating inhalations irritating the respiratory organs. General plethora, and obstructions of habit- ual sanguineous evacuations, particularly amenorrhoea. Finally, gastro-intestinal irritation, giving rise to strong determinations to the chest or head. Haemorrhages of the active kind, frequently occur as critical evacuations; more especially in the synochal grades of fever. Pas- sive sanguineous discharges are never critical, or more correctly speaking, perhaps never appear in connection with a favorable change of the malady in which they occur. In some instances, haemorrhagic discharges occur periodically. Medicus has collected a number of examples of this kind in his work on periodical diseases.* Cases occur also, in which the haemorrhage observes a strictly intermittent course—the bleeding returning daily about the same time, and continuing from a few minutes to several hours.t I have met with a case of intermitting epistaxis which con- tinued to recur daily for nearly a week. Recamier has related a case of epistaxis in which the bleeding returned every morning and evening for six days in succession. { Prognosis.—The prognosis in haemorrhages depends on the con- stitutional habit of the patient; the suddenness and copiousness of the discharge; the nature ofthe organ from which the bleeding occurs; its independence, or connection with local or general disease; the character ofthe disease with which it may be associated; the period of febrile diseases at which it supervenes; and the character of the occasional causes. Haemorrhage is not often fatal from the mere * Fr. Cas. Medicus. Geschichte Periodischer Krankheiten. Hanover, 1784. f Reil, loc. cit. bd. iii. p. 38. % Rev. Medicale, Feb. 1827. HEMORRHAGES. 555 loss of blood. In the course of twenty-two years practice, I have met with but two instances of fatal termination from direct and im- mediate effects of spontaneous haemorrhage. Great diversity in rela- tion to the power of sustaining sanguineous discharges occurs in dif- ferent individuals. In some, immediate and alarming prostration is produced by comparatively small discharges of blood. Others will sustain exceedingly copious evacuations with but little immediate inconvenience, and speedily recover their usual vigor and health. The quantity of blood which may be lost without any dangerous or ill consequences, is indeed in some instances surprisingly great. Berthoiini relates a case in which sixteen pounds of blood were discharged from the stomach without any serious consequences. In another instance, he says, the quantity of blood lost from the nose, in the course of three days, was still greater.* Nicholai also mentions extraordinary instances of this kind, (Pathologie, b. vi. p. 353.) Haemorrhages, depending on chronic visceral disease, are in general more intractable than such as are free from disorder of this kind. When they occur during the stage of excitement of fevers, their effects are usually salutary, and should not be checked unless they become very copious and debilitating. The haemorrhages which take place in the period of collapse, always portend the utmost de- gree of danger; they seem to depend on a general paralysis of the capillary system, indicative of incipient dissolution. Haemorrhages which depend merely on the local congestion or irritation in an organ, without any constitutional disease, are seldom copious, and usually terminate spontaneously as soon as the local plethora is removed. It is different with those sanguineous discharges, where the local congestion and determination are sustained by some inter- nal or constitutional irritation. In such cases the haemorrhage is particularly apt to continue long, to recur frequently, and to resist the permanent success of remediate applications. The prognosis depends also in some degree on the importance of the organ from which the haemorrhage proceeds. A haemorrhage from the lungs is, casteris paribus more to be dreaded than one from the stomach; and this latter is more dangerous than a bleeding from the nose. With regard to the remote consequences of copious losses of blood, it may be observed, that individuals of a relaxed, nervous, phleg- matic, and irritable habit of body, are much more apt to suffer dan- gerous secondary disorders from such discharges, than persons of a contrary physical temperament. Treatment.—The general indications to be kept in view in the treatment of haemorrhages, are: 1. To lessen the momentum of the circulation, if it be above, or at its natural standard; 2. To diminish the determination of blood to, and moderate the local vascular action in the part from which the haemorrhage occurs; and 3. To excite a contraction of the vessels of the part. The first indication is to be * Anatom. Quintum Renov. 375. Reil, loc. cit. p. 27. 556 EPISTAXIS. fulfilled by venesection and the exhibition of sedatives—as nitre, digitalis, cold, &c. The second indication demands counter-irrita- ting and revulsive applications—such as cold, applied, if practicable, to the part from which the blood flows; and blisters, sinapisms, warmth, and rubefacient frictions, on remote situations. The last indication requires the internal use of astringents—such as sugar of lead, alum, muriated tincture of iron, &c; and where the situation ofthe part will admit of it, the external application of styptics. Having made these general observations on haemorrhages, I pro- ceed to the consideration ofthe particular varieties, according to the part from which they proceed. 1. Epistaxis.—Bleeding from the nose. This is by far the most common variety or haemorrhage. As has already been observed, epistaxis occurs most frequently in early life, particularly about the age of puberty. The eruption of the blood is often preceded by symptoms indicative of a congested state of the vessels ofthe head—as a sense of weight and tension in the temples; violent beating pain in the head; throbbing of the carotids; flushed face; giddiness; ringing in the ears; and a sense of tickling, tension, or stinging pain in the nose. In weak and irritable persons, other symptoms, in addition to these, denoting a nervous and spasmodic condition of the system, are apt to occur—namely, slight creeping chills; disposition to syncope; cold extremities; a constricted state of the skin; and a small, corded, and quick pulse. In general, only a few ounces of blood are discharged, and with this small loss of blood all the foregoing symptoms disappear. Sometimes, however, the blood flows so copiously and continuedly as to become alarming, and to demand active measures for its suppression.* The blood very rarely proceeds from both nostrils. Causes.—The exciting causes of epistaxis are exceedingly va- rious. Whatever has a tendency to produce a preternatural determi- nation of blood to the head, may give rise to this variety of haemor- rhage; such as insolation, stimulating ingesta, protracted study, the warm bath, sneezing, coughing, playing on wind instruments, vio- lent parturient efforts, straining in evacuating the bowels, a depend- ing position of the head, violent affections of the mind, strong blushing, intestinal irritation, heavy lifting, &c. Chronic visceral disorders, particularly indurations of the spleen and liver, strongly predispose to epistaxis, and this haemorrhage appears sometimes to be the consequence of organic affections of the heart and of the large vascular trunks. Suppression of the menstrual and haemorrhoidal evacuations, may give rise to this haemorrhage; and it never fails to * Plouquet has collected a number of instances in which unusually large quan- tities of blood were discharged from the nose without fatal consequences.—Bib- liotheca Medico Pract. vol. iv. p. 69. EPISTAXIS. 557 occur in that attenuated and watery state ofthe blood which usually follows copious, sanguineous, and other evacuations, in relaxed and leucophlegmatic habits. Bleeding from the nose is no uncommon occurrence in dropsical patients, and in the latter stage of cachectic diseases, particularly scurvy. Prognosis.—Epistaxis is seldom of much consequence when it is not symptomatic of some serious visceral or general affection. When, however, it occurs readily and frequently in early life, it would seem to indicate a particular predisposition to haemoptysis and phthisis pulmonalis; and frequent or habitual epistaxis, in mid- dle and advanced age, may be regarded as a pretty sure indication ofthe existence of organic visceral disease, and of a strong tendency to dropsy or apoplexy, according to the general physical tempera- ment and structure ofthe individual. Haemorrhages from the nose, in inflammatory fevers, and in the stage of excitement of every form of fever, typhus, as well as malignant, are to be regarded as salutary; but when they occur in the sinking stage, or period of collapse, they manifest a highly dangerous condition. This, as indeed all other varieties, of haemorrhage, is most apt to become troublesome and dangerous in debilitated, relaxed, and irritable subjects; more especially, when the blood, at the same time, is thin and watery, or dissolved, as in scurvy. The most unmanageable haemorrhages from the nose, are those which depend on some abdominal irritation or obstruction, in connection with an attenuated state of the blood. Epistaxis is, however, very rarely fatal from the immediate effects of mere loss of blood, although, like other varieties of sanguineous discharges, it may lead to a train of distressing and dangerous chronic affections. Treatment.—In being called to a case of epistaxis for remediate aid, the first and most important question is:—Are the circumstances preceding and accompanying the haemorrhage; and is the haemor- rhage itself of such a character as to render it most proper to arrest it, or to suffer it to go on until it ceases spontaneously? When the haemorrhage occurs in consequence of suppressed menstrual or hae- morrhoidal discharge, it ought not to be interfered with, unless it becomes excessive; and the same observation applies to the occur- rence of this evacuation in the stage of excitement of febrile affec- tions. In general, whenever epistaxis is attended with an active pulse, and symptoms of cephalic congestion, no attempt should be made to arrest the bleeding by local applications; but, on the con- trary, nature should be assisted in the reduction of the vascular excitement by venesection, rest with the head in an elevated posi- tion, cold drinks, laxatives, and nitre. The last article, given in large doses, is often particularly beneficial, in cases of considerable arterial excitement. I have used it in every variety of active haemor- rhage with prompt and complete success, without any auxiliary application. This mode of proceeding is especially necessary in persons of robust and plethoric habits, and in such as are subject to 1 47* 558 EPISTAXIS. haemorrhoidal discharges. But when nasal haemorrhage occurs in weak, nervous, and cachectic individuals, and particularly when the manifestations of general vascular turgescence and increased mo- mentum of the circulation are absent, the sooner it is arrested the better. In moderate cases, it will often be sufficient to apply cold water to the temples, head, and nape of the neck, while the head is kept in an elevated position. Richter asserts, that cold water applied to the genital organs, has a sudden and powerful effect in arresting bleeding from the nose. If the haemorrhage should not yield to these simple measures, small doses of sugar of lead may be given internally. This is decidedly the best internal astringent in every variety of active haemorrhage.