NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service ®£&irHjts*z&a->, etc Ju. /*«-^d spot app^a™-.!. .?s in lej INTRODUCTION TO fig. 2. In a few seconds it increased in size, the adjacent parfe of the vessels were distended, and, the current of blood becoming less rapid, was for some distance Slightly tinged with a red colour, as represented in fig. 3. " This enlargement of the vessels gradually extended till the part presented the appearance of fig. 4. The circulation was at this time extremely languid, and at length was not discoverable at all. When, in this last stage the motion of the blood was entirely stopped, a reddish shade was seen to have diffused itself over those parts of the membrane contiguous to the inflamed vessels : see figure 5." The reddish shade here mentioned, was evidently owing to the ■ rritation and distension having produced a slight rupture of some of the vessels, by which a small quantity of blood escaped. It appears then, from the foregoing experiments, that the state of the capillaries in an inflamed part is that of preternatural dis- tension and debility. That of the larger vessels may be ascer- tained without the aid of the microscope. Unassisted by glasses we readily perceive that they do not suffer a similar distension, and the increased pulsation of the arteries sufficiently evinces their in- creased action. Nor is this increase of action so obscure as to be observed with difficulty ; I have often, in inflammatory affections" of the jaw, applied tbe finger to the external maxillary artery, both where it passes over the bone, and after it assumes the name of labialis, and in rheumatic affections of the head to the temporal ar- teries, and perceived them beating with unusual force. The reader will find authors observing, that an unusually strong beat- ing in the arteries indicates that inflammation, if not present, & about to begin in the parts supplied by them. It is to be observed, that, although inflammation, as was evident from several of the foregoing experiments,* begins in the capilla- ries ; if it continues, the circulation in the smallest vessels being obstructed by their debility, those immediately preceding them will soon begin to be distended, and consequently debilitated, so that, in inflammations which have lasted long, the vessels preceding the capillaries, in the course of circulation, as well as the capilla- ries themselves, are distended. Thus when the lampern was first exposed to the air, the inflammation in the fins and tail assumed the appearance of a slight blush, in which it was difficult with the * Particularly from viewing through the microscope the fin of the lampern and mesentery of the rabbit, while exposure to the air was exciting infl,mma' ?ion m thrm THE SECOND PART. 11 toaked eye to discover any vessels. But after some time had elaps- ed, vessels of a considerable size, were seen creeping through the inflamed parts. It is evident that this cannot go very far, because when the vessels preceding the capillaries have lost their power, the circulation is no longer in any degree supported in the latter, and gangrene soon ensues. When the larger arteries are debilitated, and consequently dis- tended, in the first instance, the disease which may be termed tur- gescence, or partial plethora, is of a nature very different from in- flammation. In this case there is little or no accumulation of blood i in the capillaries, as appears from their being pale, or only slightly turgid, the vis a tergo, from the debilitated state of the larger ves- sels being too weak to occasion preternatural distension in them. They, therefore, more or less perfectly, retain their power, and as long as the larger vessels can supply them with blood preserve the circulation, so that the states of turgescence and inflammation are opposite. In the one case, the action of the capillaries is weak, compared with that of the larger vessels ; in the other, the action of the larger vessel-, compared with that of the capillaries. The justness of this distinction will, I think, appear more fully as we proceed in considering the phenomena of inflammation. On the difference of the^e state? seems to depend for example, all the dif- ference between the cold apoplectic, and the furious phrenitic. In the latter we find on inspecting the brain, a general redness ■in the parts affected, indicating distension of the capillaries ; in the former often little or none of this appearance, but an evident dis- tension of the larger vessels. The difference between what is called active and passive inflam- mation seems to depend on the degree, in which the arteries, sup- plying the vis a tergo to th<' debilitated vessels, are excited. We shall find that, in the cure of inflammation by resolution, in proportion as the debilitated vessels are excited to action, the ac- tion of the larger arteries abates, and the inflammation i.s cured as soon as the proper balance is restored between the larger arteriej and the capillaries, although the vessels are upon the whole in a state of greater debility, than previous to the attack of the disease. And that such is the case appears among a variety of more direct observations, from this consideration alone, that when the inflam- mation is of such importance and extent that the increased action of the larger vessels extends to the heart, so that the inflammation is attended with general increased action of the vasrular system ; we Vor. tr 18 INTRODUCTION TO observe that, as the inflammation yields, the general excitement msubsides, and that when the inflammation is removed, the whole system is left in a state of greater debility than before the disease. In short, inflammation seems to consist in the debility of the ca- pillaries followed by an increased action of the larger vessels, and is terminated as soon as the capillaries are so far excited, and the large arteries so far weakened by the preternatural action of the latter, that the power of the capillaries is in due proportion to the vis a tergo. The symptoms of inflammation, we have seen, are redness,. swelling, increased temperature and pain. It appears from what was said above, that it is so difficult to ac- count for the increased redness of an inflamed part by tbe popular doctrine, that this symptom alone seems sufficient to invalidate it. According to the opinion we have just been considering,. the in- creased redness is a consequence of inflammation, too evident to require any comment. We shall presently have occasion to con- sider why the redness is of the florid kind, and assumes a purplish hue, where there is a tendency to gangrene. To account for the swelling of an inflamed part by the commonly received hypothesis, it is asserted that inflammation is always ac- companied by effusion into the cellular substance, for it is impos- sible even to conceive how a more vigorous action of the vessels can occasion their general dilatation. Of this mode of explaining the swelling, it may, in the first place, be observed, that it has never been shewn that any degree of effusion necessarily attends inflammation ; but admitting that it does, the swelling should be white as in anasarca, not red, for we certainly know that there is no effusion of red blood. Besides, on examining an inflamed part through the microscope by transmitted light, it is at once evident that its increased size is, at least in great part, Occasioned by ves- sels turgid with red blood. Nay, on the common hypothesis, it is even difficult, as Dr. Fow- ler confesses,* to account for the pain of an inflamed part, which is doubtless the consequence of the preternatural distension of the ca- pillaries, and which is often pulsatory corresponding with the pul- sation of the larger arteries which, being in a state of increased excitement, tend at every contraction farther to dilate the capilla- ries, the sensibility of which is increased by the unu>ual accumu- lation of arterious blood, for the whole blood of an inflamed part* * Page 24. THE SECOND PART. 19 we shall find, in what is called active inflammation, is arterious. Tbe pain remits as the blood becomes venous, which only happens in proportion as a tendency to gangrene supervenes. The increased temperature appears to be no less a necessary consequence of the debility of the capillaries. This symptom which we have reason to believe first suggested the popular opin- ion, now that the old hypothesis r-specting the cause of animal temperature is refuted, is wholly inexplicable upon that opinion. It seems impossible to conceive how an increased action of the vessels of a part can occasion an increase of its temperature. To those who are acquainted with the late chemical discoveries respecting the cause of animal temperature, it is almost superfhfc- ous to point out why debility of the vessels of a part, and conse- quent accumulation of blood in it, is attended with increased tem- perature. As animal temperature seems to be ehiefly* supported by the change of the blood from the arterial to the venous slate, by which its capacity for caloric is lessened, and as this change is constantly going on, wherever there is an accumulation of arterial blood, there must a'so be an increase of temperature. It may be urged as an objection to this, and at first sight it ap- pears a considerable one, that if the velpcity of the blood in an in- flamed part be much diminished, it will not be prepared for the evolution of caloric, since it is not sent through the luti-s so fre- quently as blood supplying parts where the circulation is more rapid, and we know that it is chiefiyt in the lungs that it is prepar- ed for this process. But it appears from a variety of observations, that although the temperature of an inflamed part is increased, any portion of its blood must evolve le.~s caloric than the same-quantity of blood in a healthy part. The cxpei-linenis of Dr. Crawford, Dr. Ford) cc, Mr. Hunter, and oiln-rs, prove that in proportion as the temperature is increas- ed, the evolution of caloric from the blood is diminished ; and, that when the blood i> raised to a degree, but a wry little higher than the natural temperature, it ceases altogether. Whatever, there- fore, be the accumulation of blood in any part, no more caloric can * Many of the secreted ^fluids having a less capacity for caloric than the blood, secretion ihu>1 he regarded as one, though probably a very inferior source of animal temperature. t It has been found by experiment that the blood undergoes the sam? change though in a less degree, on the sm'luce ©f th.e body as in the lujigi. 20 INTRODUCTION TO be evolved than is sufficient to raise the temperature to? this, deT gree. Besides, although the blood continues to evolve caloric till it ar- rives at this temperature, yet each portion constantly evolves less,, the nearer it approaches to it.* To place what is here said in a clearer point of view, let in suppose that a quantity of blood as 49, evolves a quantity of caloric capable of raising the temperature of the part to 98 degrees, and suppose 100 degrees the highest tem- perature in which blood evolves caloric, then, if this part, instead of being supplied with a quantity as 49, be supplied with a quantity as 50, the temperature of the part will not be increased to 100 de- grees, which ought to be the case, making allowance for the in- creased size of the part, if each portion of blood evolved the same quantity of caloric as when the temperature was at 98 degrees. But the temperature of the part being increased we shall suppose to 98 degrees, 30 minutes, each portion evolves le~s caloric. Then suppose the quantity of blood as CO, and that this quantity evolves caloric sufficient to raise the itmperature to 100 degrees, it is then evident that, although the temperature of the part is raised, each portion of the blood evolves.stili less caloric than when the tempe- rature was 98 degrees, 30 minute*. It is also evident, that after the temperature is increased to 100 degrees, that is, as high as it can be raised by the blood, the only effect of every fresh portion of blood accumulated in the part, will be to diminish the quantity of caloric supplied by every other, by supplying part of that which raises the temperature to 100. From all which it is evident, that the greater the quantity of blood accumulated in any part, the less is the waste of that princi- ple, whatever it be, by means of which caloric is evolved, and therefore that, if it receives a Icgs supply of this principle, it also requires a less supply of it. The waste of this principle in the whole inflamed part is greater than it was when the part was . sound ; but the waste of it in any particular portion of its blood is less. But it is only in proportion to the waste of this principle, that the blood assumes the venous colour ; hence the florid appear- ance of an inflamed part. Were this a proper place for such discussions, it would be easy to shew that the late experiments of Mr. El lu,| throw additional * See the experiment of Dr. Crawford, by which he shews that the higher the temperature m which the animal is placed, the less caloric is evolved from the plood. i Mr. Ellis's Treatise on the changes induced on atmospheric air, fcc; THE SECOND PART. 21 light on this subject. They set aside some of the most prevalent opinions respecting the office of the lungs, and consequently, res- pecting the process by which the ca parity of the blood for calorie js increased in this organ, and the additional caloric is supplied. It appears from some experiments of Mr. Hunter, on the tempe- rature of inflamed parts, that it is much lower than, from what we perceive by the sense of touch in external inflammations, we should be inclined to suppose. Mr. Hunter found that it did not at any time exceed the temperature at the heart, so that, according to these experiments, inflammation did not pioduce a greater evo- lution of caloric than is capable of raising parts at some distance from this organ, but not immediately exposed to the influence of the air, about one degree. He made his experiments on various animals, of different temperatures. According to these experiments, then, the additional caloric evolved in an inflamed part, making allowance for its increase of size, is only one in 97 or 98. Now it we suppose the quantity of blood in an inflamed part only double of that in the sound part, (and I have no hesitation in saying, from what I have observed with the assistance of the microscope, that it is often many times as much) the waste of that principle by which the blood evolves caloric must be diminished about one half, or so nearly one half, that the difference may be overlooked. It seems probable, however, that Mr. Hunter's experiments were not quite accurate, we know that the blood is capable of evolving caloric at a higher temperature than that stated by him ; but this allowed, the above statement is nearly accurate, the blood certainly ceasing to evolve caloric at a temperature a few degrees higher. Admitting that the temperature may be raised eight degrees, the statement will then be thus: a quantity of blood as 1, gives 98: as 2, gives 106. In the latter instance the same quantity of blood supplies little more than half the quantity of caloric, that is al- lowing for the increased size of the part. But the quantity of blood in an inflamed part is at least six times tfiat in the sound part. Then supposing the size of the part d©ub- led, we shall have the following proportions. The quantity of blood multiplied by 6. The size of the part by - - T 2. The proportional quantity of blood therefore multiplied by.......• - 3. Thus we have a quantity of blood as 1, evolving caloric sufficient to raise the temperature of the part to 98 degrees : and a quantity of blood as 3, raising it to 10G degrees.. 22 INTRODUCTION TO According to this, a very rude,* but I believe, moderate state ment, the waste of the principle by which caloric is evolved from the blood in an inflamed part, is about three times less than in the same part when sound; so that we readily account both for the in- creased temperature and arterial colour of the blood, although the rapidity of the circulation is greatly lessened. But may not the rapidity of the circulation, it maybe said, be so much lessened as not to be compensated for in this way ? When the circulation ceases altogether, as in the most inflamed parts in the foregoing experiments, when consequently there can be little or no supply of that principle by which caloric is evolved from the .blood, what then preserves the increased temperature and florid colour of the part? The increased temperature and florid colour then disappear ; the part assumes a purplish hue, and soon becomes gangrenous. One symptom of inflammation still remains to be considered, which is not indeed mentioned in the definition, as, however re- markable in many c;'-e-, it is often distinguished with difficulty, namely, the increased pulsation of the larger arteries of the part ; and in the Phlegma.>ia\ of the heart and whole arterial system. The final cause of this symptom is sufficiently evident ; as the. inflamed vessel* are debilitated, an increase of the vis a tergo is at once a means of promoting the circulation in the part, and stimu- lating the debilitated vessels to action. Thus we find, that wher- ever the vis a tergo is much diminished, the circulation in an inflam- ed part is apt to fail altogether. We shall find indeed that gan- grene is often the consequence of the vis a tergo being too great, and consequently overstretching the vessels of the inflamed part ; so that a principal object in the treatment of inflammation is to re- gulate this power. Here it maybe objected, that increasing the vis a tergo must always, by farmer distending the debilitated vessels, tend to in- crease the inflammation. It certainly appears, from what has been eaid, that inflammation may arise cither from a debility of the ca- pillaries, or an increased \ is a tergo. If from the latter cause, it can only be cured by diminishing the vis a tergo, which is lessened * It i.> evidently impossible in this case to arrive at perfect accuracy, as we can never determine exactly how much, the quantity of blood, or »ize of'the part, is increased. All that can be looked for is, to be assured that we do not assume too much. There is every reason to believe, that the quantity of blood in an inflamed part i< often ram* t'.;au six times that which circnlates in it white round. THC SECOND PART. 23 in proportion as the excitability of the larger arteries is diminished by their excessive action^ or as "re diminish it by means we are immediately to consider. When the inflammation arises from the debility of the capillaries, the visa tergo, it is tine, also sometimes becomes too powerful, but are we not often obliged to have re- Course to means which increase it, to bark and wine? And would not means to increase the vis a tergo be necessary in all cases of inflammation which originate frou"dcI)ility of the capillaries, did not the nature of the system itself supply them 1 If the vessels of an inflamed part can no longer be excited to due action by the usual vis a tergo, the most evident means of exciting them is an increase of this stimulous, on which their action at all times depends. In- creasing the visa tergo, certainly must farther distend, but whether that farther distension farther debilitates, or excites to action, will depend on the degree of excitability which remains in the vessels. The next step is to inquire into the efficient cau.-e of the increase of the vis a tergo, but here our inquiry is necessarily bounded by an obstacle which I have already had occasion to consider.* The increased vis a tergo may in some measure depend on the increased stimulous applied to the larger vessels, by the impedi- ment to the passage of the blood through the debilitated capillaries. But when more distant vessels, and particularly when the whole system is affected, we cannot attribute it to this cause, especially when we reflect that the slightest inflammation of an important viscus, the stomach for instance, will excite fever, v. bile a very ex- tensive inflammation in the skin or muscles is often unattended by it. We are forced therefore, for an explanation of these facts, to look to the nervous system. But to trace the changes which here take place in it, and tbe manner in which these evcitc the larger arte- ries in inflammation, is as impossible as to trace the changes pro- duced in it by an emetic, ami the manner in which they excite the action of the abdominal muscles, and diaphragm. Neither in the rase of vomiting nor inflammation can we detect the changes induced on the nervous system ; but if w hat has been said be ji;-f, we un- ■ derstand the nature of the otic, as well as that of the other. I might now shew in what manner the operation ui the remote" r.iu-t's is explicable on the doctrine of inflammation we: are consid- ering, and consequently tends to support it. But when we recol- lect, that it appears from the foregoing experiments, that v.iiate-. ;■ diminishes the action of the capillaries of the part occasions, and •» See P:iv< s 3 and 4 of rni- vMumr, 24 INTRODUCTION" TO whatever increases it tends to remove, inflammation, the manner ill which most of the remote causes act is too'evident to require any comment. If inflammation arise from the diminished proportion of the pow- er of the capillaries to the vis a tergo, it will, it is evident, be most apt to supervene under the three following circumstances. 1. In a state of plethora, because then all the vessels are overdistended, and consequently any cause tending farther to distend any of them^ whether it be a cause debilitating them, or increasing the vis a tergo, will be more felt than in health. 2. In a state of general ex- eitment, because then the vis a tergo, is every where strong, and consequently apt to occasion distension of the vessels wherever any degree of debiMty occurs. 3. In a state of great general de- bility, because then the vital powers in any part are more easily impaired than in health. These are the states of the system, it has been observed above, which are found to predispose to inflamma- tion. In the first and second the inflammation is generally of that kind, which has been termed active, the vis a tergo, is considera-1 ble, the larger arteries being readily excited to increased action. In the last, it is what has been termed passive inflammation, the lar- ger arteries, in proportion as the system is debilitated, being les.3 readily excited. The greater the general debility, the greater it is evident, must be the partial debility before inflammation can take place, because, however debilitated the vessels of any part may be, inflammation will not supervene if the vis a tergo is debilitated in the same pro- portion ; hence in very debilitated states of body inflammation soon runs to gangrene, as happens in the inflammations so readily excited in typhus, &c. Nay, in cases of extreme debility an injur- ed part runs to gangrene almost without any symptom of inflamma- tion, the vis a tergo being too feeble to distend the vessels, how- ever much debilitated. Of the Terminations of Inflammation. The most common terminations of inflammation arc, Resolu- tion, Suppuration, and Gangrene. Of the first there is little to be added to what has been said;. We have seen in the foregoing experiments that, in proportion as we succeed in exciting the capillaries of an inflamed part, we re- lieve the inflammation. When an inflammation is cured by reso- lution, that is, v>: ,iout the deselection of any of the parts it occu- pies, the vis a tergo has succeeded iu restoring the proper action of TITS SECOND PARI. ££> toe capillaries. Resolution is often promoted by an effusion from the inflamed vessels, for when the vessels are so much debilitated by distension that the only effect of the vis a tergo is farther to dis- tend them, there is no hope of exciting them to action with dimin- ishing the volume of their contents. Sometimes a vessel gives way and the inflammation terminates by hemorrhagy, when this does not happen, the fluid discharged is often serum or coagulable lymph. If the inflammation has its seat in a secreting organ, its Secretion is generally increased, and sometimes, particularly on secreting surfaces, the fluid discharged we shall find is a true pus, for it will appear that the forntation of pus is not always attended with a destruction of parts. Whether the termination by a secre* tionof pus,* the texture of the parts remaining entire, deserves the name of suppuration or resolution, it is of little consequence to in- quire. It belongs to the latter according to the 6ense in which I use the terms. The resolution of inflammation is sometimes promoted by a dis- charge, hot from the part itself, but some other, often from a neigh- bouring secreting organ, sometimes, particularly where the whole system is affected, by a discharge of blood in consequence of the rupture of vessels in some of those part3, where they are most nu* merous and delicate, the internal nares, lungs, &c. When inflammation terminates by suppuration, there is a de- struction of a certain portion of the inflamed partj in consequence of which a cavity termed an abscess, is formed, which from the first is filled with pus, the quantity of which increases in proportion as Ihe cavity enlarges. It has been a prevalent opinion, that pus is nothing more than serum discharged during the inflammation, and changed by stagna- tion. It is now generally admitted, however, that the experiments hf Sir John Pringle,t and M. Gaber,| at one time regarded as con- clusive, do not warrant the inferences of these writers. M. Brugman, in the first section of the second chapter of his Pu- ogenia, has ascertained that the sediment from the serum is not the same with purulent matter. " Nee juvat unum alterumve praedica- *' turn habuisse commune, aut externo habitu quodammodo conve- u nire. Quid enim inde, nonne et cremor lactis varia cum pure com- "*' munia habet ? Utrumque album est viscidum blandissimumque." '-"■ We shall presently have occasion to consider the properties of this fluid. {> The appendix to Sir John Pringle's work on the jDhease.8 of the. At»rv, X Misccll. Taurin. v A. ill Vnj . If- t 26 INTRODUCTION TO In the second section, Brugman compares pus with the coagula- ble lymph of the blood, in the third with the buffy coat, in the fourth with the muscular fibre, in the fifth with fat ; and from ^ ali his experiments concludes, " Naturam, corruptione vel partium « qualiu;iicumque putredine, tanquam medio in creando pure, non "uti." This inference is confirmed Vy the observations of Mr. Home,* who made a very conclusive set of experiments on thhj subject. He found pus formed by a blistering plaster in twenty-four hours ; by means of the microscope he fron time to time examined tli.. discharge while it was being changed from a colourless fluid in- to pus. In anot'ier experiment he found that pus is formed by irri- tating the urethra in the short space of five hours, and that in half an hour the discharge begins to assume the purulent appearance. He also found that it has not this appearance, when it is first poured out,"but acquires it while it remains on tbe inflamed surface^ and that this change takes place as readily, although the matter dis- charged be removed while it still remains colourless, provided the propei temperature be preserved, as when it remains on the part. It is ] r anoted by exposure to the air. Mr. Hunter was led, from the phenomena of inflammation to re- gard pus as a secreted fluidi He found vessels formed in extrava- sated blood and lymph, and supposes that in the extravasated lymph, which precedes the formation of pus inwrounds, a system of vessels is formed for the secretion of this fluid. Mr. Home adduces several facts to countenance this opinion. In performing the operation for strangulated hernia, he observed the intestines smooth and polished, an inflammation supervened and speedily proved fatal, and the body was opened within twenty four hours after the operation. On various parts of the inflamed intestines, whose surface the day before had been uniform! v smooth, there were found small masses of extravasated lymph n W .ich ves- sels were formed. Pus, he observes, is more readily formed by secreting surfaces, on the skin for example and in the urethra, than in the body of a muscle. Many proofs of the tendency of secret- ing surfaces to form pus will occur in considering the Phlegmasiae. The part in which pus is about to be formed assumes a more vascu- I r appearance, that is, more of the appearance of a gland; and pus bears much resemblance to some secreted fluids, particularly miik and the pancreatic juice. * A Treatise oa the Properties of Tus, by Everard Home, Etu THE SECOND PART. 27 fndependantly of these reasons, which Mr. Home justly considers .a« favourable to the opinion, if it can be shewn that pus is different irom any of the component part9 of the blood, and that neither these Jfior the solids are by any spontaneous change convertible into pus, }he only opinion which seems to remain is, that pus is a secreted fluid. We have no other proof of the nature of many secreted fluids, for the secretion of which the glandular structure is at least as ob- scure, as in the case of suppuration ? But the manner in which pus is produced is of less consequence than a criterion to distinguish it from other fluids, which in some cases, we shall find, is an object of the first importance. Chemical analysis, it is probable, will never enable us to distin- guish pus with sufficient ease to render the distinction useful. Most animal substances, when chemically analised, give very similar results. Other means of distinguishing it have therefore beep looked for. M. Brugman,* Mr. Darwin,t and others indeed have attempted %o distinguish it in the former way. To determine, however, with certainty the presence of pus, by their criteria, supposing them ac* curate, requires more experimental nicety than is possessed by the generality of practitioners. The most useful tests, as far as I am capable of judging, are those proposed by Mr. Hunter :J Its car agulation by sal ammoniac, and globular appearance through the microscope. If to these we add some of the most remarkable of its other properties, we shall seldom be at a loss to distinguish it. The following is the selection made by Mr. Home. Pus is of the consistence of cream, its colour is whitish, it hasa maukibh taste. When cold it is inodorous, when warm it has a peculiar smell. Examined by the microscope it consists of scmi-opake globules, and a transparent colourless fluid, which is coagulated by sal am- moniac. Pus may be evaporated to dryness without coagulating, Its specific gravity is greater than that of water. It does not pu- trify readily. It is not readily diffused, in cold water. In warm water it is readily diffused, and remains diffused after it cools. It is a property of pus that it separates readily from the sore., discovering granulations on the places it covered. * Brugman's Puogenia, t Experiments determining a criterion between mucilaginous and purulent, (natter, by Mr, Charles Darwin. X Mr. Homes paper, just alluded to. 2g INTRODUCTION TO Mucus is the fluid from which it is of most consequence to distin- guish pus, which may, for the most part, be readily done by the foregoing properties. With respect tp the test most commonly em- ployed for this purpose, derived from the specific gravity of the two fluids, it is very fallacious. The specific gravity of the mucus of those cavities to which the air is not admitted, is greater than that of water,* and even in those to which the air has free access, it be- comes so, if the mucus is allowed to stagnate, by which its thinner parts are absorbed, it is not uncommon as I have often observed, for mucus expectorated in the morning, when it has lain, during the night, in the trachea and its branches, to sink in water ; and on the other hand, when pus, which is specifically heavier than water. has entangled small globules of air, which frequently happens in that which comes from the lungs, it will remain suspended in water, t From the other animal fluids, which bear a resemblance to pus, Mr. Home points out the following means of distinguishing it. From chyle it differs in its globules being larger, and in its not coagulating by exposure to the air and a high temperature. The globules of the pancreatic juice are smaller than those of pus. Solutions of animal substances contain flakes instead of globules, or at the same time with globules. The globules of milk are nearly of the same size with those of pus, but much more numerous. Milk coagulates by runnet; pus does not. Milk contains oil and sugar which are not found in pus. Pus is distinguished from the discharge of ill-conditioned sores, by the latter, when examined by the microscope, being found to contain a flaky matter; and from the discharge of blisters, by this containing neither flakes nor globules. It has been the opinion of some, that pus maybe formed without previous inflammation. This opinion Mr. Home combats, and ob- serves, that the matter discharged where there had been little or no previous inflammation, differs materially from true pus. Instead of being globular, it has a curd-like appearance, and contains, flakes. The formation of proper pus seems to depend much on the state of the circulation in the part, and in the system in general. The author just mentioned found that, cet. par. pus is more apt to degen- erate the farther it is from the heart, and relates a striking instance, * Mr. Darwin's paper, just alluded to. i« Corrosive sublimate consulates mucus but not pus." Mr. Darwitfi paper. THE SECOND PART. 29 j.u which a cause, affecting the whole system, produced at one time a sudden alteration in the discharge of the sores, in no less than twenty patients. From a sudden change of weather, instead of a well formed pus, coagulable lymph was spread over their surface like melted tallow, adhering to it with such force that it could not be separated without injury. Fewr have long attended hospital? without having occasion to make similar oi servations. The discharge from ill-conditioned ^ores is very various. In- stead of coagulable lymph or a flaky discharge, they often pour out a thin ichorous matter, which, examined with a microscope, is found to contain few or no globules. It is often mixed with blood, probably in consequence of its eroding some of the small vessels. Mr. Home made some experiments to determine whether true pus, as some have supposed, is capable oferoimg th« animal solids, the xusultof which is, that the purer the pus, the less of this property it has, and that the purest pus is a very mild fluid. When suppuration commences in an inflamed part, the pain and redness generally abate, the temperature falls nearer to the healthy degree,* and the throbbing becomes more sensible. In the phleg- masia? we shall find the commencement of suppuration indicated also by certain symptoms affecting the system in general. The matter of an abscess is either absorbed or discharged, if it is well conditioned, the cavity is obliterated either by its sides grow- ing together, or by its being filled up by an operation of nature, termed granulation, from the new parts appearing in the form of small red grains. When this process is most favourable, the gran- ulations are of a florid red colour, and proceed in a regular manner till the cavity is accurately filled, its edges (if the matter of the ab- scess hass been discharged externally) being even or nearly even with the sound skin. The cavity of an abscess is never filled up with matter exactly similar to that which was destroyed, often, however, with such as is capable of performing its functions. Thus, the matter formed in wounds of the skm, tendons, ligaments, bones, and some other parts, performs the functions of these parts; and sensation has sometimes been restored through a nerve which had been divided. The matter formed in wounds of muscles or glands appears to bt wholly incapable of performing the office of these parts.\ * When, however, the matter is confined by the less yielding parts of the b«- dy, the symptoms often do not abate much till it is discharged. t Pee Mr. Moore's paper on t£ip filling tip of cavities, ic- $q rNTRODUCTION TO The last of the more common terminations of inflammation fc% gangrene. Under Dr. Cuilen's seventh genus, (Phlogosis) he gives the following definition of it. " Post phlogosin, pars livens, mollis, parum sensibilis, seep« *' cum vesiculis ichorosis." Such is the appearance which precedes mortification ; the cir.-. culation fails, the vessels are obliterated, or an ichorus and bloody- matter runs from their relaxed extremities. Mortjfication, or as it js termed by medical writers, sphacelus, is defined by Dr. Cullen. "Post grangrrenam pars nigricans, flaccida, facile lacerabilis, •*« sine sensu vel calore, et cum fuetore carnis putrida3 ; vitio cele.s " riterserpente." It happens, however, especially in those cases where gangrene comes on without much previous inflammation, that the mortified part assumes a different appearance, becoming dry and hard, as for example, in the sphacelus produced by caustic. It has then been termed necrosis, or the dry gangrene. As in the case of suppura- tion, gangrene in the phlegmasia is attended with a change in the state of the general symptoms, which wil.l presently be considered. The milder the symptoms, the better is the chance of the in- flammation's terminating by resolution. When it is of the pustular kind and does not readily yield to proper remedies ; or when ery- tbematic, if unusually obstinate and deep seated, there is reason t« believe that it will terminate by suppuration. When the sympr toms are very violent, especially if the inflammation it of the eryr thematic kind, we have reason to fear gangrene. Resolution is always a favourable termination. Suppuration also, forthe most part, is favourable, if the inflammation be exter- nal arid the habit good; in internal inflammations it is generally unfavourable. Internal gangrene is always fatal. It is only Avhenthe gangrene is external that any means can avail, and the* they^often fail. The steps by which inflammation terminates in gangrene are sufficiently obvious from what has been said. By degrees, the de- bilitated vessels wholly lose their power, and the part becomes sub- ject to the laws of dead matter. The process of suppuration is more complicated; and between the inferences from the experi- ments which have been related respecting the state of the vessels in an inflamed part, and those afforded by Mr. Home's experiments on the formation of pus, there is a chasm which must be filled up hy future observation. It appears from what has been said, tfcat THE SECOND PART. 31 whei the capillary vessels of any part remain for a certain length Of time in astate of debility and distension, the part begins to se- crete a fluid which becomes pus ; but whether this fluid is secreted by a new action of the capillaries, or, which seems more probable, as Mr. Hunter supposes, by a new set of vessels formed in the dis- eased part, we cannot tell. We are also unacquainted with the process by which the diseased parts are removed in the formation of abscess. It is probable that this process is also performed by a hew set of ve-.sels, which, as the secretion of the purulent fluid goes on, make room for it by the absorption of the now useless parts, We cannot suppose that these parts are melted down and assimi- lated into its own nature by the powers of this fluid; because we find, that pus, with all its properties, may be secreted by in'lani- cd surfaces without occasioning any loss of substance, and it ap- pears from experiments of Mr. Home, above alluded to, that it does not possess the property of eroding the solids. These topics open a fruitful and interesting field of inquiry. By patient obser- vation, and the aid of powerful glasses, it is not improbable that tbe whole process of suppuration might be unfolded. Some have ranked schirrus among the terminations of inflamma- tion. " The schools," Dr. Cj.len observes, " have gene-rally '' marked a fourth termination of inilamm: lion, which is by a schir- •*' rus, or an indolent hardness of the part formerly aflected within- " flammation. This, however, is a rare occurrence, and does not " seem to depend so much on the nature of inflammation, as upon " the circumstances of the part affected. It is in glandular parts •; chiefly that schirrosity is observed, and it is probably owing to '! the parts readily admitting stagnation of the fluids. 1 have ob- " served that inflammation seldom induces schirrus, but that this "more commonly arises from other causes; and when imiamma- '• tion supervenes, which it is sooner or later apt to do, it does not a so commonly increase as change the schirrosity into a kind of "abscess. From these observations it does not seem necessary to v" take any further notice of schirrus as a termination of inflamma* " tion." Other terminations, or rather consequences of inflammation will be noticed as we proceed in considering the phlegmasia;, depend- ing, like schirrus, on the structure of the part, as palsy or ri^idit^ ef the muscular fibres, opacity of the cwruea, ka.. U INTRODUCTION T0 Of the Treatment of Inflammation, As simple inflammation is generally a slight disease, considera' ble inflammations, though external, be ng always accompanied by- fever, it will not be necessary to enter particularly on its treatm;-m% Which indeed will sufficiently appear from what Will be said of Ine treatment of the Phlegmasia;. The means which promote the resolution of inflammation may be arranged under two heads : 1. Those which lessen the volume of fluid distending the de- bilitated vessels by directly abstracting part of it, by occasioning a discharge from, or an accumulation of blood in, some neighbour- ing part, or by diminishing the vis a tergo. 2. Those which stimulate the vessels of the inflamed part. How well the operation of these means correspond with the fore-- going doctrine of inflammation need not be pointed out. It is true that, did inflammation depend on a morbidly increased action of the inflamed vessels, it would be relieved by abstracting part of the fluid which supports this action. But how shall we on this supposition explain the effects of astringents and other stimuli ap- plied to the inflamed part ? These * it has been said, exhaust the excitability of the inflamed vessels, and thus lessen their action. But it appears from the foregoing experiments, that their effect is that of increasing the action of the inflamed vessels, and that it in only in proportion as they have this effect, that they relieve the in* flammation. After what has been said of inflammation, a very few observa- tions on the other local affections of symptomatic fevers, hemorrha- gy,and profluvium, will be sufficient. The experiments which have been related, appear also to throw light on the nature of these affections. Of Hcmorriiagyr The effusion of red blood is generally the consequence of rup* Jure, either from external violence or increased vis a tergo ; hence the frequency of hemorrhagy in synocha, and in active inflamma- tion. In the latter, the local debility at the same time rendering the vessels more subject to rupture and increasing the vis a tergo* THE SECOND PART. 35 borne vessel at length gives way, the distension is relieved, the ves- sels recover their tone, and the inflammation ceases. Hence we may see why inflammation is cured by a spontaneous hemorrhagy from the part; and why more or less inflammation often precedes what is called active hemorrhagy ; the increased Vis a tergo before it occasions rupture, necessarily occasioning more or less disten- sion. Thus tbe only difference between active hemorrhagy and inflammation is, that in the former a vessel gives way, the flow of blood relieving the distended vessels in the same way that artificial blood-letting from the part is found to do. The vis a tergo previous to hemorrhagy sometimes distends the larger vessels of the part instead of the Capillaries, and then tho symptoms of congestion, not of inflammation, precede the hemorr- hagy, the patient complaining rather of a sense of fullness and dis- tension, than of heat and pain in the part from which the blood fc about to flow. Active hemorrhagies then, are spontaneous evacuations of blood Which relieve an inflammation, or what has been termed congestion, and in proportion as the hemorrhagy is profuse, the inflammation or congestion, we shall find is more perfectly relieved. Passive hemorrhagy is only a greater degree of that state which, We term passive inflammation. When the vessels of a part, we have seen, are greatly debilitated at a time when the vis a tergo, From general feebleness, is much below the healthy degree, but still sufficient to distend the vessels of the debilitated part, passive inflammation ensues ; that is, that kind of inflammation in which the local symptoms, as well as general excitement, are inconsidera- ble, the vis a tergo not being sufficient to distend the Vessels to the flegree which occasions the pain, temperature, and other symptoms. of active inflammation. Bui when the relaxation of the vessels is extreme, the blood Oozes from their extremities, preventing its accumulation in tbe part, and consequently the symptoms of inflammation. Thus in r>ad forms of typhus, any irritating cause readily excites languid in- flammation of the stomach, intestines, &c. ; but in extreme cases of typhus, instead of inflammation, dark coloured blood oozes from the kides of these cavities. vol. ^ Of Prqfluvium, If the relaxation is chiefly in the colourless vessels, and particu- larly in the exhalants, which frequently happens, because the far- ther vessels are removed from the heart, they are tlie more easily debilitated, the discharge is colourless ; and this discharge increase ing as the vis a tergo increases, prevents inflammation by prevent- ing distension of the capillaries. But should any cauSe debilitate the red vessels of the part, the smallest of which supply the vis a tergo to the colourless vessels, the colourless discharge must cease, from the want of the vis a ter-* go which supports it; and the smaller red vessels, now debilitat- ed, will be distended by the vis a tergo which impels the blood into them, and inflammation ensue ; as often happens from cold in gonorrhoea, coryza, catarrh, kc ; for it is to be remembered, that the heart supplies the whole vis a tergo only to the arteries, into which it immediately propels the blood, the vis a tergo in all the other vessels, whether arteries or veins, depending more or less on the action of those which immediately precede them in the course of circulation. On the other hand if the colourless discharge by which local congestion is prevented, be checked by powerful astringents, the congestion must soon extend to the red vessels, and all the symp- tom^ of inflammation in this way also supervene, as happens in^o- norrhcea, dysentery, &c. from astringent applications. But if in either of these cases, any of the red vessels give way, the flow of blood relieves the distension, and the symptoms of in- flammation are mitigated or disappear. If instead of the rupture of a red vessel^ the exhalants in the latter case again become debilitated, or the red vessels in the for- mer case are excited to action, the colourless discharge is restored, and the distension and consequently the inflammation are thus also relieved. In the phenomena of symptomatic fevers, we shall find all these observations fully illustrated. It is evident from what has been said, that the local affections of the different orders of symptomatic fevers are of a similar nature, and we readily perceive why they are so easily convertible into each other. Thus it appears, if what is said lathe preface re- THE PHLEGMASIA 35 uaecting the nature of idiopathic fever be admitted, that a state of fever always originates in debility of the extreme vessels. Having now considered simple fever, and the different local af- fections of symptomatic fevers, we are prepared to take a view of the various combinations of these diseases, which have been ar- ranged under the three heads, Phlegmasia;, Hemorrhagic Febriles, and Profluvia Febrilia, the definitions of whic^ have been given in the general Introduction. BOOK L OF THE PHLEGMASIA The Phlegmasia? are those symptomatic fevers in which the lo- cal affection is inflammation ; when the inflammation is external, it ^s known by the symptoms already laid before the reader ; when internal, by a fixed pain and lesion of function. To prevent re- petition it will be proper, before we treat of the Phlegmasia; indi- vidually, tp make some general observations on this order of dis- eases. CHAP I. Of the Symptoms of the Phlegmasia. The only diagnostic between simple inflammation and the phlegr masiae is the presence of fever in the latter. There is certainly a considerable difference between a pimple and a boil, and between erythema of the face and erysipelas. The difference, however, is only in degree. In both instances the disease is characterised by jtfdness, increased temperature, pain, and swelling. 36 SYMPTOMS OF We cannot, therefore, give any other account of the local affec* tion of the phlegmasia? manias been given of simple inflammation. The combinations of inflammation and fever are of three differ- ent kinds, to one of which only the term phlegmasia? is applied ^ the others being of a nature very different from the phlegmasia;, and requiring very different modes of practice. Inflammation and fever may be combined by a simple inflamma- tion supervening on fever, as in the exanthemata ; or they may be combined by the inflammation producing fever, as in the diseases we are about to consider ; or by a phlegmasia? (that is, the inflam- mation and the fever it occasions) supervening on simple fever. The first of these is readily distinguished, by the appearance of the inflammation not aggravating the fever. The last is readily distinguished where the phlegmasia? supervenes a considerable time after the commencement of the fever, as happened in many epi- demics alluded to in the first volume of this treatise, in which in- flammation of the stomach, bowels, brain, &c. supervened on in- termittent or continued fever, or on the exanthemata, forming diss eases essentially different, although they have not always been ac- curately distinguished, from the phlegmasia?. But when the phlegmasiae supervenes soon after the commence- ment of the fever, the diagnosis, although still necessary in regular ting the treatment of the disease, is more difficult. All that can be said on this subject, as far as. lam capable of judging, is, that wher- ever the fever is completely formed and unaccompanied by external inflammation, or any of those symptoms which we are about to con- sider as denoting the presence of internal inflammation, however early they may supervene, the case is to be regarded as a combi- nation of fever and phlegmasia?, whether they arise from the same, causes or not. It must be granted that if the fever h?s lasted for a considerable time, some days for example, before the local affection appears, the case is complicated. If then it be asserted, that there are cases ^ of phlegmasia? in which the fever is formed before the symptoms, denoting the local affection, appear, the question arises, how long may the fever last before the appearance of such symptoms, and the disease still be regarded as a simple case of phlegmasia ? In the true phlegmasiae both sets of symptoms, especially if the seat of the inflammation be internal, generally appear together. It ;s evident, that if any degree of the local affection produces a cor- THE PHLEGMASIA, 37 responding degree of fever, the symptoms denoting the former can- jH>t appear unattended by fever. How then, it may be asked, do we determine which is the pri- mary affection ? To this the following circumstances readily afford an answer. The causes which produce fever, do not at the same time produce inflammation. In 19 cases of 20 inflammation does .not supervene on fever, and when it does, it generally arises from causes different from those which produced the fever. But if, on the other hand, such inflammation as attends the phlegmasia?, be excited, fever is the constant attendant, and its degree is pro- portioned to that of the local affection. Besides, as we succeed by local remedies in relieving the in- flammation, we find that in precisely the same degree the febrile. symptoms abate. If the inflammation be not terminated by resolu- tion, but run on to some of its other terminations, the febrile symp- toms are still found to correspond to the changes which take place in the local affection, and so constant is this correspondence, that we can determine, from the state of the febrile symptoms alone, ir. what way the inflammation is terminating. Similar observations ap- ply to the other symptomatic fevers. I cannot perceive the grounds on which some have maintained, that the local affection in the phlegmasia? is the consequence of the general disease, and that when the inflammation proceeds merely from a local cause the disease is not a true phlegmasia?. I have mentioned the local affection in the first part of the characters of symptomatic fevers, as forming the most essential part of the disease ; and Dr. Cullen perhaps falls into an inaccuracy of some consequence, when he makes the febrile symptoms the first part of these characters. From regarding the fever as the most essential part of the phlegmasiae, physicians seem often to have placed too little reliance on local means in their plans of cure, for we may regard it as a rule with- out exception in this order of diseases, that when the end we havt in view can be answered by such means, they are always prefera- ble to those which more generally affect the system. This inac- curacy in Dr. Cullen's definitions (for such I. think it will appear from what will be said of symptomatic fevers) may be traced to the same source with others mentioned in the general Introduction. For as his method obliged him to arrange under one class, idiopa- thic and symptomatic fevers, it induced him to give to the latter as much as possible the appearance of the former. In the phlegmasia?, then, the local affection is to be regarded as the primary disease, and it either comes on before the febrile symptoms or at the same time with them- 88 SYMPTOMS OF Although the line of distinction between the true simple inflam- mation and the phlegmasia? is well marked, the one never running into the other, (we never see pimples, or habitual erythema of the face produce fever,) yet there are some external inflammations which may be regarded as forming the link of connection between these diseases. Thus a small boil is unattended by fever, but if it be increased by local irritation, for example, it then occasions fe- ver, farther proving the fever to be the consequence of the inflam- mation. . It may be observed indeed of all the phlegmasia? in which the in, flammation is external, that in their symptoms, prognosis, and mode of treatment, they approach nearer to the nature of simple in- flammation than the other phlegmasia? do. The fever is more mo- derate, the mode of treatment less vigorous, and the prognosis much better. In inflammations of those parts which can neither be re- garded as wholly external nor internal, the fauces rectum, meatus auditorius, muscles, &c the degree of fever and the prognosis are between these extremes. i Upon the whole, it may be observed, that the nearer the seat of inflammation approaches to the brain or stomach, the more consid- erable is the fever, and the greater the danger. Inflammations of the head, we shall find are the more dangerous, the nearer they ap- proach the brain ; and inflammations of the trunk, the nearer they approach the stomach. Inflammation of the o?sophagus, for exam-? pie, occasions a greater degree of fever, and is more dangerous than inflammation ©f the fauces ; and inflammation of the duode- num than inflammation of the colon ; and inflammation of the sto- mach is not only more dangerous than any of these, but also than inflammation of the lungs, or of any other part of the trunk. In- flammations of the extremities are less dangerous than those of either the head or trunk. We determine the presence of internal inflammation by certain symptoms, which, from dissection after death, it has been ascer- tained, always indicate this species of derangement. These symp- toms are shortly enumerated in the definition of the phlegmasia. " Dolore topico, simul laesa partis interna? functione :" wherever there is fixed pain with derangement of function, and fever, we have reason to believe that local inflammation is present, which we cannot doubt if the pulse be hard. It appears from what was said of inflammation, that when it U present to a considejable extent, and almost always when it affect* THE PHLEGMASIA. 39 ti vital organ, the whole sanguiferous system is excited to increas- ed action, the final cause of which appears to be, to restore duo Circulation to the debilitated part. The vessels, it was observed, possessing transverse muscular fibres, the effect of unusual action must be, that they embrace their contents more forcibly, and con- sequently feel harder, and the difference between a strong pulse and a hard pulse seems to arise from the artery in the latter case never being wholly relaxed, while in the strong pulse, however p®werful the contraction may be during the systole, we have rea- son to believe that there is a complete relaxation in the diastole, the time at which it strikes the finger. In the case of the hard pulse, the end being to propel the blood into the debilitated vessels of the inflamed part, the arteries in the neighbourhood of these vessels, the better to effect this end, seem forcibly to embrace their contents, although in a less degree, dur- ing the diastole ; and at length, the whole arterial system is affected in the same way, so that, however debilitated the circulation be- comes, while the inflammation lasts, the hardness of the pulse is still remarkable, and by this means we may eften detect inflam- mation when there is no other symptom to guide us. The foregoing symptoms not only leave no room to doubt the presence of inflammation, but also point out its seat. When wo know the seat of the pain, as we know that of the different viscera, we conjecture which is affected ; but when we, at the same time, observe what function is affected, the matter is generally placed beyond a doubt. Thus, if the patient inform us that the pain is in the chest, we suspect the lungs to be the seat of the inflammation ; but if, at the same time, he labours under cough and difficulty of breathing, no other function being more deranged than is usual, in the same degree of fever, we no longer hesitate in pronouncing the disease to be inflammation of the lungs. In like manner, when the patient tells us that the pain is in the region of the stomach, and he is distressed with thirst and incessant vomiting, we know that he labours tinder inflammation of the stomach ; and so on. But the manner in which we judge of the seat of the inflamma- tion, is not always so simple as in these cases ; for it often hap- pens, from the sympathy of parts, that although the inflammation is confined to one organ, the pain, and even derangement of func- tion, extends to others. Thus, in inflammation of the kidneys, pain is often felt in the stomach, and its ftmctioirs are often as much deranged as those of the inflamed part, 4fl SYMPTOMS Oi Nay, a pain is often felt in a distant part, while there is no pam whatever referred to the part affected. In inflammations of the liver, for example, the pain is sometimes confined to the shoulder. It also sometimes happens, that the functions of neighbouring parts are more obviously deranged than that of the part affected. The patient is often affected with dyspnoea and cough, or with vomit- ing, or with hiccup, when on dissection it is found, that the live* alone was the seat of inflammation. In such cases, it is often very difficult precisely to determine its ifcat; sometimes, we shall find, it is impossible ; but fortunately, it is not always necessary, and a person well acquainted with the symptoms of the phlegmasiae, will never find himself at a loss to determine the seat of the inflammation with all the accuracy that is requisite iri practice ; for although neither the pain nor lesion of function is always observed in the part affected, yet both the one and the other are always the same or similar when the same part is affected, at least, in the same degree, ,and in the affection of no other part does the same combination of symptoms occur. Thus some difficulty of breathing, sickness at stomach, or hiccup, with pain in the right shoulder, and a hard and frequent pulse, as cer- tainly denote inflammation of the liver as if the pain were referred to this organ, and accompanied with an evident derangement of its function. In this and some other of the phlegmasia?, other circumstances, particularly an increase of the pain on pressure, assist the diag- nosis. Dissection has ascertained, that in internal as in external inflam- mations the redness and swelling are either diffused, the latter be- ing hardly perceptible, or more circumscribed, and the swelling considerable. Such, in a general view, are the symptoms which attend the commencement arid progress of the phlegmasiae. Like simple inflammation, these diseases terminate by resolu- tion, suppuration, or gangrene. The local symptoms indicating the resolution of internal inflann mation, are the gradual abatement of the pain, and the restoration of the function of the inflamed part.* *See what was said of the various evacuations which frequently attend the l^olutton of inflammation, in speaking of simple inflanunation. THE PHLEGMASIA. 41 When suppuration takes place, the pain, for the most part, also abates. It is sometimes kept up by the distension which the col- lection of pus occasions. As in external inflammations, the throb- bing often becomes more remarkable during suppuration, or su- pervenes where it had not previously been perceived. The pa- tient also feels a sense of weight where the collection of matter is considerable, and if the part is not very deeply seated, fluctua- tion may be perceived through the integuments. The only local symptom which indicates the termination of in- ternal inflammation by gangrene, except the gangrene by destroy-' ing some considerable vessel occasions hemorrhagy, is the abate* ment or total ceasing of the pain. As far as wre judge of the tendency to these different termina- tions by the local symptoms, wre form our judgment in the same way as in simple inflammation. When the pain and derangement of function are unusually obstinate, we have reason to fear suppura- tion ; when unusually violent, mortification. We shall find that our judgment in this respect is also influenced by the nature of the part affected, some of the internal organs, the stomach and intes- tines for example, being more liable to gangrene; others, as the lungs and liver, to suppuration. But in ascertaining the tendency of internal inflammations, a9 well as the manner in which they are actually terminating, we trust more to the general than the local symptoms. When the fever is moderate, and yields readily to the means employed, we may hope for resolution. During this termination, the fever abates with the local symptoms, and with them disap- pears. When the febrile symptoms, though not very considerable, are obstinate, and either yield little to the remedies employed, or Soon suffer anew exacerbation, we have reason to fear suppura- tion ; especially if the inflammation has its seat in those organs which are most liable to this termination. When suppuration begins, the pulse gradually loses its hardness, and becomes fuller, but continues more frequent than natural, and at the same time more or less of a cold stage is formed, the chills often continuing or recurring for many hours or even days, some- times followed by hectic fever ; a species of symptomatic fever, which we shall soon have occasion to consider at length. It ia enough to observe here, that it is a fever consisting of evening ex- acerbations, and morning sweats which never bring complete off permanent relief. V'or. ir1. '5 42 SYPMTOMS OF If the abscess, instead of healing, continues to form matter, es*' pecially if the discharge is of an unfavourable kind, this fever con- tinues till the patient gradually sinks under it. In this way inter- nal suppurations may prove fatal, or they may destroy life more suddenly by destroying some of the vital organs, or laying open some of the larger vessels, or by the abscess bursting into tbe cavity of the longs and occasioning suffocation.' When in the phlegmasiae, the febrile, as w'ell as the local; symptoms are'unusually violent, and yield little to the means em* ployed, we dread mortification, especially if the inflammation has its seat in the parts most liable to this termination. A9 soon as gangrene takes place, the pulse loses its hardness, and becomes very feeble, frequent, and often irregular. The debility is extreme, and the surface bedewed with partial cold clammy Sweats.' So sudden and complete in many cases is the relief from pain when mortification supervenes, that the patient, for a short time, often believes himself well. A person acquainted with the nature of his disease, however, knows that he has but a few hour? to live, which is soon apparent by the rapidly-increasing debility. But such is the tranquility of this period, that many, in such cir- cumstances, being made aware of their situation, have made their wills ; for unless the inflammation has its seat in the brain, it is un- usual for coma or delirium to supervene in the phlegmasiae. Mortification may take place, however, without a cessation of pain. When the mortification is confined to a small portion of the inflamed part, the pain may continue to the last, as happened in a case in which I found, on examining the abdominal viscera after death, almost everp part of the intestines more or less inflamed, and a gangrenous Spot about the size of a sixpence on the stomach. In such cases it is very difficult to ascertain the presence of gan- grene, particularly if the inflammation has its seat in the stomach and bowels, all inflammatory affections of which are attended with much debility from the commencement. To determine the pre- sence of a disease, however, in which no remedy can avail, is of little consequence. Such is the general view of the symptoms of the phlegmasia?. Considerable deviations from the ordinary course however fre- quently occur ; thus, in some cases, particularly of inflammation of the lungs and liver, anxiety attends instead of pain, sometimes/ the pulse is not hard ; this deviation however is rare. Nay, it so etin.es, though very seldom happens, that inflammation is- present without producing any of its usual symptoms. THE PHLEGMASIA 43 The reader will see instances in which the intestines were in- flamed, with little or no pain, in the 35th Epistle of Morgagni's work, De Causis et Sedibus Morborum, in Van Swieten's Com- mentaries, Sir John Pringle's Account of the diseases of the army, and in the fourth volume of De Haen's Ratio Medendi. In the last work he will find one case where the stomach was inflamed with- out vomiting, and another in which there was neither vomiting nor pain : and even the heart, as appears from cases related in the Sepulchretum Anatomicum of Bonnetus, and the Epistles of Mor- gagni, has been inflamed without either pain or lesion of function ; a striking instance of which I have myself seen ascertained by dis- section. I have also seen the appearances of inflammation in the intestines after death, where there had neither been pain nor de* rangement of their functions. Nay the brain itself as appears from the works of Huxharn and others, has been found inflamed where none of the symptoms of phrenitis had existed. Such ano- malous cases occur so rarely, however, that they must not be ai- iowed to influence our practice. CHAP. II. Of the Causes of the PHixcMASiiE., The causes of the phlegmasia?, as I have already had occasion jto observe, are the same with those of simple inflammation. The difference of the phenomena, depending not on any difference in kind, but on the different degree or extent of the inflammation, or the nature of the parts it ppcupies. For the causes of tbe phleg- masia?, therefore, the reader U referred to the Introduction to the ,Sece»d Part. 44 TREATMENT OF CHAP. III. Of the Treatment of the Phlegmasia. The treatment, like the symptoms of the phlegmasia?, might be divided into two parts, the local and general; and these subdivid- ed, according as our view is to procure resolution or suppuration. It will give a more connected view of the subject, however, to re- verse this order, and divide the treatment into that which promotes resolution, and that proper when suppuration is desirable ; divid- ing the means employed in each case into local and general. We are now, as it were, to survey a new field in the practice of medicine. The maxim* on which the treatment of all the fevers we have hitherto considered, is founded, are no longer applicable. The most characteristic difference between the treatment ef idio- pathic fevers and the phlegmasiae is, that in tbe latter we employ antiphlogistic means more liberally, and the stimulatiug plan with more caution. It is not meant that the unguarded employment of antiphlogistic means, particularly evacuations, is not attended with danger in the phlegmasia?. Besides the danger of inducing a state of general de- bility ; if we greatly weaken the vis a tergo, the circulation in the inflamed part may cease altogether, and gangrene ensue. This, as might be supposed, is most apt to happen in the phlegmasiae of longest duration, certain species of cynanche for example, or tfie more chronic forms of erysipelas. The accession of gangrene in the phlegmasia? may be regarded as in some measure analogous to that of typhus in idiopathic fevers. The latter, we have seen, may be rendered formidable either by the excess of the previous excitement, or the unguarded use of an- tiphlogistic measures ; in like manner gangrene in the phlegmasia is to be dreaded when the various symptoms denoting active inflam- mation run unusually high, and when antiphlogistic measures have been carried very far, In some of the phlegmasia? we have to fear another consequence from profuse evacuations, their degenerating into chronic diseases, always more obstinate, and often more dan- gerous, than the phlegmasia? themselves. The maxims which regulate the employment qf evacuants in idiopathic fevers will not apply to the phlegmasiae. In the former, THE PHLEGMASIA, 45 we have seen, we almost always, cet. p; ribus, proportion the evac- uation to the degree of general excitement; in the phlegmasia? ivc, cet. paribus, proportion them to the violence of the local affection, and we attend to the nature and degree of the febrile symptoms chiefly with a view to nscertahi the state of that affection; and, as in some phlegmasia?, the infla-irnation is the greater, the greater the general depression and debility, we sometimes have recourse to powerful antiphlogistic measures on account of the wry symp- toms, which, in idiopathic fevers, render the tonic plan indi: sensi- ble. In some of the phlegmasia?, we shall find that a weak and even irregular pulse indicates the necessity of liberal evacuation?. Such a state of depression, however, L to be carefully distin- guished from debility, properly so called. The one is transitory, the other permanent. A depression of strength even to syncope may arise from the morbid contents of the stomach., and on the re- moval of these may cease in the space of half an hour. But debil- ity, properly so called, is that which arises from want of nourish- ment, profuse evacuations or diseases of long continuance. A careful distinction between these species of debility is no where more necessary than in the phlegmasia?. AVhile in them, depression of strength, properly so called, never counterindicates evacuations, real debility often does. How they arc to be distin- guished in each case will appear as we proceed. They arc chiefly to be distinguished by depression of strength coining on suddenly, and only attending inflammations of particular viscera; while real debility almost always comes on slowly, and may attend any oft Ik phlegmasia? if long protracted. The extent to which antiphlogistic measures should be carried in a great measure depends on the nature and seat of the inflam- mation. If these are such that resolution is the only safe termi- nation, they should be carried farther, than wdiere suppuration alse is favourable ; because, to procure a proper suppuration, a greater degree of general excitement, than that most favourable to resolu- tion, is requisite ; and it is sometimes better, particularly in exter- nal inflammations, to induce supuration, than to carry evacuations to the extent that would be necessary to procure resolution. Such are the general principles on which the treatment of the phlegmasia? is founded ; it will be proper to consider more particu- larly the different means employed in these diseases. Of the Treatment of the Phlegmasia? when the view i-. !' ■>- cure Resolution. 40 TREATMENT OP As resolution is the most favourable termination in all the phleg- masia?, we always in the first place, endeavour to procure it. It is onlv where we fail in this attempt, or find that it cannot succeed without inducing a degree of debility more to be feared than sup- puration, that we endeavour to induce the latter. We procure resolution, I. By removing the remote causes if they still continue to act. 2. By diminishing the distension of the vessels in the inflamed part. 3. By diminishing the vis a tergo. Of the first of these indications little need be said ; it is only ne- cessary, for the most part, to be acquainted with the causes of in- flammation, in order to remove them if they are still applied. Of the means of relieving the congestion in the inflamed part it will be necessary to speak at greater length. These may be divided, as in simple inflammation, into those which relieve the congestion by exciting the debilitated vessels, and those which directly remove part of their contents. Many of the first we shall have occasion to enumerate in speak- ing of the different phlegmasia?. They are used either by washing the inflamed part, or parts in its immediate neighbourhood, with so- lutions of them, or such solutions are made into poultices and kept applied to the parts. When the application is made to a neighbour- ing part, it seems to relieve the inflamed part in consequenoe of the sympathy which exists between all contiguous parts. The means which act by lessening the contents of the distended vessels are upon the whole more powerful ; these are of twokinds^ 1. Such as debilitate the vessels of some neighbouring part, in consequence of which, a congestion being formed there, that of the inflamed part is relieved. The means belonging to this class are termed rubefacients. These are more powerful if, at the same time that they excite in- flammation, they occasion some evacuation. Blisters therefore are found the most successful rubefacients. The evacuation they oc- casion, however, is slow; and it may be observed of local, as it was formerly observed of general, evacuations, that their effects are, cet. par. proportioned to the rapidity with which they are made. 2. Such as at once draw off a considerable portion of the blood distending the vessels. Of all the remedies employed in the phlegmasia? there is no oth- er at the same time so powerful, and so generally applicable, as lo- cal blood-letting, and when, as in visceral inflammations, we can. THE PHLEGMASIA 4t nutlet blood from the inflamed partitself, it often has an exeeller t effect to draw it from the skin in its immediate neighbourhood.* Local blood-letting is performed either by cupping or by leeches.. The former has the advantage of acting at the same time as a rube- facient. The cupping glasses are often applied as a rubefacient without the scarificator. In many cases, however, leeches are preferable. If the inflam- mation be external, they can be applied to the part, and even in in- ternal inflammations, the tenderness on pressure is often so great as not to admit of cupping. The principal inconvenience in the use of leeches arises from our not being able to limit with accuracy the quantity of blood lost. If few leeches are applied, the blood is slowly abstracted ; if many, the discharge after the removal of the leeches may be too copious; a little lint with moderate pressure is generally sufficient to check the bleeding. Where these can be conveniently employed, it is the best plan to apply a considerable number of leeches ; where they cannot, the number must be smaller, and the flow of blood promoted by cloths dipped in warm water, and renewed as soon as they cool, or, which is a much mora effectual means, the application of a large poultice. When either the excitement or the hardness of the pulse- is con- siderable, the more stimulating of the foregoing means, blisters and rubefacients, are exceptionable, as might, a priori, have been sup- posed, inflammation being the cause both of the increased excite- ment and hard pulse. In such cases, therefore, these symptoms are to be moderated by evacuations, before we have recourse to them. Such are tbe local remedies employed in the phlegmasia?, and in the milder cases, with proper means to remove any cause of ir- ritation, and support a proper action of the bowels, they are all that are necessary. In more severe cases, however, general, as well a? local, remedies must be employed, and then the third indication must direct our practice, to diminish tbe u's a tergo. This part of the treatment bears, a greater rosemblarice to that of idiopathic fevers ; the line of distinction, however, is still well de- fined. It is unnecessary to repeat what is the same in the treat- ment of both setsof diseases ; for which I shall refer the reader to :lv. first volume, confining myself to the circumstances in which th< . differ. * Sec what was said in V<.]. J n^ the rro'lus opp'-ind! rr ,'1 ^ed-t-HV-; 48 TREATMENT OI The annual functions must by a mild and cooliug diet, rest, &c< be so managed as to lessen as much as we can in this way the force of the circulation. On this part of the,subject the observations are nearly the same as in idiopathic synocha. The differences which occur will be noticed in considering the phlegmasiae separately.* As cold b a frequent cause of the phlegnia: !ae, the reader will .iot be surprised to find, that it is never app! 'd so freely in these diseases as in many idiopathic fevers. The o posite extreme, how- ever, is not less pernicious ; the temperature should be moderate and regular, and the drink tepid. The phlegmasia?, it has been observed, as well as idiopathic fe- vers, have their crises. When a tendency to sweat appears in the former, it is to be encouraged by more warmth than is advisable in idiopathic fevers. But even here the hot regimen cannot be car- ried far ; if the sweat does net flow readily it will probably be of little service. The most important part of the treatment of the phlegmasia u the diminution of the vis a tergo by Venesection. Were we at all times capable of taking from the inflamed part, or some part near it, with sufficient rapidity, the necessary quantity of blood, there can be no doubt that this would be the most successful mode of blood-letting in the phlegmasia". In this class of diseases wc have two objects iu view from blood-letting ; to diminish the con- gestion iu the inflamed part, which is best performed by blood-let- ting from the part, and to diminish the vis a tergo, which can only be effected by the loss of a considerable quantity of blood. But as the increased vis a tergo is supported by the inflammation, if the abstraction of blood be made in such a manner a3 to serve at the same time the purpose both of local and general blood-letting, a less loss of blood will, it is evident, answer the purpose. It is often difficult, however, and sometimes impossible, to take the ne- cessary quantity of blood from the part affected, or its neighbour- hood ; and then we must let blood from the arm as in idiopathic fevers. If, for example, the inflammation have its seat in the head, :t is better to take blood from the jugular vein than from the arm ; * Wc shall then also have occasion to consider a circumstance which, though icvcr a source of irritation in idiopathic fevers, in some of the Phlegmasia; ippears to be a very material one. Breathing pure oxygen -as, it has jcenfoand, is capable of exciting inflammation of the lungs, (see the experi- ments of Lavoi.hr and others) and we have reason to believe, that the great- er the proportion of oxygen in atmospheric air. the greater i* its tendency t excite information. THE PHLEGMASIA. 49 but if it have its seat in the stomach, as there is no considerable vein which can be opened in the neighbourhood of this organ, we take the blood from any of. the vessels in the upper part of the body which is most convenient.* We determine the propriety of blood-letting in the phlegmasiae, as well as the extent to which it is to be carried, by comparing the state of the general symptoms with the seat of the inflammation. The presence of inflammation in most parts occasions general excitement. In such cases we judge of the degree of inflammation by that of the excitement, and regulate the employment of blood- letting in the same way as in simple synocha, except that the same rlegree of excitement warrants a more copious evacuation, both be- cause other means are less powerful in the phlegmasiae, and because in these diseases the excitement is succeeded by a'state of mere debility, not by typhus as in idiopathic fevers. Inflammation of certain parts, it has been observed, instead of increased excitement is attended by a state of general debility. Wc then employ antiphlogistic measures the more assiduously, the greater and more sudden the depression of strength, the inflamma- tion being generally proportioned to this symptom. It sometimes happens indeed, that the circulation is rendered so languid, that even at an early period it is difficult to procure the proper quantity of blood, and in a very short time it becomes impossible. In a case of inflammation of the stomach and bowels which had only lasted ten or twelve hours, I ordered all the larger veins of both arms and both legs, and also the temporal artery to be opened, without be- ing able to procure more than two or three ounces of blood. The patient died within 24 hours from the commencement of the dis- ease, and on opening the body tbe stomach was found gangrenous. But even where the inflammation is attended with increased ex- citement, and there can be no difficulty at any period of the in- flammatory stage in taking the necessary quantity of blood, earlj' and decisive evacuations are necessary; for after a tendency to suppuration has come em, (and the same remark applies to gan- grene if the inflammation be internal) we have no means of pre- venting it; besielos the disease is confirmed by its continuance, and at the same time the strength impaired; hence it generally hap- pens, that if evacuations are nfgh cted at an early period, they • ?ec what is fuldouhe civets yiVt^ira^In^th1 blood rapidly in (.'ymncha Tonsillaris. \ T ' and R«»n>H. Vol. tr • 7 50 TREATMENT OF must be carried to a greater extent, while at the same time fhV patient is less able to bear them. The propriety of having immediate recourse to general blood-1 »' letting, then, in all the more alarming Cases of the phlegmasia?, that; y is in all cases of visceral inflammation, is unquestionable ; and in • tin's most essential respect, therefore, the practice h more uniform? and simple than in idiopathic fevers. This observation, however, applies only to the phlegmasia? not < ' complicated with other diseases. When they supervene on dis- eases of debility, or in habits debilitated by previous diseases, the employment of blood-letting requires more caution and discern- . ment. Cases of this kind we shall have occasion to consider more particularly in speaking of the phlegmasia? separately ; it is enough at present to observe, that experience has confirmed what, from the foregoing view of the nature of inflammation, might, a priori, have' been supposed, that in such circumstance/ the indication is rather to relieve the conjestion in the inflamed part, than to diminish the vis a tergo,. and consequently that we are rather to depend on local than «, . general'evacuations. I have seen general blood-letting in gastritis ,•. supervening on a very debilitated "state of the system, serve no other purpose but that of hastening the fatal termination. With the exception of such cages, then, to determine the pre- sence of visceral inflammation, and the propriety of general blood- letting is the same thing. It requires more attention, however, to determine the extent to which it should be carried, and it is in vain" (as some have attempted) to state the precise quantity of bldod ^ which must be lost to procure resolution in the different phlegmasia?.•' ' H is true that some phlegmasia? require more profuse evacuations than others, but the severity of the symptoms, and the strength of the patient, must always influence the treatment.. ' *' In visceral inflammations, we immediately have recourse to gen- eral blood-letting, "because its effects are more speedy than' those of any local evacuation. By general blood-letting* we at once df-*«V ininish the vis a tergo, and hardly ever fail to procure more or le.«s " relief. But the vessels gradually adapting themselves to their content?, ; the vis a tergo often becomes as great as ever, and thus, when the in- '\ llammatbry tendency is considerable,by repeated general blood-let- / ** ting the strength of the patient is often exhausted before the disease * » is subdued. Such, however, is a very general practice in visceraj * inflammation:-, as if the only indication were to diminish the vis i THE PHLEGMASIA".. 