* From one to two grains may be given every half hour until the bleeding is checked; and, in most cases, its effects are promptly successful. The galic acid, also, is said td be a very powerful styptic for the cure of this and other varieties of internal haemorrhage. Dr. A. T. Thomson, has lately published the result of his analysis of Ruspini's celebrated styptic, and from this it would appear, that its active principle is the galic acid—Ruspini's styptic is, according to Dr. Johnson's experience, " unquestionably the most powerful restrainer, of haemorrhage which we possess;" and as its price is "enormous," it is much to be hoped that Dr. Thomson's analysis may be correct. Be this as it may, experience has shown that the galic acid is a powerful agent for re- straining internal haemorrhages. In general, the haemorrhage may soon be permanently arrested by these means; but where the haemor- rhagic disposition is strong, or in relaxed and debilitated habits, the bleeding, though checked for a time by applications of this kind, is apt to return again and again, until the system becomes greatly ex- hausted. In cases of this kind, we may generally succeed in putting a permanent stop to the discharge, by applying a blister to the back ofthe neck; and in order to obtain vesication speedily, the skin, where the blister is to be applied, should be previously well rubbed with the terebinthinate decoction of cantharides, oil of monarda punctata, or some other active rubefacient. Warm pediluvium is always a useful auxiliary remedy, by deter- mining the circulation to the inferior parts ofthe body; or, instead of this, sinapisms may be applied to the ankles or soles of the feet Local styptics are recommended in obstinate cases, but they are very rarely of much avail, and may even do mischief by the irrita- tion they cause in the snyderian membrane, and the consequent afflux of blood. Nevertheless, in obstinate and alarming cases, a dossil of lint, dipped in some astringent solution, should be introduced into the nostril, and passed up to the part from which the blood issues. * Various other internal astringents have been recommended—as, the sul- phate of zinc, alum, sulphate of copper, gum kino, and the muriated tincture of iron. They are, however, greatly inferior to the sugar of lead. H.EMATEMESIS. 559 In general, however, simple compression, by plugging up the nostril with lint, will answer all the purposes that can be obtained from applications of this kind. The patient must be cautioned against blowing his nose, as well as against every thing which may excite the arterial system. Upon the whole, bleeding, purgatives, and nitre, with cold water to the head, warm pediluvium, or sinapisms to the feet, blisters to the back of the neck, the internal use of the sugar of lead, and finally, mechanical compression, are the remedies which must be relied on in this variety of haemorrhage. 2. Hasmat emesis.—Haemorrhage from the stomach. The premonitory symptoms of haemorrhage from the stomach, are, in general, conspicuous. They consist in a sense of weight and pressure in the epigastrium; loss of appetite, or voraciousness; foul breath; acid eructations; pain and tenderness in the hypochondria; nausea; anxiety; ringing in the ears; disposition to syncope; a small, contracted, and irritated pulse; alternate flushes of heat and chills; palpitation; cold extremities; a pale and contracted countenance; and finally, extreme anxiety; and weakness and constriction about the breast; the senses become confused; great sickness of the stomach, with a feeling of approaching syncope; and at last, copious ejections of blood from the stomach, ensue. The blood thrown up is gene- rally of a very dark color, sometimes in coagulated clots, and at others quite fluid. Occasionally, however, it is florid and liquid. Instances are mentioned, in which small masses of concreted lymph, deprived of the cruor, resembling pseudo-membranous structures, were thrown up.* Sometimes, the blood ejected is of a black color, resembling tar. In cases of this kind, the haemorrhage probably proceeds from the liver. In malignant fevers, particularly in yellow fever, the discharge resembles coffee-grounds suspended in a glairy fluid. This would seem to be generally the case when the haemor- rhage arises from inflammation and abrasion of the mucous mem- brane of the stomach. In some instances, partial syncope follows the vomiting, and the patient complains of pain in the region of the spleen and in the lower part of the abdomen. The quantity of blood thrown up at once is often very great. Instances of fatal haemor- rhage in the stomach have occurred also, in which little or no blood was discharged, (Richter;) and in some cases the blood passes off by the bowels with little or no discharge by vomiting. After the blood which had gradually accumulated in the stomach is thrown off, the patient generally soon feels greatly relieved, though often much exhausted. Very frequently, however, the same train of symptoms already mentioned return, after a longer or shorter interval, and ter- minate in another spell of vomiting of blood; and the haematemesis may thus recur several times before it finally ceases. * Reil. Fieberlehre. B. iii. p. 134. 560 H.EMATEMESIS. The haemorrhage no doubt generally occurs from the mucous membrane of the stomach, but it is thought also to proceed in some cases from the liver or spleen. When the blood comes from the former organ, it passes along the common bile duct into the duode- num, and thence regurgitates into the stomach. When the spleen is the source of the haemorrhage, if this be ever the case, the blood, it is supposed, gains admission into the stomach through the vasa brevia. Richter observes that the frequent tumefaction of the spleen, a short time before the occurrence of haematemesis, as well as the morbid or unnatural condition of this organ in those who die of this disease, render this opinion very probable. It is more likely, however, that the spleen is no further concerned in the production of this haemor- rhage than by the congestion which it is peculiarly calculated to produce in the vessels of the stomach when its own structure be- comes engorged or indurated. The darker and more coagulated the blood is when thrown up, the slower we may presume must have been the haemorrhage, or the longer it must have lain in the stomach. A portion of the effused blood always gains admission into the bowels, and hence generally dark, grumous, alvine discharges, occur for several days after an attack of haematemesis. Causes.—Every thing which tends to impede the free circulation ofthe blood in the abdominal viscera, may give rise to this variety of haemorrhage. Among the circumstances which tend most parti- cularly to this effect, are indurations of the liver and spleen. It occurs also in consequence of suppressed haemorrhoidal discharge, more especially when favored by an indulgence in the pleasures of the table, or by an inactive and sedentary mode of life. In no sub- jects, however, is vomiting of blood more apt to occur than in young females, soon after the age of puberty, laboring under menstrual irregularities. It appears also occasionally to arise from pregnancy, and from the final cessation of the menses at the critical period of life. Various local causes may produce haematemesis, such as acrid or corroding substances received into the stomach; blows on the epigastrium; and it takes place sometimes in the last stage of malig- nant fevers. The blood may proceed from the nose, and gradually descend into the stomach. This occurs sometimes in patients con- fined to bed by other diseases. In such cases, however, the quantity of blood thrown up is always small, and the vomiting is not preceded by the spasmodic and painful affections of the stomach mentioned above. Prognosis.—When haematemesis occurs in consequence of sup- pressed haemorrhoidal or catemenial discharge, it is not in general attended with much immediate danger, unless the vomiting returns frequently, in which case it seldom fails to lead to a train of distress- ing and dangerous consequences, such as dropsy, inveterate dyspep- sia, hysteria, hypochondriasis, and great languor, relaxation, and debility. It is most dangerous when it arises from visceral obstruc- HJEMATEMESIS. 561 tions, particularly in persons who are addicted to the intemperate use of spirituous liquors. There is no variety of haemorrhage more apt to become habitual than this one. Tissot relates a case which recurred regularly every month, instead of the menstrual evacuation, without any evil consequences whatever. Treatment.