51 torgo. The conjestion in the inflamed part, which supports it, ,is Overlooked. If one or two general blood-lettings remove a visceral inflamma- tion, they are the most easy and expeditious means of cure, but wherever the symptoms require a frequent repetition of this reme dy, we should call in the aid of local evacuations. .When therefore the symptoms do not yield to a second general blood-letting, we should without loss of time, apply leeches, or the scarificator and cupping glasses, as near the part as possible, by which a repetition of the general blood-letting will often be pre- ventedi and the extent to which it will be necessary to carry it, always diminished. In cases wdiere resolution is the only favourable termination, wt are to repeat the local and general blood-letting, trusting as much as the state'of the symptoms admits of, to the former, till the in- flammation-is subdued, or symptoms denoting the presence of sup- puration or gangrene, supervene. It often happens, that after* the vis a tergo has been diminished by two of three general blood-lettings, the cure may be completed by local blood-letting alone, and when it is sufficient, which will bo known by its effects, no other should be employed. With respect to the quantity of blood taken at each blood-letting. in an aduU of ordinary vigour, labouring under visceral inflamma* tion, fourteen ounces is a moderate general blood-letting ; ^.mode- rate local blood-letting is from four to six ounces; apd be;di will be the more effectual, the earlier.thty arc employed, and the more > ' -quickly the blood is taken. The repetition of the blood-Jetting must be regulated by tL. effects of that which has been employed. If the symptoms return with diminished violence, a smaller blood-letting will be suGichut if with equal violence, an evacuation equal to the first will be ne- cessary ; and if with increased violence, we must still proportion . * the evacuation to the state of the symptoms; and the quantity of ' blood which is sometimes lost, without fatal effects, in visceral in- flammations, is astonishing. There are two changes in the state of the.pulse jwhich we wish to obtain by blood-bitting-(whether local or'gentral) in the phleg- masia;. The one, to^reduce its strength; andtof course only applies ' * to those cases where .the excitement'is greater than natural; the * other is our aim in all the phlegmasia?, to remove its hardness, and it is generally in proportion as it has this effect, that blood-letting is successful in these disease? : the reason of which will readily ap- tsi TREATMENT OF pear from what has been said of the nature of a hard pulse. When*' the evacuations have greatly reduced the excitement, without re- moving the hardness of the pulse, the prognosis is bad. When ■ they have been carried as far as they can be with safety, without ■ removing this symptom, it is generally fatal. An extremely small'^ and hard pulse, in those cases where the pulse is generally strong, is one of the worst symptoms ; because, while it indicates tbe ' nectssity of evacuations, it informs us that the patient can no longer bear them. Although - in the phlegmasia? we take more blood'from the full and plethoric, than from those of an opposite habit, yet, in deter- mining the qdantity, we pay less attention to tjie habit than in the treatment of synocbus, because the blood-letting, as appears from what has just been said, is more generally requisite in the phleg- masia?, and bad consequences are less apt to follow it. "■ For the same reasons we pay comparatively little attention to „evcral of the other circumstances, which were enumerated in the ! • *.« . first volume as demanding attention 'in the employment of this re-' i, medy in synocha, namely, the nature of the cause from wliich the 4, disease proceeds, the season and climate, and the nature of the. '. prevailing epidemic. '* Some of the circumstances alluded to, however, must materially*' ' influence the employment of blood-letting in all cases. .The perf-i * 4 od of the disease, and the effects'of the blood-lettings which have* ,1 been employed, I have already had occasion to mention ; we, arc • influenced also, as in idiopathic fevers, by the appearance' of "the blood which has been drawn. The age of the , patient likewise *' demands attention ; the younger he is, if not an adult,-the same' loss of blood will produce the greater effect. In the decline of life more is to be apprehended from venesection than at an earlier period, and then, the older the patient is, it is the more to be, dreaded. ' i Among the consequences to be feared from hlood-lctliug in the* i{ phlegmasia?, was.mentioned its tendency to.convex t cvrh.in specie* ^V of there, into chronic di.-eaie.-?. In advanced age, when the powers of the system bexorn^ languid, this effect is particularly to be' dieaded,; in^ohj/peoplej^ior.example, inflammation of the lungs; '' often degejau-ates mtohha disease called, peripneumonia notha, and .N acute rheumatism into chrofiic.' . * Such are the circumstances which influence't'he employment of * hlood-letting in the phlegmasia:, and if what has just been said be ' compared with the observations ^ade on cathar,:, jn idior>athitr THE PHLEGMASIA:, 6b fevers, the reader will readily perceive what part of those obser- vations is applicable to the phlegmasiae. We are never to substi- tute catharsis for venesection in these diseases ; but more or less of it is almost universally proper in them. Every degree of irritation in the phlegmasiae is particular!) hurtful, and even that degree which attends*the healthy state of the bowels must be lessened, the faeces should be of a thinner con* sistence, and discharged more frequently. The bowels, as ii: simple fever, are generally languid, so that cathartics are doublv indicated. Although cathartics are much less effectual than blood- letting in directly diminishing the vis a tergo, yet, when they a/:t by relieving the congestion in tbe inflamed part, the cause of the increased vis a tergo, their effects may be even greater than- those of a moderate blood-letting: thus it is, that in all inflammatory^ "affections of the alimentary canal, catharsis is of the most essential use. From the immediate connection of the vessels of the head and ' trunk, we can hardly more effectually relieve thpse of the former, i- than by abstracting part of tne contents of the latteT ; hence, it is, that ftom profuse evacuations by the bowels, the depletion of the vessels of the head often goes so far as to produce syncoffe ; hence 'also, we easily explain the turgescence of the vessels of the head, with the various symptoms it occasions, previous to an attack of 'he^norfhois, and tbe immediate relief and pale countenance which •follows the discharge from the hemorrhoidal vessels. We might therefore, a priori, have supposed, that in inflammations of the bead, a copious discharge from tbe bowels would be found one of the best remedies, and experience has ascertained that venesection* itself is often less powerful. ., ■ With ftssjject to the evacuation by emetics, it is less generally, though often vcrv useful, in the phlegmasiae. It is sometimes of service by evacuating the morbid contents of the stomach, more frequently by promoting a discharge by the skin. In some of the » "phlegmasia? it is otherwise serviceable, and in some it is in every r%*^ase inadmissible.* In inflammation of the pharynx, larynx, am: trachea, for example, we shnll find it a.pdvwwfuK means of relief; in inflammation of the encepharon, one of ther most certain mean? * of aggravating the disease.- -, , ' " * We trust less to the effects' of diaphoretics in the phlegmasia ' than in idiopathic fevers : most of the phlegmasia?, indeed, are ' t03 rnpid a?d dngerous fov such roc-ar- To \hU ob=eyva!i<->", 64 TREATMENT OF however, we shall find a few exceptions ; and in all the phlegma- siae, proper diaphoretics aid more powerful remedies. It has not, perhaps, been sufficiently attended to in the treat- ment of the phlegmasia?, that evacuations are not the only means. we possess of diminishing the vis a tergo. It is sometimes advisable in these diseases, when the patient is too weak to bear a considerable loss of blood, to place him in the erect posture while the blood is taken, by which a tendency to syn-. cope will be induced by a smaller loss of blood, and temporary, perhaps permanent relief obtained. It often happens that this. tendency is more easily induced in the first, than in the second or third blood-letting. ( Naysea, it is evident, acts in a similar way. Of the medicines which tend to diminish the vis a tergo, one" has lately demanded much attention. There have been various opinions respecting the \' effects of digitalis ; we shall have occasion to consider them more particularly in speaking of the diseases, in which this medicine has- |' been employed. ' . * f . *» Of the Treatment of the phlegmasia? when the view is to pro- « cure Supjmration. When the symptoms either do not remit on tbe use of proper* remedies, or constantly return with the same, or greater violence, we have little hopes of procuring resolution. . In commencing the treatment of any of the phlegmasiae, we should consider, whether, if we fail to procure resolution, suppura- tion will be desirable. If so we must not greatly reduce the .strength,, because, after the excitement falhj to a certain point, the more the system is debilitated, the less inflammations tend to suppuration, and the more to gangrene. This is one reason, why, in external inflam- mations, and those of the fauces, we do not carry antiphlogistic •measures so far as in inflammations of the lungs, stomach, intestines, &c and if in the former cases these measures have been carried far \ in hopes of procuring resolution ; in order to induce a favorable • reppuration, we must often have recourse to such as increase the ^* excitement. It is not, however, to be inferred, that the presence of much ex- citement, and a great degree of Inflammation, are favourable to sup- puration. Although from the very commencement of a phlegmasia? we had nothing in view but to procure suppuration, we should almost always find it necessary to employ to a greater or le=s ex«- tent the means for promoting resolution. THE PHLEGMASIA. :k' The Same principle regulates the employment of the local means* While the inflammation is very considerable, attended with much pain and swelling, although we have no prospect of procuring res- olution, we must have recourse to the same local means which are employed for this purpose ; thoy must not, however, be carried so far. When, on the other hand, the inflammation is too languid, we must, by warm poultices and fomentations, endeavour to promote it ; and if the system partakes of the langour, we must have recourse to the means which increase general excitement. It is a common opinion, that in external inflammation, applica- tions which clog the pores promote suppuration by preventing the exudation of the matter. This practice seems to have originated from the opinion of pus being formed by stagnation from some of the component parts of the blood. Such applications may be of use by increasing the heat of the part, and applying a stimulus to its vessels. In short, the chief difference between the treatment for resolu- tion and that for suppuration is, that in the former we endeavour entirely to remove, in the latter only to moderate, the inflamma- tion. » When internal suppurations occur without immediately proving fatal, our practice is so much influenced by the nature ot the part affected, that I must defer speaking of the treatment till we come to consider the phlegmasia? separately. As an abscess increases, it is most enlarged on that side where the least resistance is opposed ; when it is situated near the sur- face, therefore, it generally points externally, and the matter is readily discharged, which, for the most part, should be done by an artificial opening, rather than by waiting for the slower operations ot nature. But when the abscess is deep seated, or when, as in abscesses'of the lungs, the greatest resistance is opposed on the external side, they point and burst internally. It is always of consequence, therefore, in forming the progno- sis, to ascertain on which side of an abscess the least resistance is applied, and it sometimes influences the mode of treatment, for where there is reason to apprehend that the abscess will burst in- ternally, it is advisable, in some cases, to attempt the evacuation of the matter by an external opening, although there is no appear- ance of its pointing-externally. This, wc shall find, has often bee". practised with success in abscesses of sortie of the viscera. 56 TREATMENT OF The more perfect and unmixed the pus,* the more readily may we expect the abscess to heal, and the less injury will the habit sustain. It is therefore our view in promoting suppuration, to procure a pus of the most favourable kind. For answering this intention, however, there are no other means than those which have been pointed out. The nearer the general excitement and tbe degree of the local affection approach to those best suited to promote suppuration, the more favourable will the suppuration be. There i? one case of suppuration which demands particular at- tention. When gangrene supervenes, if the case terminates fa- vourably, it is by suppuration that the dead are separated from the living parts. Those states which are unfavourable to resolution and suppuration, tend to gangrene. On the means of preventing gangrene, therefore, nothing more need be said. It remains to. make' a few observations on the mode of treatment after it has su- pervened. The whole system we have seen, partakes more of the affections of the internal, than external parts. The slightest viscrral inflam- mation, it has been observed, occasions fever, and the different changes which take place in the local affection are indicated by corresponding changes in the state of the general symptoms ; on m. the surface, on the contrary, a considerable degree of inflammation '. may exist and even run on to suppuration without being attended with symptoms of general derangement: so in the case of gangrene, ** when it is seated in external parts, the vigour of the system may 3till be such as to excite suppuration, and thus throw off the gan- grened part; but when the gangrene is internal, the system in gen- eral partakes too much of the local affection to support, or indeed to afford time for, this process by which alone the progress of the gangrene can be stopped. This is the less to be regretted, be- cause the injury done by internal gangrene is generally such, that ' '. a separation of the gangrened parts would only prolong the pa- tient's sufferings. ' ♦ Of gangrene of the throat and muscles it may be observed, a? of inflammation of these parts, that the state of the system is neither so much affected by it as by the gangrene of more internal parts, nor so little as by that of the surface, and the prognosis is neither so bad as in the one ca?e nor so favourable as in the other ; farther * Sec what was raid of pus andlb* d'*rha^f^n, f, ,* „],.-,.-< in cpPakinffn- tbe termination of inflammation THE PHLEGMASIA. 57 dvmort-trating that the danger of gangrene is proportioned to the degree of sympathy, which subsists between the system in gen- eral and the part affected. It is only then when gangrene is seated on, or near1 the surface, that we cau attempt the cure with any hopes of success. The treatment may still be divided into general and local. The general treatment is nothing more than that employed in all stages of the disease, when the inflammation is too languid, only in the case before us this mode oi treatment is carried to the greatest extent. The patient must be supported by the liberal use of wine, and tbe bark must be given as freely as the stomach will bear. To this, however, there is one exception, when gangrene is the consequence of excessive inflammation it sometimes appears while the general excitement is great, and if the seat of the disease is external, the increased excitement sometimes continues after the commencement of the gangrene, supporting the inflammation, and occasioning the gangrene to spread. In such case;, it ii evident that any means which increase the vis a tergo must promote the progress of the gangrene. " When the gangrene arises from the " violence of inflammation," Dr. Cullen* observes, " the bark " may not only fail in proving a remedy, but may do harm, and " its power as a tonic is especially suited to those cases of gan- " grene which proceed from an original loss of tone, as in the case " of palsy ant1 oedema ; or to those cases of inflammation where " a loss of tone takes place, while the original inflammatory symp- •' toms are removed." When therefore gangrene proceeds.from excessive excitement, we must delay the invigorating plan'till the presence of the gan- grene has reduced the morbid activity of the system, which soon happens and in such cases considerable attention and nicety is often requisite, to determine the period at which the exhibition of bark and wine should commence. The best rule perhaps is, as hoon as the exenemeni ii reduced to the natural degree, that is, as soon as the preternatural strength of tlio puh:> has subsided, to oxbibit tmall* elopes of bark and wine, and be regulated by their effects. With regard to the low; remedies, Jiiey are all o-uoh is tend to excite the vippuration by which :h<. gangrened nuts are to be ►hrown o.h Among the applications iJtmd s^r/ic cubic are many V-. Cul'-iV Firil L:d:;s. t- -.-a-r c>'> 970 V0r. :■ 53 TREATMENT OF of those termed antiseptics, and it has been a prevalent opinio*, that these act by checking, by their antiseptic power, the farther tendency to gangrene. But the same substances applied to parts separated from the body will not have the same effect, at least in any considerable degree, nor are the best antiseptics, best fitted for checking the progress of gangrene. Besides, whatever other effect they produce, they must tend to excite the powers employed in casting off the dead parts ; and as this alone accounts for their effects, there is no occasion for any other supposition. That they may have this effect, they must be applied to parts which still retain some degree of excitability ; it is proper there- fore, especially if the integuments remain entire, to make incisions through the gangrened part, previous to their application. Heat is stii! one of the most powerful means of exciting suppuration, so that warm poultices, whatever be their composition, are among the best applications. Some practitioners recommend the appli- cation of warm bricks over the dressings,* and they are prepared in Holland of various shapes for this and similar purposes. But the local treatment of gangrene belongs to the province of the sur- geon. There is one case which deserves notice, as particularly illus- trating" a law of the animal system, by which it is rendered mor- bidly sensible to any of the natural agents, in consequence of its usual application or its application in the usual degree being in- terrupted, without becoming more sensible to the action of any other. When heat is so rapidly abstracted from any part that it falls below the temperature necessary to life, like other dead animal matter, it runs to putrefaction. Thus the occurrence of gangrene in those parts of the body where the circulation is languid, is not uncommon in cold climates. As we should, a priori, expect gan- grene from this cause, it is most effectually checked by increasing the temperature of the part. Were we, however, at once to apply a temperature equal to the common temperature of the body, ita effect would be that of increasing, instead of checking, the gan- grene. Had not the parts in the neighbourhood of the gangrened part suffered from the application of cold, this practice might suc- ceed ; but the temperature of these parts having been greatly re- duced for a considerable length of time, the usual temperature be- comes an agent sufficiently powerful to derange the mechanism on * Van Swietou's Comment, in A ph. V.o Th.v.\r.: THE PHLEGMASIA. ob which life depends ; and as the phenomena are the same after life !,s destroyed, whether this be effected by too great an increase or diminutionof temperature, the only effect of the sudden increase of temperature is that of causing the gangrene to spread. The proper treatment therefore is to bring the part to the natural temperature by very slow degrees, and the first application is gen- erally snow or iced water. I have already had occasion to observe, that in cases of extreme debility, gangrene often supervenes almost without any previous inflammation, the vis a tergo being too feeble to occasion much dis- tension in the vessels of any part, however much debilitated. But should it happen, eveu where the system is not particularly debil* jtated, that by any abuse the vessels of a part, instead, of being de- bilitated, wliich gives rise to inflammation, are instantly deprived of vital power, gangrene would, in this instance, also, supervene with little or no previous inflammation. This has sometimes though very rarely happened.* What has been said may be regarded as nearly the sum of all that i^ common in the symptoms, causes, and cure of the phlegma- sia?. We are now to consider the different species .separately; and notwithstanding the nature of all being the same, such, we shall find, is the difference arising from the function and situation of the parts affected by the inflammation, that there arc hardly two diseases more different than some of these. Different divisions of the phlegmasia? have been proposed ; that most generally adopted appears on many accounts to be the best, namely, the division according to the different organs occupied by ;he inflammation. Ij is true indeed that the inflammation may occupy the membra- nous or paranchimatous part of the organ,! and wc know, from dissection, that the inflammation is often confined to one of these parts. No parts of the body being more different in their struc- ture, we should be inclined, a priori, to believe, that the symp- toms of inflammation in them would essentially differ, and require in some respects different modes of treatmeat. And in most wri- * A remarkable instance is related in tlic Philosophical Transactions for tbe year 1703. A poor family in Suffolk were attacked with gangrene without previous inflammation. Some died, others lost different parts, the feet, and even the legs. No probable account of tbe cause is given. t See a paper on the Phlegmasia by Dr. C. Smith, in the 2dvg!.nfthe Lon- don Medic-.! Communications. 60 TREATMENT OF, &c. ters the reader will find this distinction made, and even different names applied to the different inflammations of the same organ. Thus they point out the symptoms which distinguish inflammation of the brain from that of its membranes, terming the one Cephali- tis or Sphacelismus, and the other phrenitis ; those which distin- guish Pleuritis, inflammation of the pleura, from Peripneumonia^ inflammation of the lungs : and so on. In paranchiinatous inflammation, it is said, that as the parts are soft and yield readily, the pain is never so acute nor the fever .so violent as in membranous inflammation, where, from the parts yielding with more difficulty, the symptoms are necessarily more severe. This hypothesis seemed confirmed, when it was observed that in most visceral inflammations the symptoms are sometimes of the one kind, sometimes of the other. The opinion, therefore, was implicitly received, till Sauvages, Linna?us, and others, whom I shall hereafter have occasion to mention, made dissections in order to ascertain its validity. The result was so far from being such as was expected, that the membranes were often found inflamed where there had been only symptoms of paranchiinatous inflammation, and the paranchima where the symptoms had been those of-mem- branous inflammation. Nay, we shall find, when we consider the cases in which the distinction has been chiefly insisted upon, that where symptoms of paranchimatous inflammation alone have been present, the membranes alone have bee-m found affected, and vice versa. In short, from these dissections it appears that there are no symptoms by which we can distinguish the paranchimatous and membranous inflammations of any organ, nor is this to be regretted, since experience has proved the practice to be precisely the same in both. We can, for the most part, readily determine what organ is affected by the inflammation, and as this knowledge is all that is necessary for conducting the treatment of the disease, we need not be solicitous for more. It is unnecessary, therefore, to look for a more minute divisioi of the phlegmasiae than that adopted by Dr. Cullen, who, with a few exceptions, afterwards to be pointed out, considers the inflam- mation of each organ a different disease, and arranges the whole nnder the three heads of Cvtaneovs. Visceral, and Artiada- PHLEGMON;, 61 CHAP. IV. Of the. Phi.pgmon. It was observed, in speaking of simple inflammation, that thciy *re but two species which can be well defined, the others, appear- ing to be only varieties of these. The same observation applies to tie cutaneous phlegmasia? ; the two species of which are termed by Dr. Cullen, Phlegmon, and Erythema, forming the sevenih. genus in his system of nosology, which he call.s Phlogosis. and defines, " Pyrexia, partis externa? rubor, calor, et tensio, dolens." The first species of this genus, the Phlegmon, he defines, " Phlogosis rubore vivido ; tumore circumscripto, in fastigium " plerumque clevato, sa?pe in apostema abeunte ; dolore sa?pe puli " satili." The Erythema is defined, " Phlogosis colore rubicundo, pressione evancscentc ; ambitu " inaequali, serpente ; tumore vix evidente, in cuticulse squamulas, " in phlycta?nas vel vesiculas abeunte ; dolore urente." Although pyrexia is the first word in the definition of phlogosh?, Dr. Cullen, for reasons pointed out, in the general introduction, uses the term Phlogosis to express all species of cutaneous inflam- mations, whether accompanied by fever or not, as appears both fron there being no qther place iu his system of nosology for cutaneout inflammation unattended by fever, and from the manner in whic1 he uses the term phlogosis in hie definitions of the exanthemata anc phlegmasiae.* Strictly speaking, then, the term phlogoeis, as used by Dr. Cul- len, although he defines it to be a febrile disease, and arranges un- der it only two species, includes four ; the two phlegmasia^, the definitions of which have just been given, and the two species r simple inflammation considered in the Introduction. •iitrcIi'Mion, Volume I- 02 PHLEGMON. As there does not appear, however, to be any occasion for u generic name for the cutaneous phlegmasiae, the two species be- ing diseases nearly as different as almost any two of this order, and in reality, although both external, not having their seat in the same parts, I shall abandon both the term phlogosis* and its defi- nition. Were there no other reason for abandoning this term, the inaccurate manner in which it is used by Dr. Cullen, and by oth- ers who have adopted it from him, would be sufficient. The phlegmon, Dr. Cullen's first species of phlogosis then is, according to the arrangement I have adopted, the first genus of the phlegmasia?. Of all the phlegmasiae this is in general the least im- portant, its symptoms are least varied, and its prognosis, most fa- vourable. From peculiarity of habit, however, it now and then assumes a very serious form, spreading to great extent, and some- times even running to gangrene. Dr. Cullen also arranges as species of phlegmon, phimosis, paraphimosis, spina ventosa, &c. But all these affections belong to the province of the surgeon. The only alteration I would propose on Dr. Cullen's definition of the phlegmon is to adapt it to the mode of arrangement I follow. It maybe defined, "Phlegmasiae, rubore externo vivido; tumore circumscripto, " in fastigium plerumque elevate, saepe in apostema abeunte ; * dolore saepe pulsatili." SECT. 1. Of the Symptoms of the FhieginoSi. It has already been remarked that the phlegmon does not differ from the pustule, except in its being larger, the inflammation run- ning higher, and being accompanied by fever. What has been said of the latter, therefore, and the definition of phlegmon just * That Dr. Cullen was aware that his use of this term was not accurate, ap- pears from the following note. " Pro nomine generis cujus species est ery- " theraa minus recte in priore cditione usurpatum fuit Phlestmone. Novum !; nomen necessarium nobis videbatur, ct nihil aptius quam Phlogosis suppe- '•gi;R Method. V. i'h ». 04. 34 PHLEGMON^ SECT. III. " • Of ihc Treatment of Phlegmon. Ox this part of the subject it is only necessary to refer to whal has been said of the phlegmasiae in general. We may attempt the cure of phlegmon by resolution. Asthis mode of treatment, how- ever, would generally be tedious, and after all that could be done, would often fail to produce the desired effect, as suppuration in the phlegmon, is generally of a favourable kind, and lastly, as some ca- ses of phlegmon, (those for example, proceeding from extraneous matters introduced into, and irritating the skin) whatever relief be. obtained by resolvents, must at length terminate by suppuration, it is upon the whole found the best plan from the first to promote this termination. Both on this account, and because the fever is seldom considera- ble, it is rarely proper to have recourse to the more powerful anti- phlogistic measures, particularly general bloodletting. It is suffi- cient that the fever be kept moderate by rest, dilution, and appc rients. i With respect to the local treatment, if the inflammation run high, it must be relieved in the earlier stages by local blood-letting, and it is generally proper to diminish the temperature of the part, by the repeated application of wet clothes ; the effect of which is in- creased by adding to the water the saturn. accctat. the aq. amnion.- icetat. or other refrigerants. When the inflammation is moderate, no local application is neces<- sary, till, from the diminution of the pain and increase of the throb- bing, there is reason to believe that suppuration has commenced, which is to be promoted by warm poultices and emollient fomen- tations. The matter should be discharged as -.0011 as it is com- pletely formed, and if the wound does not heal readily, the tonic plan is proper and should be continued till tin? patient is restored to health, when gangrene is threatened this plan muot be carried to its full extent.* In some of of Dr. Cullen's species of phlegmon, phymosis, para- phyniosis, &c. other means are occasionally nece.s«arv, but for these I must refer to the worko on surgery. * Sfc t'v ."("ih :;rA !';:!lc"ingvage?cf1h;s v.htrrv: ERYSIPELAS CHAP. V. Of Erysipelas. It appears from what was said of this disease in the general in- troduction, that I use the term erysipelas in the same sense in which Dr. Cullen uses phlogosis erythema. His difinition requires no oth- er alteration than what is necessary to adapt it to the mode of ar- rangement followed in this treatise. Phlegmasia rubore externo, pressione evanescente ; ambitu inae- quali, serpente ; tumore vix evidente, in cuticula? squamulas, in phlyctaenas vel vesiculas abeu r.te ; dolore urente.* SECT. I. Of the Symptoms of Erysipelas. As the combination of erysipelas and fever had been so gene- rally regarded as an exanthema, and confounded with erysipelas according to the above use of the term, I found it necessary in con- sidering eruptive fevers to treat of what I have termed theerysipe- ■atous fever. Id considering the nature of this fever, it was neces- sary to enter particularly into the symptoms of erysipelas. For this part of the subject, therefore, I must refer the reader to the first volume. From what is there said, he will find that the erysipelas bears the same resemblance to the simple inflammation termed erythema, which the phlegmon does to that termed pustule. The only dif- ference in both cases, being, that in the phlegmasia? the inflammation is generally of a greater extent, its symptoms run higher, and it is attended with fever. f This definition does not include all the varieties enumerated by Dr. Cullen- tome of which arc merely local diseases. Vol. n. n 06 ERYSIPELAS. Guch then are the four species of cuticular inflammation, the pus- tule and erythema which are merely local affections, the phlegmon and erysipelas^which are febrile diseases. SECT. II. Of the Causes of Erysipelas In determining the nature of the erysipelatous fever, it was ne- cessary to consider the causes, as well as the symptoms, ©f erysip- elas. For these also, I must, therefore refer the reader to the first volume ; he will there find that erysipelas arises from all the caus- es of the phlegmasia? in general, and also from certain causes which particularly affect the state of the skin, derangement of the primae vH, &c. Like the other phlegmasiae, by leaving the part in a state of debility, it leaves behind it a predisposition to future at- tack:;. The c'def seat of the erysipelas and erythema is the outer sur- face of tne true skin and the corpus mucosum, but the former often spreads through the skin and affects the cellular substance be- neath if Although it was necessary, in order to place the nature of the erysipelatous fever in a clear point of view, to enter fully into the symptoms and causes of erysipelas, the treatment could not be laid before the reader till he was made acquainted with the prin- cipies on which that of the phlegmasiae is founded. On this part of the subject, therefore, I am now to enter. SECT. Ill Of the Treatment of Erysipelas J : ?. plan of treatment common to all the phlegmasia? has be?*. laid b. ,ie the reader. In considering the treatment of each sep- arately, it will only be necessary to point out what is peculiar t; it, ERYSIPELAS. , 67 lit was observed of the phlegmasia?, that the symptoms are more moderate, the prognosis better, and consequently the means required less vigorous, the more external the seat of the inflam- mation. On this account, in most cases of erysipelas, we do not find it necessary to have recource to very vigorous anti- phlogistic measures ; a cooling diet, an emetic at the commence- ment, and gentle saline laxatives repeated so as to keep the bow- els freely open, are generally sufficient, if the inflammation is confined to the extremities. When the fever is considerable, diaphoretics, particularly anti- morrials, are proper. In this case the best plan^appears to be, after the operation of an emetic, to give one or two brisk saline cathartics according to the urgency of the symptoms, and then support a moderate catharsis by antimonials. When a tendency to sweating appears, we must be careful not to check it. The propriety of attempting the cure of erysipelas rather by catharsis than by blood-letting farther appears from the evident connexion between erysipelas and the state of the prima? viae, which was considered at length in speaking of the simptoms and causes of this disease. Venesection, however, is still the best means of lessening ex- citement when it becomes considerable ; and although in erysip- elas a brisk cathartic, by removing the cause which produced Or tends to support the disease, is often the best means of relieving it, yet if this fail, blood-letting will have a better effect than the continued repetition of powerful cathartics. It is also to be observed, that although, as the inflammation is external, we do not, cet. parib. carry antiphlogistic measures so far as in many other of the phlegmasia?, yet as our view in erysipelas is always to procure resolution, erysipelas having little tendency to suppuration except when it spreads deep, and sup- puration, when it does occur in this disease, being generally unfa- vourable, antiphlogistic measures should be carried farther than in the phlegmon- While we endeavour to procure resolution, however, we mus! keep in view the tendency of erysipelas to gangrene. If the habit is good, indeed, this tendency is generally slight, and accompanied with little danger: but in debilitated habits, and particularly in those advanced in life, the gangrene, we have seen is apt to spread deep, and sometimes proves fatal. What has been said of the treatment of erysipelas is rather appli- cable to t^at of the trunk and limbs than of the face. When neither 68 ERYSIPELAS. coma nor delirium attends the latter, indeed, which is not often the case, its treatment is the same as in erysipelas of other parts, with these differences, that on account of its tendency to affect the brain, the antiphlogistic means should be more powerful in pro- portion to the symptoms, and, as the seat of the inflammation is in the head, more is to be expected from catharsis, after the removal of irritating matter from the primae via?, than in erysipelas of the trunk and extremities.* But when coma or delfrium is present, the inflammation of the face is the least important part of the disease. There is then .rea- son to believe, that the inflammation has attacked the brain,t and experience has pointed out that the treatment in such cases is the same as in phrenitis, the disease we are next to consider. In laying down the treatment of the phlegmasia?, I passed over in silence the employment of opium in these diseases, which by some has been warmly recommended, because, as there is much difference of opinion on this subject, it seemed better to defer any observations on it, till we came to consider the particular cases in which it has been recommended. The indication in all the phlegmasia?, we have seen, is to restore the proper ballance of power between the vessels of the inflamed part and the vis a tergo. 'Now as in active inflammation the vis a tergo is generally too powerful, especially, if resolution is the ter- mination we have in view, and as opium, for sometime after it is received into the system, increases the forced of the circulation, we should, a priori, believe, that in most cases of the phlegmasia?, it would be found pernicious. But as the vis a tergo, on the other band is often in a great measure supported by the pain and irrita- tion of the local affection, opium, by allaying these, may some- times be the means of diminishing it. It appears from these ob- servations, then, that the effects of opium in the phlegmasia? are most to be dreaded where the vis a tergo, which is ije*t measured by the hardness of the pulse,§ is, cet. paribus, greatest ; jiudnnost '•■ See the observations on catharsis in m-'ainmations pf the head, is: x..'c ui,ar. ter on the treatment of the phlegmpsi-o in general. t See what i* said on this -:arl -,f ti.L se-hjoci, m speahing of the svnipton.* of erysipelas, in the first volume. X See Dr. Crump's experiments on t! 74 PHRENITIS. In all parts of the body a congestion in the larger vessels OC-' casions comparatively little pain, little increase of temperature, and little fever. SECT. I. Of the Symptoms of Phrenitis. Phrenitis often makes its attack with a sense of fullness in the head, flushing of the countenance, and redness of the eyes, the pulse being full, but in other respects natural. As these symp- toms increase, the patient becomes restless, his sleep is disturbed or forsakes him. It sometimes comes on with pain, ora peculiar sense of unea- siness of the head, back, loins, and joints,* in some cases with tre- mors of the limbs, and intolerable pains of the hands, feet and legs. It now and then attacks with stupor and rigidity of the whole body ; sometimes with anxiety, and a sense of tension referred to the breast, often accompanied with palpitation of the heart. Some- times nausea and a painful sense of weight in the stomach are among the earliest symptoms. In other cases the patient is attack- ed with vomiting, or complains of the heart burn, and griping pains in the bowels. When the reader reflects on the intimate connection which subsists between the brain and every part of the system, he will not be surprised t« find the symptoms attending the commence- ment of phrenitis so various, and that the stomach in particular should suffer, which so remarkably sympathises with the brain. These symptoms assist in forming the diagnosis between phrenitis and synocha.t * Saalman's Observations on Phrenitis, in the Acta Erudit. Lipsien. t The pain of the head soon increases, and sometimes becomes very aoute. " If the meninges" says Dr. Fordyce, (Practice of Medicine), " are " affected, the pain is acute ; if the substance only, obtuse and sometimes " but just sensible." And Dr. Cullen remarks, " I am here, as in other anal- " ogous cases, of opinion, that the symptoms above mentioned of an acute in- " flammation, always mark inflammations of membraneous parts, and that au " inflammation of paranchima or substance of viscera exhibits, at least common- " ly, a more chronic inflammation." It is unnecessary here to make any farther observations on this part of the subject. When we consider pneumonia, in which the destinetion has been chiefly insisted upon, and is still v«ry generally admitted, I shall have occasion to enter upon it at length. •t PHRENITIS. 75 The the seat of the pain is various, sometimes it seems to occu- py the whole head : sometimes, although more circumscribed, it is deep-seated and ill-defined. In other cases it is fe It principally in the forehead or occiput. The redness of the face and eyes gen- erally increases with the pain, and there is often a sense of heat and throbbing in the head, the countenance acquiring a peculiar fierceness. These symptoms for the most part do not last long before the patient begins to talk incoherently, and to show other marks of de- lirium. Sometimes, however, Saalinan observes, delirium did not come on till the fifth, sixth, or seventh day. The delirium gradually increases, and often arrives at a state of phrenzy. The face becomes turgid, the eyes stare, and seem as if starting from their sockets, tears and sometimes blood flow from them, the patient resembling a furious maniac, from whom it is of- ten impossible to distinguish him, except by the shorter duration of the disease. The delirium assists in distinguishing phrenitis and synocha,* as it is not a common symptom in the latter. When delirium does attend synocha, however, it is of the same kind as in phrenitis As we should, a priori, expect in phrenitis, the different organs of sense are generally much affected. The eyes are incapable of bearing the light, and false vision, par- ticularly that termed musca? volitantes,t and the appearance of flashes of light passing before the eyes, are frequent symptoms. The hearing is often so acute, that the least noise is intolerable ; sometimes, on the other hand, the patient becomes deaf, and the deafness, Saalman observes, and morbid acuteness of hearing now and then alternate. Affections of the smell, taste, and touch, are less observable. As the organs of sense are not frequently deranged in synocha, the foregoing symptoms farther assist the diagnosis between it and phrenitis. The pulse is not always so much disturbed at an early period, as we should expect from the violence of the other symptoms com- pared with what we observe in idiopathic fevers. When this cir- cumstance is distinctly marked, it forms perhaps the best diagnosis * Lobb's Practice of Medicine. t It may sometimes arise from this deception of sight that the patient picks the bed-clothes. This, however, I have observed, he often does without direct- ing his eyes to the bed-clothes, of indeed particularly to any object. 76 PHRENITIS. between phrenitis and synocha, and gives to the former more of the appt-arance of mania. "Interea exurgit febris nunc levis nunc intensa* " ncc semper morbi impetui consona, adeo ut sola diuturnitate dis- " crepare videatur hoc deliri genus a mania, quam contumaciorem " esse nemo nescit."* In many cases, however, the fexer runs as high as the dilirium. In general, the hardness of the pulse is more remarkable than in synocha, sometimes it is both small and hard, and sometimes irreg- ular ; the pulse in synocha is always strong, full, and regular. The respiration is generally deep and slow, sometimes difficulty now and then interrupted with hiccup, seldom hurried and frequent, except from the patient's exertions. In many of the cases mention- ed by Saalman, pneumonia supervened. The deglutition is often difficult, now and then convulsive. The stomach is frequently oppressed with bile, which is an unfavourable symptom ; and complete jaundice, the urine and skin being tinged with yellow, sometimes supervenes. Worms in the stomach and bowels are also frequent attendants on phrenitis, and there is rea- son to believe, may have a share in producing it. The hydro-. cephalas internus, which is more allied tophrenitist than to dropsy of the brain, properly so called, seems often, in part at least, to arise from derangement of the prima? via?, particularly from worms. We cannot otherwise, I think, account for the frequent concur- rence of these diseases. As we proceed in considering the differ- ent phlegmasia1, we shall find that there are few to which derange- ment of these passages does not give some predisposition. Instead of a superabundance, there is sometimes a deficiency of bile, which seems for the most part to afford a still worse progno- sis. The fatces being of a white colour, and a black cloud in the urine are regarded by LobbJ as fatal symptoms. The black cloud in the urine is owing to an admixture of blood ; when unmixed with either blood or bile the urine is generally pale. There is often a remarkable tendency to the worst species of hemorrhagy towards the tatal termination of phrenitis. Hemorr- hagy from the eyes has already been mentioned. Hemorrhagy from the intestines also, tinging the stools with a black colour, is not un- common. These hemorrhagies are never favourable ; but the hc- * Lieutaud's Synopsis Med. Pract. de Phrenitide. t See what is said in the next section on the appearances on dkscctionin phre- nitis. \ Lobb's Practice of Physic. PHRENITIS. rt naorrhagies characteristic of synocha, particularly that from the nose„ sometimes occur at an earlier period, and, if copious, bring relief. More frequently, however, blood drops slowly from the nose, de- monstrating the violence of the disease without relieving it. In other cases there is a discharge of thin mucus from the nose. Tremors of the joints, convulsions of the muscles o/ the face, grinding of the teeth, the face from being florid suddenly becom- ing pale, the urine being of a dark red or yellow colour or black, or covered with a pellicle, the faeces being either bilious or white and very fceted, profuse sweat of the head, neck, and shoulders, paralysis of the tongue, general convulsions much derange- ment of the internal functions, and the symptoms of other visceral inflammations, particularly of pneumonia, supervening, are enu- merated by Saalman as affording an unfavourable prognosis. The delirium changing to coma, the pulse at the same time becoming weak, and the deglutition difficult, was generally the forerunner of death. When, on the contrary, there is a copious hemorrhagy from the nose, hemorrhoidal vessels, lungs, mouth, or even from the urinary passages ; when the delirium is relieved by sleep, and the patient remembers his dreams, when the sweats are free and general, the affection of the sight is diminished or removed, and the febrile symp- toms become milder, the prognosis is favourable. In almost all diseases, if we except those which suddenly prove fatal, as death approaches, a similar train of symptoms, denoting extreme debility of all the functions, supervenes. These the read- er will find enumerated at length in the first volume ; it is unne- cessary to repeat them here. The blood does not always shew the buffy coat. Phrenitis, like most other diseases, has sometimes assumed an intermitting form, the fits coming on daily, sometimes every se- cond day.* When phrenitis terminates favourably, tbe debility which suc- ceeds the increased excitement is less, in proportion to that ex- citement, than in idiopathic fevers, a circumstance which assists in distinguishing phrenitis from synocha. The diagnosis between these diseases is farther aided by the effects of the means employed. For if in phrenitis, we succeed in removing the delirium and other local symptoms, the febrile symp- toms in general soou abate. Whereas in synocha, although the Saalman, 73 PHRENITIS. delirium and head-ach be removed, the pulse continues frequent and other marks of indisposition remain for a much longer time.* It will be of use to present at one view the circumstances which form the diagnosis between phrenitis and synocha. Synocha generally makes its attack in the same way ; its symp- toms are few and little varied. The symptoms at the commence- ment of phrenitis are often more complicated, and differ consider- ably in different cases. Derangement of the internal functions i9 comparatively rare in synocha. In phrenitis it almost constantly attends, and often ap- pears very early. The same observations apply to derangement of the organs of sense. In synocha, the pulse from the commencement is frequent, strong and rapid. In phrenitis, the symptoms denoting the local affection are often well marked before the pulse is much disturbed. In phrenitis we have seen, the pulse sometimes very suddenly loses its strength, the worst species of hemorrhagies and other symptoms denoting extreme debility shewing themselves. This never happens in idiopathic synocha, at least in this country. When the termination is favourable, the degree of debility which succeeds is less in proportion to the preceding excitement in phrenitis than in synocha. Lastly, if we succeed in removing the delirium and other symp- toms affecting the head, the state of the fever is found to partake ©fthe favourable change more immediately and completely than in synocha, where, although we succeed in relieving the head-ach 0T delirium, the fever often suffers little abatement. In speaking of the phlegmasia? in general, I had occasion to ob- serve that certain anomalous cases now and then occur, in which they are unattended by the usual symptoms. Thus, Drs. Willis, Langrisb, and Iluxham relate cases in which traces of inflamma- tion of the brain were discovered after death where the symptoms of phrenitis had not appeared, and Bonnetus and Morgagni on the other hand, relate some in which the symptoms of phrenitis where present, and yet no traces of inflammation discoverable after death. * " Delirium vero febrile vel symptomaticum," says Lieutaud (Synopsis Medici. Practic.) " praeviae febri appenditur, solosque febricitantes adoritur^ « cur minime mirum si hoc sedato, perstet febris, solitamque periodum absol- " vat. Aliter se res habet sub phrenitide ; h enim resipiscant aegri, illico sa- "nati restituuntur, si excipias virium debilitatem qua aliquandiu tenentur hoc *' gravissimo morbo convalescentes." PHRENITIS. 19 With regard to the duration of phrenitii, Eller* observer, that when it proves fatal, the patient generally dies within six, or seven days. In many fatal cases, however, it is protracted for a longer time, especially where the remissions have been considerable. Such are the symptoms of the only form of phrenitis which, as far as I am capable of judging, deserves the name, for the coma- tose phrenitis differs in no essential from apoplexy. It is true in- deed, that the furious and comatose phrenitis by imperceptible de- grees run into each other; for as phrenitis on the one. hand runs into synocha ; on the other, it runs into apoplexy. From what has been said of congestion and inflammation, we may see why coma supervening on delirium in phrenitis, generally proves fatal: if, while the capillaries are debilitated, the larger vessels, supplying the vis a tergo which supports the circulation in them should greatly partake of the debility, there w ill be little hopes of restoring the action of the former. But in those cases where the congestion of the larger vessels, and consequently the coma has been present from the beginning, the capillaries have never been much distended, the vis a tergo propelling the blood into them, having, from the first attack of the disease, been enfee- bled ; they therefore support the circulation, and the hope of re- covery is better. SECT. ir. Of the Appearances on Dissection. It appears from dissection, that inflammation of the brain, like other inflammations, may terminate in suppuration, or gangrene.t But it sometimes proves fatal without running to either of these terminations. The part affected then exhibits the same appear- ance as in external inflammations. Inflammation of the brain generally appears in distinct spots, and for tbe most part spreads to the membranes in the neighbour- hood of the parts affected, j When the dura mater, is inflamed, the number of red vessels pas- sing between it and the cranium is increased. Dr. Baillie observes, that there is sometimes, though very seldom, a layer of coagulable lymph formed on its inner surface. It is also rare for adhesions to * Eller de Cog. et. Cur. Morb. t The Sepulcretum Anatomicum of Bonnetus, the Epistles of Morgagni, Dx. Haillie's Treatise on Morbid Anatomy, &c X Dr. Baillie's Morbid Aaatomy 80 PHRENITIS. form between it and the pia mater. It often secretes pu?. feome* times, though rarely, it is found ulcerated, more frequently morti* lied. The pia mater is not apt to adhere to the brain, but is some- times converted into a membrane resembling the dura mater iri thickness and consistance. Dr. Baillie observes, that the proces- ces arising from the under surface of the pia mater, sometimes adhere more strongly than usual to the brain. This membrane also fre- quently secretes pus, but very seldom forms a layer of coagulable lymph. There is often a considerable effusion into the ventricle^. If a tendency to gangrene has taken place, the fluid effused is a thin acrid serum. In those who have laboured under phrenitis, and died afterwards of other diseases, the membranes of the brain have been found thickened, and in some instances converted into a substance almost as hard as bone,* and the dura mater is sometimes found firmly adhering to the skull in the places which had been occupied by the inflammation. SECT. III. Of the Causes of Phrenitis. In temperate climates phrenitis is a rare disease, and when it does appear, it is generally as symptomatic of fever. In the Works of Sir John Pringle, and a few other European practition- ers, the reader will tind an account of dissections in which absces- ses of the brain were found in those who died of fever. This, however, is very rare. It is in warm latitudes that idiopathic phrenitis most frequent* ly occurs. Young people, especially those of a sanguine and plethoric habit, are liable to it, and all who indulge freely in the use of fermented liquors. The exciting cause can frequently be traced to an injury im- mediately applied to the brain, such as violent exercise, intoxi- cation, rage, the head being long exposed to a warm sun, long ani intense study, or any other cause tending to occasion an accumu- lation of blood in it. It often arises, however, from causes less exclusively affecting the brain, cold, fatigue, excessive venery, indigestible and pois- * Van Swieten's Comment, in Aph. Boexh. Aph. 775. PHRENITIS. 8* fcnous substances received into the stomach, and the suppression Of habitual discharges. It is evident that many or all of these may sometimes act mere- ly as predisposing causes. Saalman saw phrenitis epidemie, and asserts that it was conta- gious. It was chiefly confined to the lowest ranks of the people, who were covered with filth ; and the contagion, he observes was tendered so virulent by a neglect of cleanliness, that in a single hovel five or more were seized with the disease. This epidemic attacked the old rather than the young ; it was most fatal to those above 40. The hypochondriacal and melan- cholic were most subject to it. Phrenitis often arises in the predisposed, when it cannot be tra- ced to any particular cause, especially in those who have formerly- laboured under it, for, like the other phlegmasia?, it leaves behind it a predisposition to future attacks.* SECT. IV. Of the Treatment of Phuenitis. From what has been said of the treatment of the phlegmasiae., mid of the nature of phrenitis, the reader will infer that the most vigorous antiphlogistic measures are requisite in this disease. It fortunately happens, that a sufficient quantity of blood can generally be procured from tlie neighbourhood of the part affected, so that the same operation serves the purpose of both local and general blood-letting. Many therefore advise blood to be taken from the temporal artery in phrenitis. Dr. Cullen thinks blood- letting from the jugular vein preferable ; which is also particular- ly recommended by Hoffman and Eller. The frantic state of the patient, however, often renders it troublesome to let blood from this \essel.* * Van Suicten's Comment, in Aph. Boerhaavii. * Several other modes of .blood-letting have been proposed in this disease- We have been advised to open the ^sublingual veins; this, however, is attend- ed with several inconveniences. It is difficult to open them when the pa- tient is delirious, a small orifice is not sufficient, and a large orifice is danger* ous on account of the difficulty of stopping the bleeding. Some recommend •opening the frontal vein, others, scarifying the nostrils. In neither of these ways, however, can we in general procure a sufficient quantity of blood. If phrenitis be threatened, HofTmantJobserves, in consequence of the suppression of the menstrual dihetmrgfe. or lochia, venesection p to be performed from ttoe foot VoU ri. 'it 9* PHRENITIS. Dr. M'Bride recommends carrying the blood-letting to syncope. With regard both to its extent and repetition, our practice is regu- lated in the same'way as in synocha, except that the evacuation should be more copious in proportion to the violence of the symp-1 toms. It may be inferred from what has been said of catharsis in in- flammatory affections of the head, that when spontaneous diarrhoea supervenes, we should be careful not to check it, and that when it does not, the free use of cathartics is proper in all cases. Saal- man gave calomel with other cathartics. Blood-letting, cathartics, and acidulous fluids he found the most successful remedies. To assist in diminishing the determination of the blood to the head, the patient should be kept as nearly in the erect posture as can easily be borne.*,. A very few observations on the local remedies employed in phrenitis will be sufficient. Of these, local blood-letting is still the most powerful, and in all cases, where the blood in the gener- al blood-letting is not taken from the head or neck, should be em- . ployed at an early period. The head should be shaved, and, after the excitement has been sufficiently reduced, a blister applied over it. A variety of rubefacients have been applied to the head in phre- nitis, the effects of which, especially at an early period, are doubt- ful. The application of cold to the head is often beneficial ; cloths dipped in cold water and vinegar, or iced water, are applied with advantage.- Is the alternate use of cold and warm applications preferable? An irruption on the head has sometimes followed these applications, and very suddenly brought relief. Warm bathing of the inferiour extremities, and the application of rubefacients to them, have been very generally recommended. Dr. Cullen, however, regards them as ambiguous remedies. If they be employed before the excitement has been sufficiently re- duced, they may do harm. Some recommend immersing the trunk and limbs in the warm bath, while cold applications art made to the head. if by a suppression of the ha-morrhois, leeches should be applied to the he- morhoidal vessels ; concerning the efficacy of these practices, at least after the symptoms of phrenitis have actually appeared, there is much doubt. Lo- cal blood-letting appears always to be most successful when the blood is tak- en from the part affected, or as near it as possible. In the above cases how- ever, the application of leeches to the abdomen and hemorrhoidal vessel? may assist more powerful remedies, and is a probable means of preventing a relapse. OPHTHALMIA. 83 When phrenitis can be traced to the suppression of some dis- charge, attempts to restore the discharge must make a part of the treatment. CHAP. VII. Of Ophthalmia. Ophthalmia is defined by Dr. Cullen, " Rubor et dolor oculi, •• lucis int©lerantia,"plerumque cum lacrimatione." Except omit- ting plerumque, for a reason which will presently appear, the only alteration I would propose on this definition is similar to that proposed on the definition of phrenitis. Phlegmasia cum ru- bor et dolor, &c. Here, however, the change proposed is of more importance, and confines the definition to one species of ophthalmia. A de- fect in Dr. Cullen's mode of arrangement, which I have already had occasion to consider, isagain felt here. The reader will ob-^ serve, that fever.'makes no part of his definition of ophthalmia,' and although he arranges ophthalmia among febrile diseases, there is but one species of it, and that the least common, which is at- tended with fever. It is evident, however, that this is the only species which belongs to the phlegmasia?. The others belong to the order of simple inflammations. Dr. Cullen divides ophthalmia into idiopathic and symptomatic. It is the former only we are to consider. The latter proceeds either from diseases of the eye, or parts in its neighbourhood, and comes under the care of the surgeon ; or from diseases of the sys- tem, scrophula, lues venerea, or fever. The last I have frequent- ly had occasion to mention ; like it, the other species of symp- tomatic ophthalmia can only be considered with tbe diseases of which they form a part. Dr. Cullen divides the idiopathic ophthalmia into two varie- ties ; the ophthalmia membranarum, and ophthalmia tarsi. The former he defines, « Ophthalmia in tunica adnata et ei subjacentibus membran.s • sive tunicis oculi." The latter, « Ophthalmia cum tumorer erosiooe. et exudatione glutinos* ;' tarsi palpebrarum." 54 OPHTHALMIA. Other writers have divided ophthalmia into many varieties • for most of their distinctions there appears to be no sufficient foundation ; but Dr. Cullen, as far as I am capable of judging,. has attempted to simplify too much. Had he made fever part of his definition of ophthalmia, he would have excluded by far the majority of cases. He therefore, in his Nosology wholly overlooks that species of ophthalmia which almost uniformly occasions fever, and in his First Lines he re- gards it as only a greater degree of the ophthalmia raembranarum ; and it is true, that the inflammation of the adnata often spreads to the deep-seated parts of the eye, and produces the form of the disease alluded to, but it also spreads to the tarsi, producing Dr. Cullen's second species of oi hth Imia, and the inflammation of' the deep-seated parts often exists with little or no inflammation of the adnata, and produces a disease certainly as different from the ophthalmia membranarum and tarsi as these are from each other. This species of ophthalmia has been termed ophthalmitis; to which I have adapted the definition by introducing the term phleg- masia, and omitting plerumque, the ophthalmitis being always at- tended with an increased flow of tears. Ophthalmia then is divided into three species, according as it affects the eye-lids, the membranes which cover the anteriour part of the eye, or the deep-seated parts of the eye, its muscles, and the lachrymal gland. It is very rarely, however, that, any of these exist in a consid- erable degree without producing some degree of the others. The inflammation readily spreads along the conjunctiva, from the tarsi to the eye, or in the contrary direction. When the conjunctiva of the eye is much inflamed, the adnata soon partakes of the in- flammation, and if the disease increases, it gradually spreads tq the deep-seated parts. When, however, it first seizes on these parts, it is often very severe, and continues for a long time, with- out appearing externally. From the connection of the ophthalmitis with the other spe- cies of ophthalmia, it will be proper to lay the symptoms of all before the reader ; and it will be the most distinct plan to consid- er-those of each species separately, beginning with the most coni* mon, the ophthalmia membranarum. OPHTHALMIA. 86 SEC. 1. Of the Symptoms of Ophthalmia. The tunica conjunctiva, is the chief seat of the ophthalmia (nembranarum. It was formerly doubted whether this membrane covers the cornea, by later anatomists it has been dissected from this as well as from the tunica albuginea ; to the former, however, it adheres much more firmly. In the eye of some quadrupeds, particularly that of the ox, the conjunctiva is separated from the cornea more readily. The part of the conjunctiva covering the cornea is least subject to inflammation. Neither in this part nor that covering the albu- ginea while in a perfectly heatlhy state, are there any red vessels. That part of the conjunctiva which lines the eyelids, however, is, at all times supplied with red blood. Ophthalmia sometimes comes on ajmost instantaneously. In gen- eral, however, its attack is more gradual. The first symptom of the ophthalmia membranarum is an unsual, redness of the conjunctiva covering the albuginea. The redness, is sometimes diffused over the whole albuginea, and sometimes apr pears in pretty well defined blotches on different parts of it. I have observed it come on in this way in both eyes at the same time, where the injury was not applied to any part in particular. In general the red vessels appear ramified on the albuginea, but m more severe cases it is so completely covered by a thick net- work of vessels, that it seems as if uniformly painted of a red col- our, and then some red vessels can generally be traced on the cornea. At the same time the inflammation spreads along the conjunctiva lining the eye-lids, and often extends to the tarsi. The patient complains of a sense of heat, and of a pricking or stinging pain, frequently resembling the sensation produced by a jsjiarp particle of dust blown into the eye. In mild cases the sensation accompanying ophthalmia is rathejj an itching than pain. Sometimes the itching is felt not in the eye itself but in tbe forehead. Although the inflammation has not spread to the lachrymal gland, ophthalmia membranarum, except in the mildest cases, is very fre- quently accompanied with an increased flow of tears. It has hence been divided into wet and dry. 80 OPHTHALMIA. The secretion is sometimes vitiated, becoming glutinous, adher- ing to the tarsi, and often during.sleep glueing thein together. This symptom, however, is more troublesome in the dphthalmia tarsi. Sometimes pus is secreted by the inflamed conjunctiva. The mildest form of this species of ophthalmia, is termed tarax- 3s. The more severe form, chemosis.* In the taraxis the swelling is generally inconsiderable and whol- ly confined to the eye-lids, for even in mild cases of ophthalmia, the inflammation generally spreads to the conjunctiva lining the eye-lids. In the chemosis tbe swelling of the eye-lids is often so great, that the tarsi are turned inwards upon the ball of the eye, the irritation of the eye-lashes rubbing against the conjunctiva in- creasing the inflammation : or the eye-lids are almost inverted, the tarsi being turned outwards and the eye remaining open-t But in the more severe cases, the swelling is not confined to the eye-liels ; the coats of the eye partake of it. " Conjunctivam," Schmuckerus observes, "ab accumulato sanguine usque adeo tum- " uisseobservatumest,uttresquartuorpluresvelineascrassafuerit."J , So great a degree of swelling in the conjunctiva is uncommon, but the coats which lie under it partaking of the swelling, it often ap- pear* upon the whole very considerable. As this, like the other symptoms, is generally less considerable in the cornea than the other parts of the eye, it often appears sunk in a hollow formed by the tumified coats. " Son epaisseur," St, Ives§ observes, " egale celle d'untravers de doigt, ce qui fait par- ; oitre la cornee transparente comme dansun enfoncement." When the swelling of the eye and eye-lids is such that the patient •is unable toopen the eyes, the disease has been called phymosis,the name of a similar affection of the penis. The degree of swelling in the worst cases of the ophthalmia membranarum is sometimes as- tonishing ; we find one author relating a case in which the tumour equalled a man's hand, and another declaring that he has seen the eye so far protruded from the socket, that it rested on the upper lip, * Trnka's Ilistoria Ophthahnhe. The reader will find a good account nf chemosis in the l\?7th and following pages of Vogol's Frcelectioncs Aca- demics. f Vogel Prael. Acad, de Cog. et Cur. Morb.. X Trnka, Ilistoria Ophthalmiae. i Traite des Maladies des Yeux, by St. Ives, ^ee also Vqgel's Prxl. Acad: OPHTHALMIA. 57 In such-cases the inflammation not only spreads to every part of the eye and eye-lids, but to the whole side of the face ; the cheek becomes swelled and inflamed, and the patient complains of violent pains in the forehead and temples. Although the disease is at first confined to one eye, when it be- comes considerable, the other always partakes of it. The intolerance of light in the less violent cases of ophthalmia membranarum seems to proceed from the sympalhy.which sub- sists between the retina and other parts of the eye. In the worst cases the retina itself is inflamed, and complete ophthalmitis su- pervenes. Spasms of neighbouring parts, particularly of the eye-lids,- often attend ophthalmia. In the more severe cases they sometime^ spread to all the muscles of the face. It was observed above, that external inflammations are less apt than internal to produce fever, and that inflammations of the head are apt to produce fever in proportion to their vincinity to the brain. In all cases in which fever is symptomatic of ophthalmia, we have reason to believe that the inflammation has spread to the eleeper-seated parts-. Such are the symptoms which attend the commencement and progress of ophthalmia membranarnm ; its consequences are- very various. Like other inflammations it is subject to resolution, suppuratiou and gangrene. If the inflammation be confined to the eye, resolution is the only termination which can be regarded as favourable; for ac- cording to the definition of suppuration I have adopted, a dis- charge of pus without ulceration, which frequently takes plate from the eye and has given rise to the name purulent ophthalmia. does not deserve the name of suppuration. When the eye-lid par- takes much of the inflammation, suppuration is often a favourable termination. If the abscess is discharged on the inner side of th? eye-lids, it frequently proves very troublesome. The effects of suppuration of the eye itself arc different in dif- ferent cases, but as this part of the subject belongs to the province of the surgeon, I shall not enter upon it here.* Mortification is a rare occurrence in any form of ophthalmia. and never perhaps supervenes in the ophthalmia membranarum, unless it be complicated with the ophthalmitis, * Sec these effects detailed in Mr. Ware'* TVnti*e on Ophthalmia, w*. •■\thor Into work* rrt the !*rr. 88 OPHTHALMIA, Besides the terminations common to ail cases of inflammation^ ophthalmia is sometimes followed by consequences resulting from the nature of the parts it occupies. For these, which also belong to the province of the surgeon, the reader is refered to the works' just alluded to. In its attacks the ophthalmia tarsi often resembles the ophthalmia membranarum, the inflammation first appearing on the eye, or to speak more accurately, the former often follows a slight attack of tbe latter. The inflammation, however, soon spreads to the tarsi, where it frequently indeed makes its first appearance, but it sel- dom becomes considerable there, without affecting the conjunctiva of the eye. The tarsi are red and swelled, and pour out a glutinous matter which glues the eye-lids together during sleep, and both in this way, and by forming small hard masses adhering to the eye-lashes, increases the disease. The patient complains of a constant uneasiness of the eyes, but never of the severe pain which sometimes attends the ophthalmia membranarum. The uneasiness is increased by the falling off of the eye-lashes which defend the eye from strong light, dust, &c. Both the ophthalmia membranarum and tarsi are apt to become' chronic diseases, but the latter much more frequently than the for- mer. It is not uncommon, particularly in scrophulous habits, for the ophthalmia tarsi to last for the greater part of life, but it is less apt to be followed by injury of the sight than the ophthalmia mem- branarum. It more frequently runs to suppuration than the other varieties of ophthalmia, small suppurations often forming at the same time in various parts of the tarsi, and frequently without con- siderably relieving the inflammation. Except when combined with ophthalmia membranarum, it never runs to gangrene. It often happens when the ophthalmia tarsi is attended with much swelling, as where it is accompanied with a considerable degree of the ophthalmia membranarum, that the eye-lids grow together. This is the consequence of small suppurations forming on the tarsi, or of the cuticle being abraded by the acrimony of the discharge. When inflammation attacks the deep-seated parts of the eye, it gives rise to one of the most tormenting diseases we are subject'to. It » termed by some ophthalmitis, by others phlegmon oculi, some OPHTHALMIA. 89 Vrm it chemosis, the appellation generally Used for the severe* cases of the ophthalmia membranarum. It sometimes comes on without being preceded by either of the other species of ophthalmia, and it now and then happens, as I have already had occasion to observe, that the anteriour parts of the eye remain free from inflammation. In many cases, however, the an- teriour parts are first affected, and the inflammation spreads gradually to the deep-seated, sometimes leaving the former. As soon as the inflammation spreads to the deep-seated parts, the pain becomes more severe, extending to the temple and over a great part of the head, often particularly felt, St. Yves remarks, on the crown of the head. It is generally by the slightest pressure of the eye. When the inflammation seizes the lacrymal gland, there is a severe pain referred to its seat, the flow of tears is very great, and some protuberance of the upper eye-lid may often be observed.* As soon as the retina partakes of the inflammation, the sight be- comes confused, every thing is seen covered with black spots, in- cessant clouds pass before the eyes, or fire seems to dart across them. As the disease increases, the intolerance of light becomes extreme, and the patient is often seized with a degree of phrenzy, if the eyes be exposed to it. These symptoms never last long without producing fever; and when the pain of the eye is great, delirium is not uncommon. With one or both eyes thus affected, he passes sleepless nights, irtways in severe pain, and often in excruciating torture. When the retina is much affected, the disease sometimes ter- minates in amaurosis.! It is unnecessary to observe, that resolution is the only favoura- ble termination of ophthalmitis. Suppuration is often attended with a general efflux of the humours: and gangrene, while it proves as destructive to the eye, endangers life. We judge of the tendency to these terminations in the same way as in the other phlegmasia?. When the symptoms are moderate., and yield to the usual remedies, we have reason to hope for reso- lution ; when they are unusually obstinate, suppuration is to be dreaded ; when unusually violent, gangrene. With respect to schirrus, regarded by many as a consequence of ophthalmia ; it seems to proceed less from the inflammation, than peculiarity of habit. * Lieutaud's Synopsis Medicinae Praxcos. t Lieutaud's Synr>p«is TnikaV I-Tt^oria Ophthalmia VoE. If. I?' 90 OPHTHALMIA. Like other febrile diseases ophthalmitis is occasionally terminal ted by critical evacuations, by spontaneous hemorrhagy, sweat, r three hours, that he was almost starved, being supported solely by strong soups and other fluids, no quan- tity of wiiich he found capable of affording sufficient nourishment, or even of allaying the calls of hunger. It was observed in the first volume, that fluids, however nutricious, if unmixed with any solid matter, are very imperfectly digested. As tooth-ach is merely a local affection, local remedies alone, are for the most part necessary. Where the tooth is apparently sound, a large dose of opium may be tried previous to extraction. This will always afford temporary relief, and by promoting the perspiration, if the disease rather proceeds from cold than any fault of the tooth, will often remove it. A small dose, by quickening the circulation, frequently does more harm than good. When tooth-ach arises from the state of the stomach, an emetic will frequently give relief, and in such a case as that just alluded to, where it has become habitually connected with the state of the stomach, stomachic medicines particularly bit- ters and steel, afford a probable chance of cure. It is needless to mention various means of temporary relief, with which every one k acquainted. The means of preventing the tooth-ach, which is always sooner or later attended with decay of the teeth, demands serious attention. I believe they may all be arranged under three hGads, cleanliness, means of obviating the effects of cold, and those of strengthening the gums. To keep the teeth perfectly clean, they should, after every meal, be freed from the small pieces of aliment which often lie be- tween them till they putrify. The concretion which is apt to form on the teeth should be prevented by carefully brushinc them; and as soon as any appears it ought to be removed. CYNANCHE. The effects of cold on the teeth are best obviated by habituating them to its application, which may be done most effectualy by re- peatedly washing the mouth morning and evening with cold salt and water. If the tendency to tooth-ach proceeds from fault in the gums, this must be corrected by strengthening the system in general, by the frequent use of stimulating and astringent applications to the gums themselves, and by occasionally bleeding them if they appear in- flamed and spongy ; but frequently bleeding them soon produces a habit which demands aNconstant repetition of the remedy. CHAP. IX. Of CYNANCHp. Dr. Cullen defines cynanche, his 10th genus, and the 4th of the phlegmasia?, " Pyrexia aliquando typhodes, rubor et dolor faucium, degluti- *' tioet respiratio difficiles, cum angustiae in faucibus sensu," This disease he divides into five species in most of which the symptoms, and in some the mode of treatment, are very different. These differences arise partly from the nature of the organs affect- ed in the different species of cynanche, and partly from less evident causes. The first species, the cynanche tonsillaris, he defines, " Cynanche membranam faucium mucosam et prcecipue tonsillas ; tumor et rubor afficiens, cum febre synocha." His second species 1 had frequent occasion to mention in treat- ing of the scarlatina, the cynanche maligna. It is defined, " Cynanche tonsillas et membranam faucium mucosam afficiens ■■' tumor, rubor, etcrustis mucosis coloris albescentis vel cineritii, "serpentibuset ulcera tegentibus ; cum febre typhode et exan-* " thematibus. The third species, the cynanche trachealis, is defined, " Cynanche respiratione difficili,inspiratione strepente', voce rau, 'ca,tussiclangosa, tumor fere nullo in faucibus apparente, deglur '« titione parum difficili et febre synocha." The fourth species is the cynanche pharyngea. CYNANCHE. 103 " Cynanche cum rubor in imis praescrtim faucibus ; deglutitione •• maxiuie difficili, dolentissima ; respiratione satis commodaet fe- " bre synocha." The last species, cynanche parotidcea, Ts defined, " Cynanche cum tumor externo parotidum et maxillarum gland- " ularum magno ; respiratione et deglutitione parum laesis ; febre " synocha plerumque leni." The definition of cynanche must be adapted to the mode of arrangement I follow, and I would propose to omit rubor in this definition, in two of the species, there being no redness of the fau- ces ; and to change deglutitio et respiratio, to, deglutitio vel respira- tio, because both of these functions are rarely impeded, unless twc» of the species are combined. I would also propose to include in the defination of the cynanche tonsillaris that of cynanche pharyn- gea. These varieties of cynanche differ considerably when they are exquisitely formed. But the one is seldom present in any con- siderable degree without being attended with more or less of the other. Dr. Cullen declares indeed, that he never saw a case of the true cynanche pharyngea, that is, a case in which the inflammation was confined to the pharynx ; it almost constantly spreads in a greater or less degree to the tonsils and neighbouring parts. Be- sides, the mode of treatment is in almost every instance the same in both cases ; and it will appear, from what is about to be said of the symptom? of these forms of cynanche, that if we admit the cy- nanche pharyngea to be a distinct variety, we must admit another, the cynanche oesophagea, for the inflammation, we shall find, fre- quently attacks the oesophagus, and is sometimes confined to it. The following may be assumed as the definition of cynanche : Phlegmasia pulsu plerumque valido, nonnunquam debili, cum dolor faucium, respiratione vel deglutitione difficili, cum angustia? in faucibus rensu. The first species of cynanche, then, according to the mode of arrangement I shall follow, includes the inflammation of the tonsils velum pendulum, uvula, pharynx, and oesophagus. As the tonsil* are the parts in most cases principally affected, and it is rare for the others to be affected without some affection of them, we may. for the sake of brevity, assume the term cynanche tonsillaris to ex press the inflammation of all these parts ; which may be defined, Cynanche, pulsu valido membranam faucium et pharyngis muco sam, praecipue tonsillas tumor et rubor afficiens, deglutitione diff cili nonnunquam dolentissima. 104 CYNANCHE. The only alteration which, the mode of arrangement I follow renders necessary in the other definitions, is to insert, pulsus validus and pulsus debilis, instead of synocha and febris typhodes ; symp- tomatic fevers, according to that mode of arrangement, forms * class of diseases distinct from the idiopathic. SECT I. Of the Cynanche Tonsillaris. 1. Of the Symptoms of the Cynanche Tonsillaris. This disease generally begins with an uneasy sense of tightness about the fauces, which, when the inflammation occupies the pha- rynx, is deeper seated than when it occupies tbe tonsils and neigh- bouring parts. The deglutition soon becomes more or less difficult and painful ; in the former case more so than in the latter, for, while the inflamma- tion is confined to the tonsils, velum pendulum palati, and uvula, the pain is rather while wre are preparing to swallow, or in the very first act of swallowing, than during it. In most cases, however, more or less of the inflammation spreads to the pharynx, and then the pain peculiar to both forms of the disease is perceived. On inspecting the fauces, the parts, as far as the inflammation ex- tends, appear swelled and of a more florid red than natural, and here and there, particularly on the tonsils, small white or yellow specks are often observed. While these remain of a light colour, and the pulse continues sufficiently strong and full, they never in- dicate danger. The inflammation is generally confined to the parts which can be brought in|o view ; it sometimes, however, extends along the oesophagus, which is known by the greater difficulty and pain of swallowing, as well as by the seat of the pain. In some rare cases, I have just had occasion to observe, the inflammation is wholly confined to the oesophagus. In these no morbid appearance pre- sents itself on inspecting the fauces. Whether the oesophagus be primarily affected, or the inflamma-' tion has spread to it from the fauces, it is a very alarming accident. Cases have occurred in which, the cavity of the oesophagus being wholly obliterated by tbe swelling, the patient has been starved to death. Even in less violent cases the pain of swallowing is some- times such, that he abstains from food, and some have sunk under the debility thus occasioned. CYNANCHE TONSILLARIS. 105 The deglutition is now and then impeded by the inflammation's 'Spreading in an opposite direction It is not very common for the tongue to be affected in cynanche ; in some cases, however, it has been so much swelled as to fill the mouth, and wholly prevent de- glutition, nay, it sometimes, Tissot observes, becomes too large to be retained in the mouth, and is thrust out, assuming a purple colour. The pain during deglutition in cynanche seems often in a great degree to depend on tbe muscles employed in this function, par- takng of die inflammation •{ hence it seems to be, that fluids, con- trary to what we >:io iid, a priori, suppose, are swallowed with more pain than solids ; in swallowing liquids, a greater number of muscles being employed, and those employed in both cases acting more powerfully. The patient feels most difficulty in swallow mg the saliva, partly owing to its being a fluid, and the quantity be- ing small, and partly to its becoming viscid. In some cases, however the saliva becomes thinner, and is pour- ed out in great quantity. This, although it often relieves the in- flammation, sometimes proves a source of much uneasiness. If the inflammation runs high, the exertion of spitting it out is attended with considerable pain ; and when as happens in all the severer ca- ses of cynanche tonsillaris, the disease extends to the pharynx, the pain of swallowing it is greater. When the inflammation extends to the oesophagus, the pain of swallowing the thin saliva is sometimes such as to throw the pa- tient into convulsions ;* and to avoid swallowing it is not always optional, for the irritation it occasions frequently excites involun- tary attempts to swallow. This is particularly apt to happen dur- ing sleep, as the saliva is then permitted to accumulate in the fau- ces, and it is generally owing to this cause, that the patient often starts up with horror. The only situation in which he finds relief is lying in such a position that the saliva may run from the mouth. Sleep is often wholly prevented by this symptom. Long continu- ed sleep, iudeed, when the throat is much inflamed, by permitting tbe morbid secretion to accumulate in it, is generally injurious. The irritation occasioned by the accumulation in the throat often * Tissotaayi he has seen women in this disease thrown into convulsion.