—The momentum of the circulation must be dimin- ished by venesection when it is above the natural standard. A large sinapism should be immediately applied to the epigastric and hypochondriac regions, in order to derive the blood as much as pos- sible from the vessels of the stomach. Dry cupping may also be beneficially used for this purpose; and warm pediluvium will assist materially in deriving the circulation from the congested abdominal viscera. Laxative enemata should be administered. In that variety of haematemesis which attacks females between puberty and the age of thirty, purgatives, according to the experience of Dr. Hamilton, are among our most valuable remediate means. There is generally in cases ofthis kind considerable menstrual irregularity, caused ap- parently by a loaded and torpid state of the intestinal canal. Free purgation, by exciting the portal circulation, and removing the in- testinal irritation, will generally prevent the recurrence of the hae- morrhage in cases of this kind. 1 have in a few cases known decided benefit obtained from the use of active and repeated purgatives in this affection. Dr. Sheridan has published some cases which go to show that emetics will sometimes do much good in this variety of haemor- rhage. He states that his father had used this remedy with great advantage in haematemesis, more than fifty years ago. 1 have not myself employed emetics in this affection; but I understand that Dr. Chapman has resorted to them with much benefit. Ipecacuanha would appear to be the proper emetic. Various astringents have been recommended in this affection. Saccharum saturni; galic acid; muriated tincture of iron; spirits of turpentine; alum-whey; muriate of soda; kino; cold water; and a variety of astringent vegetable infu- sions, have been employed and praised for their effects. The sugar of lead does not appear to be as efficient in this as in the other varie- ties of haemorrhage, although without doubt the best astringent we possess in this affection. Indeed, internal astringents can afford but little advantage when the disease depends on obstructions of the liver or spleen, or upon some other chronic impediment to the regular circulation of blood in the portal circle. I have nevertheless derived very great advantage from the use of the spirits of turpentine with castor oil, in purgative doses, in several cases of haematemesis. In cachectic and debilitated subjects, more especially in chlorotic fe- males, the muriated tincture of iron sometimes affords peculiar ad- vantages. Burserius recommends the use of copious draughts of cold water in this affection. The expressed juice of the common nettle, (urtica dioica,) has been much extolled for its effects in this haemorrhage, and I have known it used with apparent benefit. 562 HEMATURIA. The diet should be ofthe lightest and most unirritating kind, and the drink bland, cool, and acidulated. After an attack of this dis- ease, the diluted sulphuric acid will generally be useful in restoring the tone of the stomach, and checking the tendency to sanguineous effusion. 3. Haematuria.—Haemorrhage from the urinary organs. It is often difficult to say whether the haemorrhage in bloody urine comes from the bladder, the ureters, or the kidneys. As it is of some importance in a practical point of view, to form a correct opi- nion concerning the source of the bleeding, it will be proper to point out the diagnostic circumstances particularly. When the blood passes off unmixed with urine, or without an effort to evacuate this secretion, the haemorrhage, it may be inferred, proceeds from some part of the urethra, (stimatosis.) When the discharge of bloody urine is attended with a stinging or dull pain about the neck of the bladder, and a sense of fulness and uneasiness in the perinaeum, accompanied with frequent painful erections, and burning pain in the glans penis and anus, and the blood comes off in small flocculi, intermixed with pretty large coagula floating in the urine, there is good reason to infer that the haemorrhage proceeds from the bladder. The coagula sometimes block up the neck of the bladder or urethra so completely as to cause complete suppres- sion of the urine, and render the introduction ofthe catheter neces- sary to procure its evacution. In haemorrhage from the kidneys or ureters, the blood is always very intimately mixed with the urine, so as to give to the discharge a uniform bloody appearance, without flakes, or small coagulae. After the urine has stood some time, the blood subsides to the bot- tom of the vessel, into a uniform paste-like substance, leaving the supernatant urine clear. In haemorrhage from the kidneys, the patient in general experiences little or no unpleasant sensations in the bladder; but in the region of the kidneys more or less pain and uneasiness is always felt, and there is usually a retraction of the tes- ticle on one side, with a feeling of numbness on the thigh. Haematuria sometimes occurs periodically. This is most apt to be the case when the haemorrhage proceeds from the neck of the bladder, and is attended with an irregular or ineffectual haemorrhoidal effort in the system. I am now attending a gentleman who has been regularly affected with bleeding from the bladder every two months for the last four years. He was formerly much troubled with hae- morrhois, but since the present complaint began, he has had no hae- morrhage from the rectum. This variety of haemorrhage is most apt to occur in old people— more especially in such as have been much affected with haemorrhois, or in such as are of a gouty habit. Richter says that plethoric and corpulent women are peculiarly liable to haematuria about the period HEMATURIA. 563 of the final cessation of the catamenia. It is not uncommon to meet with this affection in very young children during dentition. Causes.—Haematuria is often excited by calculous concretions in the kidneys and bladder, and by acrid or stimulating diuretics, as cantharides, spirit of turpentine, garlic, and other similar substances. It arises also from organic affections of the urinary organs. Scir- rhus, ulcerations, and vascular or fleshy tumors in the bladder, ureters, and kidneys, may produce it. In some instances, the hae- morrhage occurs from a varicose state of the mucous membrane of the bladder; and it would seem that a highly congested condition of this membrane from chronic inflammation, is sometimes the cause of this affection. When the predisposition to the disease is strong, it may be readily excited by whatever is capable of increasing the general momentum of the circulation, and particularly by mechani- cal agitation of the urinary organs. There is a gentleman in this city who has been affected with bloody discharges from the bladder, at short intervals, for more than six years. It is frequently brought on immediately by active exercise, and especially by riding in a car- riage over a rough pavement. It is not connected with calculus, nor with pain, though often accompanied with a sense of weight, pressure, and uneasiness, about the neck ofthe bladder. One of the most frequent causes of haematuria in advanced age is an ineffectual haemorrhoidal effort, or suppression of this discharge after it has become habitual. Haemorrhage from the urethra frequently occurs in gonorrhoea, in consequence of irritating injections. This variety of haemorrhage is seldom attended with alarming effects from the mere loss of blood. When it occurs in the latter stage of violent grades of fever, it is indeed one of the most fatal signs. Frequent and copious haemorrhagic discharges from the blad- der in old people is particularly apt to lead to dropsical effusions. (Richter.) When, however, it occurs vicariously in the place of haemorrhois or menstruation, it is rarely followed by serious conse- quences; nor is this haemorrhage attended with danger when it arises from irritating diuretics from dentition, or from overheating, unless it be connected with considerable inflammation. Persons who have once been affected with this complaint, are in general particularly liable to a return of it from the action of any of its exciting causes. Treatment.—In plethoric and young subjects, an attack of haema- turia, like any other haemorrhage in such a habit, requires a prompt reduction of the momentum of the circulation by venesection. When the haemorrhage depends on calculous irritation in the kid- neys, the warm bath, assisted by opium and sugar of lead, are gene- rally decidedly beneficial. A quarter of a grain of opium with a grain of sugar of lead, may be given every hour, until the pain and irritation are allayed. Free venesection should, however, be pre- mised in such cases; and much advantage may also be obtained from 564 HEMATURIA. cupping and sinapisms over the region ofthe affected kidney. Along with these measures, copious draughts of mucilaginous diluents should be taken, more especially when the renal irritation arises from acrid diuretics, or other substances taken internally. The uva ursi has been much recommended for the cure of this affection; but although I have tried it repeatedly, I have never yet derived any obvious benefit from it. Dr. A. T. Thompson says, that "theaddi- tion of some galic acid to a tincture of uva ursi, will be found to answer every indication that can be expected from the employment of astringents in haematuria.* When the haemorrhage is not attend- ed with symptoms of renal irritation, or pain in the region of the bladder, the muriated tincture of iron, with the free use of mucilagi- nous drinks, will often do much good. I have in several instances found this astringent decidedly beneficial, after the sugar of lead had failed to procure any advantages. From twelve to twenty drops of this tincture may be given, three, four, or five times daily, according to the urgency of the symptoms. In all instances the diet should be light, unirritating, and digestible, and all kinds of stimulating beverages, and active diuretics, most carefully avoided.t In one case of long standing, I succeeded in putting a permanent termina- tion to the haemorrhage by small doses of alum and ipecacuanha,^ in conjunction with a milk diet, mucilaginous drinks, and the occa- sional use of a mild aperient. Reil recommends cold and bland in- jections into the bladder when the blood proceeds from this viscus. He mentions also strong coffee, with laudanum, taken occasionally, as useful when this affection is attended with difficulty and pain in voiding the urine. In habitual haematuria, a caustic issue on the upper and inner part of the thigh, or near the groin on the abdomen, is said to have proved very beneficial. (Richter.) In recent cases of an obstinate character, we may sometimes make a successful impres- sion on the disease by sinapisms applied over the sacrum. I have known this application to arrest a copious haemorrhage from the bladder, after various other measures had been adopted without avail. Various astringent vegetable infusions have been employed and recommended in this variety of haemorrhage, but they seem to be of little value. In chronic and moderate cases, we may employ a decoction of logwood with occasional benefit. Where the blood proceeds from the urethra, cold water or ice should be kept applied to the genitals. This will seldom fail to put a stop to the bleeding. We may also inject cold solutions of the sugar of lead in cases of * Ed. Med. & Phys. Jour. Jan. 1831. X Burserius relates an instance of obstinate haematuria, which was cured by a long course of milk diet, without any other remedies.