* u>nj txcessof painevery time they attempted to swallow the -aliva. In the third vol. of the Physical Ussays, the reader will find a case related b, Dr. Monro, which in a striking manner exemplifies this symptom. Vol. n. 14 106 CYNANCHE TONSILLARIS. excites frequent attempts to vomit, which may be mistaken for an. indication of a foul stomach. The pain is generally greatest when the patient attempts to swallow lying on the back ; and when the oesophagus is much af* fected, the pain is often felt chiefly in the back, and is of the same kind with that produced by any acrid or bulky substance passing along the oesophagus. If the pharynx, and still more if the oeso- phagus, be much inflamed, the fluid, instead of passing' to the stomach, is often returned by the mouth, thrown through the nose, or into the wind-pipe, exciting a painful fit of coughing. The inflammation is not apt to spread to the stomach. I had occasion to observe, in speaking of erysipelas, that that species of inflammation sometimes spreads along the oesophagus to the stomach ; but erysipelas of the fauces, which is more uniformly diffused, generally of a darker red, and attended with little swel- ling, is of a very different nature from the cynanche tonsillaris. When the inflammation spreads to the trachea, the danger is very great, But the inflammation of this organ forms a distinct species of cynanche according to the foregoing division ; it is sufficient here to remark, that we may sometimes look for a concurrence o{ these species. Although ihe inflammation spread no farther than the fauces properly so called, the breathing is often considerably affected, The more, we have seen, the disease partakes of the cynanche pharyngea, that is, the more the inflammation spreads towards the resophagus, the more difficult is the deglutition ; it it the reverse with respect to the respiration, for if the inflammation be wholly confined to the pharynx and oesophagus, however violent it may be, the breathing is always free, but when its chief seat is in the ton- sils, velum pendulum palati, and uvula, the passage of the air is often much contracted, and sometimes almost closed ; that by the nose frequently is so, and the patient can only breath with the mouth open. In such cases it might be imagined that deglutition is wholly interrupted. This, however, very rarely happens, except where the tongue partakes considerably of the swelling, the tonsils, ve- lum pendulum palati, and uvula, being very compressible. The voice is often affected, becoming hoarse and confused, and being sometimes almost lost, especially where the swelling is con- siderab t- he aflect-o 1 of the voice, however is more remarka- ble in the cynanche trachealis than tonsillaris, and never attends CYNANCHE TONSILLARIS. 10*? 1ue exquisitely-formed cynanche pharyngea or the cases in which the inflammation is confined to the oesophagus. None of the neighbouring parts so frequently partake of this disease as the internal ear. Tbe patient at first complains ot a ringing, and a sense of rattling in it when he swallows, and at length often of severe pain following the course of the eustachian tube. A degree of deafness which frequently attends violent cases of cynanche is probably owing to the swelling occasioned by the inflammation obliterating this passage. When the deafness is com- plete, it must arise from some other cause. In severe cases, the whole face partakes of the disease, the eyes are iuflamed, the cheeks swelled and florid. I have already had occasion to observe, that the muscles employed in deglutition gen- erally partake of it, in the more violent cases it often spreads to almost all the muscles and more external parts of the neck, which becomes stiffs hard, swelled, and sometimes red, and the sublingual audother glands in the neighbourhood are often enlarged. Ibis affection of the external, frequently relieves the internal parts.- The swelling which appears externally, however, proceeds in ma- ny cases, not from the disease spreading to neighbouring parts, but from the swelling of the internal fauces. The enlarged tonsils in particular may often be perceived externally. In mild cases it is common for the inflammation to be chiefly con- fined to one of the tonsils at the commencement, and to leave it, or in some measure to leave it, when it attacks the other. Such are the local symptoms of cynanche tonsillaris. It ap- pears from what has been said, that the difference between the symptoms of cynanche occupying the tonsils, velum pendulum palati, and uvula, and that occupying the pharynx, consists chiefly in the former being often attended with some difficulty of breathing, on account of its having its seat in the passage which the air take? to the lungs ; and in the latter being attended with more difficulty of swallowing, from its affecting parts more essentially concerned in the act of deglutition. In this form of the disease, we have seen, the inflammation sometimes spreads to the oesophagus and the deglutition is wholly interrupted. On this account the cynanche pharyngea is a more dangerous disease than the cynanche tonsil- laris strictly so called. Besides having its seat nearer to the stomach, the whole system, according to the general rule, sym- pathises more with this form of the disease. It is very rare for the swelling of the toiibils, velum pedulum, and uvula, to increase till it occasions suffocation. This, however, has eometimes happened. CYNANCHE TONSILLARIS. The foregoing symptoms arf seldom present to a considerable degree without being attended with those of ireneral derangement. In the mildest cases the fever is hardly perceptible, and it is sel- dom so considerable in proportion to the local symptoms in cynan- che tonsillaris, as in the cynanche trachealis and maligna. These symptoms, however, never run high in this form of cynanche, without the pulse becoming stronger, harder, and more frequent than natural; and all the usual symptoms of fever soon shew them- selves. The thirst is often great in proportion to the other febrile symptoms, particularly when the; oesophagus is inflamed. It sometimes, though very rarely happens, that the febrile symptoms run so high as to endanger life. Even delirium and co- ma supervene. Whether in such cases the brain or its membranes are affected (which there is reason to believe) has not been deter- mined. Those who have seen only the more common cases of cynanche tonsillaris, can form little idea of the appearance which it now and then assumes. As the return of the blood, Boerhaave observes, i» obstructed in the external jugulars by the swelling of the neighbour- ing parts pressing on them, and he might have added, as Van Swie- ten has done, in all the veins of the neck by the dyspnoea imped- ing the passage of the blood through the 'ungs, a swelling of the face, tongue, lips, and fauces is the consequence ; the tongue is thrust out, distorted, and inflamed ; the eyes are red, swelled, frightfully staring, and pushed from their sockets ; the brain is compressed and overpowered, the sight, hearing, and touch being, impaired. In other cases the patient becomes delirious, lies with the mouth open, snores, and is obliged to be supported in nearly an erect posture to prevent suffocation. There is frequently, red- ness swelling, pain, and pulsation in the external fauces, neck, and even breast ; hence, he continues, the jugular veins with those nf the forehead and under the tongue become distended with vari- ..e.s.* The cynanche tonsillaris, may terminate in resolution, suppur- ation, gangrene, or schirrus. The two former aro common, the two latter very rare.t * Aph. Boerh. • It sometimes leaves a permanent hard swelling of the eoasils, which does mt dr-^rvc the name of h iiirrus, and is attended with no inconvenience but from its bulk. This c tlVction of the tonsils more frequently comes on without .inflammation, and s imerimes goes *o fox as to render it necessary to remove ■ie or boil,, which is done by throwing a ligature around the ba«e. CYNANCHE TONSILLARIS. 109 Resolution ie at all times a favourable termination, and, in the present case, suppuration, although troublesome, is seldom attend- ed with danger. If indeed the suppuration of tbe fauces is very general, even although the trachea is not affected, the matter may be suddenly poured into it, and induce suffocation, which, Van Swieten and others assert, sometimes happens ; it is so rare an ac- cident, however, that it is hardly to be feared. When suppuration takes place, the febrile symptoms abate, gen- erally with some degree of shivering, the throat becomes paler and less painful, and sometimes a sense of pulsation is felt, or if it has been present at an earlier period, becomes more sensible. We know that the abscess is ripe by a small white soft tumor appearing about the centre of the inflamed part. The quantity of pus discharged from such abscesses is often very considerable, and of an intolerable taste and smell. The abscess sometimes points at a more concealed part ; the surgeon must then feel for it with the finger, when there is reason to believe it formed. There is always reason to suspect the pre- sence of an abscess, when the patient, after the febrile symptoms have abated, experiences a considerable difficulty of swallowing, although the inflammation is evidently diminished, is restless and complains of a general pain in the mouth, with slight and irregular shiverings. The pulse, Tissot observes, is then soft, without be- ing natural; there is a sense of weight in the tongue, small white spots often appear on the gums and inside of the cheeks, and the patient complains of a disagreeable taste and smell. " Cynanche tonsillaris," Dr. Cullen remarks, " hardly ever ter- rt minates by gangrene, although, in this disease, some sloughy " spots, commonly supposed to be the forerunners of gangrene, " sometimes appear upon the fauces." By other writers, howev- er, who seem to have met with the disease in a more violent form, gangrene is regarded as rather a more frequent occurrence.* It is almost always fatal. Like suppuration, the gangrene is sometimes situated in parts which cannot be brought into view. From the course of the dis- ease, however, and the state of the symptoms in general, we may always readily determine its presence. Upon the whole, when both the local and general symptoms have been unusually violent, andt he means en ployed have failed to procure any considerable remission ; when the pain and inflam* * Sf e the observations of Van Swieten and others-. HO CYNANCHE TONSILLARIS. ed appearance of the fauces are suddenly diminished, the degluti- tion rendered easier, the pulse from being strong becomes small, weak, and irregular, the face assumes a cadaverous appearance, the extremities become cold, with clammy sweats, and the breath fetid, although we cannot perceive the gangrene, we may be as- sured that it has taken place. The termination in schirrus* is still more rare. Tissot observes that he has seen the cynanche tonsillaris terminate in mortification or schirrus when treated with heating medicines, in order to force out sweats, but that if properly treated, it never terminates in eith- er of these ways. Like other febrile diseases, it is sometimes relieved by a critical discharge, a flow of sweat, or a diarhoea. The increased flow or saliva is sometimes so great, and attended with such relief, as to de- serve the name of critical. The disease generally comes to its height on the fifth or sixth day.j * 2. Of the Causes of Cynanche Tonsillaris. Like most of the other phlegmasia?, the cynanche tonsillaris is most apt to attatk the young, robust, and plethoric, especially those of a sanguine temperament. It is a remark of Sydenham, that those who have red hair are most liable to it. Quarin thinks that men are more subject to it than women. It is most frequent in spring and autumn. In 6ummer it rarely appears ; sometimes it appears periodically in the former seasons. In its exciting causes, also, the cynanche tonsillaris agrees with the other phlegmasiae. Cold, particularly if alternated with a high temperature or partially applied- especially if applied to the seat of the disease, is still the chief exciting cause. Sudden vi- cissitudes of temperature, riding against a cold wind, much singing or vociferation, tbe blowing of the wind instruments, acrid ali- ments, medicines, or poisons, the suppression of accustomed evacu- ations, and a peculiar state of the atmosphere, are enumerated by Quarin} as the chief exciting causes of cynanche tonsillaris. With respect to the last of which much has been said, if we ex- cept cold, damp, and variable weather, there does not appear to be any peculiar-state of tbe atmosphere which tends to produce this disease. * Mead's Mon. et Praec. Med. cum Notis Wintringhami, vol. 1. Quarto de *et>. Aph. Boerhaav. cum Com. Van Swieten. de An-ina. t Dr. Sims on Epidemic Diseases. t Dr. Febribus. CYNANCHE TONSILLARIS. HI Cynanche tonsillaris is usually a mild disease. It is in the highly-predisposed that it assumes its more alarming forms. 3 Of the Treatment of Cymanche Tonsillaris. There is a striking resemblance between the treatment of the inflammatory sore-throat and ophthalmia ; the chief differences ar- ising from the nature of the part affected, and from the former be- ing more frequently a febrile disease. In the milder cases of cynanche tonsillaris we trust chiefly to lo- cal means. They are either internal, or external. In the mildest cases the former only are necessary. They consist chiefly of mixtures for washing the inflamed parts, the composition as well as|the effects of which are analogous to those of collyria in inflamma- tion of the eyes. They may be divided into four classes, accord- ing to tbe different objects we have in view in employing them. 1. Those employed tor the purpose of procuring resolution. 2. Those proper when suppuration is unavoidable. 3. Those em- ployed when the abscess has burst spontaneously or been laid open ; and, 4. Those which are necessary when a tendency to gangrene has supervened. The purposes for which they are employed point out what their composition ought to be. In the use of the first class our objects are. by their stimulous, to diminish the inflammation ; by their mucilaginous property, to defend the parts when the saliva is thin and acrid ; and by their detergent quality, to cleanse them, when clogged with thick viscid mucus. The first purpose may be answered by the vegetable and mine- ral acids, vinegar, the juice of acidulous fruits, the sulphuric and muriatic acids properly diluted, k.c. by some of the neutral salts, particularly borate of soda, nitrate of potash, and muriate of am- monia, alkobol in various forms, and many of the gums, particu- larly myrrh, capsicum, an infusion of which is an excellent vehi- cle for other ingredients, horse-radish, mustard, &c. Various as- tringents, particularly alluin and Peruvian and oak bark. The gargle may be made more or less stimulating according to its ef- fects, and the degree of the inflammation'. When mucilaginous gargles are indicated, we may add, gum arabic, ©r the white of egg, or use a decoction of some of the mu- cilaginous herbs. When the fauces are clogged with thick mucus, a mixture of honey and the muriatic acid may be applied with a pencil. Sy- denham recommends the sulphurio acid. A principal part of their 0* 112 CYNANCHE TONSILLARIS. effects seems to arise from their increasing the flow of saliva, by which the mucus is diluted and washed off. But if the disease has continued for a considerable time with little remission, especially if the pain abates while the swelling still continues or increases, we have little hopes of procuring reso- lution. Our view is then to induce a speedy and favourable sup- puration, and for this purpose gargles of a different kind are proper. They should consist entirely of warm emollient fluids, and be used in large quantity. " Sed hoc primo elapso tempore; emolli- " entia et demulcentia proescribi solent, e lacte nimirum, radicibus " althoeje, floribus malva?, seminibus lini, carricis pinguibus, gam- " mi arabico,"* &c. In short, here, as in the former cases, the composition of the gargle is readily determined by reflecting on the end we have n view. It is no longer our wish to diminish tbe inflammation, we therefore avoid those applications which tend to reduce it, the gargle ought therefore to be mild. We wish to promote suppuration ; nothing for this purpose is more powerful than warmth, the gargle should there* fore be used warm, and in large quantity, that its temperature may pot be suddenly reduced. The best way of using this gargle is from time to time to permit as large a quantity as can conveniently be retained to iie on the part, till its temperature falls to that of the mouth. After the abscess has burst, our view is to dispose the parts to heal, emollient and gently astringent gargles are the best for this purpose. If a tendency to gangrene appear, the gargles may be compos- ed of infusion of bark and capsicum with port wine or diluted spir- its. If tbe parts lie within reach, they should be scarified and touched with more stimulating applications. But the local means employed in such cases we shall presently have occasion to consid* er more fully. They are the same as in cynanche maligna. As gangrene in cynanche tonsillaris, however, is the consequence of increased excitement, we must, especially on its first appearance, be cautious in the use of means which tend to increase the inflam- mation, lest we rather increase than diminish the tendency to gan- grene. There has been some difference of opinion respecting the best way of applying medicine to the internal fauces. Garg'mg . ashes them best; but the motion seems often to increase the inuamr * Lieutaud's Synopsis Prax. Med. CYNANCHE TONSILLARIS. 113 mation, 60 that many dissuade from it iri the severer cases. The lhedicine should then be thrown Into the fauces by means of a syr- inge, or applied by a pencil ; or, as Sydenham recommends, merely kept in the mouth for sometime and then allowed to run out. In this way, however, it is only applied to the anterior parts. When the deep sealed parts are affected, swallowing is tbe only means of making any application to the inflamed part, and it un- fortunately happens, we have seen, that in these cases swallowing is most difficult and painful, aud most frequently interrupted. When the pain occasioned by swallowing is very great, it more than counterbalances any advantage to he expected from this class of medicines. Some practitioners affirm that gargles and other washes for the throat should be used cold, while others maintain that they should always be of the same temperature with tbe body. When tbe in- flammation is slight, it is of little consequence whether they be cold or tepid ; we have reason to believe, that when it is more severe. they should be of the same temperature with the body. If we are endeavouring to promote suppuration, their temperature, wc have just seen, should be higher. Applications to the internal fauces are sometimes made in the form of vapour. The vapour of warm water employed at an early pe- riod tends to procure resolution ; at a later period to induce a fa- vourable suppuration. In tbe former case, vinegar, distilled spirits, &c. may he added to the water. The vapour may be drawn in through the spout of a tea-kfettle, Or more effectually by the instru- ment termed an inhaler. We have reason to believe that little ad- vantage is derived from impregnating tbe vapour with flores sonbu- ci, and other herbs recommended by Eller, Lieutaud, and other foreign writers. There is some difference of opinion respecting the employment of sialogogues. The advantage often derived from spontaneous sal- ivation has induced sOme to recommend them, hut the irritation they occasion seems generally to counteract any benefit to be ex peeled from the increased flow of saliva; Physicians therefore sel- dom employ mere sialogogues in cynantbe tonsillaris, but if the means which prove otherwise serviceable excite a flow oi saliva, ii adds to their good effects. According to the mode of arrangement I follow, local blood-let ting, when performed from the internal fauces, should be consider- ed here. It will be better, however, to throw into one place the few remarks t be made on this remedy. Vol. ii. j .5 114 CYNANCHE TONSILLARIS. When the inflammation is considerable, the foregoing must be aid- ed by external means. The simplest are warm applications and rubefacients. With respect to the composition of the rubefacients, mustard isloo harsh an application here. Sir John Pringle advises a piece of flannel to be applied to the neck, moistened with oil and a solution of the carbonate of ammonia, in the proportion which the patient can easily bear; by which he remarks, a sweat is brought out on the part, and sometimes over the whole body. This application is more effectual than bags of hot salt or sand recom- mended by some, and more agreeable than tbe dung of animals which has actually been employed for the same purpose.* A plaister composed of the liniment, sapon, and muriate of ammonia, in which the ammonia, being gradually evolved, acts as a power- ful rubefacient, is perhaps the best application of this kind. If the general exeitement be considerable, it is proper to delay tbe use of rubefacients till it has been reduced by proper evacua- tions. The same may be said of the employment of blisters, which are a more powerful remedy in this disease. They should be pretty large, and applied near the seat of the disease. Although blisters do not at first bring relief, we are not to despair of their proving useful, for when the first fails,, a second often succeeds, or when the discharge excited at first brings no relief, the continued discharge kept up by the ung. cantharid. frequently succeeds better. But no local remedy is so generally beneficial in such cases as local blood-letting. Scarifying the parts affected as far as they can be reached, is often recommended. This is particularly ser- viceable when the swelling is great. The ranular veins are some- times opened, but this, as Dr. Cullen observes, is an insignificant remedy, and as it is at the same time a troublesome one, it is sel- dom put in practice. Scarification and cupping on the neck is more effectual. When the neck is much swelled and inflamed, Tissot observes, one or two cuts made pretty deep have often saved the patient's life ; leechesvhowever, are here the most convenient means. When a tendency to suppuration has taken place, emollient poul- tices are useful. Certain operations form part of the local means employed in the cynanche tonsillaris. These belong to the province of the sur- geon. I have already had occasion to mention laying open tbe abscess, wliich lessens the duration of the disease. * Dr. £ims on Epidemic Diseases. CYNANCHE TONSILLARIS. 115 Bronchotomy is a more serious operation, and, fortunately, less frequently necessary. When the swelling threatens suffocation, however, it ought not to be delayed. Many have laid it down as a rule, never to perform this operation, when, frdm a weak and intermitting pulse, and other symptoms of extreme debil- ity, the patient's death appears inevitable. This advice seems to proceed from too anxious a regard for the practitioner's repu- tation. It is to be recollected that in such cases the most alarming symptoms are often the consequence of impeded respiration, and will disappear when a free passage is ghen to the air. The read- er will find Michaelis, in his Treatise de Angina Polyposa, and -others, who were conversant with bronchotomy, speaking of it as a comparatively trivial operation, always to be resorted to Where there is any risk of suffocation. When the general excitement is increased, every part of the an- tiphlogistic regimen is necessary ; all kinds of animal food and fer- mented liquors must be avoided, and the diet should be mild and diluent. Tbe patient should not, however, be forced to drink when the pain of deglutition is great, but copious clysters should be exhibited. In the one way or the other, dilution should, in all the severer forms of the disease, make a principal part of th* treat- ment. " Interea larga manu propinantur serum Jactis aqua nitrosa *„' aliaque diluentia et demulcentia."* When deglutition is wholly interrupted, the patient must be nourished by farinaceous clysters, till by the most active means the inflammation of the fauces is reduced. The first evacuation affecting the whole system, generally em- ployed in inflammatory sore-throat, is vomiting. Emetics given ear- ly, and they should never be omitted where the symptoms are con- siderable, often put a stop to the disease, and seldom fail to brinu considerable relief. Where there is much fever the effects of emet- ics may be explained by their tendency to promote perspiration ; but it is remarkable, that even where there is no affection of the ^ysfem, they often, in a way it is not easy to explain, more effectu- ally relieve the inflammation at an early period, than any local remedy we can employ. After the disease has lasted for some time, their exhibition requires more caution, and is always less effectual. If the inflammation runs very high, they may do harm. Tjssot even asserts, that under such circumstances they may ren- der the disease fatal. Where, however, the swelling is considera- ble compared with the other symptoms, hut not extreme, they an * Lieutaud.?s Synopsis Prax. Med. U6 CYNANCHE TONSILLARIS. often serviceable, even at a late period. Lieutaud says he ha« seen patients labouring under inflammatory angina snatched from the jaws of death by an emetic. Emetics are indeed sometimes employed with advantage even af- ter the formation of the abscess. When the abscess is situated in the deeper parts of the pharynx, or in the oesophagus, the surgeon cannot reach it, and the exhibition of an emetic, if it is ripe, will almost always occasion its bursting. Not only vomiting, but even cough- ing or laughing, will sometimes have this effect.* Vomiting is also proper towards the end of the disease, when a collection of irritating matter is accumulated in the stomach, in consequence of the patient's having swallowed large quantities of acrid or viscid saliva, which both load tbe stomach and vitiate its secretions. From the general efficacy of cathartics in inflammatory affec- tions of the head, and from the cynanche tonsillaris sometimes ter- minating by a spontaneous diarrhoea, physicians were led to rely much on them. More than a free action of the bowels, however, is seldom beneficial. When the inflammation and general excite- ment are great, some degree of catharsis may be kept up wah ad- vantage. At an early period saline and mercurial cathartics are the t-est. In the worst cases, where either tbe pain of ^wallowing is so great that the patient refuses to take any thing by the mouth, or deglu- tition is absolutely interrupted^ we must have recourse to the ex- hibition of copious cathartic clysters. When the excitement is great, venesection should never be neg- lected at an early period, and the blood as in other inflammations of the bead, should be taken from the jugular vein, if it can be readi- ly done, that the same operation may serve the purpose of both to- tal and general blood-letting. When delirium or coma supervenes, in treatment, with the addition of local means to relieve the throat, must be the same as in phrenitis. Diaphoretics are more serviceable in inflammatory sore-throat than in most of the diseases we have been considering. It is of- ten terminated, we have seen, by spontaneous sweating. A sweat forced out by external warmth and heating medicines, however,'is rarely serviceable, and generally does harm. If diluting fluids, with the ainmoni i acetata, or any other mild diaphoretic, induces sweat, it often brings relief. * Tjisot. CYNANCHE TONSILLARIS. in When a tendency to gangrene appears, we must hare recourse to tbe bark and wine, with caution, however, lest by exhibiting them too early we rather increase than diminish this tendency.* There is a material difference in the treatment as well as prog- nosis of gangrene supervening on the cynanche tonsillaris, and the cynancha maligna. In the latter, it arises directly from debility ; the most invigorating plan is proper and ofteu successful. In the former, it is the consequence of excessive general excitement; till this is sufficiently diminished, the invigorating plan will do harm, and then it is often too late for any plan to be of service. When deglutition is interrupted, tbe bark and wine must be ex- hibited per anum. Such are the various means employed in the inflammatory sore- throat. It is to be Temembered that the practice should be the more vigorous, tbe more the inflammation extends towards the (esophagus, and most so when it has its seat there. " Funeslissi- " ma est angina, que nee in faucibus nee in cervice quidquam con- " spicuum exhibit."t As metastasis sometimes happens, in the cynanche tonsillaris, most frequently to the lungs, we must be prepared for this acci- dent, and watch tbe tendency to it. The deglutition in this disease is now and then interrupted by spasm of the oesophagus which sometimes appears as an idiopa- thic disease. Various remedies have been recommended in it( few of which, however, are of much service. As in the case be- fore us it arises from tbe irritation of the primary disease, anti- phlogistic measures are chiefly to be relied upon, Emollient and oily applications used externally, and internally if any power of deglutition still remains, and tbe medicines which have been term- ed antispasmodic, particularly opium, are occasionally useful.— Van SwietenJ reccoinroends a soap composed of oil of turpentine, vegetable alkali, and muriate and acitate of ammonia, to be ap- plied externally, and also used nternally if it can be swallowed. But tbe relief obtained by oiiy and emollient medicines is seldom permanent.§ Dr. Johnstone thinks that opium and extract of cicuta promise most in this case. When any power ot deglutition remained, hi * See what was said on this subject in ?p eaking of the treatment of tl Phleema*i;e in general. t Quarin De Febnbus. X Com. in Apb. Boer. Aph. "97. j See a ,-aper by Dr. Johnstone, in tbe 2d vol. of the Memoirs of tbe M f?f. ofLondon. nd CYNANCHE MALIGNA desired tbe medicine to be swallowed , in other cases the opium and cicuta were made into pills which the patient was desired to., bold in the mouth. The exhibition of mercury has been > arried to salivation without bringing relief.* Mechanical force has been employed. This, however, is always attended with danger, and has even proved fatal, as in a case mentioned by Dr. Johnstone. A schirrous affection of the oesophagus or permanent enlarge- ment and induration of the lymphatic glands of the neck some- times, though rarely, succeed cynanche tonsillaris. They more frequently arise from other causes. When there is reason to be- lieve that deglutition is prevented by a schirrus of the oesophagus bougies of a proper size may be used, and we have been advised to let small doses of hydrag. submuriat. and cicuta remain in the mouth, that they may be gradually swallowed. I have seen several cases of this kind, but none in which this or any other mode of treatment proved successful. If the dysphagia arises from a swelling of the lymphatic glands, the means employed in scrophula are sometimes serviceable. When the inflammatory sore-tbroat has been severe, it is often succeeded by a considerable degree qf debility. Nourishing food and the moderate use of wine are generally sufficient to restore tbe strength. Dr. M'Bride and others recommend the bark and iron, which may be used, if the tendency to the disease has whol- ly subsided. Frequent attacks leave the fauces in a state of relaxation which is favourable to the return of the disease ; by the use of astringent gargles the parts are strengthened. The recurrence of the dis- ease, however, can only be prevented by carefully avoiding.,its exciting causes, and by temperance and exercise, which correct the tendency to plethora. SECT. II. Of the Cynanche Maligna. Tins form of cynanche, as appears from the definition quoted from Dr. Cullen's synopsis, affects the tonsils and mucous mem- brane of the fauces with tumor, redness, and mucous crusts of a whitish or ash colour gradually spreading and covering ulcers.— The fever which attends it^ contrary to what happens in the other phlegmasiae, partakes more of the typhus than synocha, and it is * Dr. Johnstone succeeded in one case by means of corrosive sublimate and the bark, but thinks they do not promise to be generally successful. CYNANCHE MA£iGNA. 119 very frequently attended with an eruption on the skin of the same nature with that of the scarlatina. Som«^ doubt whether cynanche maligna and scarlatina should be regaided as different diseases. If by different diseases we mean those whose symptoms differ, they are surely very different ; if by different diseases" we mean those whose causes are different, and which never run into each other, they must be regarded as va- rieties of the same disease. Others have not only regarded the scarlatina and cynanche ma- ligna as different diseases, but bave looked on those cases in which they are combined, as of a nature different from either. This view of the subject is neither useful in practice nor accurate in a nosological point of view. According to the most accurate view perhaps, the scarlatina sim- plex alone should have been ranked among the exanthemata ; and the pure cynanche maligna, namely ^that unattended by an affec- tion of the skin, alone considered as a distinct disease. It would then have been easy to describe the appearances resulting from the combination of the two diseases, and the manner in which the treatment should he adapted to different cases, according as the symptoms of the one or other prevail. As the scarlatina and cjtf- anche maligna strictly so called appear unattended by each other, in a system of nosology they should be regarded as distinct dis- eases ; as they are so frequently combined, their combinations must be treated of in a system of practice j and this arrangement would appear to be sanctioned by the history of the diseases, which on their first appearance were certainly more distinct than we find them at present. 1. Of the Symptoms of the Cynanche Maligna. The symptoms of this disease are so complicated, that it is difficult to give a view of them at the same lime sufficiently full and distinct. We shall in the first place consider the manner in which the dis- ease makes its attack ; then describe tbe affection of the fauces ; next the symptoms which attend it; then the various appearances of the eruption ; and lastly the different ways in which the disease terminates. The attack of cynanche maligna often differs bat little from that of simple fever. The patient complains of lassitude, dejection of spirits, and giddiness. He is generally affected with more or less shivering, frequently alternating with fits of heat. The pulse is frequent, and the breathing more or less hurried. 120 CYNANCHE MALIGNA These symptoms seldom continue long before the patient com plains of a sense of stiffness about the neck, with some pain and difficulty of swallowing, and on inspecting the fauces, they ap- pear red and swelled. In many cases the affection of the fauces is troublesome from the beginning, a»?d sometimes it is tbe first symptom. When the disease makes its attack in this Way, the prognosis ii favourable ; it is probable that the disease will partake coittidera- bly of the nature of scarlatina. But when along with the foregoing symptoms tbe patient com- plains of severe head-ache, especially a pain in tbe crown of the head, violent pains of the back and limbs, or pain in the stomach, with nausea and vomiting, or with diarrhoea ;* when instead of giddiness, he is* affected with coma or delirium ;' when tbe eyes are heavy and watery, the countenance either full and bloated, or pale, shrunk, and dejeoted ; when he complains of an unusual sense of oppression and debility ; when the pulse is small, irregular, or tremulous, whether frequent or not,t or full, heavy undose, and un- equal, as Huxhamj expresses it; when the breathing is small, bur* ried, anxious, and interrupted with sighing ; when the urine is quite limpid, or very high-coloured and turbid ; when the sensa- tion in the fauces is rather that of an uneasy stiffness than of pain, the deglutition being little impeded ;§ when the internal fauces ap- pear of a dark red with brown spots, the tongue, especially to-j wards tbe root, being loaded with much viscid white mucus ; when an eruption of small red postules or purplish blotches appear on the skin soon after the commencement, or at the very commence- ment, (for in the worst cases of cynanche maligna tbe eruption has been known to be among the first symptoms,) the prognosis is bad. * The diarrhoea is often bilious. Both the vomiting and diarrhoea are most frequent in children. Although nausea and vomiting are among the worst symp- toms of this disease, they do not always appear even in fatal cases. Mr. Col- den says they rarely occured in the epidemic he saw. See Mr. Colden's letter to Dr. Fothergill, in the first volume of the Medical Ob». and Inq. a + Quarin (Dr. Febribus) observes, that the puke is sometimes less frequetf than natural at the commencement of cynanche maligna. X On the malignant Ulcerous Sore-throat 4 The pain and difficulty of swallowing, Dr: Wall observes, is sometimes •otnning, Uiat the disease often makes great progress without ji.c ,-u.ent knowing that there is any disorder in the throat. He relates a case » wbick this happened. CYNANCHE MALIGNA. 121 lt"is not meant that all the foregoing symptoms shew themselves iit the commencement even of the worst cases. It is sufficient, if several of these appear, to denote the malignity of the disease. The very worst cases of cynanche maligna, however, some- times make their attack in so deceitful a way, that for some time, the symptoms differ little or not at all from those of the most fa- vourable cases, so that although the one set of symptoms always af- fords an unfavourable, the other does not uniformly afford a favour- able prognosis. In some cases the symptoms remain very mild for several days. The strength in particular is often not much im- paired at an early period, nor always indeed at a later period. Even in the worst cases, Mr. Colden observes, many walked about till within an hour or two of their death.* It has sometimes happened, as in an epidemic described by Mr. Stephen,! that the temperature of the body was hardly greater lhan natural, not only at the commencement, but throughout the whole disease. The absence of all the symptoms of fever indeed at an early period, does not always assure us that the case is free from danger. Mr. Collins;}; remarks, that in the malignant sore-throat epidemic- in St. Vincent, the fever did not usually appear till the affection of the throat had lasted seven or eight days, and the patient gene- rally walked about, notwithstanding a very bad state of the throat. till the fever came on. It is even asserted by some that the cy- nanche maligna has appeared without being accompanied by fever at any period.§ Such varieties, however, are very rare. On the state of the throat depends the prognosis at every period of the disease. At first, we have seen, the patient complains of a stiffness of the muscles of the neck, and some difficulty in swallow- ing.|| As the affection of the fauces increases, it is often attended with a degree of hoarseness, which, like the difficulty of deglutition, however, is seldom considerable. If the breathing be much affected, it proceeds from the inflam- aiation spreading to the trachea. * Med. Obs. and Inq. vol. i. t Med. Comment, vol. xii. X Med. Comment, vol. ii. v Mr. Short, in his Chronological History of the Weather, observes, thai this was the case in the malignant sore-throat which raged in England in 174i?. || As in^he cynanche tonsillaris, the oesophagus is sometimes but rarely af- /«" ted with spasm, rendcrins: the dentition very diiTicult or whelly interrupt- ing: it. Vor,. ir. Ifi 122- CYNANCHE MALIGNA. However florid, and free from specks the fauces may appear af the commencement of cynanche maligna, they soon assume a dark red colour, and specks of some shade between a light ash colour and a dark brown appear scattered over the tonsils, velum pendu- lum palati, and uvula. The lighter the colour of the specks, the better is the prognosis. The formation of these specks, it has been observed, is sometimes preceded by inequality and increased frequency of the pulse, and by an increase of the restlessness and depression.* The first appearance of the internal fauces, is sometimes that of a large whitish coloured stain, surrounded with a florid margin, the stain soon becoming a large slough. The swelling is sometimes considerable, but seldom so much so as in the cynanche tonsillaris. In the appearance of the throat in- deed, as well as the other symptoms, the cynanche maligna, fre- quently at an early period so nearly resembles this disease, that? they can only be distinguished by the causes from which they arise, and the nature of the prevailing epidemic! As the specks spread, they generally-become of a darker colour, the interstices at the same time assuming a purple hue, new specks appear, and the whole internal fauces are at length covered with thick sloughs, which frequently fall off, discovering ulcers some- times deep-seated. When the sores left after tbe separation of the sloughs, appear of a fiery red, the danger is very great. If they become covered with a black crust, the event is generally fatal. When, on the , other hand, the parts which the sloughs covered appear florid and clean, the prognosis is more favourable. As the disease advances, the breath becomes fetid and is often disagreeable to the patient himself. He generally spits up mucus tinged with blood, and often a matter of a livid sanious appearance, wliich sometimes excoriates every part it touches. The lips are frequently of a livid or black colour, and on their inner sides, cov- ered with small vesicles containing an ichorous matter. The sud- den suppression of the discharge from the throat has been observed, especially in children, to be followed by a fatal train of symptoms. In the worst cases, the fauces at length appear quite black, and pieces of mortified skin and flesh are spit out. It is. needless to * Dr. Willan on Cutaneous Diseases. t See the diagnosis between these diseases, in the 2i lth page of Dr. Folk-" enjill's works published by Dr, Letlsc-m. CYNANCHE MALIGNA. 1& •*say that this symptom affords a very unfavourable prognosis ; it is not always fatal, however, as I have myself witnessed. When the disease takes a'favourable turn, the parts surrounding the sloughs begin to assume a more florid appearance, and a better conditioned matter is discharged from the ulcers. While the affection of the fauces increases, the various symp- toms of general derangement keep pace with it. If delirium or coma has not come on at an early period, it generally appears in the progress of the disease. The eyes become more fixed, dull, and heavy ; the delirium for the most part being of that kind which attends typhus. Dr. Fothergill has observed, that the delirium in cynanche maligna is of a peculiar kind; an observation which has ,not been confirmed by the experience of others. In some cases it is of the phrenitic kind. There is then reason to believe that the inflammation has spread to the brain; generally a fatal accident. The countenance is then flushed and assumes an expression of fierceness. In tbe generality of cases it is either swelled and bloated, sometimes so much swelled as to close the eyes,* or shrunk and cadaverous. Early in the disease, it has a strong expression of anxiety, which wears off as the debility increas- es. At a more advanced period the eyes are generally affected with s languid inflammation, and in the worst cases often suffused with blood. All bemorrhagics, except very eaily in the disease, are unfavour- able in the exquisitely-formed cynanche maligna. Though some, as in fever, indicate more danger than others. The observations made respecting them in typhus are applicable here. Petechia? do not so frequently attend cynanche maligna, as the -other symptoms would lead us to expect. In some epidemics they are more frequent than in others : Dr. Wall, and a few other writ- ers speak of them as not an unusual symptom. In an epidemic mentioned by Mr. Short, they seem to have been almost a constant symptom. As the disease advances, the pulse becomes more depressed. On touching the skin, which is generally parched, the same sensa- tion of heat is experienced as in malignant typhus. There is often an exacerbation in the evening, during which the breathing is some- times rattling or even sterterous. The diarrhoea increases in the progress of the disease, or super- venes if it did not appear at the commencement, the patient com* * Mr. Russell'* CEconomv of.N'ature in Acute and Chronic Diseases 124 6YNANCHE MALIGNA. plains of griping pains, and the matter discharged often excoriates the anus and neighbouring parts. When the faeces become black„ the prognosis is very bad. The supervening or increase of the diarrhoea seems often to pro- ceed from the acrid matter of the fauces getting into the stomach and intestines, or from the sloughy affection spreading to these parts, for in some cases it has been traced along the whole course of the alimentary canal,* and considerable hemorrhagies often suc- ceed the abrasion of the sloughs in the intestines. It was observed above, that the inflammation in some cases spreads to the larynx and trachea. Tbe same is true of the ul- cers ; they have been traced by dissection even beyond the di- vision of the trachea. When the disease attacks the wind-pipe, a very troublesome set of symptoms come on; the voice is alter- ed, assuming a wheezing or ringing sound, sometimes if is lost; the breathing becomes difficult ; the patient is teased with a se- vere cough, endeavouring to bring up the acrid matter secreted by the ulcers, which resembles that spit out from tbe fauces ; it is sometimes mixed with tubiform substances, once supposed to be portions of the internal membrane of the trachea and bronchia?, but now known from dissection to be a matter formed by the dis- ease, which lines these canals, and which we shall have occasion to consider more particularly in treating of the cynanche trache- alis. In such cases the patient is sometimes suddenly carried off by suffocation. The tendency of the cynanche maligna to affect the trachea has induced Dr. Johnstone to propose dividing the disease into the cynanche maligna tonsillaris, and trachealis. In the more severe cases indeed, almost every part in the neigh- bourhood partakes of the state of the fauces; the membrane lin* ing the nostrils is generally much affected, often occasioning fits of sneezing, an acrid matter mixed with blood frequently runs from it, excoriating the lips ; sometimes even blisters are raised on the hands and arms of children, when they use them for wiping away the discharge. However unfavourable this discharge, its sudden interruption is still more so.t It is seldom so considerable in adults as in children. The inflammation, as in the cynanche tonsillaris, sometimes spreads to the tongue, sometimes along the eustachian tube to the - Mr. Russell's Treatise just referred to, Huxham on the Ulcerous sore- throat, &c. t See the Observations of Huxham and others. CYNANCHE MALIGNA. 125 Internal ear, occasioning ulceration, and sometimes wholly de- stroying its structure. Sometimes it spreads to the parotid, maxillary, and other glands in the neighbourhood of the fauces, which become swelled and painful. Huxham says that be has seen this happen at the \ery commencement of the disease to such a degree as to threaten suf-^ focation. They sometimes suppurate and form tedious and pain- ful abscesses. The whole neck indeed sometimes swrells, becomes tender to the touch, and assumes a dark red colour, and the head is retract- ed. Even the arms, hands, and fingers, in some cases are inflamed, swelled, stiff, and painful. When the trachea is much affected, particularly if the disease spread beyond its division into the bronchia}, inflammation of the lungs often comes on and proves fatal. This indeed sometimes happens in cynanche maligna, without being preceded by any affection of the trachea, and has even suddenly destroyed the patient, where there bad been no symptom of alarm, as Mr. Colden ascertained by dissection. Mr. Collins observes, that the cynanche maligna sometimes proved fatal after the affection of the fauces had wholly disappeared, the inflammation having spread to the stomach or lungs. Hiccup, wiiich particularly at the height ot the disease, has been observed to be a very unfavourable symptom, seems often to arise from the inflammation spreading to the oeso- phagus and stomach. Mr. Colden makes the following curious remark ; that some had sores, like those in the throat, behind the ears, on the genitals, or other parts qf the body, and in these cases there was sometimes no ulceration nor even affection of the throat, Others make similar observations. The cynanche maligna generally arrives at its height about the fifth or sixth day, and in cases which terminate favourably de- clines in five or six days more. It has been observed, that it run? its course more slowly in adults than in children. Such are the symptoms attendant on the worst state of the fauces in the cynanche maligna. When the disease takes a favourable turn, the symptoms which have just been enumerated are either absent or considerably modified. The countenance begins to lose that peculiar expression, so characteristic to the worst forms of the dis- ease. ' The pulse becomes stronger and less frequent. The res- piration freer. The skin from being parched becomes soft and often moist, one of the most favourable symptoms, tbe evening ex- 126 Cynanche maligna. acerbations, less remarkable, and the discharge from the intestines and nares, if it still continues, less acrid. But whether the disease proves favourable or otherwise, a set of symptoms which still remain to be considered, generally attends it. The connection between the cynanche maligna and scarlatina, I have already had occasion to notice. It sometimes happens, we have seen, that the former, such as it has just been described, appears without any affection of the skin, in the same manner, as we some- times meet with the scarlatina without any affection of the throat ; in general, howrever, both affections are combined, and seem won- derfully influenced by the state of each other. But while the ab- sence of the sore-throat in the scarlatina always affords a favoura- ble prognosis, that of the eruption in the cynanche maligna generally affords an unfavourable one. In some epidemics, the generality of cases have appeared with- out any affection of the skin. Lieutaud even speaks of the erup- tion as a rare occurrence in cynanche maligna. " Ut sileamus de " efilorescentiis cutaneis aliisque variis symptomatibus."* Dr. Wall also observes of an epidemic cynanche maligna, that ve- ry few had the scarlet eruption. There are instances of epidem- ics indeed, as that described by Dr. Collins, in which the eruption did not appear in a single instance. Tfie period at which the eruption shews itself, is various ; it is rarely later than the fourth day, and seldom so early as the first. The early appearance of the eruption is unfavourable. It gener- ally first shews itself about the neck and breast, sometimes with itching of the skin, more frequently without this symptom ;t and, as in the scarlet fever, the eruption spreads to the mouth and throat; the inner surfaces of the nostrils and eyelids also partake of it,and it sometimes even extends to the tunica albuginea.J The eruption, oftenattended with some degree of swelling, gra- dually spreads over the trunk and extremities. As in the scarlati- na, it comes ou£ in stains which, when nearly inspected, appear composed of small prominent pustules, with the interstices, Dr. Willan observes, of the natural colour. Their prominence may be distinguished by the eye, more easily, by the touch. * Synopsis Prax. Med. t In some cases, Huxham observes, there is itching and desquamation with- out any eruption. t Pr. Willan, on Cutaneous Diseases-, CYNANCHE MALIGNA. \n There ace sometimes pustules of a larger size, particularly on the extremities, which are'readily seen, being of a more intense red than the parts which surround them. The appearances of the eruption affording a favourable progno- sis, are the same as in the scarlatina, a florid colour, uniform diffu- sion, and a copious desquamation. The eruption being full, however, by no means insures the mild- ness of the disease, nor does an unsteady and partial eruption uni- versally indicate that the disease will be severe. Huxham say6, he has seen some in this disease die of a phrensy, who were covered, with " the most fiery rash" he ever saw. It rarely happens, however, that the eruption is uniformly diffus- ed in severe cases of cynanche maligna ; it generally comes out in blotches, or small points scattered over the trunk and extremities, which are seldom of a florid red, but of a dark purplish or livid hue, and which terminate in but a very scanty desquamation. When the eruption is favourable, a remission often takes place on its appearance, and almost always at the period of desquama- tion. When it is unfavourable, its appearance never, and its ter- mination rarely, brings relief. The duration of the eruption, like that of the disease, previous to its appearance, is seldom less than one day, and seldom more than four. In some cases its duration on the whole is longer, from its disappearing and returning again, which is far from being fa- vourable. Dr. Willan observes that it is generally more florid in fhe evening than in the morning. As in other eruptive fevers, the eruption has sometimes suddenly ceceded, an alarming train of symptoms supervening.* The patient falls into dropsical swel ags, the countenance assumes a cadaver- ous appearance, and he .., frequently carried off by convulsions. A similar train of symptoms has supervened on the eruption sud- denly assuming a livid appearance, or becoming pale from being very high coloured. All these symptoms it is evident are the effects of debility, farther illustrating what was s,aid of the re.1 trocession of eruptions. The desquamation often continues a long time after every other symptom has disappeared. It is not uncommon to see patients peeling the cuticle from their fingers, after they have been well for a fortnight or three weeks. In the cases which terminate favourably, the symptoms some- times gradually abate without the appearance of any which ran be * Mr. RupfcII and others, on the CvnancheMaliCTa 126 CYNANCHE MALIGNA, regarded as critical; in most favourable cases, however, a gentle sweat appears about the time of desquamation. This cruris ha3 been observed to be less perfect in adults than in children. The sweat sometimes appears earlier ; it then generally brings relief but seldom wholly removes the fever.* A moisture on the skin irt the mornings, however, which does not bring relief, seems merely the consequence of debility, and indicates danger. The cynanche maligna, like most other febrile diseases, often abates with a copi- ous sediment in the urine. The other symptoms occasionally critical in continued feveiy seldom prove so in this disease. With regard to the unfavourable terminations, some I have already had occasion to mention ; the patient, we have seen, i3 sometimes destroyed by the inflammation's spreading to the trachea, or lungs, or to the stomach, or brain ; and more rarely by metastasis of the inflammation to these parts. A retrocession of the eruption, and ceasing of the discharge from the fauces, have also been mentioned as sometimes attending the fatal termination. The dicharge from the fauces is most apt to be diminished during sleep. Some die of profuse hemorrhagy from the intestines, nose, mouth* or ears. The menstrual discharge frequently appears before the usual period in the cynanche maligna, and sometimes becomes pro- fuse. Many in this disease have had it for the first time. If co- pious, or before the proper period, it is generally an unfavourable symptom ; if very profuse, it may prove fatal. Some die suddenly by suffocation, in consequence of the swel<- ling of the glands of the neck. In other cases the patient is gradually reduced by an acrid ca- tharsis. When the trachea and its branches have been much affected, ul- cerations are sometimes formed in the lungs, and hectic fever comes on. I shall not here enter into the question whether the cynanche maligna gives rise to phthisis, except where tubercles have previ- ously existed, it is certain that it has occasioned phthisis where no tendency to this disease had previously appeared. In many cases, the fatal, like the favourable termination, is un- attended by any peculiar symptoms. The worst of the symptoms * " General sweats," Huxham remarks, " on the third, fourth, or fifth day, " or later, were salutary." Dr. Fothergill observes, that the morning sweats, when they occurred early in the disease, often brought such relief that the dis- ease assumed the intermitting form. CVNANCHE MALIGNA. 129 which have been enumerated gradually supervene ; the fauces be- come black ; the eruption assumes a dark purple colour, especially about the throat; the breathing becomes difficult and sonorous, and is frequently interrupted for some seconds. A degree of stupor comes on, the eyes appearing glossy. Dark coloured and very offensive firces are passed involuntarily. Hiccup, in bad cases one of the most fatal symptoms, supervenes, the extremities be- come cold, and are covered with a clammy sweat; the pulse in- termits, at length cannot be felt, and the patient gradually expires, or is carried off by convulsions. We estimate the danger more by the state of the general than tbe local symptoms. Whatever be the appearance of the fauces, if the pulse be pretty steady, and the strength not much exhausted, we need not despair. The prognosis in cynanche maligna is best determined by ob- serving how far the symptoms incline to those of scarlatina. To place it in a clear point of view it will be useful, notwithstanding it must occasion some repetition, to contrast the symptoms of the exquisitely-formed cynanche maligna with those indicating a ten- dency to scarlatina. In the scarlatina the first symptoms are those common to fevers in general, particularly to the varieties of synocha. If these be the only symptoms at the commencement of the cy- nanche maligna, they are generally more severe than in the scar- latina. In most caseb, however, the patient complains at the same lime of acute pains in the back and limbs, he is troubled with nau- sea and vomiting, or diarrhoea, or both. In the worst cases the pulse from the first is weak and tremulous ; the loss of strength for the most part, great and sudden ; the extreme anxiety which gen- erally attends this disease is strongly marked in the countenance ; and even delirium or coma supervenes on the first night. In the scarlatina the eyes are inflamed and prominent. In the cy- nanche maligna they are often more or less inflamed also, but heavy, watery, and in tbe progress of the disease, fixed and glossy. When the eruption is florid and uniformly diffused, there is gen- erally from the beginning considerable pain of the throat increas- ed on swallowing, the fauces are florid, and considerably swelled, Aiin! if specks appear they are almost always of a light colour. In the true cynanche maligna the patient complains of little pain, but rather of an uneasy stiffness about the neck ; the fauces have a dark red or purple hue, and are covered with crusts of an ash or brown colour. In this respect, however, there is much variety. Vol.. ir. 17 ISO cyNancih:?maligna. In some cases of cynanche maligna the fauces at the commence* ment appear of a florid red, and not unfrequently redder in some places than in others. In the progress of the scarlatina the specks are not readily changed into ulcers, and never spread so as to-cover the whole or greater part of the fauces, nor erode the subjacent parts ; thosa parts which are not occupied by them remain of a florid colour, and if there is an unusual secretion from the fauces it is only of ar thin or viscid mucus or saliva. The contrary of all this is true of the cynanche maligna, the specks soon degenerate into ulcers, which spread rapidly to the adjacent parts, eroding those which lie beneath them. The whole fauces often assume a black colour, mucus mixed with blood, a livid sanies or even pieces of mortified flesh are spit out, and the fcetor of the breath is intolerable. In the scarlatina there is no acrid discharge from the" nostrils or intestines ; in the cynanche maligna the discharge from both is oft- en so acrid as to excoriate every part it touches. The worst hemorrhagies occasioning a bloody saliva, bloody urine and stools, and bloody suffusion of the eyes, and tinging the sweat, are symptoms which we never meet with in scarlatirfe. In the progress of scarlatina the face is generally red and some- what swelled ; in the cynanche maligna it is pale, swelled, and bloated, or shrunk and cadaverous. In the scarlatina the mental functions are rarely deranged. In the cynanche maligna, if delirium or coma do not appear at the commencement, they seldom fail to supervene afterwards. Various symptoms above enumerated, which never appear in scarlatina, often attend cynanche maligna from the affection of the fauces spreading along tbe oesophagus to the stomach, or even along the whole tract of the intestines, and from its spreading to the trachea and larger branches of the bronchiae.* All the parts in the neighbourhood of the fauces, the eustachian tube, the internal ear, the parotid, maxillary, and other glands of the neck, more frequently partake of the affection of the throat in the cynanche maligna than in the scarlatina. In the cynanche maligna, the period at which the eruption shews itself is uncertain ; we have seen that it sometimes comes out evei* on the fir.it day ; in the scarlatinia it generally makes its appear- ance on the third or fourth day. * All those parts to which the inflammation spreads, arc often found on dis- section in the same gangrenous state with the throat. CYNANCHE MALIGNA. 131 In the latter it is of a florid colour, and soon spreads uniformly over the whole or a great part of the body. In the former it often appears in blotches or points, and is frequently either pale or purplish. ■ In the scarlatina the appearance of the eruption often brings re- lief, particularly to the sickness and anxiety ; it terminates in a copious desquamation of the cuticle, and if its appearance failed to bring relief, its termination seldom does. In the cynanche malig- na it terminates in but a very partial desquamation, which, like the appearance of the eruption, rarely brings relief. In the scarlatina the eruption for the most part is steady, grad- ually assuming a.brownish hue, which precedes the desquamation. In the cynanche maligna it is often inconstant, disappearing and again coming out several times in the course of the disease. It is in the cynanche maligna that a retrocession of the eruption. and the symptoms which accompany it, are most apt to occur. Phrenitis and pneumonia rarely supervenes in the scarlatina, nor is it liable to be followed by phthisis. A gentle sweat, which only sometimes appears at the time of desquamation in the cynanche maligna, and seldom proves criti- cal, very generally accompanies the same period in scarlatina, and is almost constantly attended with an abatement of the symptoms.* Such are the symptoms of the cynanche maligna, and the means pf collecting the prognosis in this disease. Death may happen at any period ; it has often happened even on the first day. Dr. Fothergill observes, that in the greater number of cases which ter- minated fatally under his care, the patient died before the fourth day. Those, he observes, who survived the fourteenth, were thought to be out of danger, at least from the disease itself, though some died unexpectedly after a much longer reprieve. The pa- tient sometimes recovers from the disease, and falls a sacrifice to its consequences, dropsy or other diseases of debility. The ana- sarca which succeed^ the disease, and is generally unattended with danger, belongs rather to the scarlatina than cynanche maligna, as it is most frequent and considerable where the eruption is ful- lest and most florid, When the voice is much impaired, it some- times does not recover its tone for many months or even years. 2. Of the Causes of Cynanche Maligna. The cynanche maligna is one of the {ew phlegmasia which are produced by a specific contagion. The proofs of its arising from * See a short parallel of the symptoms of the scarlatina and cynanche maligna, ijiven by Dr. Withering in Hs Treatise on the £e».ria there is seldom any delirium. A degree of coma frequently supervenes. 148 CYNANCHE TRACHEALIS. If the symptoms are severe and without remission, the patient s?t dom survives- more than three or four days, and frequently dies inN four and twenty hours, or even less. In tbe more lingering cases the symptoms gradually increase, and many of those which pre- cede death in other febrile diseases supervene. The mouth be- comes very foul ; the respiration more hurried, small, and diffi- cult, with great restlessness and dejection. Under these circum- stances that species of dilirium which is most allied to coma some- times comes on, the patient seeming stupid, and frequently mut- tering to himself with marks of great impatience. The pulse in such cases is often near two hundred, tremulous, and irregular. At length it can hardly be felt, the extremeties become cold, and the patient soon expires. Death sometimes approaches in a different way ; profuse swreats and fainting fits precede the coldness of the extremities. The eyes appear glazed, the lips, tongue, mouth, and throat parched, and the patient falls into general convulsions, the immediate fore- runner of death. Some of Dr. Molloy's patients* had a tumour behind the ears, which run speedily to mortification, and many, he observes, had profuse weeping behind the ears of a very corrosive nature.! The r osing of the cough is to be ranked among the fatal symptoms, as we Might, a priori, have supposed, since its absence can only be attributed to increasing insensibility, and deprives the patient of the chief means of removing the morbid secretion from the trachea. But whatever accidental symptoms, if I may use the expression, may appear, if the strength fail, the breathing becomes remarkably small and hurried, the face assume a livid and cadaverous appear- ance, the pulse flutter, and the extremities become cold, we know that death is at hand. Suffocation may take place at all periods of the disease. When the patient dies on the first or second day, it is generally fron: this cause. Death from other causes seldom happens earlier than the third day, and often later. The chief critical symptom is a spontaneous flow ©f sweat, which sometimes lasts for several days. Spontaneous vomiting and diarr- hoea are also sometimes attended with a mitigation of the symp- * Their disease seems to hav e rather been the acute asthma than the croup. t Dr. Eard saw the cynanche maligna complicated with croup epidemic. In some patients, instead of the croupy symptoms, there were ulcers behind the ears. See American Phil. Transact, vol. i. CYNANCHE TRACHEALIS. 149 toins. The same may be 6aid of a discharge of phlegm from the nose. Dr. Bard says salivation sometimes proves critical. A co- pious sediment from the urine is also regarded as critical. Dr. Rush observes, that he has frequently seen an eruption of little red blotches in the croup which generally brought relief. He some- times observed them appear and disappear several times in the course of the disease. Upon the whole, whatever be the attending symptoms, if the pulse become fuller, more steady, and less frequent, the breathing freer and less hurried, the peculiar sound of the voice and cough be- gin to wear off, and the patient appear less anxious and oppressed, the prognosis is good. We cannot, however, with certainty rely on the favourable change till the remission has lasted a considera- ble time ; for after the most favourable appearances, the disease has returned with greater violence, and proved fatal. The disease described by Dr. Millar, under the name of acute asthma, which seems at least allied to that we are considering, of- ten wholly assumes the intermitting form, as appears both from his observations and those of Dr. Molloy and Dr. Rush. It is on this account that Dr. Millar terms the disease asthma. He adds acute to distinguish it from chronic asthma, into which, he observes, he has seen it changed, the patient ever after remaining subject to the latter. It is of the first importance to distinguish a remission, from a complete solution of the disease ; a mistake here, by inducing the practitioner to abandon the means of cure too early, has frequently proved fatal. All that can be said on this head is, that where the patient still remains dejected and oppressed, however free the breathing may be, we have reason to dread a return ; and the more the symptoms have inclined to those of acute asthma, (of the diag- nosis between which and the croup I am about to speak more par- ticularly), the more reason we have to fear that the relief will only be temporary. Such is the general course of the cynanche trachealis infantum ; as in almost all other diseases, we occasionally meet with certain anomala in it which do not deserve to form part of its history. Thus it has appeared unaccompanied by fever, as observed by Dr. Rush, and others ;* the shrillness of the voice and cough, Dr. Home observes, sometimes goes off before death ; even the leading * Dr. Dixon gives an account of a case in which the cynanche trachealis ap- peared as a chronic disease in an adult, ^ee a paper by him in the 9th vol, •■">;' the Medical Communication*. 15U CANANCHE TRACHEALIS. symptoms, the dyspnoea and cough are occasionally absent in the progress of the disease. It may be mentioned among the anomala of the croup, that the membrane excreted by coughing has some- limes appeared black and gangrenous. Dr. Home * who has the merit of having first made this disease known in Britain, divides tbe croup into two varieties, the one he terms inflammatory, the other purulent. In the former, the pulse is strong, the face florid, the thirst great, and the disease, he observes, is relieved by evacuations ; in the other, the pulse is very frequent and soft, the debility great, the tongue moist, the thirst less thanin the former case, the anxiety much greater, and here, he observes, evacuations hasten death. It would appear, however, that these ought rather to be esteemed different stages, than varieties, of the disease, the former, if the symptoms are not soon relieved, degenerating into the latter. I have already observed that the croup and the acute asthma of Dr. Millar, and others, usually regarded as the same disease, are suspected by some to be of a very different nature, and it has even been asserted that a perfect diagnosis between them may be ob- tained. The following is offered by Michaelis. All the convulsive affections, he observes, are more violent in ;he acute asthma, than in the croup. In the former, also, the diffi- culty of breathing is greater. Tbe acute asthma makes its attack almost instantaneously, giving no warning of its approach ; the croup comes on more gradually. In the acute asthma, the peculiar shrillness of the voice, and the pain of the trachea increased on * Dr. Home is generally supposed in this country to have been the first who distinguished the croup. But it appears from the observations of Michaelis and other foreign writers, that it was known in many parts of the Continent long be- fore his observations were published. And even in our own country it was ac- curately described in a paper by Dr. Starr, in 1719, published in the Philoso- phical Transactions for 1750. Dr. Starr's account is in some respects confu.-- ed; from the cynanche maligna in many of the cases he saw having been com- plicated with the affection of the larynx. But he has not only given a good ac- count of the croupy symptoms, but a drawing of an expectorated membrane which had lined the whole of the trachea and part of the larger branches of the bronchiae. Dr. Home, however, may still be regarded as the first person in this country who had any accurate ideas of the disease, for Dr. Starr made no dissections, and understood its nature so little, that he believed the preternatural membrane which he saw coughed up to be the internal coat of the trachea and its branches; although, indeed, in one part of his paper he observes, that were the trachea laid open, he believes it would be found to be lined with a morbid secretion. CYNANCHE TRACHEAL^ 151 pressure, almost constant attendants on the croup, are never observ- ed. The acute asthma observes certain periods. In this disease the urine is thin and watery ; in the croup, at the beginning, red, afterwards turbid and white. The pulse in the acute asthma is small and contracted ; in the croup, at' its commencement, hard, full and inflammatory, afterwards soft and weak. The reader will find from what Dr. Cullen says in the last edi- tion of his Nosology, that notwithstanding the attempt of Michae- lis to distinguish these diseases, with which he must have been ac- quainted, as he there mentions Michaeli's treatise, he still seems to regard them as the sa/ne disease. The observations of some suc- ceeding authors, however, seem to confirm those of Michaelis, and improve his diagnosis. The acute asthma, says Dr. Rush, or, as he calls it, the cynanche trachealis spasmodica, comes on sudden- ly, and generally in the night. It has frequent and perfect inter- missions for hours, and in some instances for days, without the least sensible discharge from the trachea, and it yields to antispas- modic remedies, particularly to the warm bath. The croup, or as Dr. Rush calls it, the cynanche trachealis humida, comes on gradually, and most commonly in the day time. It continues or increases for several days without any remarkable remission or even abate- ment of the symptoms. It is accompanied with a discharge of phlegm or mucus from the trachea, or with the stools, and does not yield to antispasmodics. When the foregoing circumstances are well marked, they will generally be sufficient to distinguish the diseases ; but they are far from always being so. The croup, in particular, often as- sumes more or less of the intermitting form ; and with regard to the latter part of the diagnosis, a diagnosis from the effects of reme- dies is always objectionable, and particularly so, in so rapid a disease. The above diagnosis, however should be kept in view. and must serve till experience has furnished a better. To the cir- cumstances mentioned, it might be added, that the voice in the acute asthma is often hoarse, and the breathing, not wheezing, but rattling. It is asserted by some that the peculiar membrane lining the trachea in the croup, is not found in those who die of acute asthma When we see a chapter in Dr. Millar's treatise, entitled Dissec- tions, we expect to find this point determined, but Dr. Millar gives us an account of only two dissections, and that so imperfectly, that it is impossible to know whether or not the membrane wa.« present. L52 CYNANCHE TRACHEALIS. From the observations of others, however, we have reason to be- lieve that the membrane is not formed in the acute asthma. Dr. Rush, in his first publication on these diseases, confounds them : but in a later treatise, in which he attempts the diagnosis, he gives us an account of the dissection of a child that died of the acute asthma, in which no membrane nor even mucus was found in the trachea, this organ and the lungs appearing in a perfectly sound state. I believe the membrane, says Dr. Rush,* to be the effect of the croup only, and not an accidental effect of the spasmodic asth- ma as I once believed. The sudden manner in which the convul- sive asthma makes its attack, and its so frequently assuming an in- termitting form, oppose the idea of its being connected with the formation of a membrane in the trachea. It may be observed, however, that, contrary to what is general- ly supposed, the symptoms of croup are not essentially connected with the presence of this membrane. The ringing voice has often diappeared, especially towards the fatal termination, w:here the membrane certainly was present. This happened in the sixth case related by Dr. Home. Dr. Bard observes, that all the symp- toms of the croup often intermitted where the membrarTe was found after death. A case is related hi the Philosophical Transactions of a boy who died of phthisis ; a membrane was found in the trachea, pieces had often been spit up but no shrillness of voice is mentioned among the symptoms. The reader will find a similar case related by Dr. Dixon, in the 9th volume of the Med. Commun. in which the membrane was repeatedly formed and spit up without any shrill- ness of voice ; and Dr. Bard, on the other hand, gives a case in which the symptoms of croup were well marked, where no mem- brane bnt merely signs of inflammation were found in the trachea. It can hardly be supposed indeed that any part of the membrane is formed, as soon as the ringing of the voice and cough are perceiv- ed. Michaelis has not" only attempted to distinguish the croup and acute asthma, but also offers a diagnosis between the former and mere inflammation of the trachea. But in this instance he has suc- ceeded worse than in the other. The cynanche trachealis, he observes, may easily be distin- guished from the croup. In the former there is no symptom of a preternatural membrane present in the trachea and bronchiae. The dyspnoea he accounts for by the inflammation of thetrachea. and a*- * See his Med. Obs. and Inq. vol. i CYNANCHE TRACHEALIS. 153 .tnts that the peculiar shrillness of voice which we observe in the ni^ina polyposa, or membranacea, as Michaelis calls it, does net itteud the true cynanche trachealis. Dr. Cullen and others re- mark that the ringing voice does attend the cynanche trachealis of idults. In the cynanche trachealis, Michaelis adds, there is a vio- lent pain about the trachea ; in the croup but very little. Differ- ent degrees of the same symptom, it is evident, must afford a diag- nosis little to be depended on. The reader besides will recollect that the pain in the croup, as observed above, is increased on pressure ; a circumstance we shall find peculiarly characteristic of pain proceeding from inflammation. It is of much consequence to distinguish from the croup, the symptoms produced by the introduction of an extraneous body into the trachea. Mr. Balfour told me, says Dr. Home, that he atten- ded a child in a disease, which, from the similarity of voice, ap- peared to him the croup. The child died, and a piece of shell which he had sucked in with the breath was found lying across the trachea, about an inch below the glottis, and the membrane was inflamed and dry. Here even Michaelis confesses the diagnosis to be extremely difficult, and that the most acute may find it impossible to distinguish the cases. But a cautious physician, he observes, may proceed with safety ; he should enquire with much care, whether or not the patient feels any pain, whether it is acute, and in what place it is seated. If he feels no pain, or if the seat of the pain is in the trachea, or some of its branches, or if it changes its place, being felt during coughing in the upper, and at other times in the inferior part of the trachea, or lastly, if it occupy the trachea, and it solely, but is extremely acute and circumscribed, the case is not to be regarded as croup, but as arising from an extraneous body in ihe trachea. If even these symptoms, he adds, should leave me in doubt, I would immediately have recourse to bronchotomy, by which the nature of the disease would be discovered, and the nox- ious body whether produced by, or introduced into, the trachea, removed. When a similar set of symptoms, as sometimes happens, arises not from the iutioduction of an extran^ as body into the trachea, but from the generation of some excrc _-nce or concretion different irom that which takes place in tb' -roup, it is, if possible, more difficult to ascertain the nature of the case. The best diagnostic here is the slow and gradual way in which the disease comes on ; *nd the febrile, being moderate compared with the local symptoms. Vol. ft. 20 154 CYNANCHE TRACHEALIS. I need say nothing of the means of distinguishing the croup from certain diseases, such as cynanche maligna, hooping cough, chron- ic asthma, epilepsy, histeria, pneumonia, &c. for which those un- acquainted with its symptoms have mistaken it. Appearances on Dissection. In the trachea we find a preternatural membrane lining but scarce- ly adhering to it, for it may always be easily separated without destroying its shape. It comes out in the form of a tube exactly- adapted to the cavity it lay in. In many cases indeed it cannot be said to adhere at all, and there is a considerable quantity of puslike matter lying between it and the surface of the trachea. This membrane often extends beyond the division of the trachea, lining the larger branches of the bronchiae, and loosely adhering to them. The purulent matter extends beyond the membrane, often into the smallest branches of the bronchiae, and even in some instan- ces into the air vesicles. Mr. Wood found it in these vesicles in the 7th and 8th cases related by Dr. Home. On removing it there is no appearance of ulceration in the coats of the trachea and bron- chiae, but the traces of inflammation are in general very obvious, and sometimes extend, Burserius observes, to the very extremities of the bronchiae. It has sometimes happened, as in more than one dissection recorded by Dr. Home, that no traces of inflammation could any where be observed ; but this is comparatively rare. By squeezing the lungs a considerable quantity of a whitish glu- tinous fluid may sometimes be forced out. In different cases of the cynanche trachealis the lungs assume, according to Burserius, all the different appearances observed after pneumonia, which arc soon to be laid before the reader. Sometimes, however, they are found.* Small polypus concretions are often found in the vessels of the lungs and in the right side of the heart; never, Burserius observes, in the left side or in the aorta. These concretions, I have already- had occasion to observe, seem to be formed in articulo mortis, or soon after death, and the reason of their not being found in this case in the left side of the heart, seems to be, that the blood from * The appearances of the lungs in those who die of the croup, Michaelis ob- serves, are various; sometimes they are sound, sometimes slightly inflamed, sometime there is a sanious matter extravasated in different parts of them, some- times the matter found in them is purulent, and sometimes merely a watery flu- id, the quantity of which is often considerable. CYNANCHE TRACHEALIS. 155 extreme dyspnoea is chiefly collected in the right. It is also ow- ing to the dyspnoea which precedes death, that the vessels of the head are generally found very turgid. The preternatural membrane presents different appearances in different cases. Sometimes, Michaelis observes, it is as thin as pa- per, in other cases so thick that it almost fills up the whole cavity of the trachea. It is often of different thickness in different parts, and the thickest part is sometimes the uppermost and sometimes the reverse. In some cases it is soft and pulpy, in other cases so firm and tough that it will bear maceration in water for several days ; but however tough it is in the trachea, it becomes more tender in the bronchiae, and is always soft before its termination. In some cases it is quite white, in others marked with red spots, and it is now and then uniformly of a dark colour, and sometimes black. Some have thought this membrane possessed a vascular, others, a fibrous structure ; the former opinion appears erroneous, and the latter is not confirmed by general observation, Of the remote causes of the Cynanche Trachealis. The chief subjects of this disease are children, from the time ihey are weaned till about twelve or thirteen. After they are weaned, the younger they are the more they are liable to it. Ij appears to be the most common in marshy countries and near the coast. It is very generally agreed that the croup is not contagious, but many believe it to be hereditary. It resembles the other phlegmasiae, in being most apt to attack those who have already laboured under it. It has been said, how- ever, that after the first attack it generally appears in a milder form.* Cold is the chief exciting cause. It is more frequent in winter and spring than at other seasons, and seems particularly apt to arise from sudden changes in the weather. It is not improbable that certain states of the alimentary canal may assist^in producing it. Underwood, in his Treatise on the diseases of children, ob- serves, that the change from milk to food of harder digestion, is probably sometimes the cause of the croup. The same author alledges that it may be occasioned by fevers or chronic diseases that reduce the strength. * Fee Dr. Alexander's Treajthe on]the Croup. 156 CYNANCHE TRACHEALIS, The acute asthma in its causes as well as its symptoms resem' bles the croup, the same age predisposes to both, and the appli- cation of cold seems the chief exciting cause of both. Among the exciting causes of acute asthma, Dr. Millar ranks a laxity of the solids, food of difficult digestion, and a morbid weakness of the di- gestive organs. Of the Nature of the Cynanche Trachealis. Of the opinion which attributes this disease to an inflaminatiou of the lungs it is unnecessary to say any thing. The first probable opinion was suggested by Dr. Home. " When " there happens," he observes, " a very great secretion of this " coagulable fluid from the glands of the trachea in children, they " are either not sufficiently attentive, or too young to spit it up. " The thinner parts are carried off during expiration, while the " remainder is thickened and compressed by the obstruction which " the narrowness of the glottis opposes to the exit of the air from " a larger canal. Every circumstance, he continues, encourages " its concretion into a solid firm membrane, while tbe more intern- " al parts of the mucus continue still fluid, and the continual seer. " tion of more keeps it separated from the parts below." But Dr. Home explains the conversion of this mucus into pus by experiments of Sir John Priugle, the inaccuracy of which i have already had occasion to notice. We have seen besides, that the membrane may be formed without occasioning symptoms of croup ; which on the other hand may exist without the formation of any membrane. Dr. Rush of Philadelphia, in a letter to Dr. Millar, published in 1770, takes a very opposite view of the subject; so far from agreeing with Dr. Home in supposing the preternatural membrane. to be the cause of all the symptoms, he regards it merely as an ad- ventitious circumstance supervening after the disease has lasted for some time. The disease he regards as'a spasmodic affection. But it appears, from what was said above, that Dr. Rush did not at first properly distinguish the acute asthma and croup. Michaelis has attempted to point out the difference of the na- ture of these diseases ; his opinion of the former nearly correspond? with that of Dr. Rush : with respect to the croup he agrees with Dr. Home irt regarding the preternatural membrane as the cause ; but this membrane, instead of being concreted mucus, is composed, he maintains, of lymph, and is of precisely the same nature with the polypous conceptions found in the heart and large blood-vesseh, CYNANCHE TRACHEALIS. 15: 'Phis opinion he supports at considerable length, and with a •^reat variety of arguments, for which I shall refer the reader to hi-, work. He concludes with the following observations. These circumstances being granted, none can hesitate in ranking the pre- ternatural membrane among the true polypi. It consists of the same matter, has the same figure, and with respect to its being thiner and less compact than polypi generally are, this is to be considered as a matter of small moment; nor indeed i-, the differ- ence constant, nor does it seem of more weight than that polypi are sometimes solid and sometimes hollow. But admitting this membraue to be wholly composed of lymph, from the different circumstances attending its formation and that of polypi, and the different situations in which they are placed we cannot regard them as of the same nature. Besides, if all that Michaelis says were admitted, there would still be the same objec- tions to this opinion as to Dr. Home's. Why has this membrane existed without occasioning symptoms of croup ? Why have these symptoms been observed where no membrane was found ? Dr. Cullen's opinion of this disease is different from any of those mentioned, as the reader will infer indeed from what has already been said. He regards it as arising from an inflammation of the larynx, combined with a spasmodic constriction of the glottis, " Though this disease," he observes, " manifestly consists in an " inflammatory affection, it does not commonly end either in sup- " puration or gangrene. The peculiar and troublesome circum- *' stance of the disease seems to consist in a spasm of the muscles " of the glottis, which, by inducing a suffocation, prevents the " common consequences of inflammation. When this disease tcr- " minates in health it is by a resolution of the inflammation, by a --,<.' ceasing of the spasm of the glottis by an expectoration of " the matter exuding from the trachea, and of the crusts formed " there. And frequently it ends without any expectoration or ar " least with such only as attends an ordinary catarrh." To this opinion, by far the most probable, some objections might be found. Why does the disease chiefly attack children ? What proof is there of the spasm of the glottis ? Dr. Cullen, indeed^ grants that suffocation sometimes happens in consequence of the matter collected in the trachea and its branches. The strongest objection to Dr. Cullen's opinion, is, that traces of inflammation are not always found in the trachea of those who die of this dis- ease. It is far from being improbable, however, that although the -cynanche trachealis consists fn an inflammation of the trachea, the, lob CYNANCHE TRACHEALIS. " patient may die after tbe inflammation is gone, the effusion which relieves the inflammation occasioning suffocation. When we reflect on the means of cure in the true croup, we cannot, I think, enters lain a doubt of its being of an inflammatory nature. Of the Treatment of Cynanche Trachealis. It is unnecessary to give the treatment of the cynanche trachea- lis of adults and that of the croup separately ; we have every rea- son to believe them the same disease, and whether they are so or not, experience has assured us that the mode of treatment in them is the same. The observations made on the treatment of the phlegmasiae in general still apply. It will only be necessary therefore to make such additional remarks as particularly relate to this disease. If we consider the acute asthma and croup as the same disease. the opinion of practitioners concerning the principal means employ- ed are so contradictory, that we shall find ourselves much at a loss what plan to adopt. Dr. Home, Dr. Cullen, and most other writers on this disease speak decidedly of the advantages of blood-letting. Of all the rem- edies employed in this disease, Michaelis observes, blood-letting unquestionably holds the first place. Dr. Rutty on the other hand observes," I have tried evacuations of all kinds ; frequent bleeding " and severe blistering were of no service." And with him Dr. Rush, in his first publication, and Dr. Millar agree. "Itisdiffi- *' cult to discover," says Dr. Crawford, in his Thesis de Cynanche Stridula," in what cases Dr. Millar judged venesection proper." But it is impossible for us to read the works of these writers, and believe that they are speaking of the same disease. Without attending to the imperfect diagnosis which we possess between croup and acute asthma, on comparing together the ob- servations of those who have been most conversant with them, we shall find, that in both wc may be guided in the employment of venesection by the state of the pulse; if it be strong and hard, venesection will be found useful. In the true croup, when the pulse becomes soft and weak, as hap- pens in the latter stage, blood-letting, on which we chiefly rely at an early period, is no longer proper.* In the acute asthma, on the other hand, in which blood-letting is generally hurtful, it is found beneficial if the pulse be strong and 'Home and othersv • CYNANCHE TRACHEALIS. 15* 'hard. There can be little doubt, 1 thiuk, of the disease described by Mr. Russell, in his Crkonomy of Nature, &c. under the name Angina Inflammatoria Infantum, being the acute asthma. let he observed an abatement of the symptoms after blood-letting. Dr. Rush also observes, that blood-letting relieves the acute asthma when it is accompanied with pneumonic symptoms, but when these symptoms do not appear, evacuations always do harm. In the ca- ses described, by Drs. Millar, Molloy, and Putty, in which blood- letting was always prejudicial, the pulse was either natural, or such as would deter from blood-letting in the croup itself. By the state of the pulse, then, we are led constantly to employ blood-letteng at the commencement of the true croup, but not after we have reason to believe that what Dr. Home calls the purulent state has commenced : we are led to employ it very rarely in the acute asthma, but sometimes here also, proportioning the extent of the evacuation to the strength of the patient and hardness of the pulse. While we are guided by the state of the pulse, we ought not to neglect any circumstance tending to establish a diagnosis between the diseases ; an attention to which will confirm the judgment we thus form. After the propriety of blood-letting has been ascertained, in deter- mining its extent we are influenced by a variety of circumstances, which I have had occasion to enumerate, the state of the pulse, habit of body, age of the patient,* &.c. Dr. Home ordered no les- than five ounces to be taken from a child of fifteen months, labour ing under the croup. The pulse still remaining bard, he ordered a repitition of the blood-letting to the same extent on the same day. On the following day he ordered the child to be bled largely with leeches, and these repeated evacuations were followed by the best effects. We seldom, however, find it necessary to carry blood-let tjng as far as this. It has been proposed, as in similar cases, tc let blood from the jugular vein, when it can be readily opened, it i * the best. With regard to catharsis in the croup, if we employ it with [n view to diminish the inflammatory diathesis, the observations made respecting blood-letting are nearly applicable to it. Blood-letting, however, answers this purpose much better, and cathartics are only necessary for the regular and free excitement of the bowels. Dr. . Rush particularly recommends calomel in the croup, and think-6 i* * See the observation* on blood-letting in contim^^ fi.xr- ltiu CYNANCHE TRACHEALIS. possessed of some specific power independently oi the evacuation it occasions. The bark, he says, is hardly a more certain remedy- in intermittents, than calomel in the croup, if a large dose be given at the commencement and small doses continued throughout its course ; and some late writers have recommended a still freer use of this medicine, and trust to it alone for the cure of the disease. There has been some difference of opinion respecting emetics u this disease. Dr. Home objects to them, chiefly, however on theo- retical grounds ; and experience seems to warrant a very different opinion of them. They are employed in die croup with a double- view. At an early period, with the hopes of cutting short the dis- ease ; in a more advanced stage, with a view to expel the preter- natural membrane, which is often brought up by the act of vomit- ing. The reader will find cases related by Michaelis in which this happened. There is no author, however, who gives so favourable a*testimony of the effects of emetics in the croup, as Dr. Craw- ford. In that part of Scotland, called the Carse ofGowrie, he observes, where the croup is very frequent, the constant practice is to give an emetic at the commencement, even before the employ- ment of blood-letting or cathartics, and this practice, he adds, i- not]only safe but very successful, few dying when a timely emetic- has been exhibited. It is generally judged proper, however, to begin with blood-let- ting by which more than one advantage is gained. We both take the earliest opportunity of employing the remedy on which we place"most reliance, and lessen the determination of blood to the bead during the operation of the emetic. There is also much difference of opinion respecting the use of di- aphoretics in the croup ; and the advantage derived from them seems more doubtful. Almost all authors, however, recommend the pediluvium. It is common with nurses, in many parts of Scot- land where the disease is frequent, to immerse the whole body ia warm water as soon as]]the disease shews itself, which sometimes; it is said wholly removes it. Next to the warm bath, nauseating doses appear to be the most useful diaphoretics in the croup, and they are useful we shall find in another way. The acetate of am- monia, and other diaphoretics recommended by authors, do not seem to be of much use. In the disease described by Dr. Rutty" and. Dr. Molloy, which appears to be nearly the same as that described by Dr. Millar, di- aphoretics were the medicines chiefly relied on. Dr. Molloy oh- CYNANCHE TRACHEALIS. 161 ?evves, indeed, that those only recovered in whom he succeeded in bringing out a sweat. Respecting antispasmodics, it would appear, on comparing a va- riety of observations, that the more the disease approaches to the acute asthma, properly so called, they are the more beneficia}. In the well formed croup they seem to be quite useless. " Though " we suppose," Dr. Cullen observes, " that a spasm affecting the " glottis is often fatal in this disease, I have not found antispas- " modic medicines to be of any use." Dr. Millar, on the other hand, Dr. Rush, and others, found them the most successful medi- cines in the acute asthma. Dr. Millar chiefly employed musk and asafoetida, and after repeated trials, he informs us, that he was taoght chiefly to confide in asafoetida, very large quantities of which he found necessary. "An ounce of this gum," he observes, " has sometimes been taken by a child of eighteen months in the " space of forty-eight hours, and almost as much at the same time " injected by clysters, allowance being made for the residue of the " gum which is lost in making the solution." Some of the remedies termed expectorants, are useful in the croup. I have already had occasion to mention emetics and nau- seating doses. Opiates, after the symptoms are allayed by blood- letting, ore often serviceable. By allaying the cough, they ren- der the matter to be expectorated thicker, and consequently the expectoration more easy. Their employment, however, requires caution, both on account of the inflammatory nature of the disease, and because we cannot greatly allay the cough without increasing the dyspnoea. Gum ammoniac and squills have been recommend- ed, but in the inflammatory stage they are too irritating, and after- wards they seem useless. While the inflammatory symptoms continue, the diet should be, very diluent and strictly antiphlogistic. It may be useful when the symptoms run high to abstain from food of every kind for the first twenty-four hours. Nitre is a good addition to the drink. As the patient is generally much reduced, the bark is often ne- cessary to restore the strength, but in the true croup it must not be given till all tendency to inflammation has subsided. The bark may be ;;iven more early in the acute asthma. It is particularly serviceable during the remissions*. Such are the remedies acting on the system in general ; the lo- cal means form a very essential part of the treatment. * See' the observation? of Dr. Millar, Mr. Russell, and other*. Vol. ii 21 162 CYNANCHE TRACHEALIS1. We still find blood-letting the most powerful. If general blood*" letting is not performed from the jugular vein, it is proper to aid its' effects by taking blood from tbe external fauces ; and the local as well as the general blood-letting should be repeated according to the state of the symptoms. After proper evacuations, blisters are of great use. They should be applied as near as possible to the part affected. They do not seem to be of equal use in the acute asthma. Dr. Molloy tells us that their application was attended with no advantage whatever in the cases he saw. Dr. Millar, how- ever, thinks a blister between the shoulders a means of preventing") the recurrence of the paroxysm. Rubefacients have not been much recommended in the croup. Dr Millar found them useful applied to the extremities in the acute asthma. There is,-perhaps, no other form of cynanche in which breath- ing the steam of vinegar and water is so beneficial. In whatever manner it acts, whether by mixing with and diluting the thick mat- ter which clogs the bronchial vessels, or by its stimulating quality increasing the secretion from them, it is found to loosen the coughr to promote expectoration, and relieve tbe dyspnoea. Some recom- mend applying the steam of water externally to the neck. Blis- tering is certainly more beneficial, and both cannot well be em- ployed. From the vicinity of the trachea and fauces, many advise swallowing from time to time some emollient fluid, oil, or mucilage which is preferable because it is less apt to load the stomach. I have seen considerable relief obtained by such means. If smarl doses, however, do not succeed, little is to be hoped from larger ones. It has been proposed in this disease to lessen the proportion of oxygen in the air, from which there is reason to expect considera- ble advantage. When none of the foregoing means prove successful ; and parti- cularly when the dyspnoea greatly increases, bronchotomy is the only remaining chance of relief. This operation is less formidable than it appears, and if carefully performed is generally safe. Dr. Home saw the propriety of it in the worst cases of the croup, and was the first who proposed it as a last resource. Michaelis is bold- er, and recommends it in all cases where the symptoms do not yield readily to other means. He gives the arguments for ami against it at considerable length, for which I must refer to his Treatise. In avoiding the Vulgar prejudices against this operation CYNANCHE TRACHEALIS. 163 fce runs, perhaps, to the opposite extreme, and considers it more trivial than it really is. One caution given by Dr. Crawford is not to be overlooked, that while we are endeavouring to extract the preternatural membrane, both the artificial passage and that by the glottis may be so obstructed as . to occasion suffocation. In the convulsive asthma this membrane is often formed. Here, therefore, if the seat of the disease is in the larynx, bronchotomy will bring more immediate relief with less danger. The use of tonic medicines, the cold bath, a diet of easy diges- tion, a strict attention to the state of the bowels, and guarding against the causes of taking cold, are the best means io prevent a recurrence of this disease.* * From the appearances on dissection which are here stated, and from the symptoms of the disease, there is reason to believe, that the Cynanche Tra- chealis, or croup, as it is called, depends on an affection of the mucous mem- brane lining the Larynx, Trachea, and the whole of the bronchial vessels, which partly by the thickening of those membranes, and partly by the secre- tion of a viscid mucus, excludes the air from the vesicles, where the functions of the lungs are sustained. It is not probable, that the abstraction to the inhalation of air into the lungs, is confined to the larynx, and trachea. We do not often find a single point of the mucous membranes lining parts destined to perform certain functions, affected alone, unless it is produced by some cause purely local in its nature, wluch cannot be the fact in croup ; and as to spasm I have never seen any evidence of it in this, or any other disease affecting the lungs. The suddenness of the attack in diseases of this kind, is analogous to what takes place in other affections of the mucous membranes. The mucous mem- brane of the nose k often affected as suddenly as the coming on of the croup, or spasmodic asthma, and is frequently so thickened, as to obstruct the pas- sage of air through the nose, in one, or both nostrils. Sometimes it is caused by exposure to cold, when the body is warm, and at other times, by an epi- demic catarrh. As the croup is often epidemic, it must depend on some cause which affects many persons at the same time, wliich is in all probability a species of ca- tarrh. That thjs kind of epidemic should affect children at one time and adults at another, is not singular. The pneumonia Typhoidea which was evidently the effects of an epidemic catarrh, affected chiefly adults and those advanced in life, and of a robust constitution. Epidemic Catarrh is a perfect Proteus, in some seasons it affects principally the mucous membranes of the head, and mothers, it attacks the mucous mem- brane of the lungs, as it does in pneumonia typhoidea; and occasionally the same epidemic affects different parts of the system. Respecting the treatment of cynanche trachealis, I have seen many cases of it-in which the pulse did not indicate any active inflammation^ and where bleed- 164 PNEUMONIA CHAP. X. Of Pneumonia. Pneumonia is Dr. Cullen's eleventh genus. It is defined by him, " Pyrexia, dolor in quadam thoracis parte, dyspnoea, tussis." He divides it into two species, the peripneumonia and pleuritis. The propriety of this division we shall soon have occasion to con- sider. SECT. I. Of the Symptoms of Pneumonia. The first sense of uneasiness referred to the thorax and the cough are sometimes so slight as to be almost overlooked, or regarded as nothing more than such as in a greater or less degree frequently at- tend fevers, so that, for some time, the patient is believed to labour under nothing' more than common fever ; he is affected with shiver- ing, often alternating with fits of heat, and complains of thirst and anxiety, the breathing is hurried, the pulse more frequent than na- tural, and the temperature increased. In general, however, this disease makes its attack in a less am- biguous way. A severe pain and cough, with much difficulty of ing gave no relief. Emetics have been more successful with me in this disease, than all other remedies. 1 have seen a single dose of tarter emetic, and of ipe- cac cure the disease ; but we are not to expect this in all cases ; and in orfler to have the full effect of emetics in croup, they should be often repeated. The best emetic I have seen tried, is the infusion of the root of the Sanguinaria Can- densis. A table spoonful of a pretty strong infusion of this root may be given to a child, six years old, and repeated till it operates as an emetic; if the first dose operates, it may be repeated once an hour till relief is obtained. The inhaling of the vapour of warm v inegar, and water, have some effect ; but where it can be effected conveniently, I have thought that keeping the patient immersed in the vapour of warm water for some time was more effectual. The common expectorant and demulcent medicines, seem to have little or no effect. The palygala senega, or seneca, I have used in every form, and in large doses, and cannot say, that I have seen any benefit derived from it. N. S. PNEUMONIA. 165 breathing, and a strong, hard, and frequent pulse, are often the first symptoms. When the pain, and a degree of dyspnoea arising from it, continue for any length of time without cough and fever, the disease, we shall find, is of a different nature from pneumonia. Such, in fact, is an enumeration of all the symptoms of pneu* monia, which are much less complicated than those of many of the foregoing diseases. In considering each of these symptoms separately, we shall find them varying considerably in different cases. The dyspnoea, the most constant symptom of pneumonia, be- comes considerable in all cases as the disease advances; the breathing is often short and frequent, the violence of the pain pre- venting a full inspiration ; or where the pain is either dull or ab- sent, it is oppressed and laborious, accompanied with anxiety and a sense of weight about the praecordia. It is greatest during inspiration, and generally greater when the patient is in some particular posture. Sometimes it is greatest when he lies on the side affected, sometimes the contrary. In many cases he is easiest on the back or breast, and very often the erect posture is. necessary, some degree of which is indeed almost always so. When the inflammation is considerable, the breath is sensibly hotter than usual. The pain, in different cases, has its seat in all the different parts of the thorax. It is most frequently felt about the sixth or seventh rib, near the middle or rather more forwards. It is a belief among the vulgar, that the pain in pneumonia is al- ways in tbe left side ; and it is a common errour not to regard the case as pneumonia unless the pain be in the side. It is very frequent- ly, however, under the sternum, the clavicles, the spine, or the sca- pulae. ' It has been an opinion maintained by the best informed, that instead of the left, pneumonia most frequently attacks the right side. This observation is made both by Van Swieten and Triller.* The latter farther observes, that in this side it is least dangerous. All such observations seem founded on a partial view of the sub- ject. It has been observed, says Wendt.t that when the pain in pneumonia occupies the left side, the danger is greater than when it is confined to the right. I have not, however, found this to be the case, and the number of my patients who died of this disease * Triller de Pleuritide. i Wendt dc Pleuritide, in Sandifort's Thesauri. I6t> PNEUMONIA. »n the right side is only greater by one than that of those who died of it in the left. The pain, like the difficulty of breathing, is most felt in particu- lar postures, w,hich are different in different cases. In most cases it is fixed, sometimes it shoots in various directions, sometimes it only shifts its place, and a change of place from the sides to the clavicles or scapulae has been regarded as a favourable symptom. But Wendt justly observes, that we can make no other inference from it, but that the disease has changed its seat ; I have more fre* quently, he observes, known a pain of the arms to supervene in pneumonia, and this I have always found salutary. The kind and degree of the pain is not less various than its seat. Sometimes it is exquisitely acute, and during inspiration almost intolerable, only differing in its greater severity from the rheumat- ic affection called a stich in the side. At other times it is more general and obtuse, and in some cases rather a sense of weight than of pain. Sometimes it is only felt when the patient lies on the right or left side and makes a full inspiration or coughs ; this case has been termed the pleuritis occulta, because the pain is only felt by an effort. In some instances, however, it is not felt at all, and the practitioner is left to discover the nature of the disease by the other symptoms. There is so little alarming in the appearance 0/ such cases, the patient being only affected with more or less pough, considerable difficulty of breathing, which often prevents his lying down, and a greater or less degree of fever, that the assistance of the physician is frequently not requested till it can be of no service. It is chie#y the different seat, kind, and degree of the pain, which has given rise to the division of pneumonia, which we shall presently have occasion to consider at length, into pleurisy perip- neumony, paraphrenitis, pericarditis, &c. Cough is a very constant, and when the pain is severe, a very distressing, attendant on all inflammations of the thoracic viscera. In some cases it is dry, in others attended with expectoration ; and although dry at the commencement of the disease, it rarely contin- ues so during its progress. The occasional absence of the spitting has given rise to a useless division of pleurisy into dry arid humor- al, which is as old as the days of Hippocrates. The appearance and consistence of the matter spi^ up varies much. At the commencement it is generally thin, becoming thicker during the progress. The prognosis depends much on the kind of cough and the appearance of the matter expectorated, Celsus observes, thai when there is no expectoration, the prognosis. ' PNEUMONIA, 167 Is bad, btit worse when the expectoration is bloody ; the truth of tbe latter part of this observation experience has since called in question ; and although a spitting of much frothy blood is always an alarming symptom, it is now generally admitted that the matter spit up being tinged with blood, which it usually is, if less favoura- ble than an expectoration without blood, affords a much better prognosis than no expectoration at all. The matter spit up being greenish, of a dark brown colour, or thin and acrid, so as to exco- riate tho epiglottis, or sa'nious and fetid, is very unfavourable. A bland, copious,* free, white or yellowish expectoration of a thick consistence, is the most favourable. A vLcid expectoration is un- favourable. The viscid globular sputa, says Huxham, are bad; and Bianchus observes, in his Ilistoria Hepatica, that we cannot always draw a favourable prognosis from the expectorated matter being copious and thick, but on the contrary, that a very viscid expectoration, gradually becoming more so, often portends a fatal termination. It has been an observation from the infancy of med- icine, that much rattling in the breast before the matter about to be expectorated is brought up, is unfavourable. Upon the whole the greater relief the expectoration brings, the better is the prognosis. Every spitting, Wendt observes, which relieves the pain and renders the breathing freer, must be regard- ed as favourable, let the colour oi tbe matter be what it may, green, livid, oreven black.t If, on the other hand, the expectoration ha< been scanty or absent from the beginning ; and still more if it fails during the progress of the disease ; if it is difficult and brings lit- tle relief, we dread suppuration or gangrene. An expectoration of a thin yellow matter is noticed by many writers, which is very unfavourable. It is termed a bilious spitting, and thought by- some to characterize what has been called the bilious pneumonia. of which I shall soon have occasion to speak more particularly. Suppuration is chiefly to be dreaded when the expectoration i.- scanty or absent; a tendency to gangrene when the matter cough- ed up is livid and sanious. *'■ Schroeder justly observes, that when the expector.uion is livid and sanious. the more copious it is, the worse is the prognosis. Schroeder de Pleuritidum partitione, in his Opusc Med. t This observation is to be understood with some- limitation ; a black ex- pectoration may be regarded as favourable, because it gives temporary relief; but it always indicates a bad state of the tones. I do not allude to a blackish blue appearance which the mu--u> of the hings often HS^imes, which is always '"ivnurable. l(*b* PNEUMONIA. The spitting has been regarded as a diagnostic between perip- neumonia and pleuritis, that is, between inflammation of the sub- stance of the lungs and that of their membranes ; but we shall find this diagnostic as fallacious as others. Nothing can be more in- consistent than the observations of authors on this head. Dr. Cul- len in his definition of pleuritis, observes, that the cough although at first dry, becomes moist and sometimes bloody. Wendt re- marks, that when a patient labouring under pleuritis begins to spit, he no longer regards the case as a simple pleuritis, but a combin- ation of pleuritis and peripneumony. Sydenham, on the other hand, speaks of expectoration as a constant symptom in the true pleurisy. Such are the local symptoms of pneumonia and their principal varieties ; but no combination of these constitutes pneumonia with- out the presence of fever. The fever, it is observed above, often shews itself as early as any of the local symptoms, and the latter are never present for any considerable length of time without be- ing attended by the former. If we except the difficulty of breath- ing and cough, we shall find no symptom of pneumonia so constant as a frequent pulse. The pulse at the commencement, as in most other phlegmasiae, is generally strong, hard, and frequent. Several authors have ob- served, that in pneumonia it often differs on different sides of the body. Zimmerman gives a case in illustration of this ; and Cleg; horn says it is often most obscure on the side affected. It was ob- served of simple fever, that the pulse is sometimes oppressed at the beginning, and rises on blood-letting ; the same has been remarked of pneumonia.* But there is a species of pneumonia which comes on with a depressed pulse that sinks on blood-letting, which I shall soon have occasion to notice more particularly. Soon after the commencement the face becomes flushed, the skin hot and dry, the urine sometimes quite limped and in large quantity, which has since the days of Hippocrates been regarded as an unfavourable symptom ; at other times, scanty and high-colour- ed. The bowels are seldom regular, but either costive or too much relaxed. The thirst is considerable, and the tongue often dry, white, and rough. In short all the symptoms of synocha are su- peradded to the foregoing. Idiopathic pneumonia agrees with the other phlegmasiae in be- ing rarely attended with dilirium or coma, if, according to Boer- Huxham and other PNEUMONIA. 1*2 haave, we except those cases which are terminating by suppura- tion. Even in these indeed they are far from being common. Resolution is the only favourable termination of pneumonia; and is generally attended with a copious and free expectoration. It appears a contradiction in terms to say that the termination is by resolution when the matter expectorated is evidently purulent. It has long been taken for granted that the formation of pus is al- ways attended with the destruction of parts, so that the word im- plies not only the formation of pus, but also the ulceration which frequently attends it. Physiologists have been puzzled to account for the presence of pus in the lungs, where it was impossible to trace any marks of ul- ceration. De Hean supposed it to be formed in the blood, and poured out by the exhalents. Dr. Cullen accounts for its presence by the experiments of Sir John Pringle above alluded to.* Those of Mr. Home, demonstrating how readily pus is formed by inflam- ed secreting surfaces, removes the difficulty. If we except a free expectoration, no evacuation more frequently attends the favourable termination of pneumonia than a -flow of sweat ; any degree of ganeral moisture appearing on the skin is favourable ; a sweat seldom fails to bring relief, and if it be univer- sal and copious often carries off the disease ; a sweat that brings no relief, however, is to be regarded as unfavourable.! Hemorrhagy from the nose often brings relief. Hoffman consid- ers it most salutary when it occurs tbe fourth day. It is seldom, however, attended with a perfect crisis. Hemorrhois also, though less frequently, attends the remissions of pneumonia. Many reck- on blood in the sputa favourable, so. that moderate haemoptysis may perhaps be ranked among the critical hemorrhagica of this disease. The appearance of the miliary eruption is favourable when not forced out by the heating regimen, particularly, Allionius^ of> serves, when the disease has arisen from cold. High-coloured turbid urine, depositing a copious sediment, fre- quently, but not always as some alledge, accompanies the resolu- tion of pneumonia. * Introduction to th^ 2d part. t Wendt observes, that if the symptoms do not soon remit, the sweat often proves fruiiless or evcu hurtful. Much sweating, says Quarin, which does not relicv.- the symptoms, is dangerous. And Huxham remarks, that the fluid which the patient drinks, running off quickly by any of the excretories, even by profuse sweating, has ever since the days of Hippocrates been regarded as unfavourable. X De Febre Miliare. Vor.. n. 22 170 PNEUMONIA. Although diarrhoea sometimes brings relief, particularly says Schroeder, at an advanced period, it less frequently does so than the preceding evacuations ; and is upon the whole, particularlv at an early period, to be regarded as unfavourable, except there be bile or other irritating matter in the bowels.* Whatever oppress- es tbe bowels is particularly hurtful (n pneumonia.- Symptoms of indigestion, therefore, especially much flatulence, are unfavoura- ble. In such cases, Schroeder observes, a spontaneous vomiting is often critical. The discharge from the mucous membrane of the nose and fau- ces is also unfavourable. This case is termed by Huxham the ca- tarrhal pneumonia, and he regards its prognosis' as bad. Pneumonia sometimes terminates by inflammation and suppura- tion of the parotid glands, or by erysipelatous inflammation of the ' surface.! It is evident that every metastasis is not favourable, the inflamma - tion may eieze on a part equally more vital than that which it leaves. The liver and spleen are the viscera most frequently attacked in metastasis of pneumonia. A general remission of the symptoms, for the most part, precedes any of the favourable terminations just mentioned. Tbe unfavourable terminations of pneumonia are, suppuration and gangrene, which it has in common with the other phlegmasiae, and certain terminations peculiar toitself. We have reason to suppose that suppuration will take place, if signs of resolution do not shew themselves within four or five days, if there be either no spitting or such as brings no relief, if the symptoms have not yielded to blood-letting and proper medicines, especially if dilirium with rather a soft undulating pulse super- veues. That suppuration has actually begun we know from frequent irregular shiverings following the symptoms just enumerated with- out any manifest cause ; from the pain being mitigated or removed while the dyspnoea continues ; from the pulse becoming fuller, softer, and either slower or more frequent ; from the cheeks and lips looking red ; and from an increase of thirst and fever in the evening. \ * Quarin de Feb. t Inflamed swellings', says Quarin, sometimes appear behind the ears, or on the legs, or oth. r parts, and prove critical in pneumonia. Huxham and others- make similar observations. PNEUMONIA. 171 v We have reason to believe that a collection of matter, which in the lungs is termed a vomica, is formed, when after the above symptoms there is an obstinate dry cough, the respiration being difficult, short, rattling, and more frequent than usual ; when the patient is able to lie only on the side affected; when febrile exa- cerbations return at intervals, particularly in the evening, with red- ness of the cheeks and lips, the dyspnoea cough and fiever being in- creased by eating and exercise ; when the thirst is considerable, and there are sweats towards morning, especially about the throat and forehead, with turbid urine, a palid countenance, waisting of the flesh, and great debility. The peculiar fever (termed hectic) which attends such cases, we shall soon have occasion more pai> ticularly to consider. When the abscess is situated in the most external part of the lungs immediatly under the ribs, we may often perceive a soft swel- ling between the ribs, and a fluctuation may sometimes be distinct- ly felt in it. Many of the foregoing symptoms are not essentially connected with the presence of a vomica. The rattling breathing often aris- es from other causes; in many cases after the vomica is formed the paticit can lie on both sides without inconvenience, and it has frequently been remarked that its formation is often preceded by little or no shivering. Upon the whole, however, the ceasing of the pain, or the pain being changed into a sense of weight, without any of the evacua- tions, which it was observed above frequently attend resolution,* while the cough, dyspnoea, and fever still continue, the pulse loosing its hardness, and the fever assuming tbe form of hectic, leave no room to doubt the presence of an abscess in the lungs. About the seventh day, not the fourth, as some have alledged, i< the period at which, if the disease has continued without any con- siderable remission, we have reason to fear suppuration ; resolu- tion has taken place as late as the eleventh or twelfth day ; byt this is rare. When there are considerable remissions, it may take place at a much later period. It has been remarked that it seldom happens after the fourteenth day ; I have known it happen after the disease had lasted four or f\\c weeks. Except a vomica be situated on the surface of the lungs, so that the fluctuation may be felt externally, in which case the matter may he discharged by an opening made through the intercostal mus- cles, it generally proves fatal. There are four ways in which tlm ' Dr. Millar's Treatise m the Diseases of Great Britain. 172 PNEUMONIA. may happen. It may without bursting occasion hectic fever, which gradually exhausts the strength. Abscesses of the lungs, however, when their sides have become so callous as to prevent ab- sorption, have remained for many years without producing (ever^ or otherwise greatly impairing the health. When the abscess it large, and bursts into the substance of the lungs, it often produces immediate suffocation. When the matter is discharged into the cavity of the thorax, the disease has been termed empyema ; the matter falls down upon the diaphragm when the patient is in the erect posture, occasioning a sense of weight in the lower part of the chest. The difficulty of breathing; (which is now greatly in- creased by lying down, especially on the back) cough, and hectic fever continue, and gradually exhaust the strength. In the em- pyema we may often percieve the fluctuation of the matter in the cavity of the thorax. When the vomica is small, its bursting into the substance of the lungs does not occasion suffocation, but purulent expectoration. An ulcer of the lungs is generally the consequence, and phthisis succeeds, the symptoms of which we shall soon have occasion to consider. It somctines happens, however, in \cry healthy habits, especialjby such as are free from any scrophulous tendency, that the ulcer formed by the bursting of a small abscess in the lungs heals and the patient gets well. An abscess of the lungs sometimes, though rarely, terminates favourably in another way; cases are alluded to by Quarin and others, in which the pus was absorbed, and passed by urine or stool, and sometimes we have reason to believe it has been depos- ited in other parts of the body ; but these are occurrences so rare, that in forming the prognosis they are hardly to be taken into the account. Wendt observes, that when pneumonia terminates by suppuration, the abscess generally bursts before the twentieth day of the disease. It is often, however, delayed to a much later pe- riod. The termination of pneumonia in gangrene, which is very rare, is always immediately fatal. The tendency to gangrene is known from the unusual violence and obstinacy of the symptoms. When gangrene is about to take place, there is a diminutionof the pain» the cheeks become red, the pulse sinks, and the matter expecto- rated assumes, an ichorous appearance. When the gangrene has actually taken place, the pain ceases without any of the salutary evacuations above mentioned, the countenance becomes pale, the pulse still more feeble and intermitting, cold clammy sweats ap- pear on different parts of the body, hiccup, loss of sight, and gen- PNEUMONIA, H3 eral stupor supervene, and the patient soon expires. Dr. Cullen, however, justly observes, that the termination by gangrene is so conjoined with that by effusion, which I shall presently have oc- casion to consider, that their symptoms are hardly to be distin- guished. It is supposed by many that pneumonia may terminate in schir- rus, which is known according to Quarin, by great difficulty of breathing, and a troublesome dry cough remaining after the other symptoms are gone, and much increased by exercise or a full meal; it is distinguished from a vomica by the absence of hectic fever, and the symptoms being'nearly stationary for a considerable length of time, while in the vomica they generally increase. In some cases, however, there seems to remain after pneumonia, a difficulty of breathing and oppression, indicating no fixed disease of the lungs, but mere debility ; this is most apt to happen in nerv- ous irritable habits, and when the disease has been long protract- ed. The terminations peculiar to pneumonia are, suffocation from an effusion of red blood, or of a serous fluid into the substance of the lungs, and hydrothorax the consequence of. an exudation from the pleura. The fatal terminations of pneumonia are generally preceded by an evident increase of the whole, or part of the symptoms, the pain is often felt more generally throughout the thorax, the diffi- culty of breathing is increased, the patient becomes more watchful, or more rarely he is affected with some degree of coma or deliri- um. The cough is more distressing. The matter expectorated mixed with a larger proportion of blood, or brought up with great- er difficulty, either owing to the bronchiae being clogged by the quantity of viscid fluid poured into them, or the increasing debility. Upon the whole, the less difficult the breathing, the less severe the cough, the more copious and free the expectoration, and the greater the relief it brings,, the more regular and firm, and the less frequent and hard the pulse, and the less the strength is reduced, the better is the prognosis. Pneumonia generally proves fatal before the seventh day, some- times as early as the third ; but where death is occasioned by the bursting of a vomica it is commonly much later. Vomica;, it is observed above generally burst before the twentieth day, but, if they are succeeded by an empyema or phthisis, death may be de- layed to a much later period. 174 PNEUMONIA. There are few diseases whose diagnosis is more simple than that of pneumonia, the only difficulty is to distinguish it from cases of symptomatic and false pleurisy, of which I shall presently have occasion to speak. Yet there is no symptom in pneumonia which is not met with in other diseases. Few are more frequent than pain in some part of the chest, cough, more or less difliculty of breathing, and fever ; but where these, or the three last of these, are combined, we are assured of the presence of pneumonia. The diagnosis of this disease is easy, because the symptoms which mark It are few and distinct. Although we succeed in removing the symptoms of pneumonia, the danger is not past, the disease is frequently renewed, and the second attack is often more violent, and almost always more dan- gerous than the first. Wendt even speaks of a recovery from re- lapses as rare, " non semper sunt lethales ;" and Quarin remarks, " Pleuritis recidiva vix curanda." These observations, however, apply only to the more severe cases ; and even in these, I have seen the disease return several times, and yet terminate favourably. SECT, II. 0/ the Appearances on Dissection. O.v inspecting the lungs, the inflamed parts appear reder thai. usual, the colour, Dr. Baillie remarks, being partly florid, and partly of a darker hue, and the pleura covering the inflamed parts is crowded with fine red vessels. " The inflamed state of the "lungs," the author just mentioned observes, " is to be distinguish- tl ed from blood accumulated in some part of them, after death, in " consequence of gravitation. From the body lying in the hori- " zontal posture after death, blood is often accumulated at the poste- •' rior part of the lungs, giving them there a deeper colour, and ren- " dering them heavier. In this case there will be found no crowd " of red vessels filled with blood, nor any other mark of inflamma- " tion of the pleura. Where blood too is accumulated in any part " of a lung after death, from gravitation it is always ofa dark col- " our, but where blood is accumulated from inflammation, portions " of the inflamed part will appear florid." We often find in the substance of one or more of the lobes of the lungs a collection of a greenish yellow pus, sometimes mixed with blood of a brown or dark red colour, and ofa grumous appearance PNEUMONIA. l}S There is sometimes an extravasation of blood in the lungs without abscess,* and sometimes of coagulable lymph. Pus is often found between the folds of tbe pleura, tbe abscesses opening on the surface of the lungs, or the pus being secreted by the inflamed membrane itself ; very frequently in the bronchiae. Portions of the lungs and pleura are soft, and sometimes wholly destroyed, having been as it were dissolved in the purulent and sani- ous matter. There are cases on record, in which portions of the pleura were destroyed, the lungs being entire. This is very rare; and Schroeder and others remark, that it is unusual for the pleura to be affected with inflammation without the lungs partaking of it. The latter around an abscess are generally'more solid than natu- ral in their texture, owing. Dr. Baillie observes, to coagulable lymph being thrown out during the inflammation. This subject I shall have occasion to resume in speaking of phthisis. When the inflamed pleura remains entire, it is often covered with florid spots. On examining the lungs more particularly, we frequently find small lurking ulcers in the parenchyma and the branches of the bronchiae ; sometimes the lungs are indurated in different parts ; and Dr. Clcghorn observes, that they are now and then changed into a hard substance which sinks in water. This increased gra- vity, Dr. Baillie observes, often arises merely from an increased quantity of blood. The aqua pericardii is generally altered either in quantity or quality. In some cases it is much more copious than usual; in *ome, wholly wanting, and the pericardium itself adheres to the heart throughout its whole extent. It ?eems to be this consequence of disease which has given rise to the opinion of the pericardium being sometimes wanting. Like the pleura it is now and then soft and partly dissolved. The aqua pericardii is often tinned with blood, and in some cases wholly consists of a greenish puru- lent matter. W The heart itself, though not often, sometimes partakes of the morbid appearances. Traces of inflammation, extending more or less deeply into its substance, are now and then observed. The inflamed part is more crowded than natural with small vessels, and there is sometimes found in it spots of extravasated blood.f Ab- scesses, ulcerations, and even gangrene, have sometimes, though * Wendt. &c. t Dr. Baillie's Treatise on Morbid Anatomy, p. 1~- I7U PNEUMONIA- rarely, been found in this organ. In some eases, on cutting through its sides, small quantities of pus appear scattered here and there among its fibres. Polypous concretions are found in its cavities and in the large blood-vessels ; the nature of these I have already had occasion to no- tice. The large vessels are sometimes preternaturally distended, and the blood in them is generally ofa dark colour. The lungs often appear considerably enlarged, apparently from their containing a greater than usual quantity of extravasated fluids. Where the pleura is inflamed they are often covered with a soft whitish viscid crust of coagulable lymph, which frequently assumes a membranous form, and is the cement of the adhesions between the folds of the pleura. There is no consequence of pneumonic inflammation so common as these adhesions, they are either occa- sioned by inflammation so slight that it is not attended with the usual symptoms of pneumonia, or they arise also from some other cause, for they are found in many who never laboured under th*e symptoms of this disease. Dr. Monro, in his Anatomical Lect- ures, observes, that he has examined the thorax of few adults with- out finding more or less of such adhesions. Some imagine that the adhesions left by pnemonia are a principal cause of the frequent recurrence of this disease ; except when very extensive, however, in which case they frequently occasion habitual dyspnoea, they are attended with little inconvenience ; and the frequent recurrence of pneumonia is readily accounted for by the tendency to future attacks left by all inflammations, and the exposed situation of the lungs. It is very common to meet with morbid appearances in the abdo- men of those who die of pneumonia. The liver and pancreas are often found indurated, and the former enlarged. There is some- times also induration of the spleen, and very frequently worms are found in the upper parts of the intestines, particularly in the jeju- num. In a very large proportion of incases related by Wendt, limbrici were found in this intestine. The reader will also see similar cases in the 21st Epistle of Morgagni de Sedibus et Causis Morborum. The only morbid appearance usually found in the head is con- gestion, the effect of the dyspnoea. The reader will find it partic- ularly noticed by Dr. Cleghorn and others. PNEUMONIA. IT- SECT. III. Of the Varieties of Pneumonia. It is only lately that pneumonia has been regarded as one dis- ease. By the older writers, and by many even of our own days, particularly foreigners, it has been divided into different diseases, according to the place which the inflammation occupies. When it is seated in the substance of the lungs.vthe disease is termed peri- pneumonia ; when in the pleura, pleuritis ;"frt the diaphragm, pa- raphrenitis ; in the heart, carditis ; and even inflammations of the mediastinum and pericardium are regarded as distinct diseases. Certain combinations of these affections also have peculiar appel- lations ; that of the inflammation of the substance of the lungs, for example, and their investing membranes, have been termed pleurO- peripneumonia or peripneumopleuritis. There is so strong, and in some places so general a preposses- sion in favour of these divisions of pneumonia, that it will be ne- cessary to consider at some length on what observations they are founded, and how far they are useful in practice. Dr. Cullen, apparently more in compliance with the opinions of others than relying on his own observation, has given a place in his Nosology to the division of pneumonia into peripneumony and pleuritis. The former he defines, pneumonia, with a pulse not always hard, sometimes soft, the pain dull, the respiration con- stantly difficult, and often only to be performed in the erect pos- ture, the face swelled and purple, the tongue generally moist, and the matter expectorated sometimes bloody. Other authors give a similar, though in some respects a different account of peripneu- mony. In the peripneumony, Hoffman observes, the inflammation is seated more deeply in the substance of the lungs, the pain is more dull and extends to the back and scapulae, the breathing more laborious, and the pulse soft. The pulse, Dr. M'Bride observes, is less hard than in the pleurisy. Burserius gives a fuller account of the diagnostic symptoms of peripneumony than any other writ- er 1 have met with. It is attended, he observes, with such diffi- culty of breathing, that the patient is in danger of suffocation, which often obliges himtosit as much as possible in the erect posture, the breathing is frequent, the breath very hot, the cough at first dry or attended with a very scanty expectoration, which is frothy, tfiin, crude, yellow, or mixed with blood ; at a more advanced peY Vol. n. 23 578 PNEUMONIA. riod becoming more considerable, thicker, belter concocted, anr> more easily spit up. The patient complains of a weight, oppres- sion, and distension throughout the whole chest, but there is no pain except such as can hardly be felt, confined chiefly to the re- gion of the sternum and spine, and often only perceived when the chest is strongly agitated by coughing. The cheeks are red and swelled, the eyes prominent, the head pained, the tongue parched, at first yellowish, afterwards covered with viscid mucus, at length black and chopped. These symptoms are accompanied with a great desire for cold drink and fresh air, and a full and sometimes undu- lating soft pulse. Sometimes, however, he observes, contrary to the assertions of most authors, the pulse is strong and hard; at other times it is irregular and intermitting, or very small and quick. The patient lies with more ease on the back than on the sides. The debility is very great. The urine is sometimes pale and clear, at other times daik-coloured and turbid. Many other ac- counts of peripneumony nearly in the same tenour might be adduced. There are but two purposes which can possibly be served by thus separating from the other symptoms of pneumonia, and cal- ling by a particular appellation the symptoms just enumerated. It must either teach us to ascertain the seat of the disease with more accuracy, or enable us better to suit the modes of practice to the various svmptoms of pneumonia. Let us consider how far it an- swers either of these purposes. In the first place, it may be remarked of the different account. of peripneumony which have been quoted, that their authors are far from pgreeing among themselves what its diagnostic symptom^ are, and this is a point which must remain to be settled, although it be found that some of the foregoing symptoms always indicate an inflammation of the paranchyma of the lungs, and demand a treatment different from that necessary in other cases of pneumonia. However different the characters of peripneumony given by dif- ferent writers, they seem all to agree that an obtuse and pretty general pain, or the total absence of pain with a great degree of dyspnoea, are its chief characteristic marks ; and on comparing these characters we find, that there is no other symptom generally regarded as characteristic of peripneumony. A similar observation may be made respecting pleurisy. Wer»- we to examine 'he different accounts of authors, we should find but very few symptoms which all agree in regarding as peculiar to this form of the disease. Dr. Cullen says the cough is moist at certain periods of pleurisy. Wendt says it is always dry. Th«. PNEUMONIA. 179 • a general abstract of what has been ascertained res- pecting it. The pneumonia putrida is of two kinds, idiopathic and symp- tomatic. The latter is most generally known ; it consists merely in pneumonia supervening on the typhus gravior. This is theonly putrid pneumonia acknowledged by Dr. Cullen. But it seems as- certained by the observations of other writers, that there is an idi- opathic putrid pneumonia, a primary influinmation of the lungs, accompanied with strongly marked typhus. And this form of the disease has been epidemic, while the more common form did not appear. The idiopathic putrid pneumonia, when exquisitely form- ed, appears with nearly the same sjmptoms as the symptomatic, only the inflammation is present from the commencement. It has been observed to attack chiefly those of debilitated habits, frequently such as labour under chronic diseases of debility ; the scurvy for example. Very young and very old people and females. Cappel* observes, are most subject to it. He also thinks, that the presence of tubercles and an ill formed thorax dispose to it. The occasional cause* of the putrid pneumonia are nearly the same as those of the phlegmasiae iu general, with the addition of contagion, for the contagious nature of this form of the disease seems on all hands admitted. Among its causes Capped enumerates impurities of the primae vise, and observes, that the common pneu- monia may be changed into the putrid by heating or very debil- itating medicines. The usual treatment of pneumonia is here inadmissible. All who were bled, Tissot observes, died. The general plan of treat- ment seems to be a combination of that of typhus with the local treatment of pneumonia, particular care being taken to clear the primae viae. /The employment of these means, however, require? much attention. Local blood-letting, C'ppel thinks injurious ;' others are ofa different opinion, and it is only, perhaps, where the debility is very great, that it is inadmissible. There are instances of bleed- ing from scarification of the side in this disease becoming so obsti- nate and profuse as to baffle every attempt t« stop it till the patiew I * Cappel De Pneumonia Tvphode. 184 PNEUMONIA. expired. Dry cupping, where the debility is very great, is Used with more safety, and often brings relief. When the tendency to gangrene and hemorrhagy is great, blisters are improper. They sometimes occasion gangrenous sores. Cappel advises the plaister to be removed as soon as the skin is in- flamed. - Fomentations, cataplasms, volatile linaments, warmth applied in every other way, and watery vapours drawn in with the breath, have been particularly recommended. These are safer means than blisters, but, in proportion as they are so, less effectual. With respect to general means, there is none of equal efficacy with the bark and wine ; the former is particularly recommend- ed by Quarin and others. The expectoration is often increased, says Quarin, and the patient, as it were, snatched from death by the bark, especially if the fever, as sometimes happens, shews a tendency to remit. The bark, however, does harm if given incau- tiously. If the inflammatory symptoms are considerable, Cappel observes, the bark is hurtful. Wine is of more general use. There is no case of putrid pneu- monia where it may not be employed with advantage. The quan- tity must be proportioned to the degree of debility. I have sev- eral times seen pneumonia complicated with the low fever of this country, and in one instance had the satisfaction to see a case of this kind which was supposed to be hopeless, terminate favourably, in consequence of the repeated application of leeches and blisters to the chest, and the free use of wine. The ammonia acetata ha« been found useful when the skin is very dry. Antimonials given cautiously are of service when the expectoration is difficult. The seneka is not to be depended on. Cappel recommends camphoir in small and repeated doses, but relies more on musk, which he gave in very large quantity where other means had failed. Mer- cury he thinks useful if given so as to prevent its occasioning much evacuation. Opium has been recommended for allaying pain, pro- curing sleep, relieving the cough, and stopping diarrhoea. The observations made on the diet in typhus are applicable here. It is, however, of still more consequence to guard against every thing that deranges the primae viae. This observation will be illus- trated by what I am about to say of the symptomatic pneumoniae. It has just been observed that irritation of these passages may ex- cite the putrid pneumonia. This is particularly the case when it appeals as a symptomatic affection in typhus. PNEUMONIA. 183 Whether symptomatic or Idiopathic, it is often accompanied with the symptoms peculiar to bilious pneumonia, which we shall presently have occasion to consider. In the putrid pneumonia, therefore, clearing the alimentary canal forms an essential part of the treatment. Tbe effect of cathartics, however, is unfavourable, and it seems very generally admitted, both on this account and because the chief cause of irritation seems in most instances to be lodged in the stomach, that emetics are the best means Of remov- ing it. It appears from the observations of some, says Quarin, that the life of the patient has been saved by the operation of an emetic. Emetics, says Cappel, are useful if the stomach be op- pressed and in other cases at the commencement, especially if the disease arise from Contagion. They are also useful when the expec- toration is copious and viscid, but we must be cautious, he adds, that we do not occasion purging instead of vomiting, which is at- tended with great danger. Schroeder also remarks, that if the emetic in putrid pneumonia occasions purging instead of vomit- ing, the disease generally proves fatal. On this account, the for- mer recommends ipecacuanha in preference to other emetics, as it maybe given with safety in large doses. Other writers make similar observations. When we have succeeded in removing the rymptoms of putrid pneumonia, it is proper for some time to pur- sue a tonic plan in order to restore the strength, and prevent a re- lapse.* It will be necessary to consider at some length certain species of symptomatic pneumoniae. Mistaking them for the idiopathic disease has. often been attended with fatal consequences. The reader will find many species of symptomatic pneumonia mentioned in tbe 102nd, 105th, and 106th pages of Dr. .Cullen's Nosology, and many more in the Institut. Med. Prac. of Burserius. But those which chiefly demand attention are the pleuritis or pleu- i-i-dync verminosa, or stomachalis, as Bianchusl" calls it, and the ■" F<.r an account of thu purtrld pneumonia the reader may consult Camer- urius de Pleuritide Maligna, in the 2d vol. olllaller's Disput. ad Morb. Hist. Ct Curat. Pertinent. Do Prevalj on Vomiting in Putrid Pneumonia, in the .ame volume. Quarin de Febribus, Huxham's Treatise on Peripneumonia, :-ichro<-J.-.-'s Trothe De Pleuritidum Partitione, in his Opusc. Med. and a Treatise, De Pneumonia Typhode, by Ludov. Christoph. CviT, Cappel. *n;s!rria Hcpatica of Bianchus. Vol. ii. °.< 186 Pneumonia. pleuritis biliosa, which Dr. Cullen seems to have overlooked. It Will also be necessary to make a (ew remarks on bastard pleurisy. Any thing which greatly deranges the stomach and bowels, ofJ ten occasions a pain in some part of the side, accompaniedj with more or less dyspnoea ; which has sometimes been mistaken for pneumonia. The difference is apparent, however, on examining the pulse, which is natural, or nearly so ; not to mention that here there is not necesarily any cough. But it appears from many ob- servations that a certain degree of irritation of the stomach and bowels is capable of producing all tbe symptoms of pneumonia. Iri the 43d, 44th, and 45lh, sections of Morgagni's 21st Epistle, the reader will find the pleuritis verininosa treated of at some length. He mentions one case, in which all the symptoms of pleu- risy were well marked, that terminated by a bloody vomiting which brought up a lumbricus. We might in this instance attribute the' relief obtained rather to the loss of blood than the expulsion of the worm ; but he refers to a paper of Pedratto on the pleuritis vermin- osa, where the relief obtained by the expulsion of worms from the stomach and intestines, particularly from the former, is unequivo- cally proved. It there appears, that all who vomited worms or passed them by stool recovered, while those who did not died. All the com- mon modes of treatment in pneumonia failed, anthelmintics alone were successful. The cases related by Pedratto are the more remarkable, that they did not appear in solitary instances, but as an epidemic attacking the inhabitants of a whole town and neigh- bourhood. While the expulsion of worms from the primae viae immediately removes the disease, it is impossible for us to believe that inflamma- tion seem difficult to explain how they may occasion pain in the side and has existed. Fever frequently attends worms, and it does not dyspnoea. If it be asked, says De Haen,* in what manner worms occasionthe symptoms of pleurisy without the actual presence of inflammation in any of the thoracic viscera, it is not difficult to an- swer the question. Some parts of the intestines, he observes ri^t as high as the 9th, 8th, 7th, and even the 6th, rib. Now if lum- brici, he continues, adhere to these parts, biting and tearing them, must they not occasion a pain resembling that of pleurisy ? Will not the wounded intestine be pained more acutely when it is pres- rdbythe diaphragm in a full inspiration, and if the respiration *Mcthod Medoneli. PNEUMONIA. 187 lie thus hurt, can we suppose that there will not be some degree of cough .' This explanation is very intelligible. There is one cir* cumstance, however, overlooked by De Haen, which tends to in- volve the nature of the pleuritis verminosa in much obscurity. In those who die of this disease, the same traces of inflammation arc found in the thoracic viscera ai in those who die of other forms of pneumonia. Pedratto found, on examining the thorax of one of his patients, the whole lungs swelled on the left side, which had been the seat of the pain ; they were inflamed and of a dark colour, and in the interior part there was a collection of white ichorous matter. The pleura was every where inflamed, livid, and marked with red points. The intercostal muscles partaking of the disease. Thus it appears that the false pleurisy, arising from affection of the pri mae via;, for we have no reason to believe that there is any thora- cic inflammation at the commencement of such cases, is in the pro- gress of the disease changed into a true pleurisy. If the presence of worms in the intestines is capable of exciting pneumonia, it is not surprising that they aggravate its symptoms, and therefore that all who labour under this disease die if the offending cause is not removed. The bilious pleurisy seems only to differ from the pleurits ver- minosa in the difference of the irritating cause. Here the pres- ence of bile in the intestines produces nearly the same effects which that of worms in the former case does. It has been observed, that the pains in the bilious pleurisy are wandering, the cough dry and troublesome, with little and difficult expectoration, the beat of the pulse quick and frequent, the watching constant, the anxiety great. In this case, Burserious observes, blood-letting hurries on the fatal termination, which often happens on the fifth day when it has been employed, but is otherwise generally delayed to the 7th, 9th, or 11th. The less useful blood-letting is in pneumonia, Schroeder observes, the more reason there is to suspect an ac- cumulation of bile in the stomach and intestines. The accounts we have of this species of pneumonia are less dis- tinct than those of the pleuritis verminosa. This arises from diseas- es of different kinds having gone by the name of bilious pleurisy, for some authors have termed every case of pleurisy bilious in which the spitting is thin and yellow. The bilious pleurisy is best characterised by the various symptoms indicating the presence of bile in the primae viae ; the patient having on former occasions been subject to bilious affections, and their causes having been ap: pUed, assist the diagnosis. 188 PNEUMONIA. The chief symptoms denoting the presence of bile in thestom-. ach and intestines are a sense of oppression, nausea, and a bitter taste, with giddiness and pain in the head, and an unusual foetor of the faeces, which are often of a very dark colour. These symp- toms sometimes do not appear till after one or two blood-lettings. We must have recourse to emetics and cooling and mercurial ca- thartics. When the cause of irritation is removed, the pneumonia often ceases ; even nature, Schroeder observes, frequently relieves this disorder by spontaneous vomiting and purgingv " In this month of February, a pleurisy which had something un- " common in it was very frequent in Fife, and at first proved fatal " to many. It began with shivering, head-ache, trembling, and " bilious vomiting, which after two days were succeeded by a pun- " gent pain among the short ribs, difficult breathing, and a short " cough. The thirst of the sick was moderate if they were not " blooded, but when as much blood was taken as the degree of pain " seemed to require, the thirst increased, as likewise the sickness " of the stomach, till they fainted. The pulse quickly sunk on " drawing blood, which was brownish, yellowish, or greenish, and " hardly coagulated. The sick slept none through the whole " course of the disease, which continued for twenty-five or thirty-two "days. When blood-letting was omitted or used very sparingly, " and vomits were given early and afterwards repeated with refri- " gerent*, laxatives, and expectorants, as far as the stomach would " bear, tbe patient generally . recovered. Very strong emetics " did not answer."* The reader, however, will find some difference of opinion res- pecting the employment of blood-letting in the bilious pleurisy. Bianchus, regards it as pernicious only at the commencement. From what was said concerning the pleuritis verminosa, which is applicable to the case before us, it is more than probable that the lungs in bilious pleurisy are not inflamed at an early period, which may account for blood-letting being less successful then, than when the disease is farther advanced. It is asserted by Cleghorn, respecting bilious pleurisy, that much blood-letting was necessary. and that, after trying many remedies, this, with proper means ta clear the stomach and bowels, was found the only successful mode of treatment. The only way in which we can account for such opposite opinions is by supposing something different in the nature of the different epidemics. And, indeed, it must happen, that in * Edinburgh Medical Essays, Vol. 5 PNEUMONIA. iffil different epidemics the tendency to inflammation of the lungs, from the season of the year, state of the weather, or some less evident cause, will be different ; and the greater this tendency, it is evi- dent the sooner will the inflammatory symptoms succeed the bil- ious, and the more early, we have reason to believe, may blood- letting be employod with advantage. It has been observed, that the blood in this form of pneumonia, does not shew the buffy coat, but it is more than probable that this observation does not univer- sally apply. It is remarkable that bilious pleurisies sometimes obey the tertian type.* When this happens we can hardly suppose that real in- flammation exists. Cappel observes, that real pneumonia never. as some have supposed, assumes a regular intermitting form. It is observed above, that we frequently meet with schirrus of the liver, pancreas, or spleen, in those who die of pneumonia, and more frequently, we have reason to believe, than can be ascribed to chance. May not schirrus of these parts', particularly that of the liver, by an irritation similar to that which produces the pleu- ritis verminosa and biliosa, sometimes excite pneumonia ? In a large proportion of the dissections of those who died of pneumonia, given by Morgagni, the liver or spleen was found indurated or otherwise unhealthy, or some of the other abdominal viscera, par- ticularly the pancreas and ovaria were diseased. Pneumonia is comparatively rare in young children. Dr. Beardsley, in the Me- moirs of the Newhaven Society, however, mentions an instance of pn infant dying of this disease, in whom the liver was found to be schirrus* I have several times, indeed, seen pneumonia evident- ly induced by this cause ; and in one of my patients who died of schirrus liver, the lungs adhered to the parities of the chest throughout their whole extent. The other cases of symptomatic pneumonia requires little or no comment. The pleuritis arthritica I shall have occasion to men- tion when I speak of gout. The pleuritis morbillosa was noticed in the Chapter on Measles ; there is nothing particular either in its symptoms or mode of treatment. The pleuritis hydrothoracica ap- pears in general with little pain but much dyspnoea, and it is best relieved by repeated blisters applied to the chest, and small doses of calomel, digitalis, and other diuretics. The pneumonia phthi- sica,that inflammation of the lungs which forms the first stage of phthisis, has, though with little propriety, been ranked among <* Bianrhu?. Ilistoria Hcpatica lW PNEUMONIA. the symptomatic pneumonia. We shall soon have occasion to con« sitler it at length. The disease which has been termed the bastard pleurisy, is nothing more than ?n inflammatory affection of the intercostal mus- cles, producing an acute pain of the side, increased on inspiration. It is generally attended with little or no fever, and scarcely vith any cough. An inflammation of the intercostal muscles often spreads, as I have myself repeatedly witnessed, to the pleura and lungs, producing a true pleuiisy. Thus we find a case related by Huxham, in which some of the muscles of the thorax were wound- ed, from which, the inflammation spreading to the viscera, the pa- tient soon laboured .under all the symptoms of pneumonia. But whether bastard pleurisy be the sole disease, or combined with pneumonia, its presence may always be detected by the in- crease of pain which takes place on the contraction of the inflamed muscles. The patient generally complains of soreness on pressure in the seat of the pain. The bastard pleurisy, for the most part, yields to local means, pr these combined with sodorifics. SECT. IV. Of the Causes of Pneumonia. The strong and plethoric, who use much exercise, and readily digest their food, are most subject to pneumonia. The least sub- ject to it are those of a relaxed and weakly habit, bad digestion, and indolent disposition. It has been an observation from the in- fancy of medicine, that those who complain of acidity of the stom- ach are little subject to this disease. It is most common in middle life or rather later; Dr. Cullen says between 45 and 60, and in winter and spring, particularly the latter. It is generally the more frequent, the colder, moisler, and more changeable the weather. Huxham says he has seen the same epidemic in low warm situa-? tions near the sea prove only a catarrhal fever, in more exposed situations a true pneumonia. According to the observations of army physicians, however, all extremes of weather, whether very cold, very warm, very dry, or very moist, predispose to this dis- ease,* As in other phlegmasiae every thing which conduces to * £ee the observations of Dr. D. Monro, Sir John Pringle, Ac, Pneumonia. 1&1 plethora, full living, indolence, repelled eruptions, n'ppres.ecd ex* cretions, even drying up an issue, or healing an old sore, may have the same effect. Of the exciting causes of pneumonia the sudden or partial ap- plication of cold, especially when the skin is damp, is the chief. I have seen a fatal case of pneumonia from going into a cold bed while tbe skin was damp from exercise. Many of the predispos* ing causes applied suddenly and to a great degree act as exciting cause:-. Such are tbe causes which pneumonia ha3 in common With the other phlegmasiae. Those which are peculiar to it act immediately on the lungs ; v iolent exercise forcing the blood too rapidly through them, violent coughing, receiving acrid vapours with the breath, oth- er diseases of the thoracic viscera, asthma, hydrothorax, callosity of the pleura, &c. to which we may add, as we have just seen, certain diseases of the abdominal viscera. Adhesions of the pleura are generally ranked among the causes of pneumonia. It is only, however, when very extensive that they seem capable of exciting this disease. No phlegmasiae is more easily renewed in those who have for- merly laboured under it. Hoffman says he has seen the same per- son attacked with pneumonia four or five times within a year. It is frequently epidemic, but never it is observed by Morgag- ui and others who have been most conversant with it, contagious. ns some have supposed. This observation, however, as appears from what was said of the pneumonia putrida, only applies to the common form of the disease-. SECT. V. Of the Treatment of Pneumonia• The treatment of pneumonia, like that of the ether phlegmasia- may be divided into general and local. It differs but little from that of the phlegmasiae which have been considered ; the chief difference arising from the nature and im- portance of the organ affected. The first remedy employed is general blood-letting, which should be carried far enough either to relieve the symptoms while the blood flows, or occasion a tendency to syncope. It is supposed by many, that bleeding from the arm of the side affected is most beneficial. Dr. Cnllen does not seem to think b- Pneumonia. this opinion groundless. It may be safely asserted, however, thai letting blood from the side affected is not of such importance as to make it necessary, when it is more convenient to let it from the* other. Our view in letting blood from the arm is fo diminish the vis a fergo, and this is done equally well from whatever vein the blood is taken, provided it is of the same capacity and equally near the heart. Werlhoff has even gbrie sO far as to assert, that in one instance he had seen the blood drawn from the side not affected natural, while at the same time blood drawn from the side affected shewed the buffy coat. Other physicians, however, have maintained, that the side not affected is that from which blood should be taken in pneumonia. The reader will find an account of the disputes on this subject in Van Swieten's Commentary on Boerhaave's 890th Aphorism. In many places they were conducted with great ac- rimony, and in Portugal an edict was issued by government pro- hibiting any physician from letting blood iu pleurisy from the side affected ! It was a custom among some of the old practitioners, to open the arteries of the hand in this disease ; that which lies between the thumb and forefinger was generally chosen. Dr. Friend* observes, that Galen was the first who recommended this mode of blood-let- ting in pneumonia. Gesnerus, in his Epistle to CrattO, and some Other writers, have maintained, that there is no part of the arm from which it is proper to let blood, and that the patient can only be saved by drawing it from the foot. On such observations any comment is unnecessary. When the jugular vein can be readily struck, it is of advantage to take the blood from a vein which pours its contents into the thorax. Boerhaave considers it of so much consequence that the blood should be drawn off as suddenly as possible in this disease, thut he not only advises it to be taken from a large orifice, but that the patient should endeavour to quick en its flow by breathing quickly and coughing. The propriety Of which may be questioned. There are few cases of pneumonia which yield to the first blood letting. For even where it gives most relief the symptoms gen erally soon return, and demand a repetition of the remedy. If it be found, says Boerhaave, on repeating the blood-letting that tbe buffy coat has disappeared, we are warranted to dissuade * History of medicine, from the days of Galen to 'ho beginning of the six teenth century. PNEUMONIA. 193 irom the further use of the lancet. And the reader will find sim ilar observations made by others. But Dr. M'Bride has justly ob- served, that this is only true when the symptoms at the same time abate, for in many cases the buffy coat is never seen, and in many, he might have added, it disappears long before the inflammation yields. The appearance of the blood, however, is not to be overlooked, the diminution of the buffy coat is always a favourable sign, and it often happens that there is no occasion to repeat the blood-let- ting after it disappears. * Triller,* and some other respectable writers have advised, in repeating the blood-letting in this disease, to take the blood from different parts of the body. The arm of the side affected he recom- mends as the best place for the first blood-letting, for the second, he considers the foot of the same side the proper place, and for the third, the other foot. Little need be said of tii'w conceit; the reasons which determine Gur choice of the vein in the first blood- letting are of equal force in repeating the remedy. It has been said, that blood-letting in pneumonia is improper af- ter the fourth day. It is now very generally admitted that although it is most effectual when employed within the first three or four days ; it must be employed, if the symptoms are well marked, and the strength will bear it, at any period of the disease. When the symptoms have occasionally remitted, I have known blood-letting in the second or third week attended with the best effects. We must be careful not to repeat it after suppuration has commenced, which is known by the symptoms above pointed out. The reader will find many stating the quantity of blood which must upon the whole be lost in the cure of pleurisy. In adults, says Sydenham, pleurisy is seldom cured with the loss of less than forty ounces of blood. It is evident, however, that no general rule can be laid down. The repetition of the blood-letting, as wrell as the quantity to be drawn at each blood-letting, must be deter- mined by the state of the symptoms and the strength of the patient. It is a favourite opinion, that as soon as spontaneous evacuations, which may prove critical, take place, all artificial evacuations should be discontinued, as tending, it is said, to disturb the salutary efforts of nature.f * Trilleri Opusc. Med. et Med. Philol. t See the 8G9ih Aphorism of Boerhaave. Dr. Millar'-; Account of the Dis- "ase* "I'Great-Britain, i-c. Vol. ii. 2F> 194 PNEUMONIA. When a spontaneous evacuation relieves the symptoms, ther-t Is no occasion for blood-letting, and it is proper at all times as much as possible to save the patient's strength ; but when such evacuations bring no relief, or when they do to a certain degree bring relief, but the symptoms are still such as warrant blood-let- ting, their presence must not defer us from it; nor does blood-let- ting, cautiously employed, tend to interrupt a free expectoration or oiber salutary discharges, but frequently promotes them. There is no disease, however, in which an ungaurded use of the lancet is not attended with danger; and during spontaneous evac-' nations, which relieve the symptoms, in proportion as there is less occasion for profuse blood-letting, it is the more injudicious. If too much blood is taken away in pleurisy, says Hoffman, the ex- pectoration will be impede.1, the obstruction confirmed, and spha- celus mav ensue. It was observed above, that when the disease ha£ been tedious, and the strength much reduced, the matter pour- ed into the bronchiae sometimes accumulates in such quantity as to occasion suffocation. But although the debility induced by blood-ietting produces neither suffocation nor gangrene, it may prove tbe cause of death by giving rise to other diseases. In pneu- monia it is frequently followed by hydrothorax, sometimes by asthma, phthisis, or any other disease of debility to which the pa- tient is^predisposed. When a tendency to hemorrhagy appears in pneumonia, it is by many judged better to promote the hemorrhagy than to draw blood from other parts. If bleeding from the nose, or haemorrhois occurs, we are advised to increase the flow of blood by fomenta- tions, and applying leeches, and in the former case, by irritating the nares. If, however, the hemorrhagy thus increased does not Soon relieve the symptoms, we must have recourse to blood-letting in the usual way. In severe cases the hemorrhagy is rarely such as to induce us even to delay venesection. Some difference of opinion has arisen concerning the employ- ment of cathartics in pneumonia ; some use them for the purpose of increasing the effects of blood-letting. There is the same ob- jection, however, to this practice in pneumonia as in the cases which have been considered, with this in addition, that a spontaneous diarrhoea is generally hurtful in this disease. It is true, indeed, that in the case of spontaneous diarrhoea, the injury may proceed rather from the irritating matter which occasions it, than from the diarrhoea itself. Experience, however, seems not to warrant a freer employment of cathartics in pneumonia, than is necessary to support a due action of the bowels. PNEUMONIA. 19b Except in cases immediately connected with the state of the /Stomach, emetics are very generally regarded as hurtful in pneu- monia ; but nauseating doses, particularly antimonials, are the most valuable of all medicines in this disease, tending more than any other to promote expectoration and relax the skin. The advantage derived from spontaneous sweating has induced many to recommend more powerful sudorifics, but these have not answered the expectations formed of them. I have already had occasion to observe, that the effects of spontaneous sweating sel- dom attends that produced by art. It sometimes happens that even spontaneous sweating, particularly when it is partial and clammy, serves no other purpose but that of reducing the strength. It must then be cautiously checked, by diminishing the allowance of fluid and removing part of the bed-clothes. In like manner the advantage derived from a free expectoration has led to the use of the various medicines termed expectorants. Few of them, however, are well adapted to tbjs disease. The gums, and even squills, by their irritation increase the febrile symp- toms, and render the cough tighter. When the inflammation is nearly subdued, however, and the bronchiae are clogged with .a viscid secretion, they are often, particularly squills, of great ser- vice, promoting expectoration, and relieving both the cough and sense of Oppression,. The ammonia also is sometimes serviceable in promoting expectoration -towards the decline of the disease. But while the inflammation lasts, if we except nauseating doses of emetics, we find no expectorants so useful as mucilaginous mix- tures, and watery vapour received into the lungs. It was once a prevalent opinion, that the advantage derived from mucilaginous medicines arises from their being received into the mass of blood and conveyed to the lungs, where, it was supposed they render the matter about to be expectorated ofa proper con- sistence. This hypothesis led to forcing the patient to take large quantities of them, which, by oppressing the stomach, often did more harm than good. It is now pretty generally admitted, that a principal effect of these medicines is that .of besmearing the fauces, thus allaying the irritation which keeps up the cough, and prevents the matter poured into the lungs from remaining there till it has ac- quired a due consistence,* without which it cannot be freely ex- * It seems to be a law of the animal oeconomy, that while secreted fluids re.