—Institutionum Med. Pract. vol. iv. p. 487. X R.—Pulv. aluminis 3L ----- ipecac, gr. xx.—M. Divide into ten equal parts. S. Take one every morning, noon, and evening. HiEMOPTVSIS. 565 this kind. The patient should not be permitted to use any exercise in recent cases. Perfect rest is often essential, particularly when she haemorrhage is attended with manifest local and general irrita- tion. 4. Haemoptysis.—Haemorrhage from the lungs. This term is applied to haemorrhages from the respiratory pas- sages, whether they proceed from the larynx, the trachea, or the bronchia. In its concomitant phenomena, degrees of violence, and duration, haemoptysis varies very much. In many instances the quantity of blood brought up is very small; in some cases it is dis- charged in considerable, but not exhausting quantities; and occa- sionally the bleeding is sudden and exceedingly copious. Active haemorrhage from the lungs is often preceded by certain premonitory symptoms; such as a feeling of heaviness and lassitude in the extremities; anxiety; stricture across the breast; short cough; palpitation of the heart; deep and frequent sighing; a deep-seated, pungent or burning pain under the sternum, and slight creeping chills; cold hands and feet, alternate paleness and flushing of the face; mental and corporeal irritability; a quick, small, frequent, and corded pulse; and often a disagreeable salty or sweetish taste in the mouth. After these symptoms have continued for a longer or shorter period, the patient usually begins to feel a sense of warmth in the breast, gradually rising up towards the larynx, attended with a saltish taste. Slight coughing now ensues, or an effort is made to hawk, and the blood makes its appearance. In many cases, how- ever, the haemorrhage comes on suddenly, without any premonitory symptoms whatever. When this is the case, there is commonly but little blood discharged at a time; but the haemorrhage is apt to re- turn frequently for several weeks, and even months. The blood is usually very florid and frothy, particularly when it proceeds from the trachea and larger bronchia. In malignant fevers, scurvy, gangrene of the lungs, and in the pneumonia of old people, the blood, however, is dark, and sometimes almost black, and gene- rally dissolved. When the haemorrhage proceeds from the fauces, the blood is generally spit out without coughing and when it comes from the cavity of the mouth, there is usually neither coughing nor hawking in throwing out the blood. In some instances, however, when the bleeding is profuse, the blood descends and irritates the glottis, giving rise to a mixed effort of coughing and vomiting, which may readily lead to the supposition that the blood proceeds from the lungs. Portal mentions a singular instance, which was treated unsuccess- fully for haemorrhage from the lungs. The quantity of blood cough- ed up was very copious, and although frequently checked, recurred again and again until the patient sunk under it. On dissection, the & Vol. I.—48 ^^ HEMOPTYSIS. bronchial glands were found much tumefied—some of them as large as a hazel-nut, and charged with a large quantity of black fluid. The lungs were sound, but the bronchial cells were filled with a dark grumous fluid. In most instances, those who have once suffered an attack of spit- ting of blood, are subject to returns of it at irregular periods; and in some rare instances this affection has been known to return periodi- cally. Schrceder, mentions a case in which a considerable portion of blood was coughed up every morning for many days in succes- sion, not the least haemorrhage having occurred during the rest of the day; and Alexander Thompson relates an instance, in which haemorrhage from the lungs came on every third day with perfect regularity for upwards of a year. Reil also saw a case of quotidian haemoptysis in a female, which continued for two years. The bleed- ing always occurred in the morning. Cases in which haemorrhage from the lungs returned monthly, are mentioned by Amatus Lusi- tanus, Schenk, Meyer, and Mead; and Richter mentions an instance in which it occurred every four weeks instead of the menstrual evacuation, for upwards of twenty-five years. (Spec. Therap.) Blanchard saw an instance of its recurrence for a long period (every three months) in consequence of suppressed haemorrhoidal dis- charge.* Predisposition.—The period of life most favorable to the occur- rence of this variety of haemorrhage, is between the fifteenth and thirtieth years of age. Some individuals are constitutionally pre- disposed to it; and, indeed, in the majority of cases, in which it occurs spontaneously, such a predisposition lies at the bottom of the disease. This predisposition would seem to consist in an irritable state ofthe circulatory system generally; and in a delicate organisa- tion of the pulmonary system. The habit of body—so far as its physical conformation may be concerned—which seems most gene- rally connected with a particular predisposition to this haemorrhage, consists in a narrow, flattened, and depressed chest; high, promi- nent, square shoulders; a long and slender neck; a general slender, and delicate frame of body; fair hair, and blue eyes; a delicate and fair skin, through which the superficial veins are conspicuous; red cheeks; sound white teeth; and a clear but not powerful voice. Such individuals are of a sanguineous temperament; irritable, pas- sionate, full of activity, but incapable of enduring much exertion; they are apt to be troubled with irregular determinations of blood, particularly to the head; and slight exciting causes create palpitation of the heart and general arterial excitement. During early youth, persons of this temperament and habit, are apt to be affected with glandular swellings about the neck; eruptions on the scalp and be- hind the ears; and as they advance in age, with slight catarrhal affections, which frequently go off slowly with a copious expectora- * Medicus. Geschichte Periodischer Krankheeten. Th. i. p. 115. HAEMOPTYSIS. 567 tion. In such individuals, after they have passed the age of puberty, the ordinary exciting causes of haemorrhages are particularly apt to give rise to spitting of blood. Causes.—The exciting causes of haemoptysis are, of course, ex- tremely various. The following are among the most common and powerful. Atmospheric vicissitudes; violent bodily exertions; the intemperate use of stimulating drinks; the suppression of habitual evacuations; the sudcjen drying up of old ulcers; repercussion of cutaneous eruptions; suppressed habitual sweating of the feet; metas- tasis of gout; rheumatism; irritating substances acting directly on the mucous membrane ofthe lungs, as the inhalation of fine irritat- ing particles floating in the air, or of gaseous substances; intestinal irritation; organic diseases ofthe heart; obstruction of the spleen or liver; a sudden diminution of atmospheric pressure; breathing a very heated air; blows on the chest; costiveness; loud speaking, or sing- ing; violent mental excitement; and organic affections of the lungs, impeding the free circulation of the blood through its vessels, parti- cularly tubercles. Haemoptysis sometimes follows the amputation of a limb, or the taking up of a large artery. Prognosis.—Haemoptysis seldom proves fatal from the mere loss of blood. It is, nevertheless, generally of very serious import— being, in many instances, the forerunner or attendant of phthisis pulmonalis. It is not, however, always followed'by consumption, or even connected with a phthisical habit. Instances of pulmonary haemorrhage not unfrequently occur without any dangerous conse- quences whatever; and this is more apt to be the case when the dis- charge comes on suddenly and profusely, than when there is an ex- pectoration merely streaked with blood. The prognosis as to the remote consequences, depends, however, much on the presence or absence of the general manifestations of a scrofulous or phthisical habit mentioned above. Where these indications are unequivocal, the occurrence of haemorrhage from the respiratory passages, is always to be regarded as highly dangerous. When this haemorrhage occurs from pregnancy or suppressed catamenial or haemorrhoidal discharge, there is usually no reason to apprehend any very serious consequences, if a predisposition to consumption does not exist. In general, haemoptysis, resulting from causes which suddenly produce strong pulmonary congestion, or general arterial excitement—such as lifting heavy weights, or other violent bodily exertions; loud singing or declaiming; playing on wind instruments; over-distension of the stomach; stimulating drinks, &c. is much less apt to lead to dangerous consequences than cases that occur spontaneously. Treatment.—The remediate management of haemoptysis divides itself into that which is proper during the actual existence of the haemorrhage, and that which should be pursued after the bleeding is arrested. When the pulse is frequent, tense, or hard, the momentum of the circulation should be immediately reduced by venesection; and to 568 HJEMOPTVSIS. effect this purpose adequately, it is often necessary to abstract blood very copiously. In some instances, the pulse will be found very small, but tense and firm to the touch; and in such cases it is par- ticularly important to resort to prompt and very free venesection. At the same time that this step is taken, large portions of common salt* or small doses of sugar of lead, should be administered at short intervals, until the haemorrhage is checked. A large sinapism should also be applied over the breast, as soon as the activity of the pulse is reduced. Perfect rest and cooling drinks should be rigidly enjoined. If the feet are cold, warm applications or sinapisms ought to be applied to them; and the patient may take an occasional draught of cold water.X If the bowels are constipated, the rectum should be emptied by laxative enemata. In cases of this kind, large doses of the nitrate of potash will often promptly arrest the haemorrhage; and in a manifestly phlogistic state of the system, it is decidedly the best internal remedy we possess in this affection. This article was long ago strongly recommended by Selle;J and Richter speaks very favorably of its powers in this disease. Dickson also gave it in very large portions, dissolved in mucilaginous fluid, in this affection, with much benefit;§ and we may likewise cite the experience of Gibbon,|| and Hartman,1T in favor of its excellent effects. In Italy it has of late years been greatly extolled as a remedy in haemoptysis, and, according to my own experience, not more than it deserves. Recamier has within a few years reported some cases illustrative of its beneficial effects in this variety of haemorrhage. He gave half an ounce of nitre, dissolved in a mucilaginous mixture, in the course of twenty-four hours, and in this way three cases were promptly relieved after bleeding and other remedies had been used ineffectu- ally.