* main in any of the cavities, the absorbents are constantly employed in taking ■ip the thinner parts. 196 FNEUMONIA. * pectorated. To answer this purpose they should be given tre- quent'y. They seem also to be of service in lining the stomach and bowels, and thus preventing irritation. As might be expect- ed from this view of them, they are found most serviceable when the expectoration is too thin. When this is the case, opiates, if the state of the inflammatory symptoms admits of their use, are the most powerful expectorants. Their operation is similar to that of the foregoing, but as they act by lessening the sensibility, their effects are more certain. There is some differemce of opinion respecting their employ- ment in pneumonia, whether for the purpose just mentioned, or that of allaying pain. It appears from the observations of foreign writers, that on the Continent they are frequently employed with the latter intention. In young people, says Hoffman, small dosei of opium combined with nitre and diaphoretics may be given for the purpose of allaying pain, but in advanced life, where the juices are thick, they render the expectoration more difficult. The practitioners of this country almost wholly confine the use of opium to the latter stages. When the difficulty of breathing and fever have abated, the cough remaining, with more or less pain and watchfulness, gentle opiates are employed with safety and, often with great advantage. Watery vapour is chiefly useful when the expectorated matter is viscid and tenacious. The vapour has been impregnated with a variety of articles, onions, which are among the best, a variety of herbs, honey, &c. Vinegar has been particularly recommended. Dr. M'Bride advises a large spunge dipt in vinegar to be held close to the mouth and nostrils. It is needless here to repeat what has been said of the use of sa- line medicines, particularly the saline draughts and nitrate of pot- ash, which are always useful when the heat is much increased. All agree respecting the best regimen in pneumonia ; it should be strictly anti-inflammatory. All kinds of animal food and heating fluids must be avoided, and the diet should consist of light vegeta- bles with much dilution. The temperature of the patient's room should neither be so high as to increase the rapidity of the circula- tion, nor so low as to run the risk of increasing the inflammatorv affection of the lungs, which a very cold air is found to do. A tem- perature of about 60 degrees is the best, and it is of consequence that it should be kept as uniform as possible. It is hardly necessary to observe that all kinds of exercise '•bould be avoided. Some, in PNEUMONIA. '^ed, have advised the patient to be as much out of bed as he c.n easily bear. In this practice, however, there is much risk, and^, little advantage to be expected from it. The reader will perceive that, if we except the means for allay- ing the cough, increasing the expectoration, and clearing the pri- mae viae, there is but one view ir the general means employed in pneumonia, namely, to diminish the vis a tergo. It appears from what was said above, that certain medicines possess this power independently of any evacuation. The digitalis is the only one of this class which has obtained much attention. In the trials I have made with it in the phlegmasiae, I have generally been dis- appointed in its effects. Although we succeed by it in lessening the force of the circulation, we often find the inflammatory symp- toms but little relieved. This may be readily accounted for by what has been said of the nature of inflammation, for if inflamma- tion arises from the power of the capillaries bearing too small a proportion to the vis a tergo, it is evident that a means which equally impairs the action of all the vessels, will not succeed in restoring the due ballance between them. We have reason to be- lieve that the digitalis is a means of this kind, that it does not act by impairing the vigour of the heart and larger vessels alone, but eqally of every part of the sanguiferous system. It is more than probable that lessening the proportion of oxygen in the air would be a powerful means of relief in pneumonia. The most important of the local remedies employed in pneu- monia are local blood-letting and blisters. The former is tbe chief resourse when the patient's strength is so far reduced that he c;m no longer bear general blood-letting, and it is chiefly under such circumstances that it has been employed. But it would appear, from the observations made on the treatment of the phlegmasite, that the purposes served by general and local blood-Jetting are not the same ; that the one is better calculated to relieve the local con- gestion, the other to diminish the vis a tergo ; from which it is evi- dent, that wherever the symptoms are, considerable advantage will arise, from combining these modes of blood-letting. Relief will be more speedily obtained, and the extent to which it will be neces- sary to carry the general blood-letting will be lessened. In all the phlegmasiae, we have seen, when the fever is consider- able tbe use of blisters must be delayed till the symptoms are mit- igated by proper evacuations. This precaution is most necessary ■n those phlegmasiae in which the pulse, as in pneumonia, is most 198 PNEUMONIA. uniformly strong and hard. The period proper for the applica- tion of blisters must vary therefore according to the effects of bloodT Jetting. It is proper before their application that the hardness of the pulse should be considerably lessened. The blister should be pretty large and applied immediately over the seat of the pain, or if there is no pain on the anterior part of the thorax. If the symptoms do not readily yield, it is proper to support the discharge from the blistered part, or to apply a sucT cession of blisters, which is preferable. It is necessary to apply them to some part of the thorax, little or no advantage arising from their application to more distant parts. Fomentation of the pained side is a very ancient practice, and was recommended by Hippocrates before blood-letting. At pre- sent, however, it is little relied on, the benefit derived from it sel- dom compensating for the trouble it occasions. It is still recom- mended by some foreign writers. In bastard pleurisy, which is nothing more, we have seen, than an inflammatory affection of the intercostal muscles, the relief derived from fomentations is very considerable, and this has probably contributed to their being em- ployed in pneumonia. As the pain in pneumonia is often aggravated by the motion of the ribs, it is recommeVided by Boerhaave and others to wrap a roller round the thorax, by which considerable relief is sometimes obtained. A very few observations respecting the means to be employed ♦when any of the unfavourable terminations of pneumonia have tak- en place, will be sufficient, for little can be done. If the patient recovers after an abscess is formed in any part of theMungs, he owes his safety more to the accidental seat and size of the abscess,'and the favourable state of the habit, than to any means we possess. If the abscess evidently points outwards, I have already had oc- casion to mention the propriety of opening it. When it burst into the substance of the lungs, if it is not large enough to occasion suffo- cation, it sometimes, in very favourable habits, takes on the heal- ing process, the purulent expectoration ceases, and the patient is 'soon restored to health. In by far the majority of cases, however, the abscess confines to form matter and hectic fever comes on, it then constitutes the last stage of phthisis pulmonalis, a disease we Bhall have occasion to consider at length ; and medicine is of little avail. Nor can it do more where the abscess has burst into the cavity of the thorax forming the empyema ; in this case, indeed, it PNEUMONIA. 199 has been proposed, that the matter should be evacuated,* as in the case of abscess pointing externally, but here the operation pro- misses but little, nor, as far as I know, has it ever been successful. It sometimes happpens, we have seen, that closed abscesses of the lungs remain for a long time without materially impairing the health. It is only necessary in such cases that the patient should avoid with care all causes which may renew the inflammation. Gangrene of the lungs is uniformly hopeless. It is probable, indeed, that although we had means of checking the gangrene, the hemorrhagy which constantly attends it in this organ would always prove fatal. Plans of cure, however, have been proposed. Boer- haave, in his 902d and 903d Aphorisms, lays down what appears to him the most probable. They are evidently dictated by hy- pothesis, and their being generally abandoned is a sufficient proof of their inefficacy. Neither Boerhaave, nor his commentator indeed, give a single case in which they were put in practice. Can it be supposed that the application of the actual cautery to the side can be of any avail when gangrene of the lungs has taken place ? And Van Swieten, in adducing the authority of Aretaeus in favour of the practice, seems to have fallen into an error, for it does not appaar that it was recommended by him as a means of checking gangrene, but lessening the inflammation, with which view it might certainly be of use ; nor is the suggestion of Dr. Millar at all more likely to be of service. " When in pneumonia, gangrene has taken place," he observes, " little can be expected from medicine. If any thing " can save .the patient it is a liberal use of the peruvian bark."' He forgets that there is uot even time for the trial. It is observed above, that pneumonia has sometimes, though rare- ly, terminated in a callus or schirrus of the lungs. This termination is le.=s unfavourable than the foregoing. It is, however, extremely obstinate, and generally continues to harass the patient for the re- mainder of life. Medicine seems to have little effect; by a mild dipt and regular exercise the symptoms may often be mitigated. When pneumonia terminates in hemorrhagy of the lungs, if there is time for the use of medicine, the mode of treatment is the same as in other cases ofhaemoptysis. It sometimes happens that pneumonia leaves the patient so much debilitated that he has not sufficient strength to cough up the phlegm which attends the resolution of the inflammation, and evep Boerhanv. Aphor Aph. 99d 200 PERIPNEUMONIA NOTHA. suffocation has ensued. Here we must have recourse to blisters ind the more stimulating expectorants, the fetid gums, squills, an- ammonia. CHAP. XL Of Peripneumonia Notha. Dr. Cullen in his System of Nosology, regards this disea -• merely as a variety of pneumonia, and it cannot be doubted that it often is nothing more than inflammation of the lungs considerably modified by peculiarity of habit. Sometimes, however, it hoj much less of thb appearance of pneumonia, and upon the whole, dif- fers from it so materially that notwithstanding what Dr. Cullen says of it in the above work, he found it necessary in his First Lines to treat of it separately. Inlaying before the reader the symptoms of peripneumonia notha, I shall give a view of the disease as it appears When it differs uiost from pneumonia, and then point out in vvhnt manner it insensibly assumes more of the appearance of this disease, till it is difficult t< say by which name it should be called. SECT. I. Of the symptoms of Peripneumonia j\'otha. The peripneumoia notha often makes its attack with symptom. so similar to those ofa common catarrh, that it is hardly to be dis- tinguished from it. In other cases it comes on with languor, rest- lessness, some degree of cold shivering, or chills alternating with fits of heat, without being accompanied with catarrhal symptoms. As the disease advances, which is generally without much fever !he patient complains of dyspnoea, much anxiety, and a sense of op- pression and tightness about the precordia. A cough generally comes on at an early period, attended with an expectoration ofa white viscid frothy matter, which is rarely tinged with blood. The cough often becomes very Violent, attended by head-ach, in many cases very severe, and generally much aggravated during coughing, giving a sensation, to use Sydenham's expression, as if the head were torn to pieces.. This symptom is peculiarly char- acteristic of the disease. PERIPNEUMONIA NOTHA. 201 Vomiting is frequent at an early period, especially when the cough is violent, by which it is often excited. The matter thrown up, as in simple fever, generally consists of a viscid insipid mucus. Sometimes there is no cough. In this circumstance, and the occa- sional violence of the cough as well as the head-ach, and vomiting, it differs essentially from the true pneumonia. It chiefly differs from it, however, in the febrile symptoms, being generally mild and often wholly absent, the pulse at no period being more fre- quent than natural, except when hurried by the cough, the tongue remaining moist, and the functions in general seeming but little deranged. The urine, however, i* generally high-coioured and turbid, and even where there is no fever, the blood frequently shews the huffy coat. ,, The fu act ions of the mind are in general but little disturbed. A considerable degree of vertigo, however, frequently attends, accompanied with much flushing of the face, and sometimes drow- siness approaching to coma. There is often no pain in the thorax, or it is so trifling that 'be patient never complains of it; he some- times describes itas^an obscure dull pain which is rather trouble- some than severe. There are few diseases in which the prognosis is more difficult than in the peripneumonia notha, for when we see little appear- ance of danger a sudden exacerbation often takes place and proves fatal.* And this now and then happens at the very time when a considerable abatement of the symptoms has afforded hopes of re- covery. In most cases, however, death is preceded by a more severe train of symptoms. The dyspnoea increases, a degree of coma supervenes, the face becomes hippocratic, the nails livid, and the voice hoarse and inarticulate, the patient complaining of great anx- iety and sense of oppression ; the limbs at length become cold and the vital powers gradually sink. \^ien the peripneumonia notha terminates favourably, it is still more generally attended, than the true pneumonia, by a copious and free expectoration ; and if there be any thing which affords a just prognosis, it is the state of this symptom. The greater the debility, the more oppressed the lungs, and the less free and copi- ous the expectoration, the worse is the prognosis. * See the observations of Boerhaave, Cullen, and Lieutaud, and the 11th and other sections of the 21<=t Epistle ofMorgagni de Causis et tedious Mor- borum. Vol.. If. ?G 202 PERIPNEUMONIA NOTHA. On reviewing the foregoing account of the peripneumonia notha,' the reader will readily perceive how easily it may assume the form of the true pneumonia. If a cough attend the peripneumonia notha, which is neither violent nor attended with vomiting, and the febrile symptoms run higher than usual, it is not possible to distin- guish it from this disease, or rather it must be regarded as a case of true pneumonia, and on dissection it will be found that the lungs are actually inflamed. Dissection, indeed, has very frequently detected inflammation when the symptoms were those of well- formed peripneumona notha, as appears from cases related by Morj,- gagni and others. In many instances, however, no traces of in- flammation can be found, and the disease seems almost as much allied to catarrh as to pneumonia, and runs into it by degrees equally imperceptible. The ancients, indeed, seem to have con- founded it with catarrh.* SECT. II. Of the Causes of Peripneumonia Notha. -This is one of the diseases which has been accurately described only in later times. " A disease under this name," Dr. Cullen ob- serves, " is mentioned in some medical writings of the sixteenth " century, but it. is very doubtful if the name was then applied to " the same disease to which we now apply it. It appears to me, " that unless some of the cases described under the title of catarrh- " us suffocativus be supposed to be of the kind that I am now to- " treat of, there was no description of this disease given before " that by Sydenham, under the title I have employed here." In- the following paragraphs, he observes, that, after Sydenham, Boer- haave is the first author who in a system noticed it as a distinct^ disease, and that, notwithstanding the remarks of Lieutaud, who with confidence affirms that the diseases described by Sydenham and Boerhaave under the title of peripneumonia notha are differ- ent, he is of opinion, that not only the disease described by Syden- ham and that described by Boerhaave are the same, but that, that described by Lieutaud himself is not essentially different from them. And nobody, I think, who compares the accounts of this disease given by the foregoing writers, and distinguishes the accidental from the essential symptoms, can hesitate to agree with Dr. Cullen.- * F.lier de Cog. et Cur. Morb. PERIPNEUMONIA NOTHA. 203 The peripneumonia notha is most apt to attack those advanced in life. Women, and others ofa delicate habit are less subject to it than the robust. It is common in the full and phlegmatic, espe- cially those who have indulged much in the use of fermented li- quors, particularly distilled spirits, or have fallen into a bad habit of body from other causes. Those who have been subject to ca- tarrhal affections, who are indolent, Qjiarin observes, and whose diet is too nutricious, are particularly subject to peripneumonia notha, and may be attacked with it at an earlier time of life than that at wliich it usually appears. Like the true pneumonia, it seems often connected with the state of the liver, which is proba- bly one reason why those addicted to the use of fermented liquow are subject to it. The exciting causes of peripneumonia notha are similar to those of the phlegmasia?. It is most prevalent in marshy countries, es- pecially when the air is cold or liable to sudden changes of tempe- rature ; hence spring and autumn are the seasons at which it chiefly prevails, and it is equally occasioned by a change from heat to cold, or the contrary. It is frequent, during the prevalence of contagious catarrhs, which in the predisposed frequently terminate in peripneumonia notha ; and may be excited by the various irritations of the lungs, which were mentioned as occasional causes of pneumonia. Some remarks on the nature of peripneumonia notha, which, from what has just been said, seems to differ so essentially from the phlegmasia;, may be judged proper. Its nature, however, seems at present but ill ascertained. We appear, indeed, to class under this name diseases of very different natures ; or I would rath- er say, that the disease, which goes by this name, comprehends all the various gradations, by which pneumonia and catarrh insensibly run into each other. It is not difficult to conceive that secretion into the bronchice may take place capable of impeding or even interrupting the of- fice of the lungs, without inflammation. But such cases should be distinguished from the effects of inflammatian ? Dr. Cullen, and some others, indeed, maintain, that a degree of inflammation con- stantly attends this disease, while others run into the oppisite opin- ion, and deny that it ever is of an inflammatory nature. When the peripneumonia notha is exquisitely formed, the inflammation is cer- tainly of a very languid kind. The chief difference between the true pneumonia and the peri- pneumonia notha arises, perhaps, from the greater laxity of fibre in 204 PERIPNEUMONIA NOTHA. those who are subject to the latter, in consequence of which the et fusion being copious either wholly removes tbe incipient inflamma- tion or prevents its becoming considerable. If such be the case, it would appear from what was said in the Introduction to the Se- cond Part respecting the nature of the profluvia, that the peripneu- monia notha belongs rather to this order of diseases, than to the phlegmasiae. SECT. III. Of the Treatment of Peripneumonia Notha. The treatment of this disease varies in different cases according as the symptoms approach more or less to those of the true pneumo- nia. When the inflammatory symptoms are considerable, the treatment of the two diseases differs chiefly in degree. From the tendency to effusion, however, in all cases of peri- pneumonia notha, and the peculiar habit of body in which it ap- pears, blood-letting must be employed with great caution. It is sometimes proper, indeed, to begin with a moderate blood-lettinjr, but after the inflammatory symptoms have to a certain degree yielded, it is advisable to attempt the cure by an attention to diet, proper expectorants, and local evacuations alone. There are few diseases whose treatment is more perplexing, the inflammatory symptoms often indicating one set of means, while the tendency to effusion points out another of very opposite effects. We must stu- dy with care the nature of the symptoms and the habit of body. and obviate that tendency which seems most to threaten danger, but in such a way as shall tend as little as possible to increase the opposite train of symptoms. Boerhaave, in one passage recommends blood-letting, and in another dissuades from it, as, even while it brings immediate relief, eventually increasing the disease ; and Sydenham, who in most cases made so liberal a use of the lancet, acknowledges the bad ef- fects of the repetition of blood-letting ,n peripneumonia notha. Catharsis is a safer evacuation. Dr. Cullen thinks the little advantage'derived from it in the true pneumonia a strong argument against it here. Sydenham, on the other hand, assures us that, con- trary 1o what happens in the former disease, the free employ- ment of cathartics is useful in peripneumonia notha. The result pf general experience, however, seems to be, that mild cathartics; PERIPNEUMONIA NOTHA. 205 not too frequently repeated, and clysters* only, are proper ; for although it is of great consequence to prevent irritation of the primae viae, much evacuation by the bowels seems to be hurtful. Reasoning from the practice in true pneumonia, we should be led to very erroneous conclusions respecting the propriety of emet- ics in this disease. In peripneumonia notha, says Lieutaud, espe- cially if it be accompanied with nausea, an emetic often brings im- mediate relief. " Full vomiting," Dr. Cullen observes, " may often be repeated, and nauseating "doses ought to be costanfly employed." The benefit derived from emetics and nauseating doses seems chiefly to consist in their increasing the expectoration, on the state of which, we have seen, the event of the disease gener- 'ally depends. Nor is their tendency to promote sweat, which, if general and not profuse nor brought out by heating measures, is for the most part favourable, to be overlooked. The more stimulating expectorants are better adapted to this disease than to the true pueumonia. Opiates must be employed with great caution. They act, we have seen, by interrupting for a time the efforts \o expectorate, which, when the secretion is copious and the strength much reduced, has often proved fatal. Little is to be expected from the medicines termed pectoralia, which were once much recommended in peripneumonia notha, ground ivy, hyssop, &c. When the urine is scanty, diuretics are often serviceable. They are much recommended by Lieutaud and other writers of authority ; and some of the milder kinds should always, perhaps, form part of the treatment, when the effusion is such as to oppress the lungs. With regard to the means of obviating debility, wine is found to increase the inflammatory tendency less than the bark, and it is of- ten the more necessary in this disease, as the subjects of it are fre- quently such as have been accustomed to the free use of fermented liquors. Sydenham has justly observed, that the sudden abstrac- tion of the habitual stimulus is often in this disease attended with the worst effects. When the inflammatory tendency is great, how- ever, both fermented liquors and tonic medicines are inadmissible. As the fever then runs higher and the disease is more rapid, the change of diet is less felt in the more chronic cases. Irritating ar- ticles of food, and such as are of difficult digestion, are improper in all cases. 14. Eller De Cog. et Cur. Morb. 200 PERIPNEUMONIA NOTHA. Such are the general means employed in peripneumonia notha. The local remedies hold a higher place than in the treatment of true pnenmonia. In the more inflammatory cases, as \re dread the effects of gene- ral, we endeavour to supply their place by a more assiduous use of local evacuants. Of these, local blood-letting and blisters are still the chief. The latter are useful in all cases. As in true pneumo- nia, they should be confined to the thorax. Blistering the legs, re- commended by Eller and others, appears to be of comparatively little use. Fomentations of the chest are still less useful here than in pneumonia.* i * There ca:. be no reasonable doubt, but the disease discribed by Dr. Cullen, and other European authors, under the name, Peripneumonia Notha, is the same which has prevailed in this cr;mtry within the last five years, under the name Pneumonia Typhoidea ; and there is reason to believe, that the tame disease appeared in Athens, lon'~ before Sydenham's time, though it had not then re- ceived the name of Peripneumonia Noth.t. Adam», in hi? Book on morbid poisons, quotes one of the ancients, who men- tions a disease, which appeared in Athens, of which he save, that the disease was ushered in by a catarrhal fever; and that it resembled pleurisy, being at- tended with violent pain in the side, extremely mortal, and yielding to no rem- edies. As Adam's Book on Morbid Poisons, is not now within my reach, I can- not quote him more particularly, but when I read it, my impression was, that it was the same disease which wc now call pneumonia typhodea. So far as I know, this disease made its first appearance in New-England, in the winter of 1812.- In the winter of 1813, it prevailed to a great extent throughout all the New- England slates, in the state of New-York, and in Canada. Since that time, it has continued more or less, in various parts of the eastern states, and has ex- tended even to some of the southern states. The greatest number of cases here, ocourred in the Winter and spring months ; but it has occasionally appeared in the summer and autumn. What the author has said respecting those who are most liable to be attacks ed by this, disease, corresponds precisely with our own experience of the pneu- monia typhoidea.—But as to local situation, I have not learnt, that the disease iias been influenced by it, either as to number attacked, or its violence. The discafr has; been equally prevalent on the plains, and on the mountains; on the banks of river?, and in (he neighbourhood of standing waters : It has also ap- peared with ail its violence in the immediate vicinity of the sea. Respecting the exciting causes of pneumonia typhoidea, and the circumstan- ce of persons tending to fix it on them.... During the winter in which this disease was most prevalent, there was a catarrhal affection which prevailed very gener-; ally, and those persons who had the disease, often complained of a catarrhal af- fection for some time previous to the attack; and the immediately exciting causes of the disease, was frequently some great bobily exertion, and exposure to cold. But this disease within the last five years, has been too general, and too similar in all the cases of it, to admit of the supposition, that it depended on Carditis anp^pericaudit-. sot .If CHAP. XII. Of Carditis and Pericarditis. En'Oucu has already been said of carditis and pericarditis to •convince the reader that any particular consideration of them is unnecessary. Were we possessed of a diagnosis between them and inflammation of the lun^s, it would prove o£litt!e use, the treat- ment in all being the same. accidental causes, or that its differing from coramen pncumonickatTectioH, 'de- pended on the difference in die habits, and constitutions of patients. Pneumonia typhoideu must be considered asa true epidemic, shewing as littlu variety in different cases, as epidemics generally do, and as to its peculiar can;e, it is enveloped in darkness, like the causes of all other epidemics. The parts of the body affected by pneumonia typhoidea, are chiefly the mu- cous and serous membranes. It was not confined to the membranes and viscera of the thorax, but occasionally it attacked the throat and fauces, preventing de- glutition for a time. Sometimes it attacked both the i:u\n:t and thoracick vit- acra j and in others it was confined to the thorax. The viscera of the abdo- men were evidently more afifected in this disease, than in common pneumonic!: inflammation ; and in some instances, die serous membranes of the abdomen ■-■•ere affected in a similar manner to that of tbe thoru;, that is, on dissection. they v-.-ere f.uind coated with a membranous substance. I have said iLat in the pneumonia typhoidea, the mucous and serous mem- branes were the principal seat of the disease. This affection could be caflcd nothing else, but inflammation ; yet it was very different irom phlegmonick i:- fl&mmation, as it seldom, if ever suppurated, and always produced uu exudation of coagulable lymph, and serous fluid on the serous membranes, when diey wcru affected, and they were always found affected in those cases, where the bodic* of those who died of the disease were inspected. The disease also attacked the mucous membrane of the broschial vessels, i f educing a secretion of a dark chocolate colour. bathe pneumonia typhoidea, the parts of the body principally affected, were the mucous membrane of the throat and bronchial vessels, the serous membrane covering the viscera of the Uiorax, and abdomen. This affection of Uie serous and mucous membranes was inllammatious, bearing more resemblance to erysi- pelas, than-to phlegmonick inflammations; seldom, if ever, suppurating, but al- ways producing an exudation on the surface of those membranes. The mem- branes affected, were found coated with a membranous substance, andaquaii- lity of serous fluid was found ia the cavity. The mucous membranes of the bronchial vessels, secreted a fluid of a dark chocolate colour; In some cases, entire blood was discharged from die bronchial vessels on the first attack; and in a few cases, the mucous expectorated was not discoloured. Tbe difliculty of breathing was generally very great; this arose from two causes, viz. from the morbid xcrrti.u of viscid matter Li the bronchial ve^-els, 20t> CARDITIS AND PERICARDITIS. It is remarkable, that inflammation of the heart and pericarui um sometimes exists without betraying itself by any symptom. Abscesses and ulcerations of these parts have been found after death where none of the usual symptoms of inflammation* had appeared. Why inflammation sometimes exists in these organs, unaccompanied by its usual symptoms, it is impossible to say.— * See the Dissections of Bonnetus Morgagni, and otiiers. which excluded the air from the vecicles, and from Uie severe pain in the side, "wing probably to the affection of the serous membranes of the diorax, which rendered it difficult to enlarge the thorax in inspiration. The heat of the system was not very great, and the capillary vessels on the oUier parts of die body, did net seem to sympathize with those of the lungs, so much as they do in other inflammatory affections. The pulse also was less af- fected, than I had ever seen it in acute diseases of that danger and magnitude. fn many cases the pulse continued soft, full and not very frequent, till nearly the close of life ; and in a few cases it was preternatura'ly slow; in one case, it was below forty strokes in a minute, the patient was comatose, and almost in- sensible, and yet he recovered. The skin was generally moist, and it was not difficult to make the patients sweat; some sweat profusely through the whole course of the disease. The tongue was coated, but the mouth was not very dry, nor the thirst great. The appetite for solids was lost. The mental faculties generally remained unim- paired, till the close of life, except in a few cases, where the patient was coma- tose. Death happened from the third to the fourteenth day, but more died on the fifth day of the disease, than any other; in a few cases, life was protracted to a much longer period, even to five or six weeks, but in those cases, the lungs seemed to have suffered an irreparable injury in the violence of the disease, but vere left in such a state, as to enable them to sustain life for a time. In one in- stance the paracentesis was performed on the thorax five weeks after the at- tack, and a quantity of serous fluid was discharged which gave some temporary relief ; but the patient finally sunk under the disease. The proper mode of treating this formidable disease, has not yet been settled among the physicians of diis country. While some insist on bleeding, consider- ing it, as the most important remedy, others consider it as fatal. In die comnieiu ement of this a Auction, there were some circumstances which seemed strongly to indicate venesection, such as pain in the side, which was oft- en very severe ; and the countenance was frequently flushed, and in all cases where I saw blood drawn, it shewed the buff on the surface, after standing some time, in as great degree, as I had ever seen. A patient over seventy years of age, a strong and robust man, was bled five times. I saw the blood that was taken at the fifth bleeding, which was about twelve hours before his death; the blood on standing separated and showed much of die coagulable lymph on the surface. The circumstances, and symptoms, that contra-vindicated bleeding, vy^re a soft, and oftentimes a weak pulse, not much accelerated, and though it was CARDITIS AND PERICARDITIS; 209 In considering the other phlegmasia;, we shall find similar cases in which the inflammation existed in organs of greater sensibility than the heart and pericardium. II-v ing considered all the phlegmasiae in which the inflammation is seated in the head, neck, and thoracic viscera; we are now to consider those in which it attacks the abdominal viscera. V sometimes pretty full, yet it had not that hardness, nor did it meet the finger with that force, which we generally find in cases of pneumonic inflammations. The first bleeding where it was practiced, did not bring that relief, which was expected by the physician; for though it sometimes mitigated the pain in the side, and rendered respiration less laborious, and difficult for a time, yet those symptoms soon returned with their former violence, and when the bleeding was repeated again and again, even to the fifth time, or until the patient died—this was the course of it. This account, however, must be considered as true, only in a general point ol view, for there were exceptions, in a few cases, the symptoms appeared like tho.-e, which wc have been accustomed to meet with. i:i common cases of pneu- monia, and the patient was recovered by repeated bleeding. I was engaged in attending patients sick with the pneumonia typhoidea, the greater part of the winter, and spring of 1813 ; during that period, I bled about ten patients, and every patient which I bled except one recovered. In one case I advised to re- peat the bleeding to the third time, and it terminated favourably. This account without further explanation, appears greatly in favour of bleed- fat', but it remains to be toll.', that the greater part of the patients, whom I saw had been visited by other physicians before I was called, and many of them had been bled, and on some it had been lvp.a'.e d, before 1 was consulted. This was partic- ularly the case, when the disease fir?t appeared ; as it did not prevail much in iny neighbourhood, I hud a pretty fair opportunity of seeing the effects of bleed- ing without practicing it myself. 1 have mentioned that I bled about ten pa- ti .-.'it - during the prevalence of the disease ; it should however, be known diat those cases were not of the worst kind, and that I attended more dian ten where blecdin;-was not indicate J, and cases of appaiently more daigc-r than those where bleeding \\ .is practised. Upon the. whole if I were to :.ive an opinion respecting the propriety of t'lecdiug iu t!i^ pneumonia typhoidea, it would be, that in a majority of eases, it was not indicated by tha state of (he pulse, and when practised in such ca- -e.-, it was not succcs-u.1; a:.d on the other hand, there were case3 in which, it was indicated, and practised to advantage; even in those cases where h!Vi6d-ietting was ineffectual, the,death of the patieut was not always to bo ''ributed to the lo-.i of biood, but to the peculiar nature, and violence of the d^casV;, which often i.i a lew hones wrought such a change in the organ ei [■'■-piration, as put the patient beyond the reach of any remedies, with wliich we a:e acquainted. Eineticks w^ro useful in alr.iest «->*-ry case, and so far as I am capable oi '.ldgin.'. Ipecacuanha had better effect ihon Tartar Em: tic. The use of tar- ;ar er.mJic incase^ where venesection was not indicated, te: n.ed to prostrate :V- strength, laid : 'c no censible roiitf. Vol. ii. 27 210 CARDITIS AND PERICARDITIS. The inflammation sometimes seizes on the whole of the peri- toneum ; the phlegmasia is then termed peritonitis. It is defined by Dr. Cullen, Fever, with pain of the abdomen, increased, by the erect pos ture, and unaccompanied by the symptoms peculiar to the other abdominal phlegmasia?. The peritonitis, however, seldom exists without the inflamma- tion's spreading in a greater or less degree to the stomach and in- testines, nor does inflammation of the latter often exist without ex- tending to the peritoneum. There is hardly room, therefore, for regarding the peritonitis as a distinct disease. When it does ap- pear as such, it may easily be known by comparing the symptoms just enumerated with what is about to be said of those of the other abdominal phlegmasiae, and the mode of treatment is the sam< as in inflammation of the stomach and bowels. As the abdominal viscera were more affected in pneumonia typhoidea, than in ordinary cases of pneumonic inflammation, so cathartic medicines were more useful; but I did not find the drastic cathartics so safe as those of a milder class. Calomel by itself, or combined with Rheubarb was perhaps the best. This, it was necessary to repeat often, in such doses as to keep up a moderate catharsis. When Calomel could be used so as to afl'ect the mouth, it was salutary; but in many cases the progress of the disease was so rapid, that before the mercurial action could be excited, the case was decided. The violence of the pain in the thorax, and extreme difliculty of breathing called loudly for opium ; and when opium was combined with such medicines as determine to the surface and administered in moderate and repeated doses, it was evidently useful. One of the best forms of opiates was the Dover's powder with a small quantity of Calomel. Blistering on the thorax was very important. The blister to be effectual, must be large and repeated through the whole course of the disease. Some of these medicines, which have been called expectorants, were evi- dently useful, such as Squills, Polygala Senega, or Seneca, Aristolochia Ser- pentaria, or Virginian snake rook, small doses of Ipecacuanha &c.; but the demulcent and balsamic medicines were not so far as I could judge of any use. Some medicines which have been considered as diaphoreticks, I used with good effect, (viz.) tic old and neglected medicine called Contrayerva, given in substance by itself in large doses, or combined with Camphor. I saw but few cases, where the powerful and diffusible stimulants, as wine, alcohol and external heat, were required, and those were cases in which the patient became comatose with slow pulse, and cold extremities ; in such cases I have seen ardent spirits combined with water, and given hot, with the addi- tion of Laudanum, have the happiest effect and apparantly rescue the patient from death. X. hasa, and the vomiting frequently ceases as the diarrhoea come* on. Resolution, a tendency to wliich, as in other phlegmasiae, is known by the general mildness of the symptoms, and particularly by their yielding to the proper remedies, is the only favourable ter- mination of gastritis. If the symptoms are severe and do not suf- fer remissions, the period of resolution is generally past within twenty-four hours. In less violent cases, and when considerable remissions take place, it may happen after the disease has lasted for many days. A tendency to suppuration, which is a rare termination of gas- tritis, is known by the symptoms continuing without any consider- able remission, and at the same time with no great degree of vio- lence for one or two weeks longer. When an abscess is formed there is a remission of the pain, generally preceded by rigours, GASTRITIS. 213 But a sense of weight about the precordia and much anxiety harass the patient, a change of symptoms analogous to that above de- scribed indicating suppuration in pneumonia. The febrile symp- toms which attend all internal suppurations are the same. They are at first considerably milder than those which accompany the inflammatory stage ; in a short time, however, if they do not sub- side, they begin to suffer regular exacerbations, and by degrees, a.-rsume the form of hectic fever, of which I s"hall soon have occa- sion to speak at greater length. The danger of an abscess in the stomach is evident. It gen- erally proves fatal unless it opens into the stomach, in which case the matter is discharged by vomiting and stool, and the ulcer sometimes heals.* In the Memoirs of the Academy of Paris, for the year 1704, the reader will find a case, in which, although the abscess burst into Ihe stomach, the patient died in consequence o{ the ulcer left by it. Ellerf relates a similar case in which the patient lived several years after the formation of the ulcer. Such cases sometimes terminate suddenly by a fatal hemorrhagy.— There are instances on record in which the inflammation having caused an adhesion between the stomach and parietes of the abdo- men, the abscess broke externally. Van Swieten mentions more than one case of this kind. One from the Journal des Scavans, in which the contents of the stomach were discharged through the opening, so that it was necessary to keep it closed by compresses and bandages. The patient lived under these circumstances for no less than twenty-three years, and enjoyed so good a state of health that she was able to undergo considerable labour. When the ab- scess bursts into the cavity of the abdomen, it occasions purulent ascites, which always proves fatal. The tendency to gangrene in gastritis is known as in similar ca- ces by the unusual violence of the symptoms, and by their not yielding to the proper remedies. When gangrene actually takes place its presence is indicated by the remission of the pain, the pulse at the same time becoming more frequent and feeble, and the anxiety and debility increasing, with cold, clamy, and partial sweats. I have already had occasion to observe, that in visceral inflammations, where the gangrene occupies but a small portion of the inflamed part, the pain often continues to the last. In these * I have seen abscesses of the liver burst into the stomach and into the in testines, the wound in both cases soon healed. t Ob?, de Cog. et Cur. Morb., 216 GASTRITIS. circumstances it is more difficult to ascertain its presence. This may generally be done, however, by an attention to the other symptoms. It is almost needless to say that gangrene of the stomach is uniformly and quickly fatal. Boerhaave ranks schirrus and cancer of the stomach among the terminations of gastritis. But most writers agree that they arise from other causes. Gastritis appears sometimes to prove fatal, merely from the sym- pathy which exists between the stomach and other vital organs. " From the sensibility of the stomach, and its communication with :' the rest of the system," Dr. Cullen observes, "it would seem " that the inflammation of this organ, by whatever causes produc- " ed, may be attended with fatal consequences ; in particular, by " the great debility which such inflammation suddenly produces, " it may quickly prove fatal without running the common course " of inflammations." And Boerhaave,* after enumerating other terminations of gastritis, observes, that it sometimes induces sud- den death with convulsions, before any of these terminations ca:: take place. SECT. II. Of the Causes of Gastritis. Gastritis, fortunately is one of the most rare of the phlegma- siae. The same state of body predisposes to it as toother inflammato- ry diseases. I have already had occasion to point out the habit and mode of life which gives this predisposition. Among the occasional causes, cold applied in various ways still holds a principal place. There is no cause of this disease so com- mon as checking sweat by drinking cold fluids. Acrid substances received into the stomach, especially when its mucus has been abraded or so changed as not properly to perform its office, may excite gastritis. It is to be recollected that the sub- stances most acrid to the taste are not those which occasion most irritation in the stomach. The strongest spices are often received into the stomach without inconvenience, and the most insipid sub- stances frequently affect it most powerfully. All substances, how- ever, which strongly affect the taste, to a certain degree irritate the stomach, and if used very freely by those who are strongly predis- * Aph. 953. GASTRITIS. 217 posed to gastritis, particularly those who have lately laboured un- der it, tend to excite it. Cathartics, and emetics, possess a pecu- liar power of irritating the stomach. There are few cathartics which, if given in very large doses, do not prove emetic. It is not sur- prising, therefore, that we find the use of drastic emetics and ca- thartics ranked amongst the causes of gastritis. To this head also- belonga certain class of poisons. The more irritating articles of diet may be ranked among the exciti»g causes of this disease. Animal food and fermented li- quors often renew it in those who have lately laboured under it, and the excessive use of the latter may excite it in the least pre* disposed. It may arise from acrid matter generated within the body, as sometimes happens in various ulcerous affections of the fauces and (esophagus. Dr. Cullen thinks that gastritis occasioned by the application of acrid substances is generally of the erythematic kind. Few things apply a more hurtful- irritation to the stomach than jver-distention. When food is taken in too great quantity, and is at the same time of difficult digestion, so that the distention is kept up for a considerable length of time, it may occasion gastri- tis. The reader will find some good observations on this cause of gastritis, and cases illustrating them, in Eller's Treatise de Cog. et Cur. Morb. A blow on the region of the stomach, or wounds in the stomach or neighbouring parts, the pressure of the ensiform carthilage when it is dislocated or broken, so that it presses on the stomach, may '■xcite this disease. Like the other phlegmasiae, it may arise from the various causes oi sudden plethora, particularly the suppression of hemorrhagies or other habitual evacuations. It is not Uncommon for the inflammations of some neighbouring part to spread to the stomach, particularly that of the (esophagus and duodenum. Such are the chief occasional causes of gastritis. There are some whose operation seems wholly involved in obscurity. I have more than once had occasion to observe, that certain pestilential fevers are very generally accompanied with inflammation of the stomach and bowels, and this combination is so frequent, that Van Swieten and others have supposed that the contagion often makes its first attack on the stomach, occasioning inflammation of this or- gan. Vol. it. ?*'8 218 GASTRITIS. In eruptive fevers it sometimes supervenes on the sudden disap- pearance of the eruption ;* and, probably from the great debility Which attends such cases, generally soon runs to gangrene. The gout has been ranked among the exciting causes of gastritis. When we come to consider this disease* however, we shall find rea- son to doubt whether it ever excites visceral inflammation. SECT. III. Of the Treatment of Gastritis. The treatment of gastritis is so similar to that of several dis- eases ve have Leen considering, that it will not be necessary to speak of it at great length. There are some circumstances pecul- iar to it which -Jeserve attention. As in the other phlegmasiae, blood-letting is the remedy on which we chiefly depend, and there is no case in which it is carried to a greater extent than in gastritis. As soon as the symptoms shew,themselves we have recourse to this remedy, and if they do net ybdd, it must be carried as far as the habit will bear. And so far from only letting blood when the pulse is full and strong, the smaller and weaker it is, provided the disease is idiopathic, copi- ous and early blood-letting becomes the more necessary. As in the cases in which we have hitherto found blood-letting necessary, we employ it with a view to diminish the strength of the pulse, iu this instance it is employed with a view to increase it, and it is only as it has this effect that it gives relief. We are to dis- tinguisu, however, between a strong and a hard pulse. The re- lief obtained from blood-letting is, in all the phlegmasia?, in pro- portion to the diminution of the hardness of the pulse. The fee- bleness of the circulation in gastritis increases the danger of delay- ing blood-letting, for it sometimes, even in the space ofa few hours, becomes so languid, as 1 have myself seen, that it is impossible to procure the proper quantity of blood. It is not unusual for the symptoms of gastritis immediately to disappear on-a large quantity of blood being suddenly taken away, But we must be prepared for a recurrence of the disease, which to a greater or less extent almost always happens. The repetition of the blood-letting is regulated in the same mr.nner as 1,1 the other phlegmasia;. The less remission the symp * Dr. M'Brid/s Practice of Medicine. GASTRITIS. 219 toms suffer after the first blood-letting, it must be repeated the sooner, and to the greater extent. With regard to the evacuations by the bowels, it must be soli- cited by cathartic clysters, as the state of the stomach prevents our giving medicines by the mouth, which serve only to increase the disease. To this, however, there are exceptions. Gastritis, it has been observed, is sometimes induced by over-distention of the stomach. Nothing tends more than over-«istention to impair the power of th« muscular fibre. If the urine, for example, be retained till the quantity accumulated has greatly distended the bladder, it often has no longer power to expel it. The same happens to the stomach, when it is over-distended it loses its power to exuel its contents by vomiting ; for although the stomach is assisted in vom- iting by the abdominal muscles and diaphragm, yet it would ap- pear that the action of the muscular fibres of tbe stomach itself are necessary in this operation, Hence it is, that in gastritis occa- sioned by over-distention, the patient is often tormented by inef- fectual efforts to vomit. Little, it is plain, is to be expected from any remedy whiie the cause which produces the disease is sull ap- plied. In such cases, therefore, at the same time that we empioy fhe usual remedies of gastritis, it is necessary to have recourse to some means of lessening tne contents of the stomach. Glisters certainly tend to this effect, but not very powerfully. Emetics and cathartics taken by the mouth are the only effectual means. No- thing, it is evident, could occasion a more hurtful irritation of the stomach than an emetic, when it is so loaded that the ordinary efforts of vomiting are ineffectual. We here, therefore, endeav- our to relieve the stomach by the exhibition of cathartics by the mouth, which are often successful ;* and farther to solicit the due action of the stomach, the intestines should, at the same time, be excited by glisters. By these means, part of the contents of the stomach passing into the intestines, the remaining part wiil be rejected by vomiting. We must also give medicine by the mouth in this disease, when acrid or poisonous substances have been received into the stom- ach. It is then necessary to promote the vomiting and defend the stomach by the use of mild mucilaginous and oily fluids, till there is reason to belive that the offending cause is removed.^— Cathartics arc particularly indicated if the poison has been long enough in the body to give reason to believe that it has passed into the intestines. They should be given in small compass^ and • See the observations of Eller just alluded to, 220 GASTRITIS. in the form of pills, that they may, if possible, be retained. In these circumstances it is evident, that the frequent repetition of cathartic clysters is proper; which, while they expel the con- tents of the lower bowels, tend by sympathy to increase the pe- ristaltic motion of the whole alimentary canal. If we are ac- quainted with any substance which corrects the noxious quality of the poison, immediate recourse must be had to it. Even where diarrhoea attends, mild, mucilaginous and oily clysters are serviceable, both by promoting the evacuation of any irritating matter which the intestines may contain, and by allay- ing irritation. The urgent thirst, and duration of the disease, (for gastritis when it suffers remissions, sometimes lasts, as we have seen, for many days,) render an attention to diet necessary. The patient ought not to be tormented by constant thirst, but at the same time he must be restricted both in the quantity and quality of what he drinks. Mild acidulous fluids should be chosen, and given fre- quently and in small quantity, so that they may as little as possi- ble increase the vomiting, which with all the care that can be tak- en they seldom fail to do. The food must be regulated on the same principle. For the first days, indeed, a total abstinence from food is best; but when the disease continues longer, it is necessary to support the strength by small quantities of the mildest kinds. Any solid food irritates too much. Mucilaginous decoctions are the best. We are cautioned against endeavouring to stop the vomiting in gastritis by any preparation of opium. The impropriety of giv- ing opium at the commencement is apparent. In tbe advanced stages, however, after the force of the disease has been broken by proper evacuations, anodyne clysters, and even mild opiate? given by the mouth, (proper means being used to support the action of the bowels) sometimes allay the vomiting, and tend to shorten the disease. It seems to have been overlooked by many writers, that the bad effects of opium in the phlegmasia^ appear to proceed not from any local action of the opium on the inflamed part, but from its increas- ing the vis a tergo. When this has been sufficiently reduced, and there is consequently little or no hardness remaining in the pulse, the chief objection to opiates is removed. The temperature of the patient's chamber, as in the other pleg- masiae, should be moderate, and as uniform as possible. GASTRITIS. 221 Such are the general remedies employed in gastritis. When it Supervenes on the retrocession of eruptions, the means of recal- ling them, as far as the inflammatory nature of the disease admits of it, must make part of the treatment. It remains to make some observations on the local means employed in this disease. Local blood-letting is seldom recommended in grastritis; al- though the same good effects are to be expected from it as in the other phlegmasiae. It is peculiarly well adapted to those sympto,- matic cases in which general blood-letting to any extent is inad- missible, or at least an ambiguous practice. But in all severe cases, it should, for reasons I have already stated, be combined with general blood-letting, unless, as I have more than once wit- nessed, the disease immediately yields to tbe latter. Blisters are more generally employed, and ought never to be omitted after the hardness of the pulse is reduced by blood-let- ting. Fomentations are more useful in abdominal inflammations, than in those of the thoracic viscera. They are, however, but feeble remedies, and the constant motion of the body, from the severity of the pain, (which often makes it difficult to retain even blisters in the proper place,) generally renders them very troublesome ; and they seem often to increase the anxiety, one of the most dis- tressing symptoms. The warm bath is both more grateful and more efficacious, and may be used in aid of more powerful means. When the symptoms of suppuration make their appearance, medicine can be of little further use ; and if the patient is saved. it is by the accidental seat of the abscess. If it bursts into the stomach, irritating articles of diet should be avoided till the ulcer is healed. When its bursting forms an external ulcer, the treat- ment must be left to the surgeon. In this case, indeed, nearly all that can be done is to prevent tbe contents of the stomach from escaping by the wound. Neither are there any means of cure when the matter is discharged into the cavity of the abdomen.— This termination though certainly, is not immediately, fatal.— Gangrene of the stomach always b so. It has been said that gastritis sometimes assumes a remitting form. In such cases the bark has been recommended. Its effects however, have not been ascertained. Dr. Cullen does not treat of the inflammation of the spleen, pancreas, or omentum. From their situation and office, it is im- possible for us to distinguish inflammation of them from that of neighbouring parts. Their functions are so obscure, that lesion of 222 ENTERITIS. them produces no immediate sensible effect. The spleen has even been cut out in brutes, or the vessels going to and coming from it secured by ligature, without materially affecting the health of the animal.* And there are many cases on record, where parts of the omentum have been lost in consequence of wounds, and the patient has afterwards enjoyed good health. Nay, the omentum has been found almost wholly wanting in people who died sud- denly at a time wdien they appeared in perfect health.! Hence it often happens, that inflammation of the spleen, pancreas, or omen- tum, are mistaken for inflammation of neighbouring parts. Thus, Van Swieten gives a case, sent to him by De Haen, in which in- flammation of the spleen was mistaken for pleurisy. Inflamma- tion of the pancreas is often mistaken for gastritis ; and inflam- mation of the omentum may be readily mistaken for enteritis.— It seldom happens that any of these parts are affected with inflam- mation without some of the neighbouring parts partaking of it, which still adds to the difficulty of the diagnosis. It fortunately happens, however, that an accurate diagnosis in such cases is of no consequence ; the mode of practice being the same in inflam- mation of the spleen and of the l.'.ngs, of the pancreas and stom- ach, of the omentum and intestines. All that is necessary is to suit the practice to the severity of the symptoms. The phlegmasia which next demands attention is the Enteritis, or Inflammation of the Intestines ; which we shall find very similar to gastritis, both in its symptoms and treatment. CHAP. XIY. Of Enteritis. Enteritis is defined by Dr. Cullen, ~" Pyrexia typhodes ; dolor abdominis pungens, tendens, circa uni- *' bilicum torquens ; voraitus ; alvus pertinaciter adstricta." He divides this disease in the same manner as gastritis, into the enter- itis phlegmonodaea, and enteritis erythematica ; but finds the same difficulty as in the case of gastritis in distinguishing these species. The first part of the definition of enteritis, pyrexia typhodes, is objectionable, for the same reason that it was objected to in the de- finition of gastritis. * Malpig. de Liene, B runner de Pancreate. t The Thesaurus Anatomicus of Xtuysch. ENTERITIS. SECT. I. Of the Symptoms of Enteritis. The patient complains of an acute burning pain in the abdomen, Sometimes confined to a particular part, at other times felt more generally, and particularly about the umbilicus. Although it does not intermit, it becomes more severe at intervals, which has, with much probability, been attributed to the contents of the intestines now and then passing over the inflamed part. It is one of the best diagnostics of the pain attending enteritis, that it is greatly in- creased on pressure. Other pains of the abdomen are increased on pressure but are distinguished by. other attending symptoms. As enteritis advances, the abdomen becomes more or less tumid ; and in by far the majority of cases, obstinate costiveness attends throughout the disease. We have seen diarrhoea enumerated among the symptoms of erythematic enteritis, in which all the symptoms are milder than in the phlegmonic. Even in the worst forms of enteritis, a thin matter is sometimes past by stool There 's generally a considerable degree of nausea, and often vomiting. The inverted motion of the stomach is sometimes communicated to the intestines, and extends so far along their course that feculent matter is rejected by vomiting. \ The pulse is frequentj small, and hardj as in gastritis. Some writers assert, that the pulse is sometimes full in this disease as well as in gastritis. It is rarely so frequent in either as it usually is in typhus, seldom much exceeding a hundred. I have seen so severe a case of gastritis and enteritis combined, that it terminated fatally in about twenty-four hours, in which the pulse, at tbe height of the disease, did not exceed ninety-two. The heat is seldom very great, the thirst is urgent, and the urine high coloured. The remarkable depression of strength observed in gastritis, al- so attends enteritis, but in general it is neither so sudden nor ex- cessive. It is not always easy, we have seen to distinguish enteritis from other visceral inflammations ; and if the inflammation spreads to neighbouring parts, it often becomes impossible to ascertain its chief seat. When the upper part of tbe colon is affected, the symptoms sometimes resemble those of the pleurisy or hepatitis. When it is confined to the rectum, it produces tenesmus, censiric- m ENTERITIS. tion of the anus, and other symptoms of piles, for Which it is fre- quently mistaken. Even in this case, however, the difficulty of tbe diagnosis will seldom lead to any material error in practice, for when piles are attended with considerable pain and fever, the prac- tice in the two cases is the same, and indeed, they are then general ly attended with more or less inflammation of the rectum. The prognosis is collected as in other cases from the severity of the symptoms, and the effects of the means employed. But there are also some other circumstances which demand attention. Tbe inflammation is more dangerous when it occupies the small thaa the large intestines ; and upon the whole, the nearer its seat ap- proaches to the stomach, the greater is the danger. There is some difficulty in ascertaining what part of the intestine is inflamed. This is to be attempted by attending to tbe seat and degree of tbe pain, the degree of nausea and vomiting, and the sinking of the strength ; for all these symptoms are more violent when the disease is seated in the small than in the large intestines, and in the form* er, in proportion as it is nearer tbe stomach. When it is in the rectum, we are further assisted by the symp- toms just mentioned. When the inflammation is in the higher parts of the colon, it is very difficult to ascertain its seat, for the pain is then in the region of the stomach, and the nausea and vomiting are often considerable.* We shall not err in the treatment, however, if, without endeavouring to ascertain the precise seat of the in- flammation, we proportion the means to the violence of the symp- toms. I have already had occasion to observe, that the symptoms are milder in the cases attended with diarrhoea, than where obstinate costiveness attends. In the former, consequently, the prognosis is better. As in other visceral inflammations, the prognosis de- pends as much on the habit of the patient as on the severity of the disease. From the nature of the means of cure, the danger is always great when these diseases supervene in debilitated states of body. When enteritis supervenes on the worst forms of typhus, which is not unusual, it generally proves fatal. It is particularly dangerous, Quarin observes, in pregnant women, from the probability oi its occasioning abortion; besides the constipa- tion, and vomiting, are generally obstinate in them, and the sit- uation of the abdominal viscera compressed by the distended uterus, is unfavourable. * See the 22d Section of the 43d Epistle of Moreagni de C'ausis et Sediboi Morborum. ENTERITIS. 225 Resolution may be regarded as the only favourable termina tion of enteritis. It is frequently preceded by a moderate diarr- hoea, the most favourable symptom in this disease. When the rectum is the seat of the inflammation, it is often relieved by the haemorrhois. The tendency to suppuration and gangrene is known by the same symptoms as in gastritis. Suppuration is even more rare than in the latter disease. When the symptoms, however, have continued moderate for many days, without yielding to the em- ployment of proper remedies, it is to be feared, and if irregular shiverings come on, and the patient complains ofa sense of weight, and an obtuse, instead of acute pain, which accompanies the in- flammatory stage, little doubt will remain that an abscess is form- ed. Its consequences are similar to those of an abscess of the stomach, except that the former seldom or never bursts externally. If it bursts into the cavity of the intestines, it produces a purulent diarrhoea ; the ulcer is rarely cured. The coats of the intestines frequently slougli off and are discharged by stool ; and the patient wasted by hectic fever, suffers a lingering and painful death. When the abscess bursts into the cavity of the abdomen, it forms, as in the case of gastritis, the purulent ascites. There is no inflammation, perhaps, so prone to gangrene as en- teritis. The tendency to gangrene is known here, as in the other phlegmasia?, by the unusual violence and obstinacy of the symp- toms. The presence of gangrene is known by the ceasing of the pain; by the pulse becoming extremely feeble and frequent, sometimes intermitting ; the body being covered with a cold sweat ; thin ichorous, often livid or black, stools passing involunta- rily ; hiccup, loss of sight, fainting, &c. under which symptoms the patient soon expires. It was observed of gastritis, that it often proves fatal without the inflammation terminating in any of the usual ways. The same is Irue of enteritis ; the sensibility and importance of the stomach and intestines being such that the mere irritation and lesion of function, occasioned by the inflammation, are often sufficient to destroy life. Gangrene, we have seen above, sometimes supervenes inexter- nal parts, without previous inflammation. Many have thought that this now and then happens also internally, particularly in the intestines. I am not acquainted with any cases which sanction this opinion, except those rasps of extreme debility in which th« Voi,. ir. ?9 226 ENTERITIS. vis a tergo is too feeble to produce the symptoms of inflamma-' tion. Enteritis sometimes produces an intussusceptio. It is probable, that this has taken place when part of the gut sloughs off. The patient may survive the sloughing of the internal coat, although nc intussusceptio hz* taken place. • SECT. II. Of the Causes of Enteritis. Enteritis is a much more frequent disease than gastritis, all the' causes of the latter, above enumerated, may excite it. It is more readily produced by cold applied either [to the extremities or to the abdomen than gastritis, but less readily by acrid ingesta. The small intestines are more subject to inflammation than the large, which has been ascribed to their greater delicacy. There are some causes which more particularly belong to enter- itis, accumulation- of the faeces, spasmodic colic, certain states of the bile, concretions forming in various parts of the intestines, her- nias, and intussusceptio. A deficiency of the omentum is als^ ranked among the causes of this disease.* SECT. III. Of the Treatment of Enteritis. As in other visceral inflammations, we chiefly rely on bloocf- Ietting. The observations made respecting the extent and repeti- tion of blood-letting in gastritis, are applicable here. Catharsis is of still greater importance in enteritis than gastritis, and as the nausea and vomiting are often less urgent, we have arl opportunity in most cases of exhibiting cathartics by the mouthr which should never be neglected, but we must proceed cautiously, and use such cathartics as are least apt to offend the stomach. I have found none superiour to calomel and the sulphate of magnesia dissolved in a large proportion of water. The employment of ca- thartics by the mouth should not prevent the use of mild clysters, which .oth soothe the pain and tend to secure the operation of the cathartic.-. Blood-letting should precede the cathartic, that time may not be lost, and because it is not only the more powerful re- * Quarin de Febribus. ENTERITIS. 227 medy, but disposes the bowels to be acted upon by the cathartic. As in gastritis, we are often prevented by the nausea and vomiting from giving any thing by the mouth ; clysters must then be used more frequently and composed of more cathartic materials. They should not be so bulky as greatly to distend, which irritates the intestines, aid should be given slowly, that they may be retained for the proper time. . The observations made respecting the use of opium in gastritis, might be repeated here. Some practitioners speak of the employ- ment of opiates even at an early period of enteritis as a safe prac- tice. " I have often seen antispasmodics," Dr. Gibson observes, " and particularly opiates, successful in removing this disease."* There is every reason to believe, that those who make such obser- vations have confounded other pains of the bowels with enteritis. Sir John Pringle recommends opium to be given with cathartics, for the purpose of enabling the stomach to retain them. This, particularly at an early pengd, appears to be a very questionable practice ; and on comparing the character of this disease, which Sir John Priugle, following the Ancients, seems to adopt, in which there is no mention of fever, with some parts of his practice, it would appear probable, that even he is not wholly free from the above charge. It is an observation of Van Swieten and others well acquainted with the disease, that when opiates are given at an early period, it frequently terminates in gangrene. It may be asked, why opium is hurtful in gastritis and enteritis, while in many external inflammations, its application is highly beneficial. This seems to arise, as may be inferred from what was said above, not from the local action of the opium on the stomach and intestines, but from its being received into the mass of blood, and increasing the vis a tergo ; a similar observation ap- plies to fermented liquors and other stimulants. On the local remedies there is little to be added to what was said in speaking of other phlegmasiae. It sometimes happens when the inflammation is seated in the rectum, that piles appear, inflame, and swell. Leeches applied in the neighbourhood, or to the piles themselves, are then proper. Rubefacients are serviceable. Flannel dipt in brandy and sprinkled with pepper applied over the abdomen generally affords some relief; but all applications of this kind are inferior to blis- ters. When they are applied to the abdomen, the pain sometimes * Dr. Gibson's Treatise on Fevers. £28 HEPATITIS. abates as soon as the burning of the skin is perceived; and what deserves particular notice, the same cathartics and clysters, as in the case of blood-letting, often succeed, which before their appli- cation, had failed. Fomentations are more frequently employed in enteritis, than in any other phlegmasiae, and various disagreeable applications has been recommended for this purpose. Boerhaave and others advise young animals cut up and applied warm, the skin of sheep newly killed, &c. But there is no reason to believe that such ap- plications are superior or indeed equal to flannel dipt in warm wa- ter, and wrung so that little more than the vapour is applied. This is not only more cleanly and can be applied of any temperature, but lighter also and more manageable. Eller, who is a great ad- vocate for the use of fomentations in this disease, particularly in- sists on their being such as shall not give uneasiness by their pres- sure. The warm bath is a more powerful means. It tends to allay tbe pain and disposes the bowels to act. The diet is the same as in other visceral inflammations. To prevent a relapse, it should be mild and the body kept gently open for some time after the disease. When tbe abscess bursts into the cavity of the intestines, various medicines are recommended by the older writers for healing the ulcer, but little or nothing is to be expected from them. When the patient is much reduced by the discharge, an infusion of the bark and some chalibeate waters have been found useful. CHAP. XV. Of Hepatitis. Hepatitis has been divided into two species, the acute and chronic For owing probably to the natural insensibility of the liver, dissection has more frequently in it than in any of the other viscera, discovered traces of inflammation, where they had neither been indicated by fever, nor the other symptoms of hepatitis, properly so called. The chronic hepatitis does not of course be- long to the diseases which form the subject of this treatise. For the most part the acute hepatitis only is treated of by authors who practiced in Europe", Pringle, Boerhaave, Van Swieten, Lieutaud, HEPATITIS. 223 M'Bride, Eller, Quarin, Sims, Burserius, Bianchus, Cullen,* &c. Those who practised within the tropics, Lind, Clark, Bontius, Rol- lo, Ried, Girdlestone, &c. treat of the chronic. Dr. Cullen, in his First Lines considers the chronic hepatitis as a disease only to be known by its consequences. " As this chronic inflammation" he observes, " is seldom to be certainly known, and, therefore, " does not lead to any determined practice, we omit treating of it " here, and shall only treat of what relates to the acute species of " hepatitis." The chronic hepatitis seems to be a more frequent disease in Europe than practitioners have been aware of, which may be ac- counted for by the obscurity of its symptoms. It has even been epidemic in this part of the world. The reader will find an epi- demic of this kind described by Fisher, in the fifth volume of Hallet's Disp. ad Morb. Hist, et Cur. Pert. He may also consult two papers in the second volume of the Acta. Soc. Med. Hafn. I have often found the application of leeches to the hepatic region of great use in the obstinate bilious affections of this country, where there was none of the symptoms of hepatitis, if we except some pain, often very slight, from pressure on this region- The chronic hepatitis of Europe seldom runs to suppuration. Acute hepatitis is defined by Dr. Cullen, " Pyrexia ; hypogastrii dextri tensio et dolpr, saepe pungens " pleuritici instar, saepius obtusus ; dolor ad claviculam et sum- " mum humeri dextri ; decubitus insinistrum latus difficilis ; dysp- " neea ; tussis sicca ; vomitus ; singultus." All these symptoms are rarely met with in the same case. When the dyspnoea and cough are considerable, for instance, there is gen- erally no vomiting; and when this symptom attends, the patient is seldom much troubled with dyspnoea and cough. It is necessary, however, to mention in the definition, symptoms which only occa- sionally attend, because the constant symptoms of this disease are not sufficient to distinguish it. On this account both Sauvages and Sagar rank among the diagnostic symptoms of hepatitis those of jaundice, but they are not sufficiently frequent to materially assist the diagnosis. 1 Lysons, Millar, Saunders, and some others are exceptions. 23V HEPATITIS. SECT. I. Of the Symptoms of Acute Hepatitis. Like other inflammations, hepatitis makes its attack more or less suddenly the patient sometimes complaining of a tightness about the precordia, accompanied with a degree of anxiety and fever, for some time before the symptoms peculiar to the disease shew them- selves ; at other times, pain in the region of the liver is among the first symptoms. In either case the accession is generally attend- ed with irregular chills, The pain is sometimes shooting, accompained with a sense of tension in the part; in other cases, more constant; sometimes acute ; at other times, obtuse and deep-seated. It is not confined to tbe region of the liver, but extends to the breast, clavicle, and shoulder, particularly of the right side ; and in the last it is often more acute, than in the seat of the disease. There are sometimes acute wandering pains of the back and limbs, resembling those which attend fever. The hypochondrium is ten- der on pressure, especially when the position of the body is such as to relax the abdominal muscles. The pain is sometimes in both scapulae, and frequently felt in the left side under the lower false ribs.* It is frequently most se- vere when the patient lies on the left side ; sometimes the contra- ry. He is generally easiest on the back. Practitioners have been at some pains to determine what part of the liver is affected in different cases of hepatitis. In this we are assisted by the seat of the pain. When it extends to the clavicle and chest, the convex part is most frequently affected; when it is more confined, and much increased on pressure, the anterior part of the liver is the principal seat of the disease. When it extends, chiefly to the region of the stomach, and is not much increased on, pressure, there is reason to believe that the concave part is most affected. In this, as in other visceral inflammations, the kind of pain has been supposed to point out whether the membrane or the paranchi- ma is principally affected ; in the former case the pain being acute, in the latter obtuse. The observations made on this subject, in speaking of pneumonia, however, are applicable here. * See a paper on Hepatitis, by Dr. Chisholm, in the 11th vol. of the Medica\ Compientaries. HEPATITIS. 231 Dr. Girdlestone observes, that when the pain of the shoulder at- tends hepatitis, its seat generally corresponds with the part of the Hver most affected, being anterior or posterior, according as the anterior or posterior parts of the liver are the seat of the disease, and when the inflammation attacks the left lobe, the pain is often in the left shoulder. The pain of the shoulder, as well as the side is often increased during inspiration, which is impeded by it. It is most so-, as might be supposed, when the parts lying nearest the diaphragm are in- flamed. But m determining the part of the liver affected, we trust more to other symptoms than to the seat of the pain. In the last case the cough is most severe, and hiccup most frequently attends. The cough is generally short, dry, and frequent, and the hiccup, which is never a favourable symptom, is sometimes so violent as al- most to interrupt respiration. When hepatitis is attended with cough and difficulty of breath- ing, the reader will perceive how readily it may be mistaken for pneumonia, and he will find from the dissections of Morgagni and others, that this has frequently happened. When the convex sur- face of the liver is much inflamed, the inflammation indeed, now and then, spreads to the diaphragm, and even to the lungs. There is often also considerable external swelling, and the inflam- mation sometimes spreads to the abdominal muscles, but rarely to the skirt. When the concave part of the liver is affected, the stomach par- takes of the disorder as much as the lungs do in the former case, the nausea and vomiting being more urgent than in other forms of hepa- titis, and here the cough and dyspnoea are either wanting or pre- sent in a much less degree. In most instances the secretion of the bile is increased, and it sometimes happens, that its flow into the intestines is impeded, generally, perhaps, by a constriction of the ducts. The skin, white of the eyes, and urine, are then tinged with yellow, as in jaundice. These symptoms as we should suppose, a priori, most frequently at- tend when the inflammation is seated in the concave part of the liver.* Inflammation of this part also is generally attended with the same anxiety and debility, though in a less degree, which at- tend gastritis, from which it is often difficult to distinguish it The truth is, that although there are many cases of pneumonhirga&- * See the observations of Burserius, Quarin, and other?. 232 HEPATITIS. tritis, and hepatitis, in which the characteristic symptoms of each being distinct, there can be no doubt respecting the seat of the in- flammation ; yet, from the vicinity of the lungs, liver, and stomach* the sympathy of these parts* the difficulty with which the precise seat of internal pains is ascertained, and above all, the tendency of inflammation to spread to neighbouring parts ; the symptoms of these diseases, and even the diseases themselves, are sometimes so co.sbined, that it is impossible to say where the chief seat of the inflammation lies. The pulse, when the concave part of the liver is affected, is oft- ten small and feeble ; in other cases it is strong ; in all hard. •The urine, whether tirtged with bile or not, is generally high coloured, the heat and thirst considerable, the mouth dry, and the tongue covered with a white yellowish crust, which ih the pro- gress of the disease, often assumes a dark or even black colour. The strength is reduced by constant watching ; and delirium is more frequent than in any other phlegmasia except phrenitis. In most cases the bowels are constipated, in others a diarrhoea comes on, with griping and bilious stools, or more rarely the purg- ing is dysenteric, the effect of irritation from a redundancy of bile, often in a vitiated state.* The bilious and slightly bloody stools, which frequently attend hepatitis, have been mistaken for dysen- tery ; which has given rise to the opinion of these diseases being more frequently combined than they really are. The tendency of hepatitis to resolution, a a in similar cases, is known by the general mildness of the symptoms, and their yield- ing to the proper remedies, particularly, by there being little dysp- noea, cough, hiccup, vomiting, oppression, or debility. This disease is often relieved by hemorrhagy, particularly from the nose and hemorrhoids, sometimes by sweat, or an increased se- cretion of mucus from the lungs. There have been instances in which this secretion has been so copious towards the termination of hepatitis as to occasion suffocation. A copious flow of high coloured urine, depositing a red or whitish sediment, is a favoura- ble symptom, particularly if it appears before the fourth day. When acute hepatitis terminates by resolution, Lieutaud ob- serves, it is generally in three or four days ; if it last to the seventh suppuration is to be expected. The period of suppuration, howj ever is very various, according to the violence of the symptoms, the habit of the patient, and the plan of treatment which i* pursu- " free the observations of Van Swieten, Com. in Aph. Kocrh. HEPATITIS. 233 Sd. Of all the viscera, next to the lungs, the liver is most liable to suppuration.* When hepatitis terminates by metastasis, the inflammation is frequently translated to the spleen or the skin, appearing on the lattpr in the form of erysipelas. Resolution is the only termination of hepatitis which we can consider as favourable, although suppuration is upon the whole less fatal here, than in most other visceral inflammations. We judge of the tendency to this termination by the violence and obstinacy of the symptoms. In most phlegmasiae unusual vio- lence of the symptoms indicates a tendency to gangrene. Here, however, gangrene rarely occurs. As soon as suppuration takes place, the pain remits, and there is generally a sense of weight and pulsation in the region of the liver, the former being increased by lying on the left side. These symp- toms are attended with frequent and irregular shiverings, and at length with hectic fever. In many cases there is an evident tumor, and the fluctuation may be readily felt. Lieutaud and Burserius caution us against mistaking the distended gall bladder for abscess of the liver ; from the situation of the gall bladder, however, this mistake cannot easily be made. The danger from suppuration in hepatitis depends much on the seat of the abscess. When it evidently points outwards, there is almost always an adhesion of the liver to the parietes of the abdo- men, the matter is readily discharged by an incision, and the pa- tient frequently recovers. Dr. Clark of Dominico,t says, that of those in whom the matter was discharged in this way, two in three were saved. When the abscess is seated in the more internal parts of the liver, there is no external swelling, and the fluctuation can rarely be perceived. In such cases, adhesions are sometimes formed with the stomach or intestines, the abscess bursting into them, the mat- ter is discharged by vomiting or stool, and the patient sometimes recovers. I have seen instances ofa favourable termination in both these ways. Dr. Cullen, Dr. Saunders, and others, think it prob- * Sir J. Prjngle on the Diseases of the Army. 1 Medical Commentaries, vol. xiv. The wound formed by opening tbe ab* scess seldom heals readily, but the health frequently improves rapidly after the operation. Vol. ir 30 234 HEPATITIS. able, that the matter sometimes passes along tbe biliary ducts into> the intestines. An adhesion is sometimes formed with the diaphragm, and the abscess bursts into the cavity of the thorax, forming empyema. This is a fatal accident. The patient gradually sinks under hec- tic fever and symptoms of hydrothorax. In other instances the Jungs are involved in the adhesion, and the abscess bursts into their substance, either occasioning suffocation, or when the quantity of matter is small, purulent expectoration, and, if the wound does not soon close, (for even this termination is sometimes favourable) hec- tic fever and the other symptoms of phthisis. Purulent expectoration may occur in hepatitis without any di- rect communication between the liver and lungs, in consequence of the inflammation spreading to the latter, and there either occa- sioning abscess or a purulent secretion from the surface of the bronchia?.* Sometimes, though more rarely, suppuration takes place in the liv er without any adhesions being formed, and the matter is discharged into the cavity of tbe abdomen, occasioning the purulent ascites. Hepatitis, though very rarely, sometimes terminates in gangrene. The tendency to gangrene is known by an unusual violence of the symptoms, rapidly increasing, and not yielding in any measure to the proper remedies. When gangrene has actually supervened, the inflammatory symptoms subside suddenly, cold sweats super- vening, and the pulse becoming weak and fluttering, with constant hiccup and cold extremities. There is generally a black matter rejected by vomiting, the stools being unusually offensive and of a dark colour ; fits of syncope frequently precede death. Gangrene is here as hopeless as in other cases of visceral inflammation. Dr. Cullen does not enumerate schirrus of the liver among the terminations of hepatitis, although it has generally been ranked among them.t It has however been regarded rather as a conse- quence of chronic than acute hepatitis, and the symptoms of the former are so equivocal, that its presence has not always been as- certained with much accuracy. I have not been able to trace one of many cases of schirrus liver, which I have met with, to acute hepatitis, and the chronic inflammation which sometimes attends it is probably oftener the consequence than the cause of the schirrus. Those who maintain that it arises from chronic hepatitis, have * See a Paper, by Aaskow, in the Act. Soc. Med. Haf. vol. ii. + Se e the observations of Dr. Saunders, and other* HEPATITIS. 236 not adduced facts sufficient to establish their opinion. It is to be re- collected, that more or less languid inflammation generally accompa- nies and seems to be occasioned by a schirrus state of the viscera. I have already had occasion to observe that there is no other of the visceral phlegmasiae which so frequently exists without its characteristic symptoms. It frequently indeed assumes forms so different from hepatitis, that indepedently of their consequences, the inspection of bodies after death, and the means of cure which have proved most effectual, there is nothing to lead us even to a sus* picion of their real nature. In some instances we find it appear* ing as an irregular remittent, in others as chronic dysentery,* &c SECT. II. 0/ the Causes of Hepatitis. Hepat itis is more frequent in warm, than in cold or temper* ate climates, It is most apt to attack people of what is called a choleric and melancholic temperament. Adults are more subject to it than those under puberty. Dr, Girdlestone remarks, that while the other soldiers were seized with it, the drummers and others under age, although equally exposed to fatigue, the heat of the climate, &c. generally escaped. The small lobe of the liver is most subject to inflammation, and the outer and convex surfaces more than the concave. The occasional causes of hepatitis are very numerous. Many of those mentioned by authors have been assigned, Dr. Cullen thinks, on a very uncertain foundation. He however, seems inclined too much to abridge their number. It must be granted, indeed, that many, particularly certain supposed states of the bile and of the circulation in the vena portarum, seem quite hypothetical. Hepatitis may be excited by all the usual causes of the phlegma- siae. Exposure to the damps-of the night in sultry climates is one of its most frequent causes. Among the more peculiar causes of hepatitis, may be ranked, various causes affecting the head. Many phenomena point out a peculiar sympathy between the liver and brain. I have already had occasion to observe, that there is no other phlegmasia affect- ing the trunk so frequently attended with delirium. It is often * See the observations of Dr. Girdlestone, and others who practiced ia trop- ical climates. 236 HEPATITIS. the cqnsequence of accidents in which tbe cranium is injured, and where these do not produce hepatitis they often occasion an un- usual secretion of bile and other symptoms denoting derangement in the function of the liver. In the same way, violent passions of the mind, particularly rage and the depressing passions, and all other irritations of the brain, such as the rays ofa vertical sun fal- ling on the head,* are to be ranked among the causes of this dis- ease. It is also in this way, perhaps, that excessive fatigue fre- quently produces it. It seems to be from the two last causes that it is so apt to affect soldiers in long and fatiguing marches in warm climates. Various fevers have been ranked among the causes of hepatitis, particularly intermitting and remitting fevers, probably from these being the most frequent in the climates most liable to affections of the liver. There is often an unusual enlargement of the liver, in those who die of the plague.| The same observation has been made respecting the scurvy. How far these appearances are con- nected with inflammation has not been ascertained. Among the causes of hepatitis may be mentioned the concretions so frequently formed in the gall bladder and ducts, and a schirrus of any part of the liver, or neighbouring part pressing on the liver. Does hepatitis ever arise from a vitiated state of the bile ? There is reason to believe that any cause obstructing the course of the bile into the intestines, whether it be a biliary calculus slicking in the ducts, a spasmodic contraction of them, an inflammation com- municated to them from the intestines or other neighbouring parts, tumors of tbe liver, or other parts pressing on them, worms lodged in them, hard and the pain urgent, blood-letting is proper at any 238 HEPATITIS. period. It is the opinion of Quarin and others, that less blood- letting is necessary in hepatitis, cu account of the peculiarity of the circulation in the liver. It is true that blood-letting ought not to be carried to the same extent in this disease, as in gastritis and some other phlegmasia?, not, it would appear, for the reason here assigned, but because in hepatitis the inflammatory symp- toms seldom run so high, and the orgau affected is less immedi- ately essential to life. Cathartics are employed with great advantage in hepatitis.— The mercurial and saline cathartics, with much dilution, are par- ticularly recommended. Dr. Girdlestone remarks, that by small doses of the neutral salts, given at intervals, so as to keep up a constant catharsis, the acute hepatitis is sometimes changed into the chronic, a form of the disease less dangerous, provided we are aware of its presence. The exhibition of cathartics should not supercede the use of copious mild glisters, which are serviceable, as a fomentation, and by removing irritation, and supporting the discharge from the intestines. It is chiefly iu the chronic hepatitis that mercury has been em- ployed to a considerable extent.* Dr. Girdlestone, Dr. Chisholra, Dr. Clark, of Newcastle, and others, however, speak of it as the remedy on which, next to blood-letting, they relied in the acute hepatitis. Nor did they trust to its cathartic powers, but endeav- oured to excite salivation even where the fever was most consid- erable. According to my experience, the more acute the disease the less is to be expected from the constitutional, and the more from the cathartic effects of mercury. The diet in hepatitis should be the same as in the other phleg- masiae. The local remedies, and the mode of employing them, are al- so the same. Fomentations are very generally employed in hepatitis, and are often attended with considerable advantage. A large quan- tity of any mild warm fluid received into the stomach, seems of- ten to give relief on the same principle. The appearance of any of those symptoms which prove criti- cal demands attention ; when a bilious diarrhoea, comes on it should be encouraged by mild mucilaginous decoctions. If any erysipelatous inflammation appears externally and brings relief,, * See the observations of Dr. Saunders, and others. SPLENITIS. 239 we must be careful not to repel it. A tendency to hsemorrhoia should be encouraged by fomentations, and we are advised to in- crease the flow of blood by leeches. In all cases where there is much cough it is serviceable to promote expectoration by the an- ♦imoniuin tartarisatum, and when a moisture appears on the skin, we should encourage it by diluting fluids and mild diaphoretics. When the urine appears turbid, many recommend diuretics, a practice which seems chiefly to rest on hypothesis. Saline diu- retics are often serviceable at all periods. I have already had occasion to observe that the acute hepati- tis sometimes terminates in the chronic. When this happens, a careless observer may believe the patient restored to health.— After the inflammatory symptoms have disappeared, therefore it is necessary to examine him with care. We must feel whether there be any hardness, swelling, or tenderness on pressure, re- maining in the hepatic region ; enquire whether there be pain or itching in the right shoulder, or anxiety, oppression, and a sense of fulness after eating; and observe if the skin, eyes, fasces, and urine, have assumed their natural colour. There are few diseases for sometime after which, it is more ne- cessary to avoid the exciting causes. CHAP. XVI. Of Splenitis, Nephritis, Cystitis, and Hysteritis. I shall not enter into any particular consideration of the four genera which succeed Hepatitis in Dr. Cullen's Nosology, the Splenitis or inflammation of the speen, Nephritis or inflammation of the kidney, Cystitis or inflammation of the urinary bladder^ and Hysteritis or inflammation of the womb. A few words will be sufficient to make the reader acquainted with the symptoms which characterise these diseases, and their causes and treatment are so similar to those of the diseases we have just been consid- ering, that nothing need be said of them. The first, Splenitis, is defined by Dr. Cullen, " Pyrexia ; hypochondrii sinistri tensio, calor, tumor, et dolor " prc9su auctus ; absque signis nephritidis. It was observed above, that this disease has sometimes been mistaken for pleurisy. In the exquisitely formed splenitis, the J40 NEPHRITIS. pain is dull and the febrile symptoms are not very urgent. \V in.it these circumstances, with the symptoms just mentioned, are well marked, it may easily be distinguished. Tbe difficulty of the diagnosis arises from the obscurity of the office of the spleen ; in consequence of which an inflammation of this organ is only at- tended with apparent derangement in the functions of neighbour- ing parts. There is a chronic splenitis analogous to the chronic hepatitis, collections of matter having been found in the spleen where ho inflammatory symptoms had appeared. Dr. Cullen defines Nephritis, " Pyrexia; dolor in regione renis, saepe ureteris iter sequens ^ •' mictio frequens urinae, vel tenuis decoloris, vel ruberrimae ; " vomitus ; cruris stupor; testiculi ejusdem lateris retractio aut " dolor." He makes two species of nephritis, the idiopathic and symp- tomatic, the former arising from the causes of inflammation in general, the latter generally fiom calculi lodged in the kidney or ureter. The disease with which acute nephritis is most liable to be confounded, is the lumbago, especially when the muscles lodg- ed within the pelvis partake of the affection. In general how- ever, they may be readily distinguished by the change in the ap- pearance of the urine, and by the nausea and vomiting which fre- quently attend nephritis; by there being very rarely any stupor of the leg, and little or no affection of the testicle in lumbago, by there being either no fever in the latter, or less in proportion to the severity of the local symptoms ; but chiefly by the pain iu nephritis being much less increased by muscular exertion than in lumbago. Nephritis is distinguished from the symptoms occasion- ed by a sfone in the pelvis of the kidney or in the ureter, which has not produced inflammation, by their being unattended by fever. Clysters are particularly serviceable in nephritis. The appli- cation of blisters, Dr. Cullen observes, is hardly admissible. If they are used, great care must be taken, as much as possible to prevent the absorption of the cantharides. Nephritis frequently terminates in suppuration, and ulceration sometimes takes place in the kidney without rapidly affecting the health, which Dr. M'Bride, with great probability, attributes to the urine constantly washing out the matter. The Cystitis, or inflammation of the bladder, is defined by Dt, Cnllen. RHEUMATISM. 241 '.' Pyrexia ; hypogastrii tumor et dolor ; mictio frcquens dofor- " itica ; vel ischuria ; tenesmus." The idiopathic cystitis is a very rare disease. It is rarely idio- pathic, very frequently symptomatic of calculi lodged in the blad- der. Dr. Cullen defines Hysteritis, " Pyrexia ; hypogastrii calor, tensio, tumor, et dolor; os uteri " tactu dolens ; vomitus." It is common for writers to treat of the inflammation of the pan- creas and omentum as distinct diseases. When, however, the reader reflects on the situation of these parts, and how readily the organs in the neighbourhood of those affected with inflammation partake of it, or sympathise with the diseased part even where they do not partake of it, he will easily believe that inflammation of the pancreas or omentum is not to be distinguished from some of the foregoing phlegmasiae. The various enticular and visceral phlegmasiae have now been Treated of. The articular only lemain to be considered. CHAP. XVII. Of the Rheumatism. Rhei.matifm, like hepatitis, is either acute or chronic. It is of the former only I am to speak here. It is defined by Dr. Cullen, " Morbus ab externa ; et plerumque evidente causa ; pyrexia ; 1 dolor circa articulos, musculorum tractum sequens, genua et re- " liquos majores, potius quam pedum vel manuum articulos, infes- " tans calore externo auctus." SECT. I. Of the Symptoms of Acute Rheumatism. The seat of the pain is various, sometimes it is confined to one joint, more frequently it attacks several at the same time. For the most part it is not confined to the joints, but shoots along the mus- ics, so that we talk of the rheumatism in the leg, or thigh, as well as in the hip or knee. The muscles of tbe head, neck, and trunk are also liable to it. It generally, 33 mentioned in the definition, at- V'oL.-ir. 31 242 RHEUMATISM. tacks the larger joints; the shoulder, elbow, hip, and knee; the wrists are frequently much affected It has received various names according to the different parts affected ; in the muscles of the neck, it has been called torticollis ; in those of the chest, bas- tard pleurisy, which I have had occasion to notice ; in the muscles of the loins, it has been termed lumbago ; in those of the hip, is- c'hias or sciatica. When the rheumatism is confined to any one of these parts, it is generally unaccompanied with fever, so that the foregoing terms express species of the chronic, not acute, rheuma- tism. Vogel observes, that in young people the rheumatism most frequently attacks the head, breast, scapulae, shoulders, and hands ; in adults and oM people, the back, hips, and thighs. Rheumatic pains are much increased on the slightest motion re- quiring the action of the muscles affected, which is, perhaps, their best diagnostic, and should form part of the definition of acute as well as chronic rheumatism, to which Dr. Cullen confines it. It is not uncommon for acute rheumatism to seize at the same time on al- most every joint of both the upper and lower extremities ; the pa- tient then lies on the back with the limbs extended, enduring ex- treme pain, and unable to perform the least motion. When the pain remains fixed in particular joints, we-expect a more obstinate disease than when it moves from one to another which is usually the case, sometimes repeatedly attacking tbe same joint. Tbe pains are most severe and most apt to shift their place in the night time. Sometimes they regularly abate in the morning with a gentle sweat, and suffer a considerable exacerbation tow- ards evening, the patient remaining tolerably easy during the day. At other times the remissions are very imperfect, and the pains in some cases are as severe in the day as in the night. After the pains have continued for some time, a degree of swel- ling appears in the parts most affected, and sometimes the whole body becomes swelled and tense.* With the swelling there is generally some degree of redness and the part is painful to the slightest touch. Sometimes even the weight of the bed-cjothes is intolerable, so that it is necessary to support them over the patient's body. The redness and swelling generally bring some relief to the pain. They seldom, lrowever, remove it, or prevent its returning to the part with as great violence as before. The pains, for the most * Anni Medici of Stork. RHEUMATISM. 243 part, are the last symptoms which leaves the patient. They often begin to abate about the eighth or tenth day, but generally contin- ue with more or less severity to the thirtieth or fortieth. Some- times they continue for months or even years. It is very uncommon for the pain to disappear before the twentieth day. Tbe foregoing symptoms are, from their commencement, atten- ded with fever, the pulse being frequent, full, and hard. Some- times the fever, sometimes the pain, is the first symptom, but the one never continues long without being accompanied by the oth- er. The former generally begins with chills, succeeded by much heat and thirst. It is proportioned to the violence of the local symptoms. When the pain is no'- very severe, andconiined to a few parts, the fever is slight. When it is severe, and felt in many parts, the fever is more considerable, and it is most so when the pains extend over the whole body. Like the pain, it generally suffers an exacerbation in the evening, and a remission towards morning, especially when a degree of sweat comes on at this time. The face, particularly during tbe exacerbations, is red and some- what swelled, the urine high coloured, sometimes without sedi- ment, and at other times, particularly in the morning, and when there is much sweating, it deposits a sediment ofa white or red- dish colour, and the patient coo-plains of ardor urinae. Nausea and vomiting rarely occur. The same may be said of delirium; there is sometimes a degree of coma. The pain and fever generally prevent sleep during the first days. 1 have already had occasion to observe, that the febrile symp- toms abate sooner than the local ; they are rarely protracted be- yond a fortnight or three weeks. While the fever abates, the pains generally become less violent, and are less apt to change their place. Rheumatism differs from the phlegmasia; we have been consid- ering, in very rarely terminating in any other way than by resolu- tion. Some authors, indeed, mention cases in which abscesses were formed. It does not appear, however, whether or not in these cases the rheumatism was complicated with other diseases. Nor does it frequently happen that collections of effused fluid take place in the pained part. Stork, indeed, influenced probably by his hypothesis, observes, that if the rheumatic fever cease, and the swelling of the limbs subside suddenly, the matter formerly dis- persed over tbe whole body is collected in one place, and forms large lymphatic tumors, which generally occupy the knees, hips, groins, or shoulders. This must be rare ; for Dr. Cullen remarks, 244 RHEUMATISM. " if we may be allowed to suppose that such effusions are frequent, " it must also happen that the effused fluid is commonly re-absorb- " ed, for it has seldom happened, and never indeed to my observa- " tion, that considerable or permanent tumors have been produced, " or such as required to be opened, or have the contained fluid " evacuated." Acute rheumatism seldom terminates by a critical evacuation. It is not uncommon for a sweat to break out, continue for a day or two, and occasionally to re-appear ; but it is often partial, seldom flows freely, and still more rarely brings permanent relief. The reader, indeed, will find a sweat mentioned by Lieutaud and oth- ers as critical in this disease ; and, upon the whole, perhaps, al- though rarely, it is more frequently so than any other symptom. Unless it exhausts the strength without bringing relief, it is alway •> to be regarded as a favourable symptom. The pains have sometimes remitted on the appearance of an eruption on the skin. Various hemorrhagies, the epistaxis he- morrhois and others, and the menstrual discharge, have sometimes brought relief. " A diarrhoea," Dr. Millar observes, " is an un- " usual symptom in acute rheumatism ; when it happens, the pain " generally abates, and the fever sometimes degenerates into one " of the putrid malignant kind." The acute rheumatism often terminates in the chronic. The prognosis is generally good. Danger is only to be appre- hended when the excitement is very violent, and does not yield to the proper remedies. As the disease is usually protracted for a considerable length of time, and anti-inflammatory measures make the chief part of the treatment, it often leaves the strength much exhausted. Irregular pains, attended with a dry cough and night sweats, are sometimes the consequence. For the most part, however, they are readily removed. With regard to the diagnosis, the disease which has been most frequently confounded with rheumatism, is that we are next to con- sider, the gout. The ancients, indeed, seem to have made no dis- tinction between them, describing them both under the common name of arthritis. So little did they attempt any diagnosis, that Aritaeus says of the arthritis, it is a general pain in all the joints ; in the feet, called podagra ; in the bips, ischias ; in tbe hands, chiragra. Trallis affirms, that the term rheumatism was wholly unknown to them. It is used by Celius Aurclianus, and some oth- ers ; who do not apply it however in the same way in which we do. RHEUMATISM. 24.Ii Even to this day, in many parts of Europe, the diagnosis between rheumatism and gent is but ill understood. The rheumatism has also been confounded with bilious pains, and the pains of scurvy and lues venerea, from which, however, it may for the most part be readily distinguished, by the accompanying symptoms of the latter diseases, and the diagnostic symptoms of rheuma- tism above pointed out ; bilious, are generally less fixed than rheumatic, pains, and venereal pains are generally most felt about the middle of the long bones. I have already had occasion to ob- ervc, that rheumatism is sometimes confounded with nephrite. and to notice the symptoms by which they are distinguished. It is so difficult to distinguish tbe symptoms occasioned by -\ calculus in the kidncAy without inflammation, and the chronic rheu- matism seated in the muscles of the loins, that even Boerhaave was deceived in his own case. They are chiefly to be distinguished by the vomiting, frequent and painful micturition, and stupor of ihe inferior extremities, which generally attend the former, and the great increase of pain which attends the action of the muscles of the loins in the latter. Fevers of various kinds, we have seen, are accompanied with severe pains of the back and limbs which are often with difficulty distinguished from acute rheumatism, particularly when the excite- ment runs high. Neither Hippocrates nor Ce4ius Aurelianus, Dr. Millar observes, have distinguished rheumatism from remitting fe- vers. The diagnosis in this case is to be collected from the rela- tive violence of the symptoms, and the seat and kind of the pain. In fever, the general symptoms are more considerable compared with the pain, which is not particularly fixed in the joints, and the former do not seem to increase and abate with the latter, which is usually the case in acute rheumatism ; in which, as in the other phlegmasiae, the general appears to arise from the local affection. The pains which attend fever are seldom much increased on mo- tion, and never as much as rheumatic pains are. Ballonius, in his Treatise de Rheumatismo et Pleuritide Dorsali, is the first author who has accurately distinguished rheumatism. Both Sir John Pringle and Dr. Millar say they have been able to find no earlier account which is at all accurate. 246 RHEUMATISM. SECT. II. Of the Causes of Acute Rheumatism. All except the very young or very old are subject to acute rheumatism. Those between the age of puberty and thirty-five, Dr. Cullen observes are most subject to it. The same habit predisposes to rheumatism as to other inflamma- tory diseases. The plethoric are frequent subjects of it ; but I have already had occasion to observe, that the tendency to inflammation, is not confined to the plethoric, and to describe the other states of the habit wliich seem to predispose to it. It has been remarked of rheumatism, indeed, that the cachectic, and according to Ballonius, those who have laboured under putrid fevers, are peculiarly its subjects. These observations, however, apply only to chronic rheumatism. Rheumatism is more a disease of cold than of warm countries, and in the former it is most common in the colder seasons. Sir John Pringle ranks it among the winter diseases. It was seldom common in the army till the commencement of this season. It is in the beginning and towards the end of winter, however, that it is most frequent, for, like the other phlegmasia^, it is rather excited by vicissitudes of temperature, than the uniform application of cold. All partial application of cold is particularly apt to excite it, es- pecially if attended with damp, and applied to the extremities, where the circulation is most languid. The various causes of sudden plethora above enumerated, often prove exciting causes of rheumatism. It is remarkable that Sydenham ranks the use of the bark among the causes of this disease. This appears to be only one of the many prejudices which at one time prevailed respecting this me- dicine. SECT. III. Of the Treatment of Acute Rheumatism. This disease, we have seen, differs from most of the other phleg- masiae, in not being apt to terminate in suppuration or gangrene, on which, and the seat of the inflammation, what is peculiar in its treatment depends. RHEUMATISM. 247 The general treatment in acute rheumatism resembles that of no disease which has been considered, so much as the synocha. In most of the phlegmasiae, particularly those last treated of, the danger of suppuration and gangrene is such, that to prevent these terminations we are often obliged to risk a greater degree of de- bility than there is any good reason for risking in the case before us. It is not so much our object here by general evacuations to re- move the local symptoms as to allay the general excitement. The presence of the inflammatory affection, however, both by keeping up the excitement and assuring us that the disease will not termi- nate in typhus, properly so called, indicates a freer use of anti- phlogistic measures than is proper in simple synocha. The gene- ral excitement for the first days is often such as warrants even re- peated blood-letting. But if the general excitement does not warrant it, we are not to employ it for the purpose of relieving the pain. Sydenham in his early practice seems to have employed blood-letting with this view, but he confesses that experience taught him that he had used it too freely in this disease. And although Dr. Cullen recommends more copious blood-letting in acute rheumatism than seems fully warranted by the experience of others, he observes, " that at- " tempting a cure by large and repeated blood-letting is attended " with many inconveniences." Upon the whole, general blood- letting is seldom proper after the fifth or sixth day, and at no time when the fever is abating, although the pains should become worse. Besides the usual bad effects of much blood-letting it seems often to render the disease more obstinate, and sometimes to change it into the chronic form. Sydenham thought it of consequence in rheumatism to let blood from the side most affected, which ought «urely to be preferred. Catharsis is much recommended in acute rheumatism, and. as in almost all febrile diseases, is to a certain extent highly beneficial. As it tends less to debilitate than blood-letting, it may be used more freely. Great excitement, however, is to be reduced rather by blood-letting, than cathartics. They are less powerful in di- minishing excitement, and when many joints are affected, the fre- quent action of the bowels is attended with great pain and in- convenience. The mild saline or murcurial cathartics are the best. Emetics are seldom employed in rheumatism ; some writers think that they are used with advantage after tbe excitement is J48 RHEUMATISM. moderated by blood-letting, but nauseating doses appear to be pri- ferable. The great advantage obtained from sweating in chronic rheuma- tism, has induced practitioners to rely upon it in the acute form of the disease. But here we must avoid heating medicines and ex- ternal warmth, means employed with great advantage in the former case. There are few diaphoretics more powerful than nauseating doses of emetics ; and as these at the same time tend otherwise to allay the febrile symptoms, they are well adapted to the case be- fore us. They likewise frequently answer the purpose of ca- thartics. Many other medicines have been recommended with a view to promote perspiration, and all are said to have proved beneficial. Among the chief of these is nitre, which by some practitioners has been given in very large doses. Dr. Brocklesby* seems to have trusted chiefly to this medicine ; he gave it in very large quantity. Dr. Brocklesby's observations deserve the attention of thDse who practice in similar circumstances. In smaller doses, it is useful* in all cases, when the excitement is considerable. Camphor has been very generally employed as a diaphoretic in acute rheumatism. Sir John Pringle gave it in combination with the carbonate of ammonia. He sometimes gave the latter without the camphor. Guaiacum and opium have also been recommended vvitb the same view. The excellent effects of guaiacum in the chro- nic rheumatism seems to have led to its use here. Camphor is a feeble medicine, although it seems by its anodyne quality sometimes to add to the good effects of others. Ammonia and guaiacum are too heating while there is much fever. Respecting the use of opium in this disease, there is much dif- ference of opinion. It was observed, that opium appears to be more beneficial in the phlegmasiae, the less proportion the general, bear to the local, symptoms. As in rheumatism, the inflammation is more external, the gcnerrd bear a less proportion to the local symptom?, than in the visceral phlegmasia^; and in many cases we find the pains very severe when the general affection of the system is by no means so. As far as I can judge from my own ex- perience, it is in these cases that opium i3 most beneficial. The tendency to perspiration in rheumatism seems also often to obviate the bad effects it is apt to produce in the phlegmasiae. On this account it is generally found adviseable to use it in com- His Account of the Diseases of the Armt. RHEUMATISM. 249 bination with those medicines which direct its operation to the skin, particularly antimony and ipecacuanha. These, especially the combination of opium and ipecacuanha, appear to be of all the means we possess the most powerful in allaying the pain, when the febrile symptoms are moderate. In many cases of chronic rheumatism it almost uniformly suc- ceeds, if it be given in such doses as to render the perspiration gen- eral and profuse for several days ; great care being taken that the sweating shall abate gradually, and that the patient shall not soon after it be exposed to cold. I have found the compound tincture of guaiacum an excellent means of supporting the insensible perspi- ration, and defending the patient-against the effects of cold after such sweats. It is not to be overlooked, that when sweating does not soon re- lieve the symptoms, it often fails altogether, and persevering, un- der these circumstances, in exciting it often, like other profuse evacuations, occasions the acute, to degenerate into the chronic, form of the disease. Opium given alone and at an early period of the acute rheuma- tism, especially when the fever is considerable, often does harm. Sydenham observes, that more blood-letting was necessary in those cases where opium was used ; and Stork remarks, that when we attempt to procure sleep by paregorics, the patient becomes rest- less and giddy, troubled with distressing dreams and starting du- ring sleep, which, instead of refreshing, seems to fatigue him, the pulse becoming frequent, Unequal, and contracted. Van Swieten, Dr. M'Bride, Dr. Brocklesby, and others, make similar observa- tions. By some practitioners, opium has been given after evacuations, with a view to restore the impaired strength. Sydenham gave it after the operation of cathartics. The Peruvian bark has been found eminently serviceable towards the decline of the disease, es- pecially when the fever returns at intervals, assuming more or less of the form of an intermittent.* Some have recommended the Peru- vian bark, Dr. Cullen observes, at an earlier period, but it is pro- per in those cases only, in which the phlogistic diathesis is much abated, and where at the same time the exacerbations of the dis- ease are manifestly periodical.! * Van Sn;i.'ten1s Comment. Dr. Millar's Diseases of Great Britain, &c. r It has been lately recommended at the very commencement of the disease, *ik! even in ra-c< where the pulse is strong and hard. From the trials I have Vol. it. 3? 25d rheumatism: Mercury has been recommended in acute rheumatism, But, ex- cept as a cathartic, it seems of little use in this form of the disease. In the chronic rheumatism it is sometimes of service, but I believe much less frequently than has been supposed, the pains fn many cases supposed rheumatic, being bilious or venereal. The diet in acute rheumatism should be the same as in other in- flammatory diseases, mild and diluting. The temperature of the patient's room should be as uniform aspos sible and rather cool. Some think that he should be laid in blank- ets- in order to promote perspiration and prevent taking cold. This is often very necessary in chronic rheumatism, where pro- fuse sweating is more frequently employed, and the patient'is more susceptible of cold. Among the local remedies blood-letting holds the chief place- While the pains are general, we cannot employ local blood-letting. It is impossible by bleeding from one joint to relieve the rest. Ii' is after the fever-remits, when the pains still continue severe, and' fix themselves chiefly in a few of the joints, attended with some de gree of redness and swelling, that it is of most service. Although blisters are less proper while .the inflammation is con- siderable, after it has been to a certain degree reduced, their ef- fects will'often be found more permanent. The same observation applies to them as to local blood-letting. It is when the pains are chiefly confined to a few joints that they are to'be employed; at'an early period indeed, when the pains are general and tbe pulse hard', they do more harm than good. Rubefacients often relieve the pains, but when thus driven ,fron: one joint, they are apt to attack another. Fomentations are also of service after the fever has abated. The actual cautery has beeir employed, and is still in certain cases of chronic rheumatism re commended by some practitioners on the Continent. It is said to be a very effectual remedy, when the disease is obstinately fixed ir particular joints. What has been said on former occasions respecting the encour- agement of the symptoms found critical in tbe phlegmasiae, is ap- plicable here. If a tendency to sweating shews itself, it should be encouraged by every means that does not tend to increase the fe- brile symptoms. We are also to favour any tendency to hemorr- hagy. If an eruption brings considerable relief, we may for a day made I am inclined to subscribe to Dr. Cullen's opinion, that its exhibition ought not to be attempted under these circumstances. ♦ RHEUMATISM 262 at two discontinue the evacuating plan ; but if the eruption ap- pears without bringing relief, it should occasion no change in the mode of treatment. When rheumatism terminates in any kind of ulceration, we must not attempt to'heal it too suddenly.* # Though in acute rheumatism the symptoms of active inflammation both lo- cal and general, arc unequivocal, yet the disease is not so much under the con- trol of blood-letting, as many others which belong to the same class. In some cases when venesection and other depleting remedies have been carried to their full extent, the morbid excitement tn the capillaries and the corresponding ac- tion in the great arteries will still remain ; and in fact, the morbid action secme aot to be diminished in any greater degree by this practice, than the natural healthy action of the system. In a rase of acute rheumatism, the patient being a vigorous young man. blood-letting was carried to great length, calomel, and nauseating doses of tar- tar emetic were persisted in for a longtime, together with sudorifics, and blis- ters were applied to several of the affected joints, without gaining much relief, Notwithstanding the use of these remedies, the disease remained unsubdued? and the pain in the large joints was severe, and the heat intense. The patient was taken out of bed, laid on a straw matrass, and a bucket of cold water was thrown on him, so as to fall on every part of the body and limbs; he was then returned to his bed, and clothes wet with cold water were applied to the r fleet- ed joints, and the clothes were wet with cold water as they became dry. The symptoms of inflammation both local and general, soon abated under this treat- ment, and the patient was perfectly cured. In this case it was observed, as the disease abated, that those joints which had been blistered recovered more slowly than the others. This patient is a pretty good sample of a bad case of acute rheumatism, and the effects of the remedies were such as they often are in that disease, except the application of cold water, which in this case did more than all the rest ; but whethe* it would have had the same happy effect, if it had been applied in the beginning of the disease, or not, is a question which I am not able to solve. The remedy was then new to me, nor have I tried it since. I was driven into the use of it at that time !>y the sufferings of the patient, and the failure of all other medicines. Since the time that I attended this patient, I have found a remedy which has done more in cases of acute rheumatism than all other internal remedies which I have seen used in that disease. This is the Sanguinaria Canadensis or blood- root. I have given it in infusion and tincture with laudanum. The dose of blood-root should be as large as can be borne on the stomach without proving an emetic, combined with a dose of laudanum adapted to the circumstances of the patient. This dose should be repeated twice or thrice in a day. When the tincture of blood-root is used, the dose may be a tea spoonful to begin with, which must be increased till the patient feels the effects sensibly. When the infusion is used, half a table spoonful will be sufficient for the first dose. The best tincture of blood-root is made with the fresh root bruised, and steeped in spirit, and in such proportion as to make what is called a progf tincture. The infusion is best when made of the dried root. N. ? 252 GOUT. chap: xvhi. Of the Gout. There are few diseases on which more has been written, than the gout. A thousand treatises have promised an easy explana- tion of its phenomena, and certain means of cure ; yet it still de- fies our reasonings and our art. It is true indeed, that since the revival of literature, more careful observation has greatly improv- ed both its history and treatment ; but the latter is still extremely defective, and all our ideas respecting its nature, are as unsatisfac- tory as the neglected hypotheses of the ancients. Dr. Cullen defines the Gout, " Morbus haireditarius, oriens sine causa externa evidente, sed " praeeunte plerumque ventriculi affectione insolita ; pyrexia ; do- " lor ad articulum, et plerumque pedis polici, certe pedum et " manuum junclurus, potissimum infestus ; per intervella rever- " tens, et saepe cum ventriculi, vel aliarum internarum partium, " affectionbus alternans." It might be objected to this definition, that it does not very ac- curately include all the varieties of gout; it would be difficult, how- ever, to give a better definition of so varied a disease. It points out its most striking features. f' Dr. Cullen divides the gout into four species, the regular, aton- ic, retrograde, and misplaced, which seem with sufficient accuracy to include its different forms. Other writers have divided it into more or fewer varieties. He defines his first species, " Podagra cum inflammatione artuum satis vehementi, per ali- " quot dies perstante, et paulatim cum tumore, pruritu, et des- " quamatione partis, recedente." The atonic gout is defined, " Podagra cum ventriculi vel alius partis interna: atonia, et vel " sine expectata aut solita artuum inflammatione, vel cum dolori- " bus artuum lenibus tantura et fugacibus, et cum dyspepsia vel " aliis atonia: symptom a fib Us subito saepe alternantibus." The, retrograded gout he defines, " Podagra cum inflammatione artuum subito recedente, et ven- c< triculi vel allius partis interna} atonia mox insecuta." CiOUT. 253 His fourth species, the misplaced gout, he defines, " Podagra cum partis interna? inflammatione, vel non praegressa, "• vel praegressa et subito recedente, inflammatione artuum." It will be proper to consider the symptoms of each of these spe- cies separately. SECT. 1. Of the Symptoms of Regular Gout. Sydenham has given so full and accurate an account of the reguki gout, that it is impossible to make any considerable additions to it. Later writers indeed have generally given a literal translation of it ; and those who profess to detail the symptoms of gout from their own observation, have added little or nothing to Sydenham's ac- count of tlii j disease, and often use his very expressions. This ob- servation applies even to Dr. Cullen's account of it. The follow- ing account of the regular gout, therefore, is to be regarded as Sy denham's, interspersed with the few additions furnished by later observation. The gout sometimes comes on very suddenly, particularly in its first attacks. In general, however, the inflammation of the joint is preceded by various symptoms, indicating a want of vigour in different parts of the system. The patient is incapable of his usual exertions cither of mind or body ; becomes languid, listless, and subject to slight feverish attacks, especially in the evening, in which shivering often alternates with flushings of heat. He fre- quently complains of pains in the head, and coldness of the extre- mities. The appetite is impaired, with the usual symptoms of dyspepsia. The patient complains of heaviness after meals, which often becomes a disturbed kind of sleep, to which he is more or less subject at other times, particularly when the mind is slightly engaged while the body is at rest. He is never refreshed by this sleep, but remains languid and uneasy ; he becomes subject to fla- tulence, acid eructations, heart-burn, spasms of the stomach, thirst, vitiated taste, nausea, and vomiting. The bowels are seldom re- gular, being either constipated, or too much relaxed. The mind, at this period, is generally irritable, anxious, and alarmed at the least appearance of danger. These symptoms are often accompanied by others which more particularly presage the approaching fit, a deficiency of perspira- tion in the feet, and their veins appearing more distended than 254 GOUT. usual, cramps of the feet and legs, numbness, and a sense of prick- ing in them, or a sensation as if cold water were poured upon them, which is sometimes felt in other parts of the body, particularly in the back, and is described as different from the shivering which attends febrile attacks. The duration of these symptoms previous to the fit, is various ; sometimes only a day or two ; at other times many weeks. It is a very general observation, that the day preceding the fit, the appe- tite is greater than usual. The fit sometimes makes its attack in the evening, more com- monly about two or three o'clock in the morning. The patient ^oes to bed free from pain, and is awakened about this tiiue^by a very acute pain, generally in the first joint of the great toe. Sy- denham, who was much afflicted with the gout, observes, that the pain often resembles that of a dislocated bone, with a sensation as if tepid water were poured on the membranes of the part. It sometimes extends itself over all the bones of the tarsus and meta- tarsus, resembling the pain occasioned by the tension or laceration ofa membrane ; at other times it occasions a sense of weight, and constriction of the part, which at length becomes so sensible, that the patient cannot endure the weight of the be^d-clothes upon it, oi the snaking of the room from a person walking across it. At the commencement of the pain, a cold fit is more or less per- fectly formed ; which, as the pain increases, is succeeded by heat and other symptoms of fever. The pain and fever increase, with much restlessness, till about the middle of the succeeding night; after which they gradually abate, and in the most favourable cases there is little either of the pain or fever twenty-four hours after their first appearance. ^ The patient, as soon as he obtains some relief from pain, gen- erally falls asleep, a gentle sweat comes on before he awakes, and the part which the pain qccupied, becomes red and swelled. In most cases, however, the fit is not over, for the pain and fever return in the succeeding night with less violeuce, and continue to do so for several nights, becoming less severe till the\ cease. , Such ib a simple fit of the gout. But it often happens that after the pain has abated in one foot, it attacks the other, where it runs the same course, and in those who have laboured under repeated attacks of the disease, the foot first attacked is often seized a second time, as the pain in the other subsides, which is again at- tacked in its turn, and they are thus alternately affected for a con- GOUT. 235 % MJerable length of time. In other cases it seizes on both feet at ■he same time. In strong people, Sydenham observes, the whole fit, even al- though it attacks both feet, is generally finished in about fourteen days. In the aged, and those who have been long subject to the gout, it generally lasts about two months; and in those who are much debilitated, either by age or the long continuance of the dis- ease, till the summer heats set in. During the fit the bowels are generally costive, the urine is scanty and high-coloured, and deposites a copious red sedi- ment, particularly during the first days. Through the whole fit there is a want of appetite and sense of oppression, with rigours iu the evening. While it is going off, the patient often complains of an intolerable itching in the parts which the pain occupied, partic- ularly between the toes, from which, and frequently from tin* Whole foot, there is a desquamation of the cuticle. A fit of the gout for the time, improves the health. It leaves the appetite, digestion, and spirits unusually good, so that many de- clare, that they willingly endure the pain for the good health and spirits which succeed U. The first attacks of the gout are generally at long intervals, for Ihe most part three or four years ; at length they occur annually ; in those who have long been subject to it, twice a year, and at last several times during the autumn, winter, and spring. Upon the whole it may be remarked, that the more tedious the fits of the gout, the less severe the pain, the more urgent are the dyspeptic and oth- *>.r atonic symptoms, the longer is the duration of the fit, and the sooner it returns. The foregoing is the only form of gout which Sydenham admit- ted to be regular. When it left the feet, or attacked other parts at the same time, he believed the natural course of the disease to be disturbed by debility or some less evident cause. Dr. Cul- len, and other later writers, however, have ranked, as varieties of regular gout, all cases which run the course here described, whether the pain be situated in the feet or other parts of the ex- . treraities. After frequent returns of the gout, it" begins to seize upon the joints of the hand, and at length the larger joints ; arid when it at- tacks the knee and elbow it sometimes occasions considerable swel- ling without any change of colour in the skin. As in the smaller joints, however, the skin often becomes inflamed. The pain some- times attacks some of these joints and the feet alternately, and 266 GOUT. sometimes, though not so often, some of the joints of both the upper and lower extremities at the same time. When the gouty tendency is very great, almost every joint of the body suffers ; the pain when it leaves onej immediately fixing in another. The patient is then free from the disease only for a short time in the summer, so that tbe usual fit may be said to last for eight or ten months. In the first attacks, the joints soon recover their strength and sup- pleness, but after the disease has recurred frequently, and the fit^ are long protracted, the joints remain weak and stiff, and at length lose all motion. These effects are increased by the formation of concretions, which are often thrown out by suppuration, occasion- ing ulcers that sometimes prove obstinate. The concretions, how- ever, are not formed in the joint, but for the most part immediately under the skin. I have already had occasion to observe, that as the paroxysms are protracted, the dyspeptic and other symptoms of debility in- crease, while the pains become less severe. When the fits are protracted for the greater part of the year, the patient is hardly ever free from such symptoms, which, when there is no pain, or only very slight and wandering pains, form the species of gout we are next to consider. Most people who have suffered long from gout are more or less troubled with calculous complaints, and the nephritic often alter- nate with the gouty, paroxysms. SECT. II. Of the Symptoms of Irregular Gout. bThk term irregular has been employed to express every form of gout except that we have just been considering, so that under ii are comprehended Dr. Cullen's three remaining species. Of these the atonic is the most important. We were not supplied so early with an accurate account of these species of gout, as of the regular form of the disease. Sydenham describes them with much less precision. The different forms of irregular gout are so various and deceitful, that an accurate ac- count of them could only be expected from the united efforts of many.* To save repetition, 1 shall, along with the symptoms of * The reader will find an excellent account of irregular gout, in two treatises published by Dr. Musgrave, De Arthritide Symptomatica and Arthritide Ano- male. GOUT. £57 the irregular forms of gout, notice the causes which dispose it to assume these forms. To enter fully on a detail of the symptoms which appear in what is called atonic gout, would be to give those ofa laige pro- portion of all the diseases wc are subject to, for there are hardly any which appear in a gouty habit that do not shew some connec- tion with the habitual disease. It will be sufficient to enumerate Its more striking features. The subjects of atonic gout are generally such as have for a considerable time laboured under regular attacks of the disease ; this, however, is not universally tbe case. In some constitutions the gout soon begins to assume the atonic form. When this form appears in those who have never suffered from regular attacks, it is very difficult to determine its nature, unless the affection of the in- ternal part alternate with pains of the joints. The most common forms of atonic gout may be divided into three classes, as it attacks the abdominal or thoracic viscera, or the encephalon. The morbid affections of the stomach, which have been men- tioned as often preceding regular gout, are the most common symptoms of the atonic. But in this form of the disease they rise to a greater height, and are often attended with immediate danger. The patient is distressed with flatulence, nausea, vomiting, severe pains in the region of the stomach, &c. which often very suddenly prove fatal. He is sometimes harrassed with cramps in various parts of the body, particularly the trunk and arms, which are gen- erally relieved by a discharge of wind from the stomach. The de- bility is often extreme, the pulse sometimes intermitting, the mind anxious, irascible, and timid. There are few diseases more deceitful than what has been term- ed the gout in the stomach. Sometimes, indeed, the pain is ex- crutiating, and the patient dies in extreme agony. But in many instances he expires when the symptoms are not different from those which in ordinary dyspeptics might be pronounced free from danger. It is not uncommon for those labouring under this form of the gout, suddenly to die while conversing, and with so much ease, that death is sometimes announced by no other symptom than the head falling on the breast. AH causes of debility dispose the gout to attack the stomach, particularly the causes which act more immediately on the slom- tch itself, exce-"- in eating or drinking, a diet of difficult digestion. Voi. n "■! 258 GOUT. &c. It is observable, says Musgrave, that such as have an hered- itary gout are more liable to attacks in the stomach, than those in whom the gout is accidental ; those who are born of old parents, than those born of young ; those who have a bad appetite and la-' bour under a cold languid gout, than such as have a better appetite and whose gout is more painful and attended with a greater degree of fever. The melancholic temperament, it is said also disposes to the atonic gout. How far all of these observations are just it is difficult to say ; all that we certainly know is, that the debilitated are most subject to this form of the disease. After the dyspeptic symptoms have continued for some time, or indeed from their first appearance, they are sometimes accompa- nied by those denoting derangement in the whole intestinal canal. The patient complains ofa pain in some part of the belly, generally about the umbilicus, which gradually extends, increasing in sever- ity and accompanied with obstinate costiveness. It has been cal- led the arthritic colic, and is attended with great danger. Some- times, though more rarely, a diarrhoea comes on, accompanied with much griping, and sometimes with severe tenesmus and bloody and dysenteric stools. The patient at the same time is often troubled with dyspnoea and cough, and with a sense of oppression and heavi- ness in the chest. The arthritic colic and diarrhoea frequently make their attack in autumn, and continue to harrass the patient during the winter. who, emaciated and exhausted, at length sinks under them. Both the diarrhoea and dysentery are apt to supervene on the col- ic ; and when the diarrhoea is moderate, it often proves salu- tary ; when profuse and obstinate it is attended with great danger. It is not difficult to conceive how dreadful a disease dysentery- supervening on gouty colic must frequently be. It often prove? fatal by hemorrhagy, from some part of the intestines, ulcers and abscesses, as dissection ha3 demonstrated, frequently takes place. The most frequent causes of affections of the bowels in gouly babits are the unguarded application of cold, and the presence of much bile and other irritating matter in the alimentary canal. These as well as the affections of the stomach, are for the most part*accompanied with slight and irregular gouty pains in some of the joints, which when they become more fixed and severe often bring very sudden relief to the internal disease ; so that the latter frequently alternates with the affection of the joints, protracting the fit for many months, the prognosis being more or le*s favourable according as the one or the other predominates. GOUT. 259 Atonic gout less frequently attacks the thorax, but its effects here are equally distressing and dangerous. After the sudden ap- plication of cold, or any cause which deranges digestion, a gouty pa- tient sometimes becomes restless and uneasy, cold sweats breaking out, the countenance becoming pale, and the pulse weak and inter- mitting ; these symptoms being often succeeded by a fit of palpi- tation, or syncope. As such affections come on, the pains of the joints, if there are any, abate, and without speedy assistance death often ensues. The gout sometimes appears in the form of asthma, particularly in those who from a bad conformation of the chest or from being of asthmatic parents are disposed to it. The asthma from gout, like common asthma, is either dry or moist, the latter is regarded as most dangerous. They both speedily disappear when gouty pains come on. There is a disease of the chest, termed a gouty defluxion, which resembles peripneumonia notha, frequent in old people who have long been subject to the gout. It arises from the causes of pneu- monia, combined with those which dispose the gout to assume the atonic form. The expectoration at first is thin and scanty, becom- ing thicker and more copious, oppressing the lungs, and sometimes occasioning suffocation. It frequently returns at intervals, begin- ning with a troublesome cough. Cough, indeed, is a frequent symp- tom of atonic gout, even where the lungs are not the chief seat of the disease ; and often precedes the other symptoms. These, like almost all other affections of the chest, sometimes terminate in phthisis pulmonalis.* When the gout attacks the encephalon, it produces head-ach, giddiness, loss of memory, palsy, and apoplexy and even mania. It is not uncommon for head-ach and giddiness, accompanied with a florid countenance, noise in the ears, a large pulse, and more or less dyspncea, for sometime to precede palsy and apoplexy, and in a gouty habit, unless these symptoms are removed by the appear- ance of some other form of the disease, they often end in this way, sometimes after continuing for weeks or even months. An indulgence in full living and indolence, especially after the meridian of life, and where the habit is inclined to corpulence and plethora, particularly disposes to this form of gout. In common with other cases of atonic gout, it may be occasioned by all causes of debility. * See Mu?grave's Treatises. 2tK> ttOUT. Atonic gout sometimes appear in other forms, besides those it assumes in the three cavities. The arthritic quinsey often seizes the patient while he is labouring under pains of the joints, and sometimes makes its appearance a short time after a regular fit. This form of the disease approaches more nearly in its nature to the regular gout. It sometimes supplies the place of a regular fit, and is succeeded by the same health and cheerfulness, and it more frequently than other forms of atonic gout, if it deserves the name, terminates in a regular fit. If, says Dr. Musgrave, nausea and sickness, heaviness, numb- ness, and wandering pains, have preceded the quinsey, there is reason to believe that it proceeds from the presence of gout in the habit, especially if the patient has laboured under regular fits o( the disease.* People with short necks and relaxed and debilitat- ed habits are most subject to gouty quinsey. It attacks men about middle life, and women after the menstrual discharge ceases. More fever precedes the quinsey than any other forms of irregulai gout. There is a gouty ophthalmia as well as quinsey, which is known in the same way and terminates in a similar manner. Erysipelatous inflammation of the surface and impostume seem also occasionally to serve the purpose ofa regular fit of the gout.t The pains in the back, loins, shoulders, and external parts of tbe head, in gouty habits, resembling rheumatism, and which certainly partake much of a rheumatic nature, Dr. Musgrave considers as symptoms of atonic gout. The gouty affection sometimes fixes itself in the back, resembling a fit of the gravel. This form seldom appears except in those exhausted by old age and the long contin- uance of the disease. In short, there is no disease to which gouty people are subject "that does not shew some connection with gout. The gouty hu- mour, says Dr. Musgrave, sometimes falls on the glands within the orbits of the eyes, causing a discharge of sharp serum. Some- times it attacks the gums and membranes surrounding the roots of the teeth. Tbe nose, the lips, the tongue, and every part of the body, he observes, are subject to attecks of the arthritic matter. Dr. Whytt| of Edinburg remarks, that he has seen the atonic * See the Rev. Mr. Warner's account of his own case of gouty quinsey, in his Treatise on the Gout. t Dr. Mus-rave's Treatises, Dr. Gardener on the Gout and Gravel t See 3d. vol. of the >>?ays andObs. Phys. and Literary. GOUT. 2£l gout in form of diabetes, hemiplegia, mania, itching of the scrotum, dysuria, discbarge from the urethra, and pain in the testicles. Every physician has met with similar affections connected with gout, the connexion appearing by their suffering a considerable abatement, or wholly disappearing, as soon as the gout shews itself in the extremities. The more inflammatory of the foregoing affections may be thought more properly to belong to the misplaced gout, but this is a point of little importance.* It is the opinion of many, that the gout never shews itself for the first time in the atonic form. The best observations I have met with in opposition to this opinion, are those of Dr. Clark, in a paper on Anomalous Gout, in the third volume of the Essays and Observations Physical and Literary. The atonic gout, he main- tains, will often remain for many years without any appearance of regular gout having preceded it. If so, it is of consequence to de- termine its presence, because the treatment is in some respect dif- ferent from that of the disease which it resembles. Although Dr. Musgrave notices the appearance of atonic goujt without any previous attack in the extremities, he does not at- tempt any diagnostic of such cases, but seems to think that their nature can only be ascertained by the appearance of regular gout. Dr. John Clark, father to the author of the above paper, regarded white ropy semi-transparent filaments floating in the urine as a di- agnostic symptom of atonic gout, when it appears without having been preceded by an attack in the joints. To this symptom the author of the paper adds strangury, which he met with in a large majority of such cases, and he thinks it a peculiarity of this stran- gury that it is generally relieved by blistering the ancles ; but Dr. Whytt observes, that the same means relieve the slight strangury which frequently attends fevers. The former remarks, that the matter thrown up from the stomach in cases of atonic gout, is gen- erally a whitish gelatinous pituitous matter, which he regards as a diagnostic of this affection. Gonorrhoea in men, and the fluor albus in women, he thinks are frequent appearances in this form of gout, and may assist in distinguishing it. Sauvages mentions the gonorrhoea podagrica among the species of gout. * See Dr. Cullen's Observations on the Gouty Affection of the Bladder and Rectum. 2*2 GOUT. Both Dr. Clark and Dr. Whytt think the atonic gout more com- mon, especially, among young people, than is generally sup- posed*. After all that has been said on the subject, however, as the symp- toms of atonic gout seem to be merely those of debility, which may proceed from a variety of causes, it is probable we shall never detect any diagnostic sufficient to distinguish such case3 with cer- tainty, where the gout has not previously appeared in a less equi- vocal form. Besides if we except disorders of the stomach, an organ which so eminently sympathises with every part of the sys- tem, all the symptoms of atonic gout, those of asthma, palsy, apo- plexy, &c. are generally produced by the same causes which occa- sion these diseases in ordinary cases ; the only difference being, that in gouty habits a less powerful application of them is suffi- cient, and even the dj'spepsia of gouty patients is always observed to be most severe in those, who are exposed to the peculiar causes of this disease. It seems, therefore, that we are to adapt our language to the real state of our knowledge, instead of talking of the translation of gouty matter to the stomach, thorax, head, Sec. in the various cases of atonic gout, we should only say, that the gout gives a predispo- sition to certain diseases, which being excited may occasion the gout itself, in the same way that almost any cause of derangement occasionally excites habitual diseases. Nor need it surprise us, that the appearance of regular gout relieves the atonic symptoms. How frequently do we observe one disease subside on the appear- ance of another, where gout is in no way concerned ; and particu- larly a disease of debility when a painful disease supervenes. We often relieve apoplexy and syncope by pain artificially excited. I have seen the symptoms of dyspepsia suddenly relieved by a severe fit of tooth ach. On the symptoms of the remaining forms of gout, the retroce- dent and misplaced, a very few words will be sufficient. The retrocedent gout only differs from the atonic by being pre- ceded by part ofa regular fit. The propriety of regarding5 what is termed the misplaced gout as a species of this disease, is doubtful. It is unnoticed by Syden- ham and many other writers. If the inflammation of the internal part come on without being preceded by any affection of the joints, *The reader may consult the case of Mr. Alexander Small, surgeon to the ordnance in Minorca, related by himself in the sixth volume of the Medical Observations and Inquiries. GOUT. 2*3 how are we to determine that it is at all connected with gout. If it supervenes on the inflammatory affection of the joints suddenly receding, it may still proceed from other causes, for many of those most apt to occasion a retrocession, are also such as frequently ex- cite visceral inflammation ; so that it would not seem surprising if. in a feW instances, such inflammation supervenes on a .sudden re- trocession of the gout, although there be no connection between the diseases. Besides, if during a fit of the gout a visceral inflam- mation should by any cause be excited, we must suppose, from what we see in other cases,' that it would relieve or wholly remove the affection of the joint. Instances of misplaced gout seem rarer than from these circumstances we should expect to find tin m even ou the supposition that the gout has no share in producing them. It would appear upon the whole, therefore, that all we are to under stand by misplaced gout is a viscera! inflnmiration supervening in a gouty habit, to which, however, gout seems little, if at all, to predispose. Although Dr. Cuilen admits this species of gout, he confesses that he never met with any instance of it in his own practice, nu; found any case distinctly marked by practical writers, except that of pneumonic inflammation. I am inclined to think, that in this exception Dr. Cullen alludes to the pneumonia mentioned by Dr. Musgrave as a symptom of irregular gout. But what he says of if is not very favourable to tbe supposition of misplaced gout; for it would appear from his observations, that arthritics subject to pneu- monia are such as must, independently of gout, have been predis- posed to this disease. When the gout does not shew itself till late in life, it seldom rise* to the same degree as when it appears more early, and it is les^s frequently accompanied with nephritic and other symptoms of irre- gular gout ; as indeed might, a priori, be supposed, since the sys- tem is generally subject to gout for sometime before these symp- toms shew themselves,* most of them being nothing more than symptoms of other diseases to which the continuance of gout pre- disposes. There is no rule, however, without exceptions. Tbe gout we have seen, is sometimes, almost from the first, accompanied with the more alarming atonic symptoms. * See a paper, entitled a New Pathology of the Gout, by Stahl, in the sixth volume of Haller's Disp. ad Morb. Hist, et Cur. Pert. The reader will find some good observations on the gout in this and another paper by Hahn, in the tame volume. 26.4 GOUT. SECT. III. Of the Remote Causes of Gout. The gout is a disease of cold and temperate climates. It fre- quently makes its attack in autumn on the sitting in of the cold ; more frequently in the spring, when the temperature begins to in- crease, especially when the vicissitudes of heat and cold are con- siderable. Those most subject to gout are men of a robust and rather clumsy make, with large joints and head, a rough skin, rather corpulent ha- bit, and, it has been said, of quick parts ; such as have led an in- dolent and luxurious life, used a large proportion of animal and bigh-seasoned food, and indulged freely in the use of fermented liquors. The causes of general debility also, excessive venery, much application to study or business, vexation of mind, night watching, &c. predispose to this disease. In short, whatever tends to produce plethora, hurt the digestive organs, ind impair the vigour of the system, may be ranked among its causes. The gout more rarely attacks women and eunuchs. When it ap- pears in them, it is generally in such as are of the habit just des- cribed, and have been accustomed to indolence and full living. It has been a common opinion, that the ceasing of the menstrual discharge disposes to gout, and as a cause of plethora it probably has more or less of this effect. But as it happens about the time of life at which the gout is most apt to shew itself in both sexes, and many women have been attacked by gout before menstruation ceased, it is probable that it has little share in producing it. Dr. Cullen observes, that he has known several women subject to gout in whom this discharge was more profuse than usual. Among the people ofa country where the gout is prevalent, we find some subject to it from very slight irregularities, while others are exposed to the same or more powerful causes, and yet escape it; 3nd, on enquiry, it is generally found, that the fathers or other pro- genitors of the former had laboured under this disease. The ob- servation has been so often made by the vulgar, as well as physicians, that there is no point in medicine better ascertained. Notwithstanding this, by some it has been called in question, and has even been made the subject of serious discussion. When we read Dr. Cadogan's fallacious arguments against the opinion of an he- reditary gout, and the refutation of them bj' Dr. Berkenhout and GOUT. 265 Dr. Falconer, we are less surprised at the hypothesis of the first writer, than at seeing the others set about gravely to refute it. There are a few in whom the hereditary disposition is so strong that it is capable of exciting the disease without the concurrence of some other of its causes, so that those sprung even from the most r.rthritic parents, may escape it by temperance and exercise ; and, on the other hand, there are few in those countries where gout has been long known, so free from the predisposition that it may not be excited in them. That indolence predisposes to gout appears from it's rarely at- tacking those who have followed laborious occupations. It has often been observed, that although common soldiers are far from leading a temperate life, they are seldom subject to the gout; while, on the other hand, those who lead a sedentary life, often find the strictest attention to temperance insufficient to prevent its attack. It is the indolence of literary men, Dr. Gardener observes, wliich has given rise to the opinion of abilities indicating a predis- position to gout. There may be some truth in this observation ; at the same time long and intense application of the mind seems to deserve a place among its predisposing causes. The bad effects of nightly study, indeed are partly to be ascribed to its encroaching s on the hours allotted to sleep. With regard to the kind of diet which predisposes to gout, al- though it is granted on all hands that fermented liquors, as well as much animal food, have this tendency, there is great difference of opinion concerning the kinds of fermented liquors which have most of it, and the observations of writers are in direct contradic- tion to each other. In this country we accuse wine of giving tbe strongest predisposition to gout, because the lower ranks are little subject to it. In them, however, the tendency may be counteracted by other causes. But Van Swieten observes, that when the peo- ple of Holland drank malt liquor the gout was hardily known there, but has become very common since the introduction of wine. " I " will not take upon me to determine," says Dr. Cheyne, iu hi^ Observations on the Mode of Treatment in Gout, " but I believe " the fact is, both in the stone and acquired gouts, that those who '• only drink malt liquors, without wine or spirits, are seldom vio- " lently afflicted with either. Eiger, professor of physic in the Uni- versity of Paris, on the other hand, observes, that in Champaign and Burgundy, where the people drink nothing but wine, the gout is hardly known ; and Hoffman agrees with this writer, that beer is more apt to produce gout than wine. Liger admits, that sweet 266 GOUT. wines predispose to gout ; and it is a very general opinion, lhaf the most acescent wines have most of this tendency. This, how- ever, appears doubtful, for although acescent wines, and every thing else which occasions much acidity in the primae viae, tend to excite fits of the gout in those who are subject to the disease, it seems, from a great variety of observations, that the stronger wines are more apt to give the predisposition. Liger makes the same observation respecting beer and cider, the strongest he found most to predispose to gout. Whatever be the comparative effects of wine and malt liquor, it seems to be pretty generally admitted that cider and perry tend more than either to give this predisposition ; but here perhaps au- thors still confound the causes most apt to excite the fit in those who are subject to gout, with those which predispose to it. It seems in general to require a combination of the two last mentioned causes, indolence and intemperance, to produce gout where there is little hereditary predisposition. Where this is strong, very slight circumstances are capable of exciting it, nor can the strictest attention to temperance always prevent its ap- pearance. Proofs of this we see in our own country ; and we are told of people who use almost solely a vegitable diet, generally drink water, and attain an old age, and notwithstanding are greatly afflicted with gout.* Of the exciting causes of gout, Dr. Cullen justly observes, that although physicians have pointed them out with confidence, in a disease depending so much on predisposition they must be uncer tain ; in the predisposed the occasional causes are not always evi- dent, and in those who are not predisposed the most powerful are often applied without effect. Many of the causes just enumerated, if applied suddenly and to- a considerable degree, act as exciting causes. A single fit of intox- ication, or any other cause which greatly deranges the digestive or- gans, may excite the gout in the predisposed, exposure to a moist cold air without exercise, acescent food and food of difficult di- gestion, unusual repletion of the stomach, obstinate vomiting, acids, either vegitable or mineral, taken in considerable quantity, and bile 01* any other irritating matter iu the stomach and bowels. Many of the occasional causes of gout less immediately affect the stomach, excessive evacuations of any kind, or a want of habitual evacuations particularly costiveness or obstructed perspiration. I* See Prosper Alpinusde Med. Egyp. GOUT. 2G7 is chiefly to the last cause, perhaps, that the returns of gout in spring and autumn are to be attributed. External injuries, espe- cially done to any of the joints liable to gout, often excites it in the predisposed. In short every cause which suddenly affects to a considerable degree either the general health or the part which the gout occupies, may excite a fit, The passions and even the ima- gination may have this effect. A piece of bad news has often ex- cited the gout. A late eminent professor, it is said, often began to cripple as soon as he began to lecture on this disease. Some of the first writers believe the gout to be contagious. Both Boerhaave and his commentator are of this opinion. But the disease being so common, the opinion if it were well-founded must have been more general, SECT. IV. Of the Nature of Gout. So much has been written, and so many opinions advanced re- specting the nature of gout, that I should not, perhaps, be excused for wholly passing it over in silence. No opinion has prevailed so generally as that which supposes this disease to arise from the presence of some morbid matter in the blood. What this matter is has long been a source of dispute. Some assert that it is the natural fluids of the body changed by putrefaction or become too viscid; others, that is it a bilious hu- mour ; some, that it is a mucilage ; others, that it is atartarous or urinous salt; by some it is supposed to be the superfluous part of the chyle ; by others, an aether ; some maintain that it is an earth ; others, an alkali ; and others, an acid. This last opinion has been long prevalent, and many regarded it as confirmed by the experiments of Scheele on urinary calculi ; for at one time it was very generally supposed, that urinary calkuli and gouty concre- tions were of the same nature.* With regard to all these opinions, * It appears from the experiments of Dr. Wollaston (Observations on Gouty and Urinary Concretions, byW. II. Wollaston, M. D. Phil. Trans, p. 386, partii. 17!*7) that the gouty calculus is the lithiat of Soda, which never forms the urinary calculus, nor indeed seera6 ever to enter into its composition. According to the experiments of Furcroy and Vauquelin, (Sur P Analyse des Calculs Unnaires Humains, par les Cit, Fourcroy et Vauquelin, Annales de Chimie, No. 95, p 213) the various urinary calculi are found to be composed of one or more of the following substances, lithic or uric acid, urat of ammonia, phosphatof lime, phosphnrofammoniaco-magnecia, osalat cf lime, silex, and vnimal matter. 268 GOUT. it is only necessary to shew that we have no proof of the gout arising from morbific matter of any kind. This the reader will find done in the 529th paragraph of Dr. Cullen's First Lines. Dr. Cullen gives his own opinion in the following words. " In " some persons there is a certain vigorous and plethoric state of " the system, which at a certain period of life is liable to a loss of " tone in the extremities. This is jn some measure communicated " to the whole system, but appears more especially in the func- *' tions of the stomach. When this loss of tone occurs, while tbe " energy of the brain still retains its vigour, the vis medicatrix na- " turae is excited to restore the tone of the parts, and accomplishes " it by exciting an inflammatory affection in some part of tbe ex- " tremities." By the operations of the vis medicatrix natural we only mean certain unknown changes in the animal system, which are so termed, because they seem to conduce to the restoration of health. If we substitute the meaning of the term, operation of the vis medicatrix naturae, for the term itself, in Dr. Cullen's account, of the proximate cause of gout, we shall find it changed into a con- cise detail of the progress of the regular form of the disease, The same observation applies to what he says of the nature of irregular gout. Various other hypotheses have been advanced. The gout has been said to arise from a vitiated state of the nerves ; to be an at- tempt of nature to recover the infantile permeability of artcrie.- closed up by exercise ; to be a spasm of the alimentary canal, communicated to the extremities, &c. All that we are taught by the volumes which have been written on the nature of this disease, is the great obscurity of a subject which has wholly eluded the re- searches of so many. SECT. V. 0/ the Treatment of Gout. The gout ii- very generally regarded as an incurable disease, so that the views in regular practice are to correct the predisposition before the disease has made its appearance, and when it has ap- peared, rather to palliate than remove it ; for notwithstanding all that has been said of the effects of diet and exercise, if we except a few cases where the predisposition is inconsiderable, wc shall find, that however much they mitigate, they almost always fail to prevent the returns of gout. It is true that we possess medicines GOUT. 269 capable of preventing its returns, but they often produce worse diseases. We shall consider the treatment of gout in the same order in which the symptoms were detailed. 1. Of the Treatment of the Regular Gout. Gout, we have seen, differs in some very essential particulars from the foregoing diseases, especially in its constantly returning, how- ever carefully the exciting causes are avoided, and in the great ten- dency it occasions to other diseases. The same circumstances in- fluencing the principles on which its treatment is founded, render them very different from those which regulate our practice in the other phlegmasiae. In a paroxysm of the gout it is not our chief aim to remove the inflammation; this indication, indeed, is often almost wholly overlooked. The objects we have chiefly in view- are, so to remove the paroxysm that the succeeding interval may be as long as possible, and that any tendency to atonic gout may be obviated ; the danger in gout proceeding neither from the local affection nor the general excitement, but from the paroxysms becoming frequent and irregular. At the same time the debility left by a severe fit seems itself to dispose to irregularity, and the distress occasioned by it is so great that we are called upon to alleviate the patient's sufferings as far as it can be done with safety. Some, indeed, have asserted, that the various means of diminishing the pain are not only safe, but, by rendering the paroxysms less debilitating, tend to prevent the atonic forms of the disease. This maxim, however, is to be ad- mitted with caution ; it is only in certain cases and to a certain ex- tent that it can be reduced to practice, The constant tendency of gout to recur, renders the advice of the physician as necessary after, as during the paroxysm. Our aim is still the same, that of prolonging the interval, and render- ing the succeeding fit mild and regular. Such are the principles on which the treatment of gout is found- ed. It appears from what has been said, that during the paroxysm two indications present themselves, which in some measure stand in opposition to each other. If we use vigorous means for the re- lief of present suffering, we endanger the future health ; if we at- tend to the latter only, we often have it but little in our power to mit gate the former. 1. Of the general means employed during a paroxysm of regular gout. 270 GOUT. A physician, who bad been accustomed to practice in the phleg- masiae and had never seen a gouty patient, would not hesitate in a regular paroxysm to recommend a free use of the lancet. He would soon, however, perceive his error. The inflammatory symptoms, indeed, would be relieved, perhaps wholly removed ; but if he persisted in this practice, they would soon be succeeded by a more alarming train of symptoms. " Sin autem, in paroxys- " mic subsequentibus phlebotomia jugiter utatur, podagra quam " citissime etiam in juvene inveterascet, et intra paucos, lafius im- " perium, seu potius tyranidem propagabit, quam alias in multis " extendere valuisset."