** From fifteen to twenty grains ofthis article, dissolved in a small cup of barley-water or some other mucilaginous fluid, may be * This article was first introduced to the notice of the profession, as a prompt and efficient remedy in haemoptysis, by Dr. Rush. It would seem, however, from Schopf's account of his Travels in the United States, (Bd. i. p. 116,) that the knowledge of its powers in this way was first brought to this country from Ireland, by Schiel. F. Hoffman and Fordyce assert, that a solution of sulphate of soda will often do'more good in haemoptysis than any other remedy. X Burserius (Inst. Med. Pract., vol. iv. p. 33,) says much in favor of the use of frequent draughts of cold water, (the temperature of which is to be lessened from time to time, until it is at last taken as cold as ice,) in this variety of hae- morrhage. X Medicina Clinica. Berlin, 1797, p. 147. §. Lond. Med. Obser. vol. vi. No. XVI. || Medical Cases and Remarks, Lond. 1800. •H" Nova Act. R. Soc. Scient. Upsal. vol. i. p. 109, as quoted in Richter's Aus- fuhrliche Arzneimittellehre, vol. iv. p. 242. ** Med. Chir. Rev. January, 1826. HEMOPTYSIS. 569 taken every half hour or hour, until the bleeding is checked. A great variety of internal astringent remedies have been recommended in this affection—such as alum, colcothar of vitriol, sulphate of cop- per, sulphuric acid, &c; but they are all much inferior, in efficacy, to the sugar of lead. This article may be given in doses of from one to five grains every half hour, or at longer intervals, according to the rapidity of the haemorrhage. It appears to be equally appli- cable in cases attended with an active or debilitated state of the cir- culation. I have generally given it in union with calomel, where the diathesis was phlogistic; but in cases attended with a nervous or spasmodic condition, opium is the best adjuvant. In cases attended with an irritated, small, frequent pulse, with a pale and contracted countenance, cold extremities and a dry skin, small doses of sugar of lead, in combination with opium and calomel,* will generally procure prompt relief. Richter and Mezat recom- mend ipecacuanha in such cases. The former writer states that he has often promptly arrested haemoptysis, attended with cold extremi- ties, alternate flushing and paleness of the face, limpid urine, small and hard pulse, and much anxiety in the chest, by exhibiting a quarter of a grain of ipecacuanha every fifteen minutes. (Specielle Therapie.) It is in instances of this kind, that emetics may be given with advantage. Whenever a congestive state of the pulmo- nary system is present in this affection, with deficient action of the cutaneous capillaries, vomits will be likely to prove serviceable. They were formerly much, and too indiscriminately, recommended, by some practitioners. (Brian Robinson.) In ordinary cases, at- tended with a plethoric and excited state of the system, they are unquestionably hazardous. In the spasmodic and nervous cases just mentioned, Harles,^ Stork, Richter, Plater, and others, speak very favorably of hyoscyamus. Harles particularly recommends an oil prepared by boiling the leaves of this plant in flaxseed oil; and F. Hoffman considers the extract, given in doses of from one to three grains every hour, as one of our best remedies in such cases. Ac- cording to Dr. Miner's experience, the powdered capsicum, given in doses of from three to five grains every ten minutes, is a most efficient remedy in haemoptysis. I have had occasion to prescribe this article in one instance lately, and the result has given me a very favorable impression of its powers in this respect. When spitting of blooding assumes a chronic character,and is attend- ed with an irritated state of the pulse, digitalis sometimes does much * R.—Calomel gr. vi. Pulv. acetat. plumbi gr. xii. ----opii gr. iii.—M. Divide into 1J2 equal parts. Give one every thirty minutes if the hemorrhage is considerable, or every two hours in less rapid cases. X Reil. Fieberlehre. Bd. iii. p. 107. X Hufeland's Journal, der Pract. Heilkund. B. ix. s. ii. p. 47. 48* 570 HAEMOPTYSIS. good. From one fourth to half a grain of the powdered leaves, or from fifteen to twenty drops of the tincture, may be taken every four hours, until a manifest impression is made on the pulse. It will be proper to keep the system moderately under its influence for ten or twelve days. In cases of this kind much advantage will, in general, result from blistering the breast—or, what is still better, pustulating this part with tartar emetic ointment, or establishing a more permanent discharge by a caustic issue or seton. The nature of the occasional cause should be particularly kept in view in regulating the treatment of haemorrhage, and especially for the prevention of its recurrence. When haemoptysis supervenes in consequence of suppressed hae- morrhoidal discharge, advantage may be obtained from the use of small doses of aloes, and particularly from the application of leeches to the anus. These measures are particularly useful in conjunction with a light diet, moderate exercise, and an occasional general bleed- ing, to obviate the return of the haemorrhage from the lungs. When the disease appears to arise from general plethora, in conse- quence of a free indulgence in the pleasures of the table, and an in- dolent course of life, or sedentary habit, it will be necessary to en- join a simple, unirritating, and moderate diet, cooling drinks, moderate exercise, and the avoidance of all kinds of stimulating beverages. Should the haemoptysis be dependent on irregular, gouty irritation, or rheumatism, especial advantage may be gained from setons or is- sues on the inferior extremities, and a course of treatment calculated to counteract these affections. When abdominal indurations exist, or intestinal irritation from a loaded state of the bowels, or acrid secretions, a gentle course of mercurial and aperient remedies, the extract of taraxacum, and other deobstruents, with a regulated diet and exercise, will be most likely to ensure exemption from a subsequent attack ofthe haemorrhage. If the bleeding appears to be excited by a violent cough, attended with irritation of the respiratory passages, expectorants, demulcents, leeching and cupping on the chest, venesection, and opiates, are particularly indicated. In such cases frequent doses of flaxseed oil are said to be very beneficial.* When the cough is violent and spasmodic, and the poise contracted and small, with a dry skin, small doses of camphor and ipecacuanha, with mucilaginous drinks, often procure great and speedy relief. (Richter, Specielle Therapie, Bd. iii. p. 297.) When haemoptysis occurs in young females from menstrual ir- • regularities, we may resort to the tincture of cantharides, venesection, blisters to the sacrum, riding on horseback, and the warm hip-bath; but the ordinary stimulating emmenagogues must be carefully avoid- ed. When cases ofthis kind are attended with a chlorotic, or slug- gish and relaxed state of the system, the ferruginous preparations, * Journal de Med. torn. xxx. p. 85. MENORRHAGIA. 571 the tincture of cinnamon, exercise by gestation, a nourishing and digestible diet, with aloetic aperients, &c. may be properly used. I have employed the following pills with obvious benefit in two in- stances of this kind.* 5. Menorrhagia.—Haemorrhage from the uterus. Uterine haemorrhage appears under a great variety of modifica- tions, both in relation to its phenomena and causes. Under the present head, however, I shall treat only of those haemorrhagic dis- charges which occur in the unimpregnated state of the uterus—ex- cluding also such as depend on organic or structural disease of the womb. In some instances, the menstrual secretion becomes so copious as to cause much debility and exhaustion, and to require remediate interference. In many females, the flow of menses is always very large, who nevertheless enjoy a state of vigorous health. In instances of this kind, the discharge must not be regarded as morbid, or im- moderate, however copious it may be; for if the system sustains no inconvenience from it, it is to be viewed as natural or consistent with the constitutional habit of the individual in whom it occurs. So long, therefore, as the health of the female continues unmolested by copious menstruation, it cannot be accounted immoderate, or a proper object of medical attention; but when this evacuation gives rise to debility, exhaustion, and other symptoms of ill health, it amounts to a morbid discharge, and requires remediate measures. Immoderate flow of the menses must not be confounded with menorrhagia. This latter is, strictly speaking, a haemorrhage, whilst the former consists in a mere superabundant secretion of the natural or healthy menstrual evacuation. In menorrhagia the effused blood retains its power of coagulation, or at least shows a tendency to coagulate; but in immoderate menstrual discharge it re- mains liquid and entirely free from coagula. Menorrhagia is sometimes preceded by various premonitory symp- toms; such as pain and tension in the loins and pubic region; a feel- ing of fulness and pressing down in the uterus; frequent desire to pass urine; a small, contracted, and frequent—or a full, wave-like, or rebounding pulse; heaviness of the head; ringing and noise in the ears; slight and creeping chills, transient flushes, and sense of weight in the feet. In many instances, however, the haemorrhage commences without any indications of its approach. Sometimes a sudden gush of blood takes place, which continues to flow very copi- * R.—Prussiat. ferri Jji. G. aloes soc. gr. viii. Tart, antimon. gr. ii. Conserv. rosar. q. s. M. Divide into thirty pills. S. Take two every morning, noon, and evening. 572 MENORRHAGIA. ously for a few nosrs and then ceases. More commonly, however, the discharge continues for four or five days, and in some instances several weeks and goes off very gradually. When it occurs about the period of the final cessation of the menses, it is apt to become very protracted in its duration, more especially in females of ple- thoric and relaxed habits of body. All the consequences, that have already been mentioned as apt to occur from the excessive loss of blood, are especially prone to super- vene from uterine haemorrhage. Women of a nervous temperament are liable to sudden amaurosis from excessive uterine haemorrhage, and they are especially subject to a very peculiar nervous pain in the head over the region of the orbit of one side; and sometimes they become affected with a distressing jarring noise " like that of a mill or threshing floor." (Hall.) When menorrhagia is copious, and prolonged in its course, or recurs frequently at short intervals, it seldom fails to produce great relaxation and debility, and to lead ultimately to a train of very distressing, and even dangerous affec- tions. Females who are much affected with this haemorrhage, become pale, sallow, weak, and dyspeptic; and in phlegmatic habits, oedema of the feet, or general anasarcous effusion, pains in the sto- mach, with great muscular prostration, are apt to ensue. Leucor- rhoea, often extremely copious, almost universally occurs during the intervals of the haemorrhages, and contributes greatly to the general debility and relaxation. Menorrhagia may with much propriety be divided into active and passive.* The former variety occurs in sangnineous, robust, florid, and healthy females, and is almost invariably preceded for a short time by the natural menstrual secretion. These cases rarely * Dr. Dewees thinks there is good reason to doubt the propriety ofthis " me- chanical distinction." He adopts the doctrine of Broussais, that all haemor- rhages are active, and quotes Dr. Caldwell in support of this opinion. Strictly speaking, there is, perhaps, no haemorrhage absolutely passive, and in which the vessels that furnish the blood do not co-operate in the production of the haemor- rhage by some kind of action. In a practical point of view, however, this dis- tinction is unquestionably both proper and useful. Would Dr. Dewees not consider aloes a very improper remedy in the menorrhagia of young, sanguineous, and robust females'? He no doubt would. And why? Because experience has shown that this article is among our most efficient means for exciting the uterine vessels, and directing the afflux of blood to them. Yet this article, given in small, but frequent doses, deserves to be accounted the best remedy we possess for those protracted, exhausting, and obstinate uterine haemorrhages which occur in relaxed, nervous, and phlegmatic habits, about the critical period of life. When, therefore, we see a particular modification ofthis discharge arrested by a remedy which we are accustomed to regard as decidedly calculated to stimu- late the vessels from which it occurs—in other words, when we cure the haemor- rhage by exciting applications, we have good grounds for distinguishing if from those cases of the same affection which are invariably increased by its operation. MENORRHAGIA. 573 continue more than seven or eight days, and are often attended with considerable pain in the lower part ofthe abdomen, with a frequent and tense pulse, and a dry and feverish state of the skin. Passive menorrhagia is almost entirely confined to the period when the uterus is about losing its functions—and is met with only in such as have been much debilitated and relaxed by privations or previous diseases, particularly protracted and profuse leucorrhoea; or in individuals of a nervous or phlegmatic temperament, who have been subject to profuse catamenial or menorrhagic discharges. The pulse, in cases of this kind, is small and weak; the muscular system relaxed and debilitated; the skin cool and pale; the countenance exsanguious, and expressive of anxiety and languor; the urine generally pale; and the stomach disturbed with frequent nausea, and other unpleasant sensations. The discharge is apt to continue for three or four weeks, and sometimes much longer. When in bed, the haemorrhage is usually moderate; but on rising, or making the least bodily exertion, the flow of blood is often suddenly increased. If the haemorrhage ceases, it is succeeded by a profuse leucorrhceal discharge, which is quite thin or watery. Causes.—Females of vigorous and sanguineous habits are more subject to menorrhagia than the feeble. The predisposition to this haemorrhage is much favored, by whatever has a tendency to pro- duce general plethora, and by an irritable and relaxed state of the system. A luxurious and indolent life; the free use of high-seasoned and nourishing diet, wines, and cordials; tightly laced corsets; fre- quent and long indulgence in the warm bath; habitual costiveness, and inordinate sexual indulgence, are among the most common and influential predisposing causes of active menorrhagia. Copious and protracted leucorrhoea; mental depression; deficient and unwhole- some nourishment; habitual exposure to a cold or humid atmosphere; in short every thing that is capable of relaxing and debilitating the general as well as the uterine system, may favor the occurrence of passive menorrhagia. Whatever tends to produce sanguineous congestion in the uterus may excite this haemorrhage; such as riding on horseback; dancing; active purgating; the use of emmenagogues; immoderate venereal indulgence; long and rapid walking; a fall on the hips; stimulating diet and drinks; a loaded and constipated state of the bowels; sup- presssed haemorrhoidal discharge; induration of the liver or spleen; and reading voluptuous novels, &c. Treatment.—The indications in this, as in the other varieties of haemorrhage are, to remove the predisposing and exciting causes if practicable; to lessen the momentum of the general circulation, if it be not below the natural standard; to derive the circulation from the uterine system; and finally, to constringe the bleeding vessels. If the pulse be active, or tense and quick, venesection will be proper; and every thing which has a tendency to excite the action ofthe heart and arteries must be removed. The patient should lie 574 MENORRHAGIA. on a mattress, avoid getting up or walking about, and take only the lightest kinds of liquid farinaceous nourishment and cooling acidu- lated drinks. Having diminished the momentum ofthe circulation, recourse must next be had to such remedies as experience has shown to be capable of constringing, or in some way or other checking the haemorrhagic action of the bleeding vessels. Among these, the sugar of lead holds the first rank, and will seldom disappoint our expectations entirely, in the active variety of the disease. From two to three grains, either alone or with a grain of ipecacuanha, may be given every half hour or hour, or at longer intervals, according to the rapidity of the haemorrhage. When the pulse is contracted and quick, it should be given in union with moderate doses of opium or Dover's powder. I have been in the habit of giving it in such cases with about a grain of camphor and the same quantity of ipecacuanha in each dose, with the view of exciting a gentle diapho- resis. The tincture of cinnamon is, perhaps, more frequently used by the German physicians in menorrhagia than any other remedy; and my own experience enables me to speak with much confidence of its usefulness in cases unattended with considerable arterial excite- ment. From thirty to sixty drops of it may be given every hour or two. I have, in some instances, known the discharge very promptly moderated by this medicine alone. A great variety of other astringent remedies are recommended in the books, for the treatment ofthis haemorrhage. Alum, the extract of rathany, kino, the sulphate of copper, &c. may no doubt, be used with occasional advantage; but they are not equal to the sugar of lead for arresting sudden and rapid menorrhagic discharges. In cases attended with a moderate and protracted flow of blood, the extract of rathany will often afford much advantage; and in instances of this kind, I have also used alum, in union with ipecacuanha, with marked benefit.* Tannin has lately been administered in uterine haemorrhage or menorrhagia, with marked success. M. Chavalier prescribed this article in doses of two grains every two hours, in a case of uterine haemorrhage, after a great variety of other remedies had been used with little or no advantage. " On the first day, some amendment was perceptible; on the second, the discharge was but very slight, and on the third day haemorrhage was completely arrested, giving place to an abundant leucorrhoea, but this also disappeared under the continued use of the tannin. M. Chavalier employed this remedy in several other obstinate cases of menorrhagia, and always with the happiest effect."t In cases accompanied with increased arterial ex- citement, the nitrate of potush, given in large doses, will often * R.—Pulv. sulph. aluminis Qi. Pulv. ipecac, gr. xii.—M. Divide into [six equal parts. Give one every three or four hours. X Revue Medicale, September 1828. MENORRHAGIA. 575 afford prompt relief. When the haemorrhage is profuse and rapid, cold applications to the vulva and region ofthe pubis should be made. We may also resort to cold and astringent injections into the vagina. When the violence ofthe discharge has been in some degree check- ed, and it continues in a moderate degree, the elixir of vitriol, diluted in cold water, may be taken at short intervals with advan- tage. Should the measures already indicated fail to arrest or suffi- ciently to moderate the haemorrhage, recourse must be had to the tampon. A strip of soft linen should be introduced by pushing it gradually into the vagina on the point ofthe finger, until the exit of the blood is obstructed. This will cause the formation of a coagu- lum, which being immediately in contact with the bleeding surface, prevents the further progress of the effusion. Emetics also have been recommended for the suppression of uterine haemorrhage; and in active cases of a protracted character, attended with symp- toms of gastric disorder; an emetic dose of ipecacuanha will oc- casionally do much good.* Perfect rest, a light simple diet, and cooling drinks, must be enjoined, and all mental agitation carefully avoided. In passive and protracted haemorrhage from the womb, attended with the symptoms mentioned above as indicative of this variety of menorrhagia, little or no permanent advantage can be obtained from astringent and cooling remedies. These haemorrhages are, indeed, often extremely obstinate in their course. From much attention to cases of this kind, I am satisfied that the appropriate remedies are such as tend to invigorate the uterine vessels. Blisters to the sacrum will, in some instances, do much good; but the remedy which has most frequently succeeded in my hands, is a combination of aloes and the prussiat of iron,t in conjunction with the tincture of cinna- mon. With these medicines I have often succeeded promptly in arresting such haemorrhages. Dr. Dewees recommends small doses of hiera picra, a combination which I have known very effectual in several cases. Aloes is an old remedy in this variety of haemor- rhage. Burdach, in his Materia Medica, mentions its usefulness in such cases. Ergot may also be used with a prospect of advantage; and 1 have even resorted to the more active emmenagogues, such as the extract of savin, with evident benefit; and in no instance with disadvantage. The savin has indeed been highly recommend- ed by several German writers, in uterine haemorrhages of this kind. Dr. Feist asserts, that in menorrhagia of long continuance, attended with a sluggish and relaxed habit of body, and a pale, and fetid dis- charge, prompt and complete relief may, in general, be obtained * Eberle's Mat. Med. vol. i. p. 27. Second edition. X R.—Prussiat ferri 3i. G. aloes, gr. v. Conserv. rosar. q. s__M. Divide into 20 pills. Take one three times daily. 576 PHLEGMASIA DOLENS. from the use of savin.* He recommends the following formula for administering this article. R.—Pulv. folior. sabin. giii. Extract, sabin. ^ii. 01. sabin. 9i.—Divide into three grain pills. Take four three times daily. Dr. Gunther, of Cologne, also, has published an account of some cases of profuse and long-continued menorrhagia which yielded to the extract of savin given in scruple doses.t The prussiat of iron, in doses of from ten to fifteen grains, has been employed by some practitioners with much success; and I do not doubt from what I have seen of its powers, that it may be very beneficially given in this form of passive haemorrhage. We may also resort to the muri- ated tincture of iron in cases of this kind. I have lately succeeded in putting a stop to a protracted haemorrhage of this kind, by a mix- ture of the compouud tincture of aloes and the muriated tincture of iron, according to the following prescription. R.—Tinct. aloes compos. ----ferri. muriat. aa ^ss.—M. Take twenty drops four times daily. CHAPTER XX. PHLEGMASUE OF THE LYMPHATIC SYSTEM. Phlegmasia Dolens. This singular phlegmasial affection is almost exclusively confined to females, in the puerperal state; and is characterised by a pale, ten*se, elastic, and extremely tender swelling of one of the inferior extremities; communicating to the touch a feeling of numerous in- durated nodules and ridges under the skin; and attended with more or less fever, usually of a hectic character. As has just been stated, phlegmasia dolens is almost exclusively a puerperal affection; and it appears from general observation, that- the most common period of its attack varies between the fifth and ninth days after parturition. It is asserted by some writers, (Good,) that this disease has " never been known to affect any other part of the body than the lower extremities;" but Carus and some other authors mention instances of its occurrence in the superior extremi- ties. * Gemeinsame Deutsche Zeitschrift fur geburtskunde. | Rev. Med. Jan. 1827. PHLEGMASIA DOLENS. 577 In general, the first manifestations of the disease are: pain and stiffness in the groins of one side, preceded or accompanied with chills, or strong rigors, followed speedily by the ordinary train of pyrexial symptoms. Occasionally, though rarely, the disease com- mences by pain and swelling in the foot, an instance of which I saw about fifteen years ago. Wherever the starting point of the disease may be, the swelling more or less rapidly extends itself over the whole limb, and continues to increase until the extremity becomes enormously distended and exquisitely painful to the touch. 'Pb the sight the swelling exhibits an even and uniform surface; but when the hand is lightly passed over it, a number of hard ridges and little indurations are felt apparently immediately under the skin. The skin presents a pale or white, smooth, and glabrous appearance, and is preternaturally warm to the touch. In general, the swelling ex- tends to the labium pudendi ofthe affected side, leaving the opposite labium and contiguous parts entirely free from tumefaction and pain. More or less tenderness is generally felt in the iliac region of the affected side, and the track of the round ligament is especially apt to become painful or tender. Mr. Trye, indeed, considers the ten- derness in the course of the round ligament as a pathognomonic symptom. Position produces no change in the swelling, as is the case in oedema. When the disease is at its height, the skin of the affected limb is much whiter than that of the sound side; and its temperature is always very considerably augmented. The disease is always attended, from its commencement, with considerable irri- tative fever, and the patient is generally extremely restless, and tor- mented by her sufferings. The duration of the disease is very variable. It seldom, however, terminates under two weeks; and it may be prolonged to the fifth week, and even to a longer period. When it is about declining, slight sweats break out over the whole surface of the body, and the urine deposits a reddish sediment, whilst the fever progressively abates. The declension of the swelling is always very gradual, and the leg very rarely returns to the size of the sound one. Some degree of stiffness of the muscles of the leg usually remains after the total subsidence of the disease; and the skin continues for many months to be less moveable on the subjacent parts than in the sound state. In some instances, though very rarely, the inflammation termi- nates in suppuration; and when this happens, the cellular membrane sloughs out from between the skin and muscles, as in the suppura- tion of erysipelas. The occurrence of this accident is always at- tended with the utmost danger. The only two fatal cases I have ever seen, terminated in this way—a termination which, in both in- stances, was caused by the ruinous treatment of an empiric, under whose mismanagement the cases were placed. In general the breast becomes flaccid, and the secretion of milk is in part, or even wholly, suspended. It is singular that this fact Vol. I.—49 578 phlegmasia dolens. should be denied by Dr. Good; for I can affirm, that I have never met with an instance ofthis malady, in which the lacteous secretion was not conspicuously diminished. Dr. Huston, of this city, in a well written and interesting paper on this disease,* declares that " in all the cases he has seen, the secretion of milk was diminished, and in some wholly suspended during the violence of the disease;" and the same observation is made by nearly every writer on this subject I have consulted. In relation to the etiology and nature of this affection, writers have expressed a great variety of opinions. By many the disease has been ascribed to a metastastic transference of the lacteous secre- tion, from the breasts to the affected limb, giving rise to the deposi- tion of milk into the cellular tissue of the extremity. This opinion was advocated by Puzos, Levret, Astruc, Doublet, Mauriceau, and by nearly all the German writers on this subject, until a very recent date. Others have ascribed the disease to an obstruction of the lymphatics at the brim of the pelvis, by the pressure of the child's head during parturition, giving rise to over-distension and conse- quent rupture of the lymphatics, whence effusion and accumulation of lymph in the glands and cellular tissue of the limb ensue. This doctrine was advanced by Mr. White of Manchester; but its fallacy has been abundantly exposed by various writers. Denman and others maintain that phlegmasia dolens consists essentially in lym - phatic inflammation, commencing in one or more lymphatic glands in the groin, and thence extending along the lymphatic branches, until the whole limb becomes affected. The primary inflammation of the inguinal glands is excited, he thinks, by the acrid matter which is absorbed from the vagina. Dr. Hull conceived the disease to consist of inflammation of the muscles, cellular tissue, and inferior Surface of the cutis, giving rise to a sudden effusion of serum and coagulable lymph into the cellular texture of the extremity; and according to Dr. Hosack, the inflammation occurs in all the struc- tures of the limb—in the blood-vessels, absorbents, muscles, cellular membrane, skin, &c. In relation to this latter opinion, Dr. Huston very justly observes, that it is difficult " to conceive of an inflamma- tion" of all the blood-vessels of a limb, without the appearance of redness; or of such extensive inflammation as that involving every tissue of a part, without its termination in suppuration, gangrene, or other bad consequences, far more frequently than happens in phleg- masia dolens." More recently, Dr. Davies of London has published some observations tending to show that phlegmasia dolens is the result of an inflammation of one or more large veins, " terminating in the formation of artificial membranes and other obstructions within their cavities, whereby the free return of the blood from the extremity is prevented." This doctrine is also sanctioned by M. Velpeau; but the phenomena of phlebitis are certainly very different from * North American Medical and Surgical Journal, vols. iv. and v. phlegmasia dolens. 579 those which characterise phlegmasia dolens; and there does not, on comparing these affections, appear to exist any reasonable grounds for this opinion. (Dewees, Huston.) Whatever we may think of the mode of origin, or the location of the morbid condition which constitutes this affection, there can be no doubt that it is essentially an inflammatory affection; and there exists the highest degree of probability, that the whole system of lymphatic vessels ofthe limb is engorged and greatly distended with lymph, at the same time that some effusion may occur into the sub- cutaneous and intermuscular texture. The following sentiments, expressed by Dr. Huston, are entirely accordant with my own views on this subject, and as they embrace a clear summary of the argu- ments on this point, I cannot do better than to adopt his language. " I believe it to consist in a complete ' engorgement' of the whole lymphatic system of the affected limb; produced by an inflamed condition of the different conglobate glands, through which the chief lymphatic vessels have to pass, on their way from the affected part, to the thoracic duct. "This inflammation may occur either primarily in one or more glands, or first in a principal lymphatic trunk, and thence extend to the glands. And this may originate either, 1st, from the gland or lymphatic trunk being bruised by the passage of the child's head through the pelvis during labor: or 2d, from exposure to cold, and especially a damp or humid atmosphere; or the putting on of ill- dried clothes, during the irritable condition of the female system which attends the puerperal state: or 3d, from the absorption of some acrimonious matter, whereby the internal surface of the lym- phatics themselves may be excited to inflammation, and thence ex- tended to their appropriate glands; or the matter may be transmitted to the glands, and there excite inflammation. My reasons for the opinions which have been advanced, are briefly as follows: " 1st. The fact of every woman's exposure to one of the preceding exciting causes, and frequently to all of them. "2d. The uniform occurrence of pain or uneasiness about the passage of the round ligament, in the groin, and down the inside of the thigh, preceding the existence of swelling or other affection of the limb whatsoever : showing conclusively the priority of disease in the glands and their communicating trunks. "3d. The white color of the affected limb; which can only be accounted for satisfactorily, by supposing an ' engorgement' of the vessels which carry white fluids; for were it congestion of the blood- vessels, as in ordinary inflammation, there would necessarily be redness, instead of the white aspect. " 4th. The state of the woman's system generally, as the pulse, tongue, hectic form of fever, &c, all of which manifest a state or condition totally different from what is observed in cases of high and unequivocal inflammatory action; evidencing a state of irrita- tion, or inflammatory action of a low or subacute character. This 5S0 phlegmasia dolens. state of irritation may be readily accounted for, by the great disten- sion of the lymphatic vessels of the limb, throughout their utmost ramifications, and the consequent pressure which must thence be made upon the immensity of nervous fibrils by which they are sur- rounded. "Lastly. Its termination; which is far more uniform, and less fatal, than an equal extent of inflammation, attended with congestion ofthe blood-vessels seated in any part ofthe body; proving, incon- testibly, that it must have a course peculiar to itself; which course, very commonly commencing by a diminution of pain in the iliac and inguinal regions, and next ofthe swelling of the parts nearest those glands, indicates very clearly the seat of the disease to be in the lymphatic system, and especially the conglobate glands." This doctrine does not differ materially from the views given of the pathology of this affection by Trye, Capuron, Gardien, and Denman. The following appearances were noticed on post-mortem exami- nation of a woman who died of this disease soon after parturition. No remarkable morbid appearance in the uterus, excepting a very turgid state of the spermatic veins, which were very large and tor- tuous; " the vena cava was healthy, down as far as its juncture with the renal vein, below which it was thickened, and filled with a fibrous substance, varying in consistence, and adhering to the inner coat ofthe vessel. On laying bare the femoral vein the subcutane- ous cellular tissue was found to be infiltrated with serum, the gra- nules of fat much firmer and more distinct than natural, and the intervening cellular membrane thickened and opaque. The lympha- tic glands in the groin were large, full of serum, and closely matted together by a condensed cellular membrane. It was extremely diffi- cult to detach the iliac, femoral, and suphena veins, in consequence of their strong adhesions to their sheath, and the surrounding organ- ised lymph, in which they were imbedded." These, together with the popliteal vein, were similar in condition to the inferior cava, ex- cept that the substance they contained was thinner, of a brown color, and somewhat purulent appearance. In the remainder of the suphena, and in the veins near the foot, there was a plug of coagu- lum; they were otherwise healthy. The iliac and femoral arteries contained a small quantity of blood; the other arteries were empty.* Treatment.—From what has been said concerning the general character of this disease, it is obvious that the treatment must be decidedly antiphlogistic. Blood-letting, both general and local, are required during the early stages ofthe complaint. The momentum of the circulation should be at once adequately diminished, by an efficient abstraction of blood with the lancet; after which it will be especially useful to apply leeches to the affected limb, particularly about the groin, and along the track of the principal trunks of the * Lond. Med. and Surg. Jour. April 20, 1833. PHLEGMASIA dolens. 581 lymphatics. Dr. Dewees advises that the leeches should be dis- persed over the limb, "that their bites may not be too near each other, as they sometimes leave troublesome sores." This precau- tion is very proper; as I have myself known very obstinate and ex- tensive ulceration to proceed from a number of leech-bites near the groin, in a case of this kind. In some instances the febrile reaction, though not apparently very vehement, yields with great difficulty; and many venesections are required before the pulse can be suffi- ciently reduced. Dr. Dewees has found it necessary to bleed six or seven times before the disease yielded; and in a case which I treated about six years ago, five copious bleedings were required before an adequate impression was made on the pulse. Purgatives should be freely used during the active stage of the disease. Dr. Dewees prefers the following mixture for this pur- pose.* In one instance I used the magnesia in union with the tincture of colchicum, with peculiar benefit. The patient was order- ed to take a drachm of magnesia, with thirty drops ofthe tincture, every two hours. After the third dose, free purging ensued; and the result both in diminishing the general phlogistic habit, and miti- gating the local symptoms, was much more conspicuous than I had ever before witnessed from purgatives, or from any other remedy in this affection. 1 have not since had an opportunity of repeating this practice. In general, the purgatives should be of the saline kind. Diaphoretics, more especially antimony, may be employed with considerable advantage in the early periods of the disease. Tart. emetic, given in as large doses as the stomach will bear, without causing vomiting, is highly recommended by some writers, and I do not doubt its utility, during the active stage of the complaint. The following mixture forms an excellent diaphoretic, where, after decisive blood-letting, there is much general irritation.t Some writers have recommended emetics; but unless there are especial indications present for their employment, it does not appear that they are capable of procuring any material advantages. In debilitated and irritable subjects, and after proper depletory measures, in the more robust and phlogistic, opium is often highly serviceable to allay the excessive pain and general irritation which usually attend this affection. This narcotic may be very properly given in union with nitre and ipecacuanha; or, what is still better, in the form of Dover's powders, in combination with nitre. It must be particularly observed, however, that opium is in general decidedly * R.—Sulph. magnes. Magnesias alb. ust. aa ^iii.—M. Div. in. chart, iii. One of these to be taken every two hours, until they operate freely. •J- R.—Pulv. ipecac, compos, gr. xxiv. Calomel gr. iii. Pulv. nitrat. potass, ^i,—M. Divide into eight equal parts. S, Take one every two hours. » 582 PHLEGMASIA dolens. objectionable, so long as the general and local inflammatory symp- toms remain considerable; but in the decline ofthe disease, its effects are almost always highly soothing and beneficial. Among the external local remedies employed in this affection, besides the leeching already mentioned, fomentations with flannel, wrung out of hot vinegar and water; the application of a strong solu- tion of muriate of ammonia in equal parts of vinegar and water; and, after the pain, heat, and swelling begin to abate, moderately stimu- lating lotions—such as camphorated mixture diluted with an equal portion of brandy or whiskey, &c, may be accounted the most bene- ficial. Some writers strongly recommend the early application of blisters to the groin and to different parts of the extremity; whilst other writers, and amongst these Dr. Dewees, condemn this practice as rarely beneficial and often decidedly injurious. My own ex- perience does not enable me to say any thing in favor of blistering in this complaint, although I have never known any manifest harm to result from it. Where the pain in the extremity is very great, much relief may sometimes be obtained by bathing the limb with laudanum, more especially after proper evacuations have been pro- cured. Emollient poultices have also been recommended for the purpose of allaying the pain, as well as assisting in the dispersion of the swelling; but in the early periods ofthe disease, this application appears to me calculated to do much mischief. The two cases already mentioned as having terminated in extensive suppuration, and ulti- mately in death, were treated from the commencement with poul- tices; but as all depletory measures were neglected, much of the mischief, no doubt, depended on the want of proper antiphlogistic means. After the fever, heat and pain have in a great degree sub- sided, emollient applications in the form of a poultice may contribute in some degree to the removal 'of the stiffness and tension of the affected limb; but this purpose is much more effectually answered by frictions with dry flannel; the application of a muslin roller, pre- viously saturated with a strong solution of salt, and dried, to the whole limb; and fumigations of the extremity with the fumes of burning rosin. During the febrile stage of the disease, the diet must be of the simplest and weakest kind. During convalescence, the aliment should be digestible and nourishing, and when the patient is left in a very debilitated state, gentle tonics may be administered. If the weather is favorable, and the patient sufficiently recovered, exercise by ges- tation will be highly beneficial. end op volume i. VALUABLE BOOKS, PUBLISHED BY GRIGG