* Most European physicians give nearly the same opinion of blood-letting in gout which Sydenham gave above a hundred years ago. It is neither, he observes, to be employed for preventing or alleviating the paroxysm of gout, at least in those who are advanc- ed in age. For although the blood drawn during a paroxysm, like that drawn in inflammation of the lungs, shews the buffy coat, blood-letting is as pernicious in the one, as it is beneficial in the other. If blood be drawn in the interval, he continues, there will be much danger of another paroxysm making its appearance, which will last longer, and be accompanied with worse symptoms, than the preceding. Yet he admits, that if the patient be young, and heated by the immoderate use of wine, blood-letting may be employed at the commencement of the paroxysm. Many late writers,! although they keep these maxims of Syden- ham in view, have ventured to extend blood-letting at the begin- ning of the paroxysm to those cases where the habit is full, the ex- citement great, and the local affection very considerable. " Sy- " denham," says Dr. Cullen, " has given it as his opinion, that " the more violent the inflammation and pain, the paroxysms will " be the shorter, as well as the interval between the present and " next paroxysm longer; and if this opinion be admitted as just, « it will forbid the use of any remedies which might moderate the " inflammation, which is to a certain degree undoubtedly necessary " for the health of the body. On the other hand, acute pain presses " for relief, and although a certain degree of inflammation may " seem absolutely necessary, it is not certain but that a moderate " degree of it may answer'the purpose. And it is even probable -' that in many cases the violence of inflammation may weaken the * Sydenham De Podagra. i Boerhaave, Van Swieten, M'Bride, Liger, Cullenj Cadogan, &c. GOUT. 271 11 tone of the parts, and thereby invite a return of the paroxysms." Dr. Cullen, therefore, concludes, that in the first paroxysms in the young and vigorous, general blood-letting may be practised with advantage, although it cannot with safety be frequently re- peated. Most of the authors just alluded to appear to have recommended blood-letting too freely, and it seems, indeed, to be daily more and more going into disuse; so that, even in the cases mentioned by Dr. Cullen, many object to it; and as we can generally by local means afford all the relief which is consistent with the patient's safety, there seems very rarely, any good reason for having re- course to it. Most of the best writers on this disease have condemned the use of cathartics in it. Some, Cheyne, Hoffman, M'Bride, Cadogan, &c. recommend mild cathartics, but Sydenham declares that even the mildest employed during the paroxysm tend to render it irregu- lar. Boerhaave and Lieutaud make similar observations. Dr. Cullen makes no mention of them at this period, and the Rev. Mr. Warner, and others, who speak of their own cases, say they have experienced the worst effects from them, so that catharsis, it would seem, is even more pernicious in the paroxysm, than blood- letting. I shall presently have occasion to make some observations on the use of cathartics during the interval, at which period they have been chiefly recommended. In the mean time it may be observed, that it has been common to exhibit a cathartic immedi- ately after the paroxysm. This practice has chiefly arisen from a belief that catharsis at this period carries off the remains of the disease ; but so far from having this effect, it often renews the pa- roxysm. Sydenham confesses, that this opinion induced him to take a cathartic immediately after a paroxysm, the consequence of which was, that he immediately fell into another. " Purg- " ing," Dr. Cullen observes, " immediately after a paroxysm, " will be always employed with the hazard of bringing it on " again." Irritating matter sometimes accumulates in the alimentary canal during the paroxysm, now and then occasioning griping and diarr- hoea ; towards its decline tbe discharge of this matter is only to be promoted by mucilaginous and diluting fluids, and when it seems to be evacuated the diarrhoea must be restrained by gentle anodynes and astringents; the oedematous swelling of the feet, which sometimes succeeds the paroxysm> and for which it GOUT. has been usual to give cathartics, generally goes off without any remedy. It often happens, that the bowels are costive during the par- oxysm, which, we have seen, is sometimes protracted for a con- siderable length of time ; mild laxatives then become necessary, for we cannot long trust the excitement of the bowels to clysters only. There is some difference of opinion concerning the employ- ment of emetics in the gout. Some think they are serviceable at the commencement of the paroxysm. Dr. M'Bride recommends one of the mildest, to be given with wine, if the patient is languid. Upon the whole, however, it seems to be the general opinion, that unless the stomach is loaded, they are at least unnecessary. Diaphoretics have been esteemed more useful as alteratives in the intervals than during the paroxysm. The benefit derived from a gentle spontaneous sweat coming on towards morning, however, has induced many to recommend them at this period. Dr. Cheyne observes, that after the fit is distinctly formed, particularly in complicated and tedious cases, and when the patient is advanced in life, they are serviceable. Boerhaave, Van Swieten, Liger, Dr. Caverhill, and others, are advocates for them, especially when the paroxysm has arisen from any cause tending to check perspiration But it may upon the whole be observed, that much benefit has not attended this practice, and it is very generally lai J aside. Syden- ham even apprehended danger from it, although he considers an increase of perspiration safer than most other evacuations during the fit. Sydenham and Quincy are among the authors who have given opiates most freely in this disease. They were still given howev- er, as a dangerous remedy. If the pain, says the former, is se- vere, the patient ought to keep his bed, and be contented with this remedy. If, however, it greatly exceed his patience, he may take a small dose of opium in the evening. No other writer has bestowed such unlimited praise on opium in the gout, as the Rev. Mr. Warner. This author, not belonging to the profession, and, indeed, betraying his ignorance of the present state of medicine in every part of his treatise, would deserve little notice, were it not that he suff'ered so much from gout in his own person, and gave opium so fair atrial. Dr. Falconer justly cen- sures him for the confidence with which he speaks of its effects from a single case. I must refer the reader to his treatise for the facts on which his opinion is founded, and the manner, according GOUT. 273 10 him the only proper one, of preparing the anodyne. A safe medicine, capable of relieving the torments and shortening the paroxysm of gout, is a great desideratum. Should Mr. Warner's anodyne prove innocent, it will be an invaluable addition to the remedies at present employed in this disease. The chance, how- ever, is much against it, whether we regard the observations of various writers or the well-known effects of opium in other cases. It is an argument against it, that Mr. Warner's practice, though generally known, has not been followed. Nor is it to be overlook- ed, that Mr. Warner died very soon after the publication of his treat- ise. The bad effects ascribed to opium, exhibited during the parox- ysm, are its occasioning it, after a few hours of relief, to return with great violence, and by the debility it induces in the organs of di- gestion, giving a tendency to the atonic forms of the disease. From the tendency of opiates to induce the atonic forms of gout, they have been generally judged safer in the young and those who have been lately attacked by the disease, than in old people and those who have been long subject to it. On the other hand, it is chiefly in the young that opium is apt to renew the paroxysm. Dr. Cullen seems to have overlooked the former tendency of opium, whence he pronounces its exhibition safest in the aged and those who have been long subject^ to gout. In young arthritics he recommends an anodyne after the force of the fit is broken, when the pain only returns during the night and prevents sleep ; and most writers admit of this use of opium. Liger, and some others of less note, Dr. Bennet, Dr. Williams, &c. forbid it, but their objec- tions do not appear to be the result of observation. Sydenham long ago pronounced the dieta tenuis the proper diet in a fit of the gout. When the patient is strong and full of blood, has not suffered much by former attacks of the disease, nor been in the habit of using much wine or other fermented liquors, and the inflammatory symptoms run high, this diet is necessary. When, on the other hand, he has lived freely ; when he has long been sub- ject to attacks of the gout, especially when these have shewn a tendency to become irregular, when the system has fallen into a state of debility, or when the inflammatory symptoms do not run high, a low diet is improper. A certain quantity of wine must be allowed proportioned to the patient's habits, and he should use an- imal food ; if the stomach will not receive it in the solid form, in that of broths. Vor.. ir. 35 274 GOUT. In such cases, aromatics and strong peppers have been mucii re- commended, and to a certain extent appear sometimes to do good. The stimulating regimen, however, has doubtless often been car- ried too far.* Disputes naturally lead to extremes, and there have been so many disputes respecting the treatment of the gout, that few writers can be wholly relied on. The temperature of the patient's room should be cool and uni- form. Concerning the local nceans employed during the paroxysm, there has also been much difference of opinion, and we shall find up- on the whole, that like the means we have been considering, few of them can be employed with safety. There was a very early prejudice against local blood-letting in the paroxysm. Whether this prejudice in its full extent is well founded, his not been positively determined. It would seem that blocd may sometimes be taken with advantage from the inflamed joint in the young and vigorous. Dr. Cullci! observes, that when tbe pain is very acute, he be- lieves that bleeding by leeches in the foot and inflamed part may be repeated. " I have known instances, he adds, of its having been " practised with safety ;" but he confesses that he cannot deter- mine to what extent it may be carried. Hoffman recommends it fre;dy, and Dr. Gardener and others follow him. But they talk of it in so general a way, that it is evident their observations are not the result of experience. From analogy it would seem, that local blood-letting, indiscrim- inately employed, must often prove a dangerous remedy in the gout; and iis being very generally abandoned, notwithstanding the almost uniform relief il brings, is a sufficient proof of its having been found hurtful. Its frequent repetition is particularly to be avoided, and it must not be attempted in the aged and those whose constitutions are already broken by the disease. Many applications to the inflsnied joint, for the purpose of miti- gating pain, have been proposed. They have, however, been so often productive of bad effects, that they are very generally laid aside. It will be necessary, however, to notice those which have been most generally recommended, and particularly such as are still in use. " Blistering," Dr. Cullen observes, " is a very effectual means " of relieving and discussing a paroxysm of the gout, but has also V: See Dr. Cadogan's Treatise on the Gout. GOUT. 275 " frequently had the effect of rendering it retrocedent." What is true of blisters, is, with little change, true of synapisms. The re- lief obtained by them in regular fits is always at the risk of pro- ducing worse forms of the disease. The same observations apply to the practice of stinging the part with nettles ; applying to it va- rious aromatic oils, mixed with different kinds of soap ; vari- ous preparations of opium ; euphorbium, boiled with wax and oil; various balsams ; spirituous liquors alone, or with camphor, &c. The reader will find an instance, related by Hoffman, in which the external application of spirituous liquors repeatedly relieved the pain, but proved fatal. Every thing of a highly stimulating na- ture tends to relieve the pain, and seemingly, in proportion as it has this effect, to render the gout irregular. Quick-lime and even arsenic have been recommended, the last is the basis of Dr. Pit- cairn's recipe for the inflamed joints. Sometime ago an applica- tion, which was said to relieve the pain and shorten the fit, made much noise at Paris. This has since been found to be diluted mu- riatic acid. For the mode of using it the reader may consult Dr. Rowley's Treatise. Dr. Stukely, in a letter to Sir Hans Sloan, recommends rubbing the joints affected with warm oil, prepared in a particular manner. Various other substances have' been used in the same way, but as they are all now laid aside, they must have been found either useless or hurtful. Oiled silk has lately been much celebrated as an application to gouty joints. The reader will find it recommended by several writers, particularly by Dr. Caverhill, who is in some degree whimsical in the effects he ascribes to it. The oiled silk is said to increase the pain, although it shortens the paroxysm, when the inflammation is superficial ; it is when the pain is deep-seated, we are told, that it brings most relief. It is sometimes applied alone, at other times over the flannels, and generally occasions a profuse perspiration in the part. Some, who are afraid of most other applications, think this may be employed with safety. Anal- ogy, however, is much against it; and it is very generally laid aside in this country. By some it has been thought useful to increase the perspiration of the sound as well as the gouty foot. No external application in gout has attracted so much attention as one used in the East termed Moxa. It is the down of the artem- isia. Sir William Temple, who used it in his own case, gives us an account of the manner of applying it. It is formed into a small cone, wliich is placed with its base on the inflamed part. The 276 GOUT. apex is then 4et on fire, and the cone continues to burn till the whole, or nearly the whole, is consumed. " Upon the first burning," Sir william Temple observes, " I " found the skin shrink all round the place, and whether the greater " pain of the fire had taken away the sense of the smaller or no I " could not tell, but 1 thought it less than it was. I burned it a " second time, and observed the skin about it to shrink and the " swelling to flat yet more than at first. I began to move my toe, " wliich had I not done before, but I found some remains of pain. " I burned it the third time, and observed still the same effects with- " out, but much greater within, for 1 stirred the joint several times " with ease, and growing bolder I set my foot to the ground with- "out any pain at all. After that, I had a bruised clove of garlic i( laid to the part that was burned, and covered with a large piece of '' diapalma to keep itfixed there." He then walked with ease. " For the pain ofthe burning itself," he observes, " for the first time " it is sharp, so that a man may be permitted to complain."* He counted, he observes, six score and four as fast as he could during the burning of the moxa. The second burning was not so painful as the first, and the third much less painful than the second. The wound was not raw, but appeared scorched and black. In a short time a blister arose, which left a small sore that soon healed. Sir William Temple afterwards repeated the application ofthe moxa, with similar success. Van Swieten gives an account of the same operation, also performed with success.! Some have attributed the effects of the moxa to a peculiar quali- ty possessed by this substance, others with more probability to the burning. Sydenham does not speak much in favour of the opera- tion, but thinks it may succeed as well as dry lint. But the effect he observes, must be temporary and fleeting. Were we sure that even this character of the operation was just, it would be a valuable addition to the treatment in the paroxysm ; but it has not been often enough employed in this country to ascertain its safety ; and we have every reason to dread the same bad effects from it as from other local applications. Dr. Cullen observes, that he considers the burning with the moxa, or other substances, a remedy ofthe same kind as blistering. " I have, indeed," he adds, " noevi- " dence of its proving hurtful, but neither have I had any proper e v- " idence of its having proved a radical cure." Upon the whole * Sir William Temple's Miscellanies. t Van Swieten's Commentaries on the 1278th aphorism. GOUT. it may be observed, it will require a very long experience to esta- blish the safety of any remedy of this kind, for even the most per- nicious have been repeatedly employed before their bad effects appeared. Cold is one of the most effectual applications to the inflamed joint. By it we may to almost any degree diminish both the se- verity and duration of the pain. But many cases are on record in which it seemed to produce tbe same bad effects experienced from other local remedies, and many alledge, that in proportion as it is more effectual, it is more pernicious than most others. It has still however, many advocates, and Dr. Kinglake's Treatise has parti- cularly directed the attention of the public to it. Tup result of our experience on the subject, as far as I can judge, is, that in the young and vigorous, when the inflammation runs very high, the cautious application of cold is often beneficial, but neither the ex- tent to which it may be carried, nor the frequency with which it may be repeated with safety, have been ascertained. From what has been said on this subject, however, 1 think it appears pretty certain, that the great accumulation of heat occasioned by wrapping the inflamed joint in many folds of thick flannel or in combed wool, or applying hot bricks to it as some recommend, often unnecessa- rily aggravates the severity of the paroxysm ; and is only proper where we have reason to believe that the degree of inflammation in the joint will not be sufficient to relieve the internal parts ; keeping the inflamed joint yery warm often eventually relieves the pain by occasioning sensible perspiration of the part, but this is generally at the expence of much previous increase of suffering. Various means have been proposed to strengthen the joint, which remains swelled, stiff, and weak after the paroxysm has subsid- ed. Bathingthe part with cold water, rubbing with flannel and the flesh brush, and endeavouring to use the joints, are the best. Some have re-commended a variety of stimulating substances to be used in rubbing the joints, they do not, however, seem to add much to the effects of the friction. Van Swieten observes, that al- though he orders the woollen cloths with which the friction is per- formed to be charged with the fumes of aromatics, yet he has found the same benefit from simple friction, which should be used for an hour or longer, morning and evening. The only good effects of im- pregnating the cloths seems to be that of inducing the patient to employ thefriction. Motion of the joint, has been recommended at the beginning of the paroxysm, with, a view to Ktop the fit. However successful 278 GOUT. this practice may be, the extreme pain it occasions will prevent its becoming general. The reader will find some observations on it in Dr. Caverhill's Treatise. I may also refer him to what Sydenham says of exercise during the fit. Few, however, have resolution to go into a carriage, as he advises, or use even gentler modes of ex- ercise at this period. Certain applications have been supposed to possess a power of restoring strength to the joints without friction. Hoffman recom- mends the volatile sulphuric acid and some of the balsams with Hungary water. The reader will find Dr. James's and other pre- scriptions of this kind in Mr. Warner's Treatise. Little or nothing is to be expected from them. Nearly the same may be said of the applications recommended to prevent or remove gouty concretions. These have generally been either of an acid or alkaline nature. The diluted muriatic acid, the fixed alkalis, and quicklime, have been employed. Van Swieten speaks of the benefit derived from a weak solution of a caustic fixed alkali in very strong terms, both in gouty and other tumors. The reader will find similar applications recommended in Hoffman's Section on Gout. Upon the whole, however, we gener- ally find reason to agree with Sydenham, that exercise is the best means for this purpose. He observes, that he has even seen gouty concretions of long standing resolved by exercise alone. When they make their way through the skin, if the habit is tolerably good, the wound generally heals readily with simple poultices. When the patient is much reduced by the violence of the fit, and recovers bis strength slowly, chalibeates and the bark are often serviceable. Although the spirits and digestion generally become very good towards the end of a fit, it sometimes happens, that as the pain abates, some atonic symptoms similar to those which precede it make their appearance. They are often relieved by absorbents and stomachic medicines. We are now to consider the most important part of the treatment of gout, the means employed during the intervals with a view to prolong them, and to render the succeeding fit mild and regular. Sometimes, indeed, when the predisposition to gout is not strong, when the patient is young and the disease has only shewn itself in a mild paroxysm, we have it in view entirely to prevent its return. In both cases the means employed are the same, but differ consid- erably in degree. GOUT. 27J 1 have already had occasion to hint that certain medicines have been employed for the purpose of preventing the return of gouty paroxysms even in the most inveterate cases. But a fatal and very extensive experience has convinced most physicians of the danger of having recourse to them. After considering the regular treat- ment, it will be proper to make a few observations on the nature and effects of some of these. Although there are some medicines which have both proved safe and useful during the interval, our chief dependence is on a proper regimen; for much is not to be expected from any medicine wc can venture to employ. What was said of the causes of gout may point out the proper diet. The symptoms of the disease, indeed, naturally lead us to that which experience has proved the best. We see the fit preced- ed by symptoms of debility, which points out the propriety of a nourishing diet. At the same time we observe that the regular gout consists in a violent inflammatory affection of the joints, by which we are led to avoid the diet which most disposes to inflam- mation. If the diet be too low, the fits will not only become more frequent, but will partake more of the atonic forms of the disease. If the diet be too fulJ and stimulating, they will also be- come more frequent and the inflammation will be more severe. It is true, indeed, that in this case they will for sometime retain the regular form ; but nothing is better ascertained than that the fre- quent repetition of regular paroxysms, especially if severe, soon impairs the vigour ofthe system, and induces the symptoms of irre- gular gout. A proper diet has so long been regarded as among the most es- sential parts ofthe treatment of gout, that there are few writers on tliis disease who do not speak of it at considerable length. Ther* is, however, much difference of opinion respecting it. By some the use of animal food is forbidden. By others it is particularly recommended, and bread and vegetables are condemned as hurtful by producing acidity. Some have wholly condemned the use of wine, even in those who have been accustomed to it. Others re- commend it to all arthritics without exception. It is impossible to lay down any regulations respecting diet in the interval, as in the paroxysm, which shall be universally ap- plicable. It must be still regulated by the age of the patient, his habits of life, the length of time he has been subject to the gout, the frequency and severity of the paroxysm*, and the tendency which they have shewn to become irregular. 280 GOUT. When the patient is young and has lived temperately, wiien he has only suffered a few paroxysms and these have shewn no tendency to become irregular, he is in the most favourable state for attempting a radical cure. His constitution is not yet habituated to the disease, and he can with safety use that kind of diet which has been found best suited to prevent its return, which, as appears from various ob- servations consists chiefly, if not wholly, of milk, and the more fa- rinaceous vegetables ; an assertion which has been denied, but chiefly, it would seem, from this diet having been prescribed in improper cases and not with sufficient caution ; for it is so different from that in general use, that even the young have not sufficient strength of constitution to bear the change if made too suddenly. It is only by degrees, and in the space of some months at least, that perhaps any arthritic should be permitted wholly to abandon the use of animal food or wine. Some have thought it sufficient to persist in a vegetable diet for a certain time, during which, if the gout has not made its appear- ance, they judge it safe for the patient to return to his former mode of life. But Hoffman and others alledge that if this is done, the gout is always renewed, and sometimes in a worse form. We rarely have an opportunity of ascertaining wliich of these opinions is correct ; but we have reason to believe, that after a certain time bas elapsed, the patient may often return to the moderate use of animal food, without renewing the disease. I have known young people who had had several attacks of gout from a strong heredi- tary predisposition, having always lived temperately, remain free from it without any material change of diet ; but such cases, al- though affording an argument in favour of this opinion, are not, it is evident, exactly in point. It is seldom, however, that a milk and vegetable diet can be re- sorted to with safety. In those advanced in life, or accustomed to intemperance, or in whom the vigour ofthe constitution is at all impaired, or even the regular gout has frequently returned, it-is not to be attempted. But there is no case in which some change may not be made. If the patieut has been intemperate, he must be allowed full living, but warned against excess. If he has only been a full liver, he should be desired to eat and drink more spar- ingly, particularly to give up the use of animal food in the eve- ning, and, according to Sydenham's rule, to confine himself to one dish at dinner. He should take only a few glasses of wine, which, if it does not cause acidity, is better than distilled spirits in any GOUT. 281 hbape. We have even reason to believe, I think, that he should prefer the weak wines to the strong, or if he drinks the latter, di- lute them with water. If, with this mode of life, his strength, as Frequently happens, is rather increased than diminished, he may gradually accustom himself to drink less wine, till at length, per- haps, he will find that he can lay it aside altogether. It should, perhaps, be the view of every arthritic, whose consti- tution is still vigorous, to bring himself to use water only, (Syden- ham particularly recommends whey,) at least for his common drink. But there is not a more dangerous maxim than Dr. Cadogan's, that the change should be made as speedily as possible. There are few physicians who have not seen its fatal effects. Dr. Falconer has censured Dr. Cadogan for advising, that the diet of gouty patients should be composed rather of solid than li- quid food, and quotes Haller in support of the opposite opinion. Most dyspeptics, however, will agree with Dr. Cadogan. It would seem, that the gastric fluid having its powers diminished in the dyspeptic, will not admit of any dilution. This writer has been more justly censured for regarding bread as pernicious. Many arthritics, however, who have been long ac- customed (as a large majority have) to consume great quantities of animal food with very little bread, complain of its oppressing the stomach and running into the acetous fermentation. But this pro- ceeds not from the indigestible quality in the bread, but from the stomach not being accustomed to it. If the quantity be gradually increased, the arthritic will experience no inconvenience from it.. And as it is very nutricious, without tending to produce the full- ness occasioned by animal food, when the stomach can digest it perfectly it should form the principal part of the diet of gouty pa- tients. Such is the power of habit in this respect, that even carni- vorous animals may, by degrees, be brought to live wholly on ve- getable matter ; and granivorous, on animal food. Whereas if the change were made suddenly, the death of the animal would proba- bly, in both cases, be the consequence. Particular objections have been made to much salt, pepper, mustard, vinegar, and all kinds of pickles, and not without reason. for these, if we except the first, are not only in themselves hurtful to the .stomach, but induce the patient to eat more than is neces- sary. No attention to diet is capable of prolonging the intervals, and preserving the paroxysms mild and regular ifexerrisp be neglected. Vor. n. .°>fi 282 GOUT. When the patient is able to walk for a sufficient length of time without fatigue, this mode of exercise as most uniformly employ- ing the muscles, is preferable to any other. Some have recom- mended more violent exercise ; but to be most beneficial, it must be such as can be continued for a considerable time without fa- tigue. It is true, indeed, we have heard of people of strong constitu- tions, wholly cured ofthe gout by being subjected to much labour and abstinence There is not a {ew instances, says Hoffman, of people having lost the gout with their fortunes. Van Swieten tells us of a priest, who was taken by pirates and condemned to the oar for two years, which wholly cured him of the gout he had been long sub- ject to. In such cases, however, other circumstances concur with ti.e exercise. The power of strong affections of the mind, and a total change of habits, every body is aware of. With regard to tho^e who cannot walk, or cannot walk enough, they must ride on hoi setback, or if this is too much, in a carriage. If even this is not t'.< ' e borne without fatigue, they should morning and evening, un- ds;\,o friction of the whole body, continued till they begin to feel some degree of weariness. Friction of the joints, indeed, while the)' remain stiff should in no case be neglected. By these means the weahes' arthritic will often be brought by degrees to bear the rougher exercises. It is to be observed, however that much walking when the lit is expected, may bring it on, especially if the feet are at all cramped or otherwise injured. The exercise ofthe mind is also a matter of some importance in the intervals of gout. Nearly the same may be said of it as of bodi'y exercise. Any study which fatigues is injurious, and the constant languor ofa mind wholly unoccupied, as 1 have already had occasion to observe, is no less so. The early part of the day is the proper time for the exercise both of mind and body. Repose towards evening is particu- lar1}- necessary to invalids. The observations made on this subject during the intermission of agues are applicable here. Some attention to the proper regulation of sleep is also ntcessary. Boerhaave recommends a great deal of sleep to his gouty patients ; and within certain limits a large proportion of sleep is one ofthe best means of restoring strength. For this part of the subject I may also refer the reader to the chapter on intermitting fever. Sydenham is among the very few writers who have taken no- tice ofa choice of air in the treatment of arthritic patients. While the patient is using exercise, he observes, a wholesome air is to be preferred. Exercise in the country is better than exercise in the GOUT. 283 town, where the air is loaded with vapours, and rendered still worse by the closeness of the buildings. Many from their own ex- perience can affirm the truth of these observations ; and I have known instances in which dyspeptic patients could not with twice the exercise in London, preserve the same degree of health which they enjoyed in the country. It was supposed by many, till the experiments of several chemists demonstrated the contrary, that the air of great cities was less wholesome than that of the country, in consequence of its containing a less proportion of oxygen. From many circumstances it would appear, I think, that the un- wholesomeness of the air in great cities arises chiefly from its greater dampness ; for a damp air, from whatever cause, occasions, in tbe debilitated, the same want of appetite, depression of spirits, and other nervous symptoms.* Its bad effects cannot be attribut- ed to its abstracting the heat with greater rapidity, as the same ef- fects are not occasioned by a dry air, however cold. Nor can a damp air be supposed to affect the lungs materially which are al- ways moist. Its injurious effect seems to arise from that of moisture on the skin, which so remarkably sympathises with every part of the system, and particularly with the stomach. All the symptoms occasioned by a damp air are such as indicate a want of vigour in the skin, and consequently of free perspiration, chilliness, loss of appetite, languor, &c. The effects of damp linen, even in strong habits, shew the pernicious tendency of moisture applied to the skin. This is generally explained by the cold occasioned by the evaporation, but a much greater degree of cold is borne without inconvenience. The sensations produced by a damp air are simi- lar, though less in degree, to those produced by damp linen. * The cause of the greater dampness of the air of large cities appears from the experiments on which Dr. Hutton has founded his theory of rain. Every cool breeze much charged with moisture must, by mixing with the heated air of the city, occasion a deposition of water, since it is found that the mean tem- perature will not enable the airs to hold the same quantity in solution which they do before they are mixed. There is no part of this country in which fogs are so common or so great as in Loudon. I have myself observed, from an em- inence, that when a sea breeze was passing over the country, wherever it met with the heated air of a village, a considerable deposition of moisture took place. So that from each village, a train of fog, proportioned to its size, ex- tended itself along the country, in other parts of which the air remained per- fectly transparent. But the mixture of airs of different temperatures, without going so far as to occasion fog, is often attended with a considerable degree of dampness, to which the delicate are extremely sensible, and which in common language has obtained the name of rawness 284 GOUT. Physicians, I have already had occasion to observe, have no: trusted to diet and exercise alone during the intervals of the gout. The remedies which have been found useful at this period, like those recommended during the paroxysms, may be divided into general and local. In the first place, ofthe general remedies. The impropriety of employing general blood-letting at this pe- riod is so evident, that very few have recommended it. It would rarely have much effect in rendering the succeeding paroxysm milder, but would either by weakening the patient, tend to bring on atonic forms ofthe disease, or by increasing plethora, particu- larly in the young, to increase the violence and frequency of the inflammatory paroxysms. Physicians have been more divided in their opinions concerning the use of cathartics at this period. Hoffman thought that they might be employed a little before the accession, for the purpose of preventing the fit, and even observes, that general blood-letting has been successfully recommended with the same intention. Some recommend mild cathartics throughout the whole of the inter- val ; Boerhaave and others, even those of a drastic nature ; but Sydenham has declared against them all at this period as well as during the paroxysm. There are similar, though not so strong objec- tions to catharsis during the interval as to general blood-letting ; with this in addition, that the frequent use of cathartics tends to weaken the stomach and bowels. In modern practice they are on- ly recommended for the purpose of keeping the bowels regular, and those are preferred which occasion least evacuation, aloes, rhu- barb, magnesia, fcc. The first, for reasons which will afterwards appear, is objectionable in gouty cases, where the constant use of a cathartic is necessary. Many have endeavoured to support the strength by the Peruvi- an bark and other tonic medicines. These at first view appear well adapted to the intervals of gout, but, notwithstanding what some have said of their effects, they bear too near a resemblance to the specifics which have done so much mischief in this disease, to be generally employed. The best physicians either do not mention them among the remedies of gout or speak of them as verv doubtful means. Among the tonics which have been recommended in the interval, the cold bath holds a principal place ; even this is a doubtful rem- edy except in the young and vigorous, or at least in those who enjoy long intervals. Employed near the time of accession, it has, by preventing the regular paroxysm, induced atonic symptoms GOUT. The opinions of physicians respecting the warm bath during the intervals, are various. Sydenham and some other of the best wri- ters take no notice of it. The tepid bath, however, it is now as- certained has not the debilitating tendency formerly ascribed to it, and in those who have become cripples from the gout, it is often used with great advantage. No remedy has been so much celebrated in this country as the Bath waters, used both externally and internal- ly, for the purpose of fixing the gout when it shews a tendency to become irregular, and for restoring the strength and the use of the limbs after severe fits. It is not easy to ascertain with accuracy how far their reputation is well-founded. That they are often of use in such cases is certain. The hot waters of Bourbon,* the wa- ters of Aix-la-Chapelle, the Piermont and Seltzer, and many other mineral waters, have been celebrated in the gout, but do not seem equal to those of Bath. Drinking water impregnated with carbon- ic acid gas has been warmly recommended. It appears to be a good and innocent stomachic. Various medicines have been employed with a view to correct or expel the morbific matter to which we have seen the gout has been attributed. Many of them, sulphur, ammonia, &c.| seem more safe than effectual. They have indeed been so seldom at- tended with success, that their employment has not been sufficient- ly general, perhaps, to ascertain their safety. There are some of them, however, particularly antimonial and mercurial medicines, whose effects we have more reason to dread. The accounts which Cheyne and others give us of the effects of mercury in gouty cases, speak but little in its favour. " The fact "' is," says he, " that by a free and full salivation gouty people " have been freed from all ihe symptoms ofthe complaint for sev- " eral years ; but it is also a matter of fact and experience, that a " full and free salivation does so break, rend, and tear, all thesmal- " lest, tenderest, and finest vessels and fibres, that the body be- " comes in a worse state, in respect to the future fits, than it would " have .been in several years time under tbe common symptoms." * Pec a Treatise, entitled IJains de Bourbon, by Dr. Aubery, t There is some account of the alledged success of sulphur water in gouty cases, and the mode of preparing it, in the eleventh volume of the Medical Commentaries. For medicines employed with a view to prevent a return of the paroxysm, see the first volume of the Acta Reg. Soc. Med. Haf. A paper above referred to, by Dr. Clark, and one by Dr. Guthrie, in the fifth \olume of ,1he Medical Comment. 286 GOUT. In the Observations interessans fur la Cure de laGoute, and oth- er works, mercurials are much recommended during the paroxysm. But I have not taken notice of them among the remedies of that period, as by the practitioners of this country at least they are ve- ry generally laid aside. The reader will find antimonial medicines recommended by Dr. Cadogan, Dr. Jeans, and others. But it is justly observed by Dr. Falconer, that they have been used without advantage, and that their continued use is to be feared, as they tend to hurt the stom- ach. With respect to the local remedies at this period, there are only two which deserve notice ; local blood-letting and issues. It was common, formerly, to apply leeches to, or scarify the feet when a fit ofthe gout was expected, especially if the habit was plethoric, or any accustomed discharge had been checked. How far this practice, blistering, or other such means, might prove suc- cessful in preventing the recurrence of gout, it is difficult to say, for the hazard of all means of this kind has banished them from modern practice. We have every reason to believe that in pro- portion as they prevented the regular they would tend to induce the atonic forms of the disease. It is observed that when from the breaking of gouty tumors or other accidents, ulcers are formed and continue to discharge, the intervals of the gout are prolonged and the paroxysms rendered milder without any disposition being given to irregular gout. This circumstance suggested to physicians the propriety of making ar- tificial ulcers in the legs, which are sometimes productive of the same good effects. It is necessary, however, for a gouty patient who has once submitted to this remedy, to keep up the discharge for life. The worst consequences often follow the closing of issues, or even of spontaneous sores, which have continued for a consider- able time. In the latter case, indeed, issues should be substituted for the sore, if this precaution is neglected, the fits often become as frequent as they were, or more so, and generally shew a greater tendency to become irregular. It seems to be an observation, with few exceptions, that if gouty paroxysms be interrupted for some time, or rendered less frequent, by whatever cause, and in conse- quence of its removal or other means, they recur with their usual frequency, they generally assume a more dangerous form. Some ascribe the effects of issues to the irritation they occasion, and recommend frequently shifting their place. Their effects,. GOUT. 287 however, seem, in a great measure at least, to depend on the evac- uation, and frequently shifting them is very troublesome. It is hardly necessary to add to what has been said ofthe treat- ment during the interval, that carefully avoiding the various occa- sional causes forms an essential part of it. Such is the treatment of regular gout. Every age has tended to simplify it; and most of the numerous list of medicines, once so generally recommended in this disease, are now regarded either as useless or hurtful. Before leaving the treatment of regular gout, it will be useful to make a few observations on some ofthe specifics which have been recommended for its radical cure. Most of these are composed of ingredients which some physicians still venture to prescribe to a certain extent, and many of them are medicines on which the old- er physicians placed their chief reliance. The composition of the powder termed Portland powder, from the supposed cure of the duke of Portland, is now known.* It was used in gouty cases as early as the days of Galen, since whose time it has often been in high repute, and as often fallen into dis- use, t Its effects are now very well ascertained ; those who have used it according to the directions have been freed from their gouty pains, but there is hardly an instance in which the patient survived its use above a few years.J * It is composed of equal parts ofthe root of that species of bithwort term- ed aristolochia rotunda, of gentian root, of the tops and leaves of germander, ground pine, and centaury, dried, reduced to powder, and sifted. A dram of this powder is taken every morning for three months, three fourths of a dram, or according to some, two scruples, for three months longer, and for the ensu- ing six months, half a dram. t The reader may consult a paper, intitled an Inquiry into the Origin of the Gout Powder, by Dr. Clephane, in the 1st vol. ofthe Med. Obs. and Inquiries. X " I myself," says Dr. Cadogan, " observed between fifty and sixty of the "advocates of the Portland powder, some my patients, some my acquaintance " or neighbours, who were apparently cured by it for a little while, but in less " than six years' time they all died to a man." And Dr. Cullen observes, " in " every instance which I have known of the exhibition of the Portland powder ■" for the length of time prescribed, the persons who had taken it were indeed " afterwards free from any inflammatory affections ofthe joints, but they were " affected with many symptoms ofthe atonic gout, and all, soon after finishing " their course ofthe medicine, have been attacked with apoplexy, asthma, or " dropsy, which proved fatal." 2£8 LrOUl. Although most physicians have wholly discarded a medicine so generally productive of the worst effects, yet some, Dr. Jeans. Dr. Gardner and others, have ventured to recommend it in smaller doses, especially to young arthritics. This is at least a precarious practice, though perhaps, not more so than the daily use of other bitters anJ aromatics. The older physicians laid it down as a rule, that this medicine should not be administered to those who had been subject to gout above six or seven years. Some believe that such medicines are safer in infusion than in substance. This is probably true, as the former is less powerful ; but there is reason to believe that it is only as it is so, that it is les? pernicious. It does not seem to be the medicine, but the circum- stance of checking the gout, that occasions the fatal effects, and it is more than probable, that the use of any means capable of pre- venting the return of the regular fits would be attended with the same consequences. We have every reason to believe, that a person free from the gout might take the Portland powder, not foT one year only, but for many years without fatal effects. It was observed above, that mercury has been recommended in the gout. It has formed the basis of some specifics. The famous pills of Belloste are a mercurial preparation. The reader will find many cures by this specific related in the second volume of Belloste's Hospital Surgeon. There is every reason to belive, that mercury is no safer a specific in gout than the preceding. Wc have seen Dr. Cheyne's account of its effects. In the incautious hands ofthe empiric it is still more to be feared. Hoffman relate- the fatal effects of a mercurial specific for the gout. The alkalis have been much celebrated as specifics in this dis- ease. From the frequent concurrence of gout and gravel since al- kaline medicines have been so much used in the latter disease, they have often been employed in gouty habits. It is very gen- erally admitted that they tend to prolong the interval, whether with safety or not seems etill undecided. We have reason from analogy to dread every medicine having this tendency. If they act merely by correcting acidity, which we know frequently ex- cites the gouty paroxysm, they may be less pernicious than those that make a more direct impression on the system. Many alka- line specifics have at different times appeared ; but it is rather in calculous, than in gouty cases, that they have been celebrated. Lieutaud, M'Bride, and other writers, however, speak with confi- dence of their effects in the latter disease. Liger in particular recommends them in the strongest terms. Dr. Cullen, who wrott GOUT. £89 since these authors, although he thinks favourably of them, speaks with less confidence both of their success and safety. The long continued use ofthe alkalis has induced a bad habit of body, ema- ciation and debility. The pure alkalis combined with oil, the form in which Liger used them, are said to be more effectual, but at the same time more pernicious, than the alkaline carbonates. It would be spending time to little purpose to enquire into the merits of any other medicines of this kind. The effects of all ol them are similar. We may therefore permit the spirituous infu- sion of guaiacum, the Swiss tincture, Dr. Hill's elixirof Bardana, the Liege medicine,* Mr. Drake's specific &c. to remain in the silence into which they are now sunk. A specific which has lately come into general use in this country, termed the Eau Madicinale of Husson, differs from the preceding in being chiefly recommended during the paroxysm. For an accountof this medicine, 1 must re- fer the reader to the various publications on it. Respecting its ef- ficacy in lessening the severity and duration of the paroxysm there is no doubt, but their must long be much doubt respecting its safe- ty. Those who are acquainted with the history of the gout will not be very sanguine in their expectations from it. Its immediate effects are often very violent. I have known several instances in which its use was succeeded by symptoms of atonic gout. In one instance related to me by the patient's brother, it appeared te prove fatal. 2. Of the Treatment of Irregular Gout. It is evident that this part of the subject cannot be here consid- ered at length, for that would lead to the treatment of almost all the diseases to which an arthritic is subject. All that can be attempted, therefore, is to lay down the general principles on which the treatment of the chief varieties of irregular gout is foun- ded. In detailing the symptoms, I adopted Dr. Cullen's division of irregular gout, into atonic, retrocedent, and misplaced. I shall follow the same order in considering the treatment. Of the Treatment of Atonic Gout. By far the most common form of atonic gout is that of dyspepsia. In laying down the principles of the treatment of atonic gout, * This medicine was proposed by Dr. Le Fever, and at one time made much noise. See a pamphlet respecting it by the Rev. Mr. Marshall, and another by Mr. Drake, who was also a proprietor of a gouty specific. Vol. ii, 3" 290 GOUT. therefore, I shall keep this form of it in view, and afterwards make a few observations peculiarly applicable to its other forms. This method is more distinct than endeavouring at the same time to lay down the treatment of affections so dissimilar. Even those who have not been long afflicted with the gout gener- ally complain of flatulence and other dyspeptic symptoms during the interval. While these symptoms are moderate, alleviated by a proper attention to diet and exercise, and do not interfere with the return of the regular paroxysms, they do not deserve the name of atonic gout. But, however slight, as soon as they have this ef- fect, they are to be regarded as a disease of importance. It seems at first view surprising that the dyspepsia of gouty pa- tients should be attended with so much greater danger than dys- pepsia under any other circumstances. We see it in people of all ages and temperaments, occasioning pain, sickness, and even syn- cope, yet attended with little or no danger. This seems to be ex- plained by other tendencies of gouty habits. W'hen we consider the debility which generally precedes death in gouty dyspepsia, the manner ofthe death, and the diseases to which the habit is dis- posed, there is reason to believe that the immediate cause of death. in such cases, is that affection of the brain, which has been termed nervous, apoplexy. Were we to enter at large on the subject of apoplexy, we should find additional reasons for this opinion. We have two things in view in treating the atonic gout : to re- move the symptoms of debility, and to restore the regular fits. If we succeed in either of these indications, the other for the mosf part is answered at the same time. Of removing the Symptoms of Debility in Atonic Gout. For this purpose Sydenham relies more on regimen than medi- ciues, and justly observes, that all the means we can employ will be of little avail if the patient neglects exercise. A proper atten- tion to diet is no less necessary. What I said of these in speaking of regular gout is applicable here. Cold bathing has been recommended. There are two circum- stances, however, which render it a doubtful [ ractic^. It is apt U» overpower a debilitated habit ; and to prevent the accession of re- gular fits, if employed when they arc about to appear. It is nev- er to be recommended, if, from pains ofthe limbs or other circum- stances, there is reason to expect a fit. Some, indeed, have been so much afraid of this tendency of the cold bath, that they have whol- ly condemned its use in every form and period of the disease. GOUT. 291 The patient ought to avoid all kinds of fatigue before going into the water, to remain in a very short time, and as soon as he comes out to have the whole body rubbed with dry cloths. If by these means he feels no glow of heat, or, although he feels this in some degree, if his appetite and spirits are not improved by the bath, there can be no doubt of the impropriety of continuing it. The action ofthe bowels, which are often languid, should be pro- moted by cathartics of the gentlest kind, and ofa warm invigorating nature. The body should be moderately open, but purging is hurtful. Emetics are only proper when the stomach is much loaded and should seldom be repeated. If the strength is much reduced, Dr. Musgrave recommends wine instead of water to promote the vom- iting. But the medicines which hold the chief place in the treatment of atonic gout, are those termed stomachic, whicji consist of cordi- als, bitters, aromatics, and astringents. When the dyspeptic symptoms amount to atonic gout, it is necessary to increase the quantity of wine. Sydenham observes, that after trying many things to remove the languor and debility of the stomach, he found nothing answer so well as a small draught of Canarv wine. But in cases which threaten immediate danger, wine is often in- sufficient. In that extreme pain of the stomach, under which gouty patients frequently expire, a glass of strong brandy or usque- baugh, or even more, swallowed speedily, is the best medicine. If these fail to relieve the pain, we must have recourse to opium, tak- ing care to counteract its effects on the bowels. It is in that form of atonic gout which appears chiefly in debility of the stomach, that the occasional use of bitters is still recommend- ed by many ; but they approach too nearly to the nature of some of the specifics above mentioned to be used with freedom. " For " strengthening the stomach," Dr. Cullen observes, " bitters and the " Peruvian bark have been employed,but care must be taken that " they be not constantly employed for any great length of time." Simple astringents are safer. There is none so much celebrated as iron. Musgrave used the rust, which he regarded as a powerful means of strengthening the stomach in gouty habits. Dr. Cullen also prefers the rust, others the tincture. With respect to aromat- ics, they generally enter into the composition of cordials, and do not appear more hurtful than the other ingredients of such medi- cines. Issues, as appears from what I have already had occasion to say, are often serviceable in atonic gout. 292 GOUT. I may here refer to what was said of the Bath and other mineral waters in cases of gouty debility. " After all this man- " agement," says Dr. Cheyne, " should the gout still continue in *' the stomach and become habitual, nothing but a long course of " the Bath waters, with steel bitters and gentle stomachic pur- " ges, a regular diet, and proper exercise, can effectually re- " move it." In obstinate cases, if there is any means of relief, it is the change to a warm climate. Of the means which tend to excite inflammation in the extremities. I have had occasion to mention emetics, as recommended for an- other purpose ; they have also been found serviceable in this way ; the gout after their operation sometimes appearing in the extremi- ties. It is remarkable, that the very means which are most apt to drive the gout from the joints when it has already fixed itself there, and consequently occasion the atonic forms of the disease, are in those forms, among the most powerful in inducing the regular par- oxysm. The chief of these is the application of large blisters to the ex- tremities. If the gout does not appear within a day or two after their application, the discharge should be kept up from some ol the blistered parts, which, Dr. Musgrave observes, will either bring the gout to the joints, or otherwise relieve the urgent symptoms. With the same view a variety of rubefacients have been recom- mended, mustard poultices, bathing the lower extremities with hot wine or distilled spirits in which acrid substances have been dis- solved, &c. Some recommend applying rubefacients previous to blisters. The reader will perceive that the use of these remedies requires some caution. If they are applied after any pains have been felt in the joints, which generally indicate a tendency in the gout to fix there they may do harm. Exercise, particularly walking, is also a means of bringing the gout to the extremities. AVhen the patient is unable to walk, be may ride on horseback, or go in a carriage ; when no exercise can be borne, Boerhaave advises, that he should be kegt warm in bed and drink diaphoretic and aromatic liquors. With these means, those ot invigorating the system are to be combined. Drinking a bottle of wine has been known to bring tbe gout to the feet, when every thing the physician could think of had failed.* * See Van Swieten's Commentary on Boerhaavc's Aphorism on the Gout. GOUT. 203 Such is the manner of treating atonic gout when it assumes the form of dyspepsia ; and almost every thing, that has been said, will be found applicable to its other varieties. A very few obser- vations on these will be sufficient. The gouty, we have seen, are subject to diseases of the intes- tines as well as stomach, particularly colic and diarrhoea. In ar- thritic colic all the means just mentioned are proper, but cathar- tics more necessary. Fomentations of the belly,* and other measures recommended in ordinary cases of colic are to be em- ployed in conjunction with those which tend to fix the gout in the joints. A similar observation applies to gouty diarrheea, whether bilious or not. The means we have been considering are to be combined with those employed in ordinary cases of diarrhoea. If the diarr- hoea evidently arises from an accumulation of acrid matter in the intestines, it is necessary to promote its discharge by warm cathar- tics and copious draughts of thin broth, before we endeavour to check the action of the bowels. If the stomach is much loaded, an emetic will be of service, both by preventing the further introduc- tion of irritating matter into the intestines, and by tending to allay their motion. But when the diarrhoea is bilious, emetics should be avoided. When the intestines are sufficiently cleared, it may be allayed by astringents and opiates. Musgrave and Sydenham did not hesitate to recommend the latter, though some express fears of them, not however, as far as I can judge, on sufficient grounds. Exercise of various kinds tends at once to check the diarrhoea and bring the gout to the extremities. If exercise and laudanum fail, says Sydenham, the only remedy I know of is to bring out a sweat, both by external and internal means ; if this be done morn- ing and night for two or three days together, and for two or three hours each time, the diarrhoea is generally checked, and the gout often fixed in the joints. When the stools assume a dysenteric appearance, strong cordi- als and meats are pernicious. The diet must then be mild, and the use of astringents avoided. In such cases the best plan seems to be, to procure a discharge of the irritating matter, from which the dysenteric purging generally arises, by mild cathartics, par- ticularly ipecacuanha in small doses, and then allay the pain and irritation by small and repeated doses of opium with mucilage.| * In colic I have seen much relief obtained from flannel, dipt in brandy and sprinkled with black pepper, applied to the belly. •} See the Treatment of Dysentery in the last section of this volume. 294 GOUT. The treatment of gouty asthma differs from that of the common asthma only in the addition of means for bringing the gout to the extremities. The same may be said of the treatment of syncope in gouty habits, except that the cordials should be of the most powerful kind ; they should be given by clyster during the fit, and drank freely during the intervals. There is much danger in attempting to throw any thing into the stomach while syncope lasts ; when the patient does not make the effort to swallow, it may fall into the trachea. I have twice seen patients in a state of insensibility suffocated by this accident. In gouty palsy and apoplexy the treatment differs still less from that of other cases of these diseases ; for in palsy and apoplexy the means employed for bringing the gout to the extremities are necessary, although there be no gout in the habit, and consequently where there is, serve a double purpose. In many cases of these diseases it is difficult-to ascertain the propriety of having recourse to evacuations. To point out the various circumstances which here influence our judgment, would lead us into too long a digression, indeed to a review of almost the whole treatment of idiopathic apo- plexy ; but it may upon tbe whole be observed, that evacuations should be used more sparingly in gouty, than in other habits. When the patient is afflicted with flying pains in various parts of the body, or quinsy, inflamed eyes, tooth-ach, &c. while the common means are employed, as in the preceding cases, we hope for a cure chiefly by bringing the gout to the joints. The reader will infer from what has been said, that issues are often servicea- ble in such cases, in which I have myself seen the best effects from them. The retrocedent gout is even more dangerous than the atonic, because the means of relief are generally more confined. It would appear at first sight, that as the danger arises from the gout leav- ing the extremities and affecting some internal part, we should constantly have recourse to the means above pointed out, for bring- ing it back to the former. But I have already had occasion to observe, that although these remedies often succeed in bringing the gout to the joints when they are wholly free from pain, yet if there be any remains of pain in them, which frequently happens in retrocedent gout, they will generally render the retrocession more complete, so that it is only when the pain is wholly removed that they can be employed. GOUT. 295 When the stomach is affected, recourse must immediately be had to the strongest cordials, strong wirifs, or distilled spirits, with aromatics, given warm. The medicines termed antispasmodics have been much employed in this form ofthe disease. Many give asafoetida, musk, and ammonia, but the medicines of this class, most to be depended on, are ether, and opium. If vomiting comes on, it should be encouraged by draughts of warm wine till the stomach is cleared, and then allayed by a dose of opium and cam- phor. When the pains of the joints suddenly receded, and were followed by oppression, sickness, and vomiting, Sydenham used to drink some diluting liquor to promote the vomiting, and afterwards take eighteen drops of laudanum in Canary wine; he then went to bed and endeavoured to compose himself to rest. By these means, he assures us, he has often been almost snatched from death. Musgrave recommends blood-letting in the asthma of retroce- dent gout when the patient is plethoric. But this which has often done so much harm in ordinary cases of asthma, is still more to be dreaded here. In short, the usual means employed in asthma must be had recourse to, with this caution, that in proportion as the habit is gouty it is of the greater consequence to save the strength. Similar observations apply to all the other forms of retrocedent, as well as atonic, gout, diarrhoea, colic, apoplexy, palsy, &c. From what has been said ofthe third species of irregular gout, the misplaced, it appears, that the diseases which have been known by this name are nothing more than some of the phlegmasiae we have been considering, supervening in a gouty habit ; and the only thing, peculiar in their mode of treatment, is, that evacuations must be employed with more caution than in other cases of phlegmasiae. The gout is frequently complicated with other diseases. Its fits then often become frequent and irregular, and resist attention to diet and other means, in ordinary cases found to relieve them. All that can then be done is, as far as the case admits of it, to com- bine the modes of treatment suited to both diseases. When this cannot in any degree be done, the most urgent demands our first attention. The presence of each will generally modify the treat- ment of the other, and much must be left to the discernment ofthe physician after he is made acquainted with all that can be said of such cases.* * For a very peculiar kind of irregular gout, which I do not find mentioned by any author but Liger, and those who mention it from his treatise, the read- er is referred to the 369th page of his work. I have not quoted any part of his account, as it is very vague. Liger, indeed, has =eareelv treated any part of the subject with precision. ?9G HEMORRHAGIC FEBRILES BOOK II. OF THE HEMORRHAGIC FEBRILES. We are now to consider the second order of symptomatic fevers, which have been defined, Symptomatic fever, in which the local disease is a flow of blood not arising from external injury. In this order the diseases are so simple, and, both in their symptoms and mode of cure, so much resemble each other, that it is unnecessary to consider them separately. There is one disease, indeed, arranged by Dr. Cullen in this order, as a sequela of hae- moptysis, (the phthisis pulmonalis) which it will be necessary particularly to consider, as it is one of greater consequence and more complicated, both in its symptoms and mode of treatment, than those with which it is arranged, and indeed has very little in common with them. In treating of hemorrhagy in general, I shall point out the pe- culiarities of its principal genera. Dr. Cullen arranges under this order only four genera ; the epis- taxis, or bleeding from the nose ; the haemoptysis, or coughing of blood from the lungs ; the hsemorrhois, or discharge of blood from small tumors about the anus ; and the menorrhagia, or discharge of blood from the uterus. To these, most authors add the haemateme- sis, or vomiting of blood, and the hematuria, or bloody urine, which Dr. Cullen regards as seldom, if ever primary diseases* Some authors have still added other genera, hemorrhagy from the gums for instance, but this is endless ; we might with equal reason regard hemorrhagy from the fauces, the skin, &c. as distinct gene- ra. These rarely occur, and are generally symptomatic. The hemorrhagies I shall chiefly have in view in the following observa- tions are the four genera of Dr. Cullen, and the heematemesis and heematuria. HEMORRHAGIC FEBRILES. 297 CHAP, i. Of the Symptoms of the Hrcmorrhagice Febriles. The symptoms of the haemorrhagiae febriles may be divided in- to tho.-e which precede the flow of blood, and those which accom- pany it. The symptoms which precede considerable hemorrhagy, resem- ble those which appear at the commencement of the phlegmasiae. A cold fit comes on, the skin being constricted and the extrem- ities cold, with weariness of the limbs, pains ofthe back and head, costiveness, and other febrile symptoms ; and the hot fit, in which the pulse is frequent and full, and in many cases hard, is often formed before the blood appears. These symptoms are most re- markable before internal hemorrhagy. They are generally atten- ded witn a train of local symptoms, affecting the part from which the blood is about to flow. The patient often complains of a sense of heat, fulness, and ten- sion, sometimes of weight and pains of different kinds in it and the parts about it; and when it is external we can often observe some degree of redness and swelling in it. But the local symptoms pre- ceding hemorrhagies, are various, and differ according to the situ- ation, nature, and office of the diseased part. Before the appearance of epistaxis, we often observe all th.* symptoms occasioned by an Uhusual determination of blood to the head, strong beating ofthe arteries of the head and neck, flushing and swelling of the face,&.c. The whole head, Hoffman observes. •s sometimes much swelled, the nostrils being hot and dry. Haemoptysis is preceded by affections ofthe thorax. The pa ticnt often complains of a sense of weight, anxiety, and pain.- about the breast, with some degree of dyspnoea, often cfasense of heat, sometime* under the sternum, sometimes moving from place to place, and a little before the blood appears, there is frequently a saltish taste in the mouth. At length a tickling at tbe top of the larynx, now and then extending itself along the trachea, occasions hawking, which brings up a little blood ofa flora! colour and more or e=s frothy. As the quantity of blood inc?e;<-?=, there is a ratr ling noise in the trachea, before it is brought i:p. ,.wl then if mine* V.M K. :( 2:jC HEMORRHAGIC FEBRILEs. !e?s by hawking than by coughing, which is sometimes the ca:;e from the first. It now and then requires attention to determine whether the blood conies from the lungs, stomach, or fauces. The manner in which u comes generally indicates from what part. If from the stomach, it is vomited, not couched ; if from the fauces or nose, it is often brought up without either hawking or coughing ; or if from it- falling upon, and irritating the glottis, some degree oi tbe?': take place, the history ofthe case and other symptoms will geni- ally' point out its source ; which may often lie discovered by in- -pecting the fauces. The blood from tbe lungs is generally florid and frothy, from the stomach and fauces of a dark colour, and un- mixed with air.* Blood is seldom, perhaps never, discharged from the lower par! ofthe rectum till small tumors are formed about the anus, either externally or on tbe inner coats of the intestine a short way above the anus. These tumors are more or less distinct. Sometime: there is a general lumi faction of the anus. The tumors-are term- ed hemorriioides, (piles); they sometimes continue to tease the patient without discharging blood and are then termed the bliuu piles, hemorrhoides cajcee. They often subside, and in a short time again make their appearance, sometimes continuing to return at nearly equal periods. When they have frequently returned they generally become permanent, but only occasionally discharge blood. The appearance of piles is often preceded by a considerable de- gree of fever. The mouth and fauces in particular are dry, th: -kin constricted, and the urine at once pale and in small quantity. The local symptoms are more numerous and varied than Ihose which precede other hemorrhagies. Vertigo, head-ach, stupor, sickness, and other symptoms of dyspepsia, occasionally appear, particularly flatulence, and griping pains of the bowels, and not unircquently there is a fulness ofthe chest, with some degree of dy.-pnee;;. There is often also pain or a sense of weight and op- pression iu the back and loins, and tbe limbs are sometimes affect- ed with numbness. With these symptoms there is generally pain nbout the n*:ii«, with heat and itching, and often a sense of weight r-\lending to die perineum, accompanied with a frequent desire to empty the rectum and bladder. The stools are sometimes bilious, -omclunes mucous, and many particularly old people, are subject v v,T ,' , ■ iui a;,d •;-Mowvit paragraphs of Dr- Cullc-ii^ First L',i\r~. H.EMOhiillAGl/E FEBRILES. L'iu*, i ivi prolapsus ani ; but these ia.-t s\ inptoms are often rather the cai.!»«rs, than merely pieceding symptoms, of piles:. Ti;e degree ofthe foregoing symptoms is very various in d'ffer rnt c.-ses, and a slight attack of piles very frequently coiiiL- < i, jyjtli no olhrr uneasiness than some irritation about the anus. A si-rus discharge from the anus, accompiinied whb some'degree t-f swelling, now and then precedes the piles, and sometimes come- in place of them and the bleeding, relieving the foregoing symp- toms, though not so quickly. The disease has then been cal- led (be hannorrhois alba. Tbe symptoms preceding the menorrhagia are simibr to iho.-.c which precede die haemorrhois, but the pains of tbe back, loins and belly are often much more severe. I have often seen llie.-n such a* to occasion -\ncope. As the menstrual discharge i- frequently piece led by considerable pain, and is more or less irregular, that is, flows in greater quantity and longer at one lime than another in most women, who notwithstanding enjoy a good state of health, ev- ery little excess is not to be regarded as a case of monorrhagia. It isalu.y-, however, to be regarded as such, when coagula arf; formed. The heematemesis, or vomiting of blood, ii preceded by affec- tions of the stomach and parts in its neighbourhood. There is of- ten pain .iiid tension ofthe left hypoehondrium with much anxiety.. and a sense of tightness iu the chest. Bloody urine, when independent of calculous affections, is often preceded by no remarkable symptom. Sometimes pain- of the back and considerable uneasiness in the region of the kidney, v> :th nausea, denote its approach.. All hemorrhagies, indeed, especially when incoti«ideru!de, occa- sionally make their appearance without any preceding symptom. They are more uniformly preceded by the local than the general symptoms. There is a species of hemorrhagy termed by nosologic, pas- sive, which is never preceded by symptoms of fever, that is, by any, symptomatic of the hemorrhagy. This species Dr. Cullen ha* properly arranged among the Locales. It either origin.-tea from external violence, which according to tbe nature ofthe part af- fected md the injury done to it, may either produce active or pas- sive hemorrhagy, or is a symptom of diseases 6{ debility, scu.-vv, typhus, &c. It has few attendant symptoms, and its mode oi treat- ment will sufficiently appear from what will be said of active he- 300 HEMORRHAGIC FEBRILES. morrhagy. This, indeed, when the flow of blood induces a great degree of debility, may be said to be changed into the former. On the symptoms which attend the flow of blood in active he- morrhagy, a few words will be sufficient. When the fever has been considerable, it generally continues till the blood ceases, or pearly ceases to flow. The same may be said ofthe local symp- toms, although in general there is an abatement of both soon after tbe blood appears, especially if it flows freely. There is no he- morrhagy. perhaps, which so quickly relieves the symptoms which precede it, as tbe epistaxis. Wheu tht loss of blood is great, the patient complains of giddi- ness and other symptoms of approaching syncope ; every part of the body, particularly the face, becomes palf, and the pulse weak and unsteady. If the hemorrhagy is obstinate and profuse, the pulse ceases altogether, complete syncope supervening. Previous todeath, however, the patient generally falls into convulsions, which may be regarded as the last stage of fatal bemorrhagies. The tendency to convulsions is often indicated by subsultus tendi- num and other spasmodic affections. The quantity of blood lost is various, sometimes amounting to many quarts ; nor is the duration ofthe disease less so, from a few minutes to weeks or even months. The quanti'y of blood which may upon the whole be lost, it is eviaent must depend as much on the duration of the hemorrhagy as the size and vigour of the pa- tient. The blood assumes different appearances, according to the part from wiiich it flows, the time which it has remained in any of the cavities, the degree of inflammatory diathesis, and the age and habit of the patient. Blood from the lungs I have already bad oc- casion to observe, is more florid than from other parts, and mixed with air if blood has lain for some time in any ofthe cavities, the bladder, rectum, uterus, &c. it assumes a dark colour, and oft- en forms clots, sometimes of so firm a consistence as to resemble flesh. When there is much of the inflammatory diathesis, on cool- ing it shews the buffy coat. If the patient be young, it appears of a loose consistence and full of red globules. In middle age, the globules are less numerous and the blood of a more adhesive con- sistence. In old age it is more thin and watery ; and still more so in dropsical habits. In those labouring under diseases of great de- bility, it is thin and sanious. In all cases it becomes thinner as it continues to flow. The diagnosis of bemorrhagies is sufficiently evident; on th* prognosis it will be necessary to make a few observations. In HEM0RRHAG1E FEBRILKlb 30* habits much reduced by previous disease or other causes, partic- ulars in those inclined to dropsy, and in advanced age, even a rood".-rate loss of blood may prove dangerous. But wha'tver be the *:ibit or age of the patient, if the blood flows profusely, if the lips, nails, and other parts become pale, the extremities cold. :*nd syncope supervene, the danger is very great. It is not to be over- looked, however, that syncope is often a means of check.ii? he- morrha<.v, for as the vis a tergo is nearly interrupted in s.> ncope, the hemorrhagy generally ceases, and in the mean tiii< H-e bleed- i«_ vesxds are often closed, partly by their own contract :i and partly by the blood coagulating in them, so that, the feeble vis a tergo on recovery Irom the syncope being often insufficient to over- corn* these obstacles, for the present the hemorrhagy is renm^d. The appearance of the blood assists the prognosis. Thf nrmer its consistence, the greater the proportion of red globules, «od the less considerable the buffy coat, the less is the danger. Tbe dan- ger is great when the blood becomes watery, and still greater if it assumes a sanious appearance. The danger in bemorrhagies is not always proportioned to the loss of blood, as they often indicate the approach or presence of Other diseases. Few diseases are less to be dreaded than epistaxis in children ; but old people subject to it are in danger of apo- plexy. Although the loss of blood by haemoptysis be very incon- siderable, it is an alarming disease, because it may indicate a ten dency to ulceration ofthe lungs, or its actual presence Some attention to the causes of hemorrhagy, we shall find, is iiecessary in collecting the prognosis. I have had occasion to observe, that hemorrhagies are apt to i-eturn periodically, the prognosis therefore is collected from the state of the patient during the interval, as well as while tbe blood flows. If he enjoys his usual health, has a good appetite, and does not lose flesh, there is little to be apprehended. But if he is low spirited and indolent, if the appetite fails, and the countenance becomes pale and emaciated, particularly il dropsical symptoms appear, the danger is very great, unless the return of the hemorr haey cap hn prevented. JOiJ HEMORRHAGIE FEBRILE:? CHAP. II. Of the Causes of the Hemorrhagic; Febriles. The remote causes of hemorrhagy, like those of the phlegina siae are very simple. Those ofa sanguine habit, slender make. and delicate constitution, are most subject to hemorrhagy. The parts from which bemorrhagies most frequently happen, are those? as might a priori/aave been supposed, in which the blood vessels, are most numerous and delicate, the internal membrane of the nose, the lungs, &.c. Why different ages predispose to different hemorrhagies, it is more difficult to explain. Epistaxis is most common in children j haemoptysis from puberty to between thirty and forty ; haemorr- faois from this period to about sixty ; and hemorrhagy from the kidneys and the head in advanced old age. There is no period of life, however, at which any hemorrhagy may not occur.* Like the phlegmasiae, hemorrhagies arc most frequent in spring and autumn. If we except periodical diseases, we shall find noue which leave behind them so strong a predisposition to future attacks, as hemorr- hagies, which seems partly to arise from the ruptured vessels and those in the neighbourhood, in consequeuce of the distension they have suffered, being left in a slate of debility, and consequently subject to future distension ; and partly from loss of blood, as I have more than once had occasion to observe,! disposing to ple- thora, the powers of assimilation seeming constantly to prepare a quantity of blood proportioned to the demand for it. Ofthe predisposing causes of hemorrhagy, plethora is the mo-,* frequent; all the causes of which may be regarded as predisposing causes of this disease. It is a common observation, that those hemorrhagies which arise from mere plethora, although they are very liable to return, are of all hemorrhagies, proceeding from internal causes, most easily re- * Variou* hypotheses hav«- b*en proposed for the purpose of explHininjj this tendency to difiVrent hemorrhages al the different periods of life. But as none of them are satisfactory, I shall not detain the reader with an account of them. t Vol. i. p. 90, 91. I HEMORRHAGIC FEBRILES. 303 noved, and mo.-t frequently cease spontaneously; as might have been supposed, since, here the disease for the time removes its cause. In active hemorrhagy there seems always to be a rupture of one ir more small vessels. It has been supposed, indeed, that an in- creased force of circulation may so dilate the excreting vessels as to occasion an efl'usion of blood independently of rupture. This, however, appears extremely improbable. The phenomena of ac- tive hemorrhagy, indeed, are generally such as could not arise from this cause, the effusion of blood being sudden am! profuse. Its remote causes are such as tend to occasion rupture of the ves- sels. They all occasion distension in the part from which the blood is about lo flow.* Besides it seems often to flow only from one vessel, the- rupture of which relieves the rest. Thus in epis- taxis, the preceding fullness and redness are often equal in both nostrils. It rarely happens, however, that an hemorrhagy from both takes place at the same time ; the first vessel which gives way in either ncstril relieves both. Passive hemorrhagy, prop- erly so called, that for example which appears in diseases of ex- treme debility, seems often to be the consequence partly of relax- ation and consequent dilatation of the vessels ; and partly of tenu- ity of blood. Dr. Cullen enumerates seven occasional causes of hemorrhagy ; namely, external heat; a considerable and sudden diminution of the weight of the atmosphere ; whatever increases the force of the circulation ; violent exercise of particular parts of the body ; cer- tain postures of the body or ligatures ; a particular state of certain vessels from the frequent repetition of hemorrhagy ; and lastly, cold externally applied. On comparing these causes of hemorrhagy with what has been -aid, the manner in which they act will be sufficiently obvious, with thp exception of cold, whose modus operandi it is more difficult to race, it s-eems to be chiefly by exciting some degree of synocha, that cold occasions hemorrhagy, that is, by increasing the vis a ■ergo. Such are the causes of hemorrhagy in general. Certain hemorr- iiagies proceed from cau-es, particularly affecting the part from which the blood flows. An ulcer i:i the kidneys, ureters, bladder, btomach, intestines, &i.c. is not an uncommon cause of hemorrhagy. The contents of these cavities acquiring an irritating quality, or 'ccasioning too great distension, has often Ind u\n same effect. ■ Inl.rxb"ii^n f->t!y c,>.~."' "-■■ 304 HEMORRHAGIC FEBRILES The i -st cause, often renews hemorrhagy of the stomach and inies tines. Sudden repletion of the stomach probably acts aiso by compn s-ing tiie liver, thus tending to obstruct the circulation thiougb it, and consequently oppose an obstacle to the free return oi the blood from tiie intestines. 1 know a person in whom a eopious draught will at any time induce hetnoirhagy from the intestines. A mal- conrirmation of the thorax very frequently proves a predisposing cause of haemoptysis, and when to a considerable degree may ex- cite it. The same may be said of pressure trom affections ot neighbouring viscera, &c. as in hemoptysis from schirrous liver, be. Similar observations apply to other internal hemorrhagies. CHAP. III. Ofthe Treatment of the Hemorrhagic Febriles. Many seem to have regarded all spontaneous hemorrhagies as proceeding from a plethoric state of the system, and have main- tained that no means should be employed to check them, m less they are so profuse as to be attended with langer In these posi- tions however, many important circumstances are overlooked, and it is generally better to correct the plethora by other ineans, than by permitting the hemorrhagy either to go on or Jo recur.* The means of moderating or checking hemorrhagy, either'acton the system in general, or on the part from which the blood flows.. From what has been said of active hemorrhagy, the reader will perceive that the flow of blood is often supported by the febrile state which attends it. A principal indication iu active heniorr hagy, therefore, is to diminish excitement, and all the various- means above pointed out for this purpose mUst occasionally be em- ployed. Those which constitute what has been called the anti- phlogistic regimen, are, with the exception of dilution, in all cases essential. All muscular exertion in particular must be avoided. Every exertion of mind is hurtful. The patient must be kept quiet, and in the horizontal position, with the exception that the part, from which the blood flows, should be raised as high as Cart conven- iently be done ; and the temperature should be as low as can be borne without inconvenience. The regular excretion ofthe fteces is particularly to be attended to, and the means employed for thi- purpose must be such as occasion least irritation. * See ]>r Cullen's Observation^ on this --ubjet in his First Lines. HjEMORRHAGIiE FEBRILES. 306 In all cases of active hemorrhagy the diet should be scanty, and till kinds of animal food and fermented liquors forbidden. The patient in particular should drink very little. Whatever he takes should be cold. The use of acidulous fruit, cream of tartar, nitre, vegetable acids, and other retrigerents is beneficial. It is often proper to employ more powerful means to lessen the excitement. '' I am ready to allow," Dr. Cullen observes, " that '' the practice of blood-letting in hemorrhagies has been often su- " perfluous, and sometimes hurtful, by making a greater evacua- ;i tion than was necessary or safe. At the same time I apprehend " it is not for the mere purpose of evacuating, that blood-letting " is to be practised in the cure of hemorrhagy, but that it is farth- " er necessary for taking off the inflammatory diathesis which pre- " vails, and the febrile spasm that has been formed. Accordingly, " in the case of hemorrhagy, when the pulse is not only frequent, " but hard and full, and does not become softer or slower on the " flowing of the blood, and when the effusion i3 profuse, or threat- " ens to become so, it appears to me that blood-letting may be " necessary, and 1 have often found it useful. It seem3 probable " also, that the particular circumstances of venesection may rem " der it more powerful for taking off the tension and inflammatory " irritation, than any gradual flow from an artery." Blood-letting may often be employed with advantage, even where the hemorr- hagy is considerable, if the pulse is still hard, and it is of great imt portance from the nature of the part affected that the wound should close as quickly as possible. Burserius and others have recommended blood to be taken dur- ing hemorrhagy from the parts in the neighbourhood of that from which the blood flows. We shall presently have occasion to con- sider the effects of local blood-letting. Authors differ in opinion respecting the employment of cathar- tics in hemorrhagy. With regard to the employment of drastic or irritating cathartics, there cannot be two opinions ; but many practitioners have maintained, that the exhibition of mild cathar- tics, so as to keep up a degree ofdiarrhcea, is useful, on the sup- position that hemorrhagy often proceeds from tenuity of blood wliich they endeavour to obviate by drawing off the serous part. As far as respects active hemorrhagies, this opinion seems to be false, as must appear from what has been said of their causes, and on the other hand, in very exhausted habits, where the hemorrhagy is more ofthe passive kind, and may, in part at least, arise from morbid tenuity ofthe blood, to endeavour to relieve it, by inducing 306" lLEMOKRHAGI.fi FEBRILES. another evacuation, is at least a very precarious practice. Ihe same observation applies to cases in which active hemorrhagy con- tinues till it exhausts the strength, and renders the blood thinner than it ought to be. Upon tbe whole it would seem, if we ex- cept herr orrhagy from tbe head, that, to prevent any accu- mulation of faeces is the chief, if not the only, purpose, for which cathartics should be employed in these diseases. The same ideas which led to the use ot" cathartics, induced phy- sicians to prescribe diaphoretics in lhe?e diseases. They had still in view to carry off the thinner parts of the blood. These, partic- ularly such as are of a re frige rent quality, although the theory which first led to their use has falJen into neglect, are employed with advantage for the purpose of relieving the febrile state, which precedes and supports active hemorrhagy. The older practitioners recommend a great variety of medicines for this purpose ; acids, anodynes, diascordium, milfoil, veronica, nitre, camphor, &c. Antimony and saline preparations seem to be best suited to active hemorrhagy, and the nausea occasioned by the first is often useful here as in inflammation, by diminishing the vis a tergo. Every means which has this effect tends -to check the flow of blood. I have had occasion to observe above, that the use of the digitalis is attended with less advantage in the phlegmasiae than might have been expected, and to state the circumstances from which this appears to arise. What was there said, however, it will be evident, does not apply to hemorrhagy, in which all who have tried the effects of digitalis, will, I believe, confess, that it is a most valuable medicine. In all serious hemorrhagies it should be given in sufficient quantity considerably to lessen tbe force and frequency of the pulse. Most of the means employed for lessening the vis a tergo in he- morrhagy, may often be employed for removing the symptoms which precede, and thus preventing, the hemorrhagy. In this way we not only prevent the loss of blood and consequences to be ap- prehended from a rupture of vessels, but at tbe same time break the habit of the hemorrhagy, and thus lessen the tendency to it- rccurrence. These observations", it is evident, from what was said in speaking of the phlegmasia*, do not apply with equal force to the digitalis as to the other means we have been considering- Their effects, it is evident, will be increased by the local mean? which relieve distension in the part. HEMORRHAGIC FEBRILES. 3fiJ The reader will find opiates very generally recommended in he- morrhagy. He will readily perceive, from what has been said, that an indiscriminate use of them is inadmissible. They are im- proper while much of tbe inilammatory diathesis remains, and the pulse continues full and strong. When this state has been overcome by proper remedies, or the continuance of the disease, opiates Ly allaying irritation, tend to check the flow of blood. When the vis a tergo is not much increased thcyr may sometimes be used v. ith ad- vantage at an earlier period, combined with those medicines which obviate their stimulating quality, particularly antimonials. They irc indicated with musk and castor when subsultus fendinum and pthcr sp-icin.odic affections supervene. A variety of astringent medicines are given internally, for the purpose of constricting the vessels, and thus checking the hemorr- hagy. The vitriolic acid, is very generally used ; allum is more powerful, an.d in hemorrhagy, is perhaps, upon the whole, the most valuable astringent we possess, particularly in menorrhagia and he- morrhagy from the stomach and bowels. It is not found of equal efficacy ifi haemoptysis. Oak galls, bark, iron, lead, Lc. have also been much employed. If any of these is more powerful than al- lum, it hlcad, the acetate of which has been greatly praised. It is almost unnecessary to caution against the long continued use of this medicine, even in small doses. Where it is of great impor- tance to check the hemorrhagy, it may occasionally be exhibited with advantage. It should be given in combination with mucilage, or, some tenacious extract, as far as possible to obviate its effects on the stomach and bowels. The bark and steel are chiefly indicated when the strength, from the continuance of the disease or other causes, being greatly ex- hausted, the disease partakes more of the passive than active he- morrhagy, and then certain stimulants, although possessed of no astriogeocy, will often succeed. I have seen oil of turpentine stop menorrhagia which had resisted the most powerful astringents for many weeks. The older practitioners employed various means with a view to occasion congestion in parts at a distance from the seat of the he- morrhagy ; warm clysters, fomentations, baths, ( which were often composed of warm wine and other stimulating ingredients) frictions, ligatures thrown round the limbs, &c. ; at the same time making refrigerant applications to the parts from which the blood flowed, or those in their immediate neighbourhood. It is evident that most of the former set of remedies (all the most powerful of them) 308 HEMORRHAGIC FEBRILES. are of doubtful effect while much of the inflammatory diathesis prevails. I have already had occasion to observe, that syncope is often serviceable in checking hemorrhagy; it is improper, therefore, where the hemorrhagy is considerable, to use means to prevent it. All kinds of cordials are on this account to be avoided. Strong odours, and every other means of rousing the patient, are improper ; and if, from the situation of the part, some degree of the erect posture has been judged proper, the patient should not be laid in the hori- zontal posture with a view to prevent syncope. These observa- tions, however, do not apply when the hemorrhagy has become passive. Syncope is then attended with great danger, and must be prevented by the usual means. Many superstitious remedies have been employed, and by the impression on the mind have sometimes been serviceable ; awe and dread being powerful means of lessening the force ofthe circu- lation. We are now to consider the means which are applied to the seat ofthe disease, many of which seem to act by exciting the bleeding vessels to contract. The various astringents just mentioned are employed for this purpose, particularly alum and the acetate of lead. The sulphate of zink is among the most powerful of this class of medicines. The reader will find a great variety of astringent applications enumerat- ed by authors. Dr. Cullen observes, that the most powerful of all astringents in hemorrhagy, appears to him to be cold. It is useful, we have seen, applied generally by an atmosphere ofa low temperature. A greater degree of it ought always to be applied as near-as possible to the part affected, and when it can be done, to the part itself. Pressure is a powerful means of checking hemorrhagy, when it can be applied to the bleeding vessels. In obstinate hemorrhagy, where it can be done, the larger vessels ofthe part maybe secured by ligature. Taking blood from, dry cupping, and blistering, the parts in the neighbourhood of those from which the blood flows, is often attend- ed with advantage in internal hemorrhagies, especially when there is reason, from the symptoms, to believe that the distension ofthe vessels which precedes the hemorrhagy is not relieved. Respecting the means by which the disposition to hemorrhagy is counteracted> a few observations, in addition to what has been saidot its causes, will be sufficient. HEMORRHAGIC FEBRILES. 309 A plethoric state of the system, we have seen, is one of the most common of these causes ; and when the hemorrhagy has frequently returned, this state has almost always either been the original cause of the disease, or has been induced by it. To correct plethora, therefore, is our chief object during the intervals. The means answering this purpose I have already had occasion to point out. They are either such as diminish the ingesta, increase the excreta, or give tone to the vessels. It is difficult to resist the appetite for food, so that it is generally proper to recommend such as contains a comparatively small quan- tity of nutricious matter. It is always necessary, however, to pay attention to the patient's habits. The quantity of animal food he has been accustomed to must only be lessened by degrees, and when a great degree of debility has been induced, a nourishing diet is often necessary, which, however, must be regarded only as a means of obviating present danger, and employed with caution. The same observation applies to the substitution of water for more nourishing and stimulating fluids. The best and most effectual way of increasing the excreta, is ex- ercise. Cold bathing and tonic medicines, by increasing the power of the vessels, tend to prevent plethora, and are doubly indicated when the loss of blood has induced debility.* * The causes of hemorrhage here assigned are not very satisfactory. The vis a tergo, Plethora and rupture of vessels, are too mechanical. There are few phenomena of animal life, either in health, or disease, that are governed by mechanical principles, or admit of explanation on that ground. To bring the subject of hemorrhage fairly before the reader, it will be ne- cessary to take notice of the physiology of the vascular system, comprising the heart and arteries arising from it, with their subordinate trunks. The capillary arteries, the capillary veins, and the veinous trunks, which convey the blood to the heart. The combined action of all these parts of the circula- ting system, is necessary to the support of animal life; yet each part acts for itself. The heart propels the blood into the arteries, and the arteries act like living conduits to convey the blood to the capillaries, where all the greai functions of the circulating system, are performed ; such as the growth, and nourishments ofthe body, the secretions, and the evolution of animal heat. From this view of the subject, it appears, that the capillary vessels have an office of their own, distinct from that of the heart, and great arteries, which on- ly serve to convey the blood to them, to be applied to the purposes of life. As the capiilary vessels ars the most eftickm part of the circulating system, so they are more frequently thrown into diseased action. All febrile diseases have their origin in the diseased action >•('this system of blood vessels, and those changes which take place in the action ofthe heart, and great arteries in :)10 PHTHISIS PULMONALIS. CHAP. IV. 0/Phthisis Pulmonamm. Dr. Cullen arranges Phthisis Pulmonalis, as a sequela of haemop- tysis. He defines it, " Corporis emaciatio et debilitas, cum tussi, febre heclica, et "" plerumque expectoratione purulenta."* i: See the nosological observations on phthisis, in the appendix to this volume, under the genus pneumonia. ihese diseases, are the effects ofthe diseased actions in the capillaries ; and in case of spontaneous hemorrhage, it is more than probable, that the disease de- pends entirely on the condition of this system of vessels Hemorrhage is acknowledged to take place in persons under every variety of circumstances, in the young and the old, the plethoric and the exhausted, which would lead us to believe, that the proximate cause mui»i be the same in all; for if it depended on the vis a tergo, it should not take place in the feeble and the old ; and if it depended on plethora, the exhausted should be exempt- ed. As to rupture of vessels, it would be difficult to prove, that this does not r take place ; but such lesion has never been demonstrated to my knowledge in this kind of hemorrhage, and it is more probable that in cases of spontaneous bleeding, the blood exudes from the surface of membraneous parts, than that it proceeds from ruptured vessels. Warm water when injected into the trunks of arteries in dead subjects, exudes through the skin and membranes lining the cavities. From the foregoing considerations, I am induced to attribute hemorrhage, or the spontaneous flow of blood from the different parts of the body, to some ob- stacle in the transmission of the blood from the capillary arteries to the capil- lary veins, at that point in which the blood changes its course and becomes veinous blood. This obstruction to the passage ofthe blood from the arteries to the veins I apprehend depends on a torpor, or inaction ofthe origin ofthe veins, which ren- ders them incapable of taking up the blood from the extreme arteries ; for it is not to be supposed that the veins are passive tubes especially their capillaries, or origins, or that the blood would pass into them from the arteries without their own peculiar actions. This inaction of the capillary veins in certain cases, is confined to particular parts, as the membranes of the nose, the lungs, the uterus, &c. when the blood flows only from these parts;—in other instances it becomes general, and the blood issues from various parts ofthe body, and escaping from the vessels, ap- pears in form of vibices and petechia?, under the cuticle. PHTHISIS PULMONALIS. 311 lie divides this disease into two varieties, the phthisis incipiens without purulent expectoration, and phthisis confirmata with purulent expectoration. Purulent expectoration, however, we shall find, sometimes attends from the beginning, and in some cases never ap- That this obstruction in the passage ofthe blood from the arteries to the veins, should, in certain cases, produce an accumulation of blood, and a preter- natural excitement in the capillary arteries of the part, is what would be ex- pected in cases of obstruction in one part of the vascular system, while every other part acted v, ithits usual energy. That this is the true theory of spontaneous hemorrhagy, the phenomena of the disease, and the effects of remedies render probable. That this disease should take place in persons whose general appearance indi- cates health and vigour, is analogous to other cases of local disease. We oft- en meet with those, w•!.<>.-.! general health is good, while they are affected with a disease in some particular parts, depending on loss of action, or morbid ex- citement ; and that opposite remedies should b^ accessary in different cases 01" hemorrhage, issimi'ar to what occurs in fevers a particular type. In some cases of typhus fever cold water tpplied externally is the best remedy ; in other cases, or in a different staf ofthe same disease, it would be fatal. With rc-pectto tbe effects of remu es in cases of spontaneous bleed- ing, cold, blood-letting and other sedative remedies, which are admissible only in cases of considerable arterial excitement, produce their good effects by equalising the action between the capillary arteries and veins. But incases of hemorrhagy unattended by any sensible increase of arterial excitement, sedative remedies are manifestly injurious and cold is often an ex- citing cause ofthe disease. While those kinds of stimulants that act particu- larly on the capillary vessels, are the ouly remedies to be depended on. Opi- um, and external warmth, are the two most powerful of this class of remedies. The following cases of hemorrhage, will serve to illustrate the principles above advanced. A gentleman about middle age, of a good constitution, and rather full habit. had been affected with an intermitting fever ofthe tertian type about five weeks, riding on a cool morning in the montli of October, and on the day he should have no fit, a hemorrhage commenced from the nose, and continued sometime : at length medical assistance was obtained ; cold water was firsi applied to the head, this proving ineffectual, the semi cupium in cold water was tried, but UV bleeding increased under this treatment. The patient was next placed in a warm bed, seem to occasion an exacerbation. But this must not make us judge " the mid-day exacerbation to be the effect of eating only, for I have often ob- '• served it to come on an hour before noon, and often some hours before din- ''' ncr, which in this country at present is not taken till sometime afternoon. •It is, indeed, to be observed, that in almost every person the taking food oc- casions some degree of fever ; but lam persuaded this would not appear so ■'considerable in hectic, were it not that an exacerbation of fever is present ,: from another cause, and accordingly the taking food in a raorninghas hardly ■' any sensible effort.1' Vol.u. 40 $u PHTHISIS PULMONALE. There is seldom much head-ach at airy period of the disease; and delirium, except towards the fatal termination, hardly ever appears ; for the most part, indeed, the senses are retained to the last, and, what is more surprising, the spirits and even the appe- tite. It has been observed, indeed, that the appetite is often better than usual a few days before death. Such is the general course of the disease ; it will be necessary to consider its symptoms more particularly. The cough at the commencement, I have just had occasion fo obsprve, is generally dry, or nearly so, unless blood be expec- torated, and sometimes it continues so during the whole course of the disease. In most cases, however, it becomes moist, and the matter expectorated is various. In the beginning it is generally mucus, and as the disease advances,gradually assumes a purulent appearance, and then there is generally some, often a very slight, admixture of blood, although haemoptysis had not occurred at an early period. Much has been said ofthe means of distinguishing an expecto- ration of pns from that of mucus, which cannot with certainty be done by the eye. For this part of the subject I may refer to* what was said in the introduction to this volume, where it is con- sidered at length. When the cough is violent, particularly in the advanced stage ofthe disease and after meals, it is often accompanied with reach- ing and vomiting, which has been regarded by Morton and others as a diagnostic of the phthisical cough. This, however, is fai from being constant, and vomiting frequently accompanies violent coughing from whatever cause. Exposure to cold, drinking cold fluids, the horizontal posture, and every thing which tends to hurry the breathing, are apt to excite the cough. It is generally worst in tiie evening, during the night, and on awaking from a sleep of some continuance. Sometimes it is short and hard, at other times full an soft, and often comes on by fits, which either cease spon- taneously, or are relieved by a more or less free expectoration. Some have thought that they can distinguish a consumptive from a catarrhal cough by-the sound, and in the advanced stages it fre- quently has a particularly hoarse sound, which is very remarkable, though not altogether peculiar to phthisis. At early periods the sound of the cough but little assists the diagnosis. The short hol- low cough, supposed characteristic of phthisis, is not always very distinctly marked, and often attends other diseases. A cough can only with certainty be pronounced phthisical, by attending to ihe PHTHISIS PULMONALIS. 315 aymptoms which accompany it, particularly to the state of the fe- brile sympto.ns and the nature ofthe matter expectorated. There has been some difference of opinion concerning the in- ference to be drawn from purulent expectoration. It has till lately been generally supposed that it always indicates ulceration of tbe lungs. " In every instance of an expectoration of pus," Dr. Cul- len observes, " I presume there is an ulceration ofthe lungs. •' The late Mr. De Haen is the only author that I know of who 41 has advanced another opinion, and has supposed that pus may be " formed in the blood-vessels, and be from thence poured into the " bronchiae." The reader will readily perceive the fallacy of Jiiis explanation, but the fact that pus is sometimes expectorated without ulceration of thd-lungs, has been confirmed by other writ- ers, whom Dr. Cullen overlooked. In the 28th section of the 22d Ep. of Morgagni de Sedibus et Causis Morborum, there is a case related, wliich seems to be of the same kind with that mentioned by De Haen. To this Burserius refers, and also to Bennet's Ta- bidorum Theatrum, Lieutaud's ilistoria Anatomica Medica, and the first volume of the Colleclio Obs. Med. Pract. by Fred. Casi- mirus, for similar cases. Tbe reader may also consult a Treatise. in Schroeder's works, on the production of Pus without Ulceration. It is true, indeed, that a charge brought against De Haen, that he did not with sufficient accuracy determine the matter to be puru- lent, may be urged against the inferences of all these writers. When we compare them, however, with later observations, there can be little doubt of their accuracy. Dr. Hunter relate* a case of empy, ema, where there was no ulceration. Pus is often discharged in gonorrhoea without ulceration. I have seen it discharged from tins nose, where there was no reason to suspect any ; even in common catarrh the expectoration often becomes purulent. The matter is placed beyond a doubt, and the great facility with which inflamed secreting surfaces form pus, is ascertained by the experiments of Mr. Home above related.* It would be of considerable importance to be able with certain- ty to distinguish the cases in which purulent expectoration takes place without ulceration. The diagnosis offered by the late Dr. White, published in 1792 by Dr. Hunter, of York, will not, I fear be found sufficient for this purpose. He terms the pus produced by inflammation without ulceration, intla nuiatory exudation. This, ne observes, does not ferment or become putrid per s,\ A "* See the 25th aid following page of this volume. 316 PHTHISIS PULMONALIS quantity of It, kept by way of experiment, after some time became dry and tough, smelling sour and faintish. This species of matter, he observes in another place, in its natural state, appears to be a homogeneous, smooth, yellowish fluid, resembling good cream, without smell, and rather sweetish to the taste, it swims in water, and when burnt smells like burnt cheese. The matter of ulcera- tion, he thinks, is a compound, consisting of inflammatory exuda- tion and a portion of putrid blood and solids, varying in its appear- ance according to the predominance of the one or other of its component parts. The greater the proportion of the latter, the more feted, brown and sanious, it is. The contrary condition makes it more like laudable pus, yellower or whiter, more unctuous and homogeneous, and less putrid. This kind of sputa, like the c1her, according to Dr. White, swims in water, but has an offensive smell, except when the proportion of putrid matter is very small, even then if it be burnt its putrescency becomes manifest. Dr. Stark* also proposes an experiment for determining wheth- er or not the matter expectorated in phthisis comes from an ul- cer. As the spitting, he observes, is perhaps the most certain cri- terion of vomica, it will be proper to enquire into its peculiar character, that it may be distinguished from pus and rnucus, two substances which it greatly resembles. All of them, when free from air bubbles, sink in water, f Pus is easily diffusible in it, by gentle agitation, but in a few hours falls to the bottom. Mucus cannot be diffused in water without strong agitation, but when dif- fused, forms with it a permanent ropy fluid. The spitting of con- sumptive patients is more easily diffusible in water than mucus, and, like that, forms with it a ropy fluid, which although it depos- ites a sediment like pus, still continues ropy, resembling mucus and water. This experiment only tends to prove that the matter expectorated in phthisis contains both pus and mucus, which may be the case whether it comes from an ulcer or not. Baglivi says, that an excretion of small granules by coughing, which, squeezed between the fingers, have much fetor, certainly indicates a latent vomica. Dr. Stark also observes, that when the matter expectorated is yellowish and in small round masses, it probably comes from small vomicae. Dr. White, however, re- marks, tnat he has seen an expectoration of this kind without any * Observations on Pulmonary Consumption. t When the thinner parts of mucus have been absorbed, it readily sinks in water. PHTHISIS PULMONALIS. 317 bad consequences, an observation I have myself seen confirmed, so that it is probable a purulent or some other secretion may as- sume this appearance without the presence of vomica;. In the purulent stage of phthisis the expectorated matter is fre quently more or less mixed with the blood or sanies discharged from ill-conditioned sores, which removes all doubt respecting its source. In different cases the colour and consistence of the matter ex- pectorated is very different. It is often ash-coloured, yellow, or greenish, and very frequently of all these colours. It is gcnerally more or less viscid, and charged with air bubbles, and tbe blood mixed with it, is of different shades. Calcarious matter is some- times expectorated in phthisis. Sometimes a white, tough, rami- fied matter, which has the appearance of small branches of the bronchiae, is coughed up. It consists of mflammatory exudation, which becomes dry and tough, assuming the form of the cavities in which it is deposited and appears to be of the same nature with the membrane formed in croup. The same matter is sometimes observed in the stools of phthisical patients, from their swallow- ing the sputa. The quantity of matter expectorated is various. In most cases it gradually increases as the disease advances ; and after it assumes the purulent appearance, often amounts to ten or twelve ounces, a pound or even more, in twenty-four hours. It is common for it to decrease towards the fatal termination, especially when the sweats become very profuse, and more frequently after the colliquative diarrhoea comes, on. When this happens, it has been observe*!. that very little matter is found in the vomicae after death. It is chiefly after the expectoration of pus commences, that phiiii sis has been regarded as contagious. I shall presently have oc- casion to make some observations on this opinion, and likewise o-< the question, whether hectic arises from the absorption of pus. The breathing, particularly in the more advanced stages, durinc the exacerbations, is quick, and laborious. It is not uncommon for it to be attended with a rattling or wheezing, sometimes very n markable, at other times only to be perceived when the ear is pla- ced near the thorax of the patient. In the advanced stages ti.r; breath is often offensive. The dyspnoea is generally attended with a sense of weight or tightness in the chest ; and walking, and every other exertion which accelerates the circulation, increase it. Sometimes the 3M PHTHISIS PULMONALIS. breathing is easier when the patient lies on one side than on the oth: er, and sometimes it is easiest when he lies on the back. Sometimes there is no pain at any period of the disease. In many cases, there is sooner or later a fixed pain in some part ofthe thorax, seldom acute and sometimes only to be felt when the patient makes a deep inspiration or coughs. The cough and pain are sometimes troublesome for a considerable time before the fe- ver appears. It is of much consequence to attend to the state of the pulse at the commencement of phthisis, for when it is uniformly more fre- quent, and particularly when it is harder than natural, without the characteristic symptoms of hectic, there is reason to believe that the languid inflammation which precedes the purulent stage of phthisis, is going on but that matter is not yet formed. In this state the tongue and skin are dry, and the appetite not so good as it usually is in hectic. Whatever be the form of the fever at an early period, it almost always assumes that of hectic. This generally happens about the time that the matter expectorated begins to assume a purulent ap- pearance, sometimes before this poriod, seldom long after it.* The face then becomes pale, and the redness of the cheeks more circumscribed. In some the lips are remarkably pale ; in others, both these and the internal canthus of the eye, very florid while the adnata appears ofa dead white colour. ' The fever has generally been observed to run highest in the most robust, and consequently higher in men than in women ; but it never rises to an alarming height, hardly ever being attended with delirium, and rarely with head-ach. The skin in the progress ofthe paroxysm is hot and dry, some- times hard and painful to the touch, the patient generally complain- ing of much heat in the hands and feet. The pulse, which during the remission is seldom under 90, is gen- erally, during the exacerbation, (particularly in those of an irrita- ble habit,) near 120, and often above 130. It is generally small, and at an early period, more or less hard. The thirst is not considerable, the tongue moist, and, particular- ly in the advanced stages of the disease, remarkably clean and in * There are cases of well-marked phthisis on record, in which the fever nev- er assumed the form of hectic. I have known many die of this disease, in which the leading characteristics of hectic, the evening chills and morninc n examination with a microscope, and after the pulmonary artery and vein have been injected. They adhere tothe substance ofthe lungs, Dr. Baillie observes, without any peculiar covering or cap- sule. On the cut surface of some are observed small holes, as if made by the pricking of a pin, and at the bottom of the cavities contain- ing pus, several small holes arc frequently to be seen, from which, on pressure, purulent matter issues ; but in neither case do they seem to communicate with any vessels. The purulent cavities of tubercles are of different sizes, from the most minute to half an inch or three quarters of an inch in diamc- :er, and when cut through and emptied, have, if the suppuration has been completed, the appearance of small white cups nothing re- maining of the substance of the tubercle, except a thin covering or capsule. The cavities of less than half an inch diameter are generally shut, those which are larger open into the bronchiae by one or more holes. The largest cavities, which arc generally of an oval shape, arc lined partially or wholly with a smooth, thin, tender slough or membrane. The matter found iu these cavities or vomicae, as they are called, is similar to that expectorated, and has seldom any admixture of blood, except where there are ulcer- ations. They often communicate with each other by ragged openings. The larger vomica?, which have numerous bronchial openings, are found to contain scarcely more matter than is sufficient to be- smear "their surface. The largest are generally situated toward" the back part of the lungs. Several small apertures on the sur- face of the lungs often lead to the vomicae ; and sometimes, though * Observations on pulmonary consumption by Dr. Stark, to whose labours we are indebted for most ofthe following observations on the appearand? ar.i^ itructure of tubercles. s:-i PHTHISIS PULMONALIS. not often, a vomica is a hemispbenicai cavity in the external part of the lungs. Wherever there is a vomica, there is a broad and firm adhesion of the pleura, so as to preclude all communication between the cavity of the vomica and that ofthe chest; even tubercles, indeed, are seldom found without adhesions. Those parts ofthe lungs which are contiguous to tubercles, arc red, sometimes soft, but more frequently firm and hard.* And while the sound parts of the lungs are artificially distended, the parts in the neighbourhood of the tubercles and vomicae remain depressed and impervious, whether the air be blown through the trachea, or into incisions made in the surface of the lungs. So that the function of the lungs in those parts is wholly lost. The pulmonary arteries and veins, as they approach the larger vomicae, are suddenly contracted; when outwardly, the vessel appears nearly of tbe proper size, the cavity is often found to be much lessened, being almost filled up by a fibrous substance and the vessels passing along the tubercles are often found detached from the neighbouring parts for about an inch of their course. When the lungs are injected, the injection seldom enters the mid- dle-sized vomicae, and still more rarely the larger or smaller ones. The bronchiae themselves are never found contracted. But the internal surface of those which open into the larger vomicae is oft- en of a deep red colour, its vessels appearing enlarged, and the internal surface ofthe trachea is sometimes partially red. "In cutting into the lungs," Dr. Baillie observes, " a consider- " able portion of their structure sometimes appears to be changed " into a whitish soft matter, somewhat intermediate between a sol- " id arid a fluid, like a scrofulous gland just beginning to suppu- " rate. This appearance I believe is produced by scrofulous mat- " ter being deposited in the cellular substance ofa certain portion " ofthe lungs, and advancing towards suppuration. It seems to be " the same matter with that ofthe tubercle, but only diffused uni - " formly over a considerable portion ofthe lungs, while tbe tuber- u cle is circumscribed. " 1 have seen abother sort of tubercle in the lungs, which I bo- ; lieve to be very rare. It consists of a soft tumor, formed of.* " light brown, smooth substance. This is not contained in anv " proper capsule, but adheres immediately to the common struct- >' ure ofthe lungs. In cutting through several of these tumors f * Dr. Bailiie's Morbid Anatomv. PHTHISIS PULMONALIS. 32', ** did not find any of them in a state of suppuration. They were " commonly as large as a gooseberry, and were chiefly placed up- " on the surface of the lungs; some, however, were scattered " through their substance, of a smaller size. These are very dif- ferent in their appearance from the common tubercle last de- " scribed, and are the effect of a diseased procc??, which probably '■'• is very imperfectly known. The lymphatic glands of the chest are of a dark colour, and sometimes contain a matter like moistened cheese.* When cal- caneus matter has been expectorated, it is generally found in the lungs in considerable quantity. The pleura costalis and the pleura of the lungs sometimes adhere almost throughout their whole ex- tent. Ulcers are often found in the branches of the bronchia?, and sometimes in the trachea itself, t In some cases of phthisis, where ulcers have been found in the trachea, there has been reason to sup- pose that they first, attacked this part and afterwards spread to the lungs. It is not uncommon to see a whole lobe, or even a larger portion ofthe lungs^ almost consumed by suppuration. We even read of cases whore half or more ofthe lungs was consumed, so that it iv,r s-urprising that life could go on so long. From a rude calculation, made on the lungs of many who died of phthisis, the part which remains fit for the admission of air may. it a medium, be estimated at one-fourth of the whole. The higher nnd posterior parts are most frequently affected and to the greatest degree, and the lungs on the left side, it is said, more frequently tban those on the right. The f.bdominal viscera are often much affected. Dr. Stark says *hat there is seldom any morbid appearance in them, except s]iglj erosions of the villous coat ofthe intestines. But other wri>-v mention induration, enlargement, ulceration, and abscess of t'ie liver, spleen, and other abdominal viscera. With regard to the ratio symptomatum of phthisis, it mry tic observed of this, as of most other diseases, that the symptoms are either such as we can at once account for, or involved in such ob •curity, that it is in vain to attempt any explanation of them, ft is unnecessary to inform the reader, that the irritation, occasioned by the matter in the bronchiae, causes coughing, or that the fnflam- * Dr. Stark's Treatise. t For an accouut ofthe phthisis tracheal!?, see the Institut. Med. Prac. of Burseriu?. 32ti PHTHISIS PULMONALIS. mation,-abscess, and ulceration are the causes ofthe pain. It is impossible to be acquainted with the appearances on dissection, without making these inferences. But who can explain why the cheeks become florid, in proportion as the adnata becomes pale ; or why the discharge by the skin is at a certain period exchanged for that by the bowels 1 I should, therefore, have passed over !n silence the ratio symptomatum of this, as of most of the foregoing diseases, were it not that the disputes respecting the cause of hec- tic fever has rendered it interesting. Some have maintained that hectic fever always, others, that it never arises, from the absorption of pus. Both sides of this ques- tion have been supported.by arguments of two kinds ; the one, in- ferences from matters of fact; the other, certain reasonings deriv- ed from the sensible and other qualities of pus. I shall confine myself to a short review ofthe former, leaving them for the readers consideration. None of the latter appear at all satisfactory, nor does the state of our knowledge seem to admit of reasonings of this kind. The principal arguments tending to prove that hectic fever does 'not arise from the absorption of pus are, that abscesses, even of considerable size, have existed for years without occasioning hectic fever, for the most part indeed producing fever, but fever ofa very different nature ; after the amputation of a considerable limb, a very large surface is constantly covered with pus, and even expos- ed to the air, a circumstance acknowledged to favour the produc- tion of hectic fever, yet this fever rarely appears ; towards the end of dropsy, where there is no abscess, hectic fever often shews it- self ; when any acrid matter is absorbed, we generally find tumors in the lymphatic glands through which it passes ; when a purulent ulcer is attended with hectic fever, this is seldom observed ; it has been maintained that hectic fever is often completely formed in consequence of inflamed tubercles in the lungs before suppuration has taken place.* Were we assured that this observation is well founded, it would be sufficient to determine the question ; but this feems far from being the case. There are many instances of in- cipient phthisis in which debility, emaciation, and fever, which, may be mistaken for hectic, especially as it is frequently attended with some degree of morning sweats, occur, without suppuration having taken place in the lungs ; but it does not appear that ex* * Dr. Reid's Essay on the Nature and Cure of Phthisis Pulmonalis, PHTHISIS PULMONALIS. :sn quisitely formed hectic ever supervenes in phthisis till pus has been formed. Those who maintain that hectic fever always arises from the absorption of pus, admit that abscesses have sometimes been known to continue for a long time without producing hectic fever; but in these cases, they maintain there is little or no absorption of pus, the sides of the abscess having become callous and the abscess it- self continuing without either increase or diminution, and giving little or no uneasiness. Towards the fatal termination of dropsy, it is granted that hec- tic fever often makes its appearance. But on inspecting the drop- sical cavities after death, the fluid is frequently found more or less mixed with pus, which is often the case also with what is drawn off by tapping, for some time before death. Besides, towards the fatal termination of ascites, there is sometimes an expectoration of purulent matter. With regard to pus not occasioning tumors in the lymphatic glands, in its passage to the blood, it may be said, that pus is not ofa nature apt to irritate or inflame these glands ; in the same manner as the matter of syphilis and cancer, which inflame the glands, is not fitted to excite fever. That hectic fever does not so frequently succeed large wounds as it ought to do, were it occasioned by the absorption of pus, seems to be the argument of most weight, and to which it is not easy to find a satisfactory answer. It may be observed, that when wounds continue to form a great deal of pus for a considerable length of time, they often do produce hectic fever. The removal of the dressings, and frequent cleaning of the wound, must tend to prevent the absorption of pus. While granulations are going on, the matter secreted is less copious and more bland and thick than when the wound is ill-conditioned, which is generally the case ir ulceration ofthe lungs. SECT. III. Ofthe Causes of Phthisis Pulmonale. Phthisis pulmonalis is mentioned in the medical writings o: every period since the days of Hippocrates. It is a disease of tern perate climates, and in no country so frequent as in Great-Britain. In London it is said that 6000 die of it annually. Allowance, however, must be made for other diseases passing under the nam* 3j28 PHTHISIS PULMONALIS. of consumptions Sydenham alledges, that two thirds of those who d' ■; of chronic diseases in this island, fall a sacrifice to it. Those who are of a slender make, with a long neck, delicate smooth skin, and a fair ruddy complexion, with white and trans- parent teeth, aud the albugenea of the eye of a bluish hue, who have a flat or narrow chest, with high shoulders, and stoop when they walk, who possess an habitual and great flow of spirits, with an early acuteness of understanding, are most liable to phthisis. As the peculiar make and habit of body are hereditary, some ac- count in this way for phthisis being so, and we have every reason to believe that these alone are sufficient to dispose to the disease,. but we often see the children of phthisical parents, who inherit very little of this habit, fall a sacrifice to it. Women> upon the whole, are more liable to phthisis than men and those between the age of puberty and thirty-five than others. It appears, however, much later than thirty-five, and sometimes, though more rarely, long before puberty. Children have been born labouring under phthisis, and died of it soon after birth. The exciting causes of this disease are very numerous. They may be divided into three classes. The first comprehending those causes which exist in the lungs themselves and the parietes ofthe thorax; the second, external causes acting on the lungs ; and the last, causes acting on the system in general. The causes existing in the lungs themselves, and the parietes of the thorax, are tubercles, suppuration of the lungs inconsequence of common pneumonia forming cHther an open ulcer or a vomica, the presence of calcarious concretion in the lungs, haemoptysis, ca- tarrh, asthma, metastasis of pus from other parts to the lungs, ex- tensive adhesions of the pleura, tumors and other affections of the abdominal viscera pressing on the diaphragm, fracture or exostosis ofthe ribs, and mal-conformation of the thorax. The external causes.'acling on the lungs are, bad air, dust taken in with the breath, other irritating matter introduced by the trach- ea from aphthae or other afl'ections of the mouth, contusions and wounds of the thorax. The causes of phthisis affecting the system in general are, an in- active sedentary life, indulging much in the use of intoxicating li- quors or in venery, the lues venerea, suppressed hemorrhagies, certain eruptive, fevers, any repelled eruption, in short, whatever reatly debilitates or tends to occasion a plethoric state of the system ; and many add contagion. PHTHISIS PULMONALIS. 329 In the following observations on these causes, I shall not follow the order in which they have been mentioned. As most of the causes of phthisis act by producing tubercles, by treating of them in the first place, we shall be better prepared to understand the mo- dus operandi of its other causes. It seems now very generally admitted, that a scrofulous habit is in most cases the predisposing cause of tubercles. They resemble scrofulous swellings in other parts of the body ; like these their progress to suppuration is generally slow, and the ulcer formed by them difficult to heal. Those born of scrofulous parents are most subject to them. They are often accompanied with scrofulous af- fections in other parts ofthe body, mesenteric obstruction, glandu- lar swellings in the neck, &c. It also often happens in the same fami- ly, that some are affected with external marks of scrofula, others with phthisis. I have seen confirmed phthisis relieved by the ap- pearance of scrofulous swellings and sores about the neck. Those who have been much troubled with scrofulous swellings and sores at an earlier period of life, are often attacked with phthisis about the age of puberty or soon after it. Where no scrofulous taint can be observed either in the patient or his relatives, his habit is gen- erally of that kind which accompanies scrofula, and gives reason to believe that the constitution is not free from a tendency to it. Dr. Cullen and some other writers have enumerated causes as capable of producing tubercles, independently of any scrofulous tendency. On a fair review of the subject, however, the existence of such causes appears very doubtful. It is evident that the idea of exanthematic acrimony being lodged in the lungs, and there producing tubercles,* is merely hypothetical. It is by no means a fair inference, that because phthisis follows a disease produced by a certain morbific matter, that the former, as well as the latter, arises from the presence of this matter. Sometimes in small-pox, and more frequently in measles, there is an evident tendency to pneumonia ; and it is where thi.-> tendency is most considerable, and in those of a scrofulous liabit, that phthisis is most apt to su- pervene on these fevers, and in such habits tubercles may be exci- ted by whatever tends to irritate and inflame the lungs, as will ev- idently appear from a consideration of their other causes. Similar observations are applicable to the other cases of suppos- ed acrimony producing tubercles, in some of these the debility occasioned by tedious disorders seems to be the exciting cause. . ■* Dr. Gallon's First Lines. Vor.. L *• 12 360 PHTHISIS PULMONALIS. It is well known that, in the predisposed, whatever debilitater may occasion scrofulous affections. Upon the whole we shall net err much, perhaps, by regarding a scrofulous habit as necessary to give the predisposition to tubercles. We can have no doubt, how- ever, that this predisposition may remain through life without pro- ducing them, if not called into action by some ofthe causes above enumerated. It is not easy to ascertain the presence of tubercles while they remain in an indolent state. In an inflamed state, they occasion the symptoms which have been mentioned as forming the first stage of phthisis. The following are those which give reason to saspect the pre- sence of indolent tubercles. A slight short cough, not easily alle- viated by mucilaginous medicines, increased on lying down, ei- ther without expectoration, or with a scanty expectoration of a vis- cid matter, or as Burserius describes it, of a matter like water in which soap has been dissolved ; some pain in the chest, more or less «cute ; sometimes fixed, more frequently wrandering and ir- regular, with a degree of dyspnoea, uniformly increased on using exercise, or by any other cause which accelerates the circulation. If with these symptoms the patient becomes languid and indolent, and loses his flesb, and some degree of hardness in the pulse, with occasional heat of the skin, is perceived, especially if he be ofa phthisical habit, there can be little doubt of the presence of tuber- cles. They will sometimes continue in an indolent state for many months, or for even years, during which the patient is never long free from cough. It will appear from the following observations on the other caus> es of phthisis, which of these seem to act by producing tubercles, and which seem to occasion this disease without their intervention. It sometimes happens, it was observed above, that suppuration takes place in pneumonia without immediately proving fatal, nor is it always followed by phthisis. Abscesses often remain for a long time, we have seen, without occasioning hectic fever. There- have even been instancesdn which the pus was absorbed, and the patient restored to health. In general, however, if the bursting of the abscess does not occasion suffocation, hectic fever comes on and gradually exhausts the strength. When the matter is poured into the cavity of the thorax, it sow; produces all the symptoms of phthisis, except the purulent expec- toration, and sometimes this symptom also, in consequence of part of the lungs contiguous to the pleura baing consumed. When a PHTHISIS PULMONALIS. 33 i small abscess from pneumonia, as appears from what was said of rhis disease, bursts into the substance of the lungs, the quantity of matter discharged not being sufficient to occasion suffocation, a pu- rulent expectoration is the consequence ; but the chance of reco- very is much better than in the case of tubercles. If the constitu- tion is healthy, the expectoration sometimes gradually diminishes, and in a short time disappears.* Haemoptysis is regarded as so frequent a cause of phthisis, that Dr. Cullen, we have seen, ranks the latter as a sequela of that dis- ease. It is supposed by some, that it occasions phthisis in conse- quence of some portion of the extravasated blood which is not ex- pectorated, stagnating and becoming putrid in the cells of the lungs. It is not impossible that lucnioptysis may produce phthisis in this way. In most cases, however, as it is the consequence of repeated haemoptysis, it seems probable that ii arises from the ves- sels which have been frequently ruptured not healing readily, par- ticularly in lungs inclined to disease. Tiie commencement of phthisis, from whatever cause, so fre- quently resembles catarrh, and has so often been mistaken for it, that there is reason to believe this disease less frequently the cause of phthisis, than is generally supposed. There appear to be four ways in which catarrh may induce phthisis. It may occasion pneumonia or haemoptysis; or it may- excite a languid inflammation of the internal membrane of the bronchiae, occasioning a purulent secretion from its surface, which now and then degenerates into phthisis. I have had occa- sion to remark above, that pus is cometi.rjes expectorated in ca- tarrh. It would seem that this purulent expectoration has some- times gradually increased, without ulceration, and at length becom- ing copious, and in some measure habitual, has given rise to hec- tic fever. Dr. Cullen and others doubt of such cases having exist- ed, but their doubts seem chiefly to, arise from a belief that pus is rarely, if ever, formed without ulceration, copious and habitual expectorations of phlegm, says Itauliu, sometimes become purulent and degenerate into phthisis, particularly after irregularities of diet, or any thing else which impairs the healthy state of tin; fluids. But catarrh most frequently acts by exciting tubercles. This it may do merely by the violent and repeated agitation of the chest, when the cough is severe and long continued ; or in the same way thatwe see scrofulous tumors occasioned in external parts, by tak * Dr. Oillen's First Lines. 332 PHTHISIS PULMONALIS. ing cold ; and this we have reason to believe is the way in which catarrb generally acts, for its tendency to produce tubercles is by no means proportioned to the severity of the cough. Contagious catarrh, although generally more severe than that from cold, does not appear to be more apt to produce tubercles. I think we have reason to believe that it is less so. We see the most violent coughs continue for a great length of time without producing phthisis. How much more frequently is measles than hooping cough the cause of this disease ? It has been a common opinion, that syphilis occasions phthisis by producing venereal ulcers in the lungs. There is no direct proof of this, and there are other ways of explaining the concur- rence of these diseases. Ulcers of the mouth of various kinds, indeed, sometimes spread to the trachea and lungs ; and in this way venereal ulcers seem now and then to have occasioned phthisi-. Inveterate apthae of the mouth, (Raulin observes) which proceed from some sorbutic, scrofulous, venereal, or other diseased state ofthe habit, spread to the pharynx and larynx, and produce ulcers in the oesophagus and trachea, which occasion the symptoms ofa confirmed phthisis. The general opinion is, that the syphilitic matter occasions tu- bercles ; and Dr. Cullen, wehaves»en, seems even to suspect that it may have this effect where there is no predisposition. It is verv doubtful, however, if this matter ever produces tubercles. even in the predisposed. Syphilis seldom occasions phthisis, ex- cept in scrofulous habits, and even in these, for the most part, not till after the constitution has been debilitated by repeated attacks. But in such habits, whatever debilitates may have the same effect. Immoderate indulgence in venery has often occasioned phthisis in those who have never laboured under any venereal disease ;* and indeed such causes produce all the various forms of scrofula. From these circumstances it appears probable, that syphilis, if we except the spreading ofthe ulceration in the way just pointed out, only tends to produce phthisis as it tends to debilitate ; and we have reason to believe that the very debilitating remedies employ- ed, and often continued for so great a length of time, in syphilis, have no small share in this effect. It appears highly probable, that some other diseases, particularly the scurvy, (which have been supposed to occasion phthisis by the application of some peculiar acrimony to the lungs,) act in the same way. * The reader will find excessive venery ranked among the causes of phlLiri", by Raulin, Lieutaud. and others. PHTHISIS PULMONALIS. 333 Among the exciting causes of tubercles, a mal-conformation of the thorax is one of the most frequent; nor is it necessary that it should go to the length of deformity to have this effect. It seems equally pernicious whether it arises from the distance between the Spine and sternum or that between the sides of the chest being too small. Binding children with rollers, and the improper use of stays, may be ranked among the causes of mal-conformation. As any mal-conformation of the bones of the chest renders the breath- ing less free, and slight irritations applied to the lungs, where some irritation already exists, will be sufficient to excite coughing, it is not surprising that it should dispose to tubercles. It is a common observation, that those who are subject to coughs from any cause, are, cet. par. most liable to phthisis. An habitual tendency to coughs may proceed from various causes. It often arises, we have just seen, from tubercles themselves in an indolent state, and very often, we have reason to believe, merely from that peculiar state of the lungs which disposes to them. An inactive sedentary life seems to dispose to tubercles in two ways; by debilitating the system in general, and by the habit of stooping, hurting the lungs in the same way with mal-conformation ofthe chest. It has been observed, that occupations which confine the body to a bent posture are particularly favourable to the pro- duction of this disease. The free use of intoxicating liquors is a frequent cause of tuber- cles. All causes of plethora have the same tendency. Suppressed hemorrhagies, the drying up of issues or old wounds, &c. It fre- quently happens, that where the symptoms of phthisis have been removed by an issue, they return on drying it up. Although sup- pressed hemorrhagies seem frequently to produce tubercles, they oftener, perhaps, induce phthisis, by occasioning hannoptysis. Of all the causes of this kind, the suppression ofthe menstrual dis- charge most frequently occasions phthisis. Bad air is mentioned by writers as a cause of phthisis ; and it is probable that it operates by producing tubercles, or tending to inflame them. What was said of bad air in speaking of gout is applicable here. Moisture seems still to be the noxious principle. A moist air materially affects the breathing in asthmatic people. It seems likewise to dispose to phthisis by occasioning general re- laxation and debility. The frequency of phthisis in Holland has been attributed to this cause. Tbe good effects of sea voyages in this disease might be urged against the probability ofa moist air Occasioning phthisis. This objection, however, seems to be an- 334 PHTHISIS PULMONALIS. swered by what was said ofthe causes of a damp atmosphere in speaking ofthe treatment of gout; from which it appears, that the air at sea, from the greater uniformity of its temperature, can hardly ever be so much charged with moisture as it frequently is on land. Breathing a dusty air seems often to inflame tubercles, if it does not excite them. " I have not," Dr. Cullen observes, " met with " many instances of phthisis which could be referred to exposure " to dust; but from Ramazzini, Morgagni, and some other writers, " we must conclude such cases to be more frequent in the southern " parts of Europe." So powerful is this cause, that the needle- pointers of this neighbourhood seldom escape phthisis above a few years, unless they use means to prevent the dust from entering with the breath ; and with every precaution, the danger is consid- ered so great, that it is only by very high wages that any one is induced to work in this part ofthe trade ; and those who do, are excluded from the associations, formed by the labouring tradesmen, for the relief of their widows and orphans. Blows or wounds ofthe thorax may occasion phthisis in several ways. In producing tubercles they seem to act in the same way with many of the foregoing causes of irritation of the lungs. Among the causes of tubercles are ranked malignant fevers, to which all other highly debilitating causes may be added. Obstructions ofthe abdominal viscera, particularly an enlarged and indurated state of the liver, often prove fatal, by inducing phthisis. In most of these cases, the formation of pus seems at an early period to be unattended with ulcsration, for I have seen some supposed to labour under confirmed phthisis restored to health by removing the abdominal disease. If such cases are neglected in the beginning, tubercles and ulceration succeed. An indurated liver may occasion phthisis by pressing on the lungs. But we have every reason to believe that affections of the abdominal vis- cera, often produce it, by the same kind of sympathy which gives rise to certain species of symptomatic pneumonia.* If contagion is ever the cause of phthisis, it is probably by pro- ducing tubercles. It seems less likely that it should give rise to the other changes which precede phthisis, pneumonia, haemoptysis, &c. It has not been regarded as contagious till after the purulent stage commences. The reader will find in authors, particularly foreign authors, a variety of cases in which it seems to have aris* en from contagion. As in some countries it is very frequent and particularly as it is hereditary, it has probably been often ascribed * Soe the 185th and following pacres of this volume PHTHISIS PULMONALIS. 336 *<* contagion when it arose from other causes. It may often be at- tributed to the fatigue and anxiety of mind occasioned by attend- ance on the sick in so tedious and hopeless a diseose. It does not seem improbable, however, that inhaling the fetid breath ofa per- son in confirmed phthisis may prove a sufficient cause of irritation to excite tubercles in the predisposed, or inflame them where they exist in an indolent state. Phthisis has been regarded as conta- gious from very early times. It is certain, however, that it is not of a very contagious nature. There is perhaps no other country in which it is so common as in Britain ; yet Dr. Cullen says, that he never knew it evidently to arise from contagion. Upon the whole, there is reason, I think, to believe that contagion may co- operate with the hereditary disposition to render phthisis so fatal as it is in some families. It is prudent, therefore, in those of a phthisical habit to avoid spending much time, and particularly- sleeping in the same bed, with patient's labouring under this dis- ease. It appears highly improbable, that the clothes of consump- tive patients, as some have maintained, are capable of communica- ting the disease. Pus absorbed from other parts of the body, and deposited in the lungs, has been ranked among the causes of phthisis.* It was observed, that calculi are sometimes expectorated by phthisical patients. Their formation generally precedes the phthi- sical symptoms, and seems to produce them. They may by their irritation occasion tuberclps ; but they seem to excite phthisis, where there is no disposition to tubercles, merely by wounding the lungs. In cases of this kind the phthisical symptoms are some- times never completely formed, and the termination is sometimes favourable, if the causes of inflammation are carefully avoided. It is a curious circumstance in the history of phthisis, that its progress is often interrupted by pregnancy or mania. The latter has been known to produce a radical cure, but almost always after delivery, and often after the removal of the mania, the disease re- curs. * Many doubt whether phthisis ever proceeds from this cause. Raulin re- lates a case in which the scrotum was wounded, and a considerable dis- charge of pus took place. The discharge gradually diminished, and the pa- tient at the same time was sc ized with a frequent and troublesome cough, and began to expectorate pus, as Raulin calls it, " tres caracterise." But on f bringing back the purulent discharge, the cough and expectoration ceased. The man died of the wound, and the lungs were found sound, and without the l«*ist mark of any suppuration having taken place in them. 3Sb* PHTHISIS PULMONALIS. Phthisis from tubercles is the most fatal. There is reason to be- lieve, as Dr. Cullen observes, that there have been recoveries af- ter the suppuration of a tubercle, but they are extremely rare. SECT. IV. Ofthe Treatment of Phthisis Pulmonalis. Ir has been common with those who have written on the treat- ment of phthisis, to lay down certain indications of cure, which we have no means of fulfilling ; that of correcting the vitiated state ofthe fluids, of curing the ulcer in the lungs, &c. These tend only to mislead. As far as I can judge, our present knowledge of phthisis admits of no other indications but those of obviating the inflammatory diathesis, and supporting the strength. After the means offulfiUing these are considered, it will be nece?sary to point out those of alleviating certain symptoms, whose treatment does not fall under the general plan ; and I shall in the last place make some observations on the remedies which have been recommended as specifics in this disease. The means of obviating the inflammatory diathesis are the same as in other inflammatory diseases, but the languid nature ofthe in- flammation and the tendency to debility in phthisis greatly circum- scribe their employment. At one time general blood-letting was very freely employed in the early stages,* and some advised it to be repeated two or three times a week as long as the buffy coat appeared. It is now em- ployed much more sparingly. When the pain is severe, the breathing difficult, and the pulse unusually hard, if less debilitated means have'failed, a moderate blood-letting is proper. Local, is preferable to general, blood-letting, and when the inflammatory symptoms are considerable, is often employed with great advant- age. 1 shall soon have occasion to speak of it more particularly. The symptoms just mentioned are such, it is evident, as can only attend an early period. It is almost unnecessary to say, that when the expectoration has become purulent, and the night sweats at- tend, loss of blood in any way is inadmissible; the motive for it no longer exists. Sydenham recommends the free use of cathartics at the com- mencement, and if it ever is proper, it is at this period. * See the observations of Sir J, Pringlc and others. PHTHISIS PULMONALIS. 337 What has been said of blood-letting is in a great measure true of cathartics, when employed with a view to reduce excitement. Blood-letting, however, is more effectual, and on several accounts preferable for this purpose. Cathartics, therefore, are chiefly used for supporting the regular action of the bowels. In inflammatory affections ofthe chest in general, we have seen, much purging is seldom beneficial. In the early stages saline cathartics are the best. Diaphoretics have been much employed when the excitement was considerable. The antimonium tartarisatum has the addi- tional advantage of promoting expectoration. Its debilitating ef- fects, however, make it a doubtful remedy, except in the com- mencement, and when the excitement is greater than usual. It is only at an early period, indeed, that diaphoretics of any kind are proper. The saline diaphoretics, particularly the acetated ammo- nia, and nitrate of potash, used in small doses and much diluted, appear best adapted to phthisis. I have often seen great advant- age from their cooling effects. If only used when the skin is hot and dry, and the pulse pretty strong, they will rather prevent than occasion an increase of debility, few things debilitating more than a state of increased excitement. Sassafras and sarsaparrilla were once much used as diaphoretics in this disease, but are now regard- ed as insignificant medicines ; and guaiacum, which has also been much recommended, is too heating. Emetics have been employed with a view to reduce the fever and promote expectoration, and at an early period they seem of- ten to be of service in both these ways, but they have been fre- quently repeated throughout the disease, and have been supposed to possess a specific power in phthisis. I shall soon have occasion to make some observations on this use of them. Of the acids and neutral salts, those just mentioned, and the sa- i ine mixture in a state of effervescence, at an early period, the vitriol- ic acid when a tendency to sweating has supervened, and at all pe- riods, fresh acidulous fruits ate the best. Dr. Percival says, that although the pulse in hectic fever is at first reduced by the use of nitrate of potash, it afterwards rises higher than before. 1 have not observed the latter effect from a moderate use of it. Muriate of ammonia has been much recommended by some writers, either alone or with nitrate of potash, but seems to be much inferior to the latter. Dr. Cullen thinks the vegetable acids preferable to the mineral, as thev are safer and can be taken in larger quantities- Vor.'ir. -13 330 PHTHISIS PULMONALIS. This observation applies only to the early periods of the disease ; after the sweats come on, no acid is equal to the vitriolic. While there are hopes of resolving the inflammation of the tu- bercles, the diet should so far co-operate with the other means employed, that the patient should avoid both solid animal food and broths. But there is no period of phthisis, perhaps,- unless the symp- toms approach to those of pneumonia, where the diet should be very spare. A milk diet, therefore, is proper at an early period, and, indeed, almost universally recommended. Fresh subacid fruits, I have just had occasion to mention. They tend to allay excitement, and correct any redundancy of bile. If they occasion diarrhoea, it must be checked by mild astringents and anodynes. Hoffman even declaresr that he has seen confirmed phthisis cured by large quantities of strawberries. Some ofthe mineral waters impregnated with carbonic gas, and lommon water combined with a large quantity of this gas, have been recommended for the drink of phthisical patients. The good ef- fects of these waters, if they have any that deserve to be mention- ed, probably arise from the effects of the gas on the stomach. It is often-a grateful stomachic. Much attention has been? paid to the choice of milk in phthisi- cal cases. Cows and goats milk, if used in considerable quantity,, oppress the stomach, so that the lighter kinds of milk, particularly that of asses, have been prefered. Asses milk is supposed by many to possess medicinal powers in phthisis. How far this opin- ion is well founded it is difficult to say. Women's milk has been still more celebrated in this disease. Van Swieten, Dr. Robinson, .. and others, relate cases in which they ascribed the cure to it. Mares' milk has also been recommended. In short, the great ob- jects are, that the food should be nourishing, easy of digestion, and afford as little irritation as possible while digestion goes on. Such are the means of fulfilling the first indication. The reader will perceive, that in this part of the treatment we have it more in view to save and support the patient's strength, than in other in- flammatory diseases. The necessity' of this seems to arise from the scrofulous nature of tubercular inflammation, which is so im- mediately connected with a debilitated state of the system, that every cause,of debility, as we have seen, may excite it. We are now to consider the means employed with a view t» support the strength. This indication applies chiefly to the more advanced periods of the disease. It is answered by an attention ♦n diet, exercise, and climate, and by the use of tonic medicines. PHTHISIS PULMONALIS. a3? in the purulent stage of phthisis, the diet should be more nutri- tricious. A certain quantity of the milder kinds of animal food &nd wine are proper, if they are not found to increase the exacer- bations. Some, indeed, maintain, that such a diet is often proper in the early stages, and it is certain that in external scrofulous in- flammation, not only the most nutricious diet, but tonic medicines are often used with advantage. Dr. May, in his treatise on pulmona- ry consumption, a-nd €ome other writers have related cases in support of this plan ; but it does not seem well ascertained in what cases it is proper, and it is certain that in many it is injurious. When dur- ing the remissions there is great depression of strength, a little wine, if the inflammatory symptoms are not considerable, is gene- rally allowed at all periods of the disease. It is found much less apt than animal food to increase the exacerbations. Many of the observations made on sleep and exercise, in the sec- tion on the treatment in the intervals of intermitting fever, are ap- plicable to phthisical eases. With regard to the former, there is little to be added to what wa.> iheresaid. It is sometimes prevented by the cough. While the excitement is considerable, the employment of opiates is in some degree a doubtful practice ; although tbe excitement is seldom such as wholly to exclude their use, especially combined with saline medicines. In the advanced stages they may be given more freely. As the most effectual means of allaying the cough, they doubly dis- pose to sleep. 1 shall have occasion to make some farther obser- vations on the use of opiates, in considering the means employed for relieving this symptom. With respect to exercise, it chiefly demands attention, that it shall be such as may be continued for some length of time without fa- tigue, and does not much accellcrate the circulation. Gestation iif various kinds, therefore, is preferable to afly kind of exercise, depending wholly on the patient's own exertions. Some .observing the bad effects of fatigue, have proposed that those labouring under phthisis should wholly abstain from exercise, and when the febrile symptoms are considerable, and particularly inthe earlier stages, this may sometimes be proper. But it is a disease of such continuance, and depending so much on the state of the general habit, that some attention to exercise is generally indispensible. Many go to the opposite extreme, and maintained that certain kinds of exercise may be regarded as specifics in thic disease. 310 PHTHISIS PULMONALIS. Sydenham's authority has contributed to render riding on horse- back in phthisis a general practice, and when the strength is such that it can be continued for a sufficient length of time, it is perhaps preferable to every other, although we have to lament that Syden- ham's observation, " Sane haud multo certius cortex Peruvianus " febri intermittenti, quam in bac aetate equitatio phthisi medetur," has not been confirmed by observation. He remarks, that in those who were cured of phthisis in this way, a tumor rose in the neck not very different from scrofulous tumors. An indiscriminate use of any particular mode of exercise in this disease.seems to be improper ; the degree and kind must be suited to the patient's strength. It sometimes happens, that riding on horseback increases the dyspnoea, and occasions pain of the chest, or is attended with fatigue. It must then be changed for gentler exercise, and riding in a carriage is often beneficial, and generally well borne by phthisical patients. " All the modes of gestation," Dr. Cullen observes, " that are employed on land may fall short of " the effects expected from them, because they cannot be rendered " sufficiently constant, and therefore it is that sailing, of all modes " of gestation, is tbe most effectual in pneumonic cases, as being " both the smoothest and most constant." There has been much difference of opinion respecting the cir- cumstances to which the benefit derived from sea voyages ought to be ascribed. Many, with Dr. Cullen, ascribe it to the constant and moderate exercise ; others, to the purity of the sea air, and the constant change of air. If the benefit derived from change of air, except it be to a purer air, or one different in temperature or mois- ture, ought to be ascribed to the occupation ofthe mind, and the cheerfulness occasioned by a constant change of scene, as seems highly probable ; it is not likely that much is to be attributed to change of air in a sea voyage, unless it be to a more southern lati- tude. Some have ascribed much ofthe good effects of sea voyages to the smell of the tar and rosin of the ship, and many to the sea sickness and vomiting. On the cases enumerated by Dr. Gilchrist,'* Dr. Reid observes, " The patients were generally sea-sick, and " vomited much bile ; and in some the good effects ceased when "they grew familiar to the ship's motion, and were no longer sea " sick. He relates the case of a consumptive patient who went to " sea three times, the distance ten leagues; each time he was " sick, vomited bile, and was cured of his disease. In the last, ' Dr. Gilchrist, on the r.sc of sea voyages in medicine. PHTHISIS PULMONALIS. 341 " where the patient was at sea only five or six hours, the effects " cc-uld not proceed from the air or exercise." Dr. Carmichael Smith, on the other hand, in his treatise on the effects of swinging in pulmonary consumption, remarks, that if the benefit derived from sailing were owing to the sickness and vomiting it occasions, its good effects ought always to be in proportion to these. But this he maintains, is so far from being the case, that he has seen the greatest benefit from sailing where the patients were either little or not at all affected with nausea and vomiting ; while, on the other hand, patients have been much affected with both during the whole time they were at sea, and yet neither the cough nor fever relieved. Dr. Smith attributes the benefit derived from sailing to the mo- tion, and constant change of posture, both to one more or less bent, and from or towards the horizontal posture. It is probable that the same circumstances in sailing may not be equally beneficial in every case. Their effects, in all probabili- ty, in some degree depend on the cause ofthe disease. In many cases it seems probable that the good effects of sailing are not to be ascribed to any one, but a combination of all its circumstances, particularly to that of the sickness and constant gentle exercise. Dr. Smith strongly recommends swinging, and says, that the cough is suspended, and the frequency of the pulse generally dir minished, after the patient has been in the swing about ten minutes. In fourteen cases, he thinks the disease yielded to this remedy. The patient was generally in the swing from ten minutes to half an hour at a time. Others, however, have not met with the same success from it. " We are sorry to add." Dr. Duncan observes, after giving an account of Dr. Smith's treatise, in his Commenta- ries fdr the year 1788, " that from our own experience we cannot " say much in favour of swinging. Since the publication of Dr. " Smith's treatise we have had recourse to it in a considerable num- " ber of cases. In some few, where there were symptoms giving a " presumption of phthisis, benefit seemed to arise from it; in others, '* though employed ataperiod when the symptoms were very slight, " it had no influence either in checking the progress of this insidious " disease, or in preventing its fatal conclusion. And, indeed, we " have not met with any one case where phthisis had decidedly " taken place, in wliich any material benefit arose from its em- " ployment. With some patients the sickness it occasioned was so ?< distressing, that they could not be prevailed upon to give it a " proper trial ; while with others it produced no obvious effect 342 PHTHISIS PULMONALIS. " whatever, and particularly no change on the slate of the pulse.'* The experience of others has probably coincided with that of Dr. Duncan, as the remedy has not come into use. With regard to climate, it has always been observed that phthisi- cal patients are more or less relieved by the summer, their com- plaints generally increasing as the winter comes on, and gradual- ly becoming worse during the winter and spring, particularly the latter season. This, together with phthisis being rare in warmer climates, suggested the propriety of sending those afflicted with this disease to such climates ; and when the change has been made at an early period, it has often been successful. In most instances, it is delayed too long to be of any use. The exhausting heats of sultry climates have not, for reasons sufficiently evident, been judged proper. Phthisical patients are advised to visit the mild climates of Madeira, Sicily, Italy, Spain, or the southern parts of France. Whatever climate is preferred, as much uniformity of temperature as possible should be studied. Wearing flannel next the skin tends both to support the perspiration in cold weather, and to prevent sudden chills when the weather is warm. Nor are the sweatings in this disease much, if at all, in- creased by this practice. The patient may be kept cool by hav- ing the rest of his clothes light, and (in warm climates) the flan- nel of a very thin texture. The chill of damp linen is particularly hurtful. To prevent catarrhal affections is of the first importance n the treatment of phthisis. The night air should be carefully- avoided. It is the opinion of many that the chief advantages of a warmer climate may be obtained in this country by confining the patient to apartments kept uniformly of a proper temperature. Although he cannot by this means enjoy the full advantages of fresh air, 1 can, from my own experience, speak of its excellent effects in tbe colder seasons. The tonics which have been chiefly employed in phthisis, are, the bark, iron, cold bath, zink, and vitriolic acid, and certain mineral waters. It is not surprising in a disease which has been so commonly treat- ed as merely inflammatory, that the use ofthe bark should have been very generally reprobated, especially as tubercles have by many been regarded as ofthe same nature with obstruction of the liver, spleen, &c. for the production of which, we have seen, the bark has erroneously been blamed. Many, Raulin, Desault, &c. have for these or similar reasons, condemned the bark without a PHTHISIS PULMONALIS, 343 trial. Others have condemned it from finding that it increases the exacerbations, anxiety, and dyspnoea. When such are its effects, it ought to be immediately laid aside. The cases where it appears to have been of service are those in which the debility is great, and the remissions well marked, so that the disease has more of the in- termitting form than hectic fever generally assumes. " In some cases," Dr. Cullen, who is no advocate for the use of bark in phthisis, observes, " when the morning remissions ofthe " fever were considerable, and the noon exacerbations well mark- ,c ed, I have observed the Peruvian bark given in large quantities " with the effect of stopping these exacerbations, and at the same " time of relieving the whole of the phthisical symptoms ; but in " the cases in which I observed this, the fever shewed a constant ten- " dency to return, and at length the phthisical symptoms also re- " turned and proved quickly fatal." In the first volume of the Medical Communications the reader will find cases of this kind more successfully treated with bark by Dr. Samuel Chapman. It would appear, however, from some observations, that even where the remissions were less considerable, the bark has occasionly been successful. Burserius speaks of its use in phthisis in the highest terms. Its wonderful virtue, he observes, is most remarkable in those who in their youth laboured under scrofulous swellings. In such habits the excitement is generally moderate. The Peruvian bark has also been much praised where there is considerable ad- mixture of blood in the sputa. Upon the whole, our experience seems to be deficient in this part of the subject ; but from the tri- als which have been made, as well as from phthisis partaking so much ofthe nature of scrofula, in which the bark is often of great use, it seems to demand more attention than it has received from the practitioners of this country. Iron produces some of the effects ofthe bark, and is, perhaps, less apt to increase the oppression, dyspnoea, and febrile exacerba tions. It has been chiefly recommended in incipient phthisis, aris- ing from amenorrhoea, the constitution being relaxed, and the in- flammatory syrmptoms moderate. In these cases, combined with other stimulants, particularly myrrh, by restoring the menstrual di* charge, it often at the same time, removes the phthisical symp- toms. Iron has been frequently employed in phthisis, in the different mineral waters. Physicians, says Raulin, who have had most ex- perience of pulmonary consumption, have recommended the use ot lerruginous mineral waters in the earlier stages. I have seen these 344 PHTHISIS PULMONALIS. waters, he adds, have good effects chiefly in the phthisis from tu- bercles. These cases were probably ofthe same nature with those in which Burserius recommends the bark. The reader will find, in a variety of authors, different mineral waters recommended in this disease. In this country they seem to have lost their credit. The Bristol water was once celebrated in this disease. Much of the good effects of mineral waters are doubtlessly to be ascribed to the change of scene, often of climate, and the amusements and reg- ular exercise which frequently attend their use. In most phthisi- cal cases, the ferruginous mineral waters are too stimulating, and on this account many practitioners have wholly condemned their use. The cold bath has been recommended by Dr. Rush and others. If it is ever admissible, it is in the cases in which bark and steel are recommended. In these, however, the debility is often such as to preclude its employment; and upon the whole, most practitioners- have been afraid to make a trial of so doubtful a remedy. Zink has been much praised as a tonic in phthisis, particularly by Dr. Percival; respecting it future experience must determine. Small doses of sulphat of zink seem often to possess a tonic, with little or no heating property, and in larger doses, many think it the best emetic in this disease. Of mineral acids, I shall have occasion to speak more particular- ly. It is only necessary to observe here, that they are among the best tonics in phthisis. Such are the means of fulfilling the general indications in phthi- sis- We are now to consider those of alleviating certain symptoms, the treatment of which do not fall under these indications. The chief of these are coughing, suppressed or difficult expector- ation, dyspnoea, pains of the thorax, vomiting, profuse sweats, and diarrhoea. The most effectual means of relieving the cough, anodynes, I have already had occasion to mention. There are few cases oi phthisis in which they may not, to a certain extent, be employed at every period. In advanced stages the excitement is never such as to forbid them, and the relief they afford renders them use- ful when there are no longer hopes of permanent advantage from any remedy. I have in treating of another disease, had occasion to make some observations on the manner in which opiates promote expectoration, by at first interrupting it. On this account they must be used with PHTHISIS PULMONALIS. 34D Caution, when the debility is great, as the lungs may be so oppress- ed by the retention of what should be expectorated, that suffoca- tion may ensue. This, however, is less to be feared in phthisis than in some other affections of the chest.* In the advanced state ofthe disease, they tend to increase the sweats ; but this effect may be counteracted by the use of astringents, and the relief they afford generally more than compensates for it. Many other medicines have been recommended, with a view to relieve the cough in phthisis. The best of them consist of mu- cilaginous fluids, either prepared by decoction from vegetables, or by dissolving gum arabic or tragacanth in water. It was at one time customary to give very large quantities of such medicines. In modern practice, they are, perhaps, used too sparingly. They seem to serve a double purpose, besmearing the fauces, and lining, as it were, the stomach and bowels ; in both ways often prevent- ing the irritation which excites cough. For the former purpose they should be given in small and repeated doses ; for the latter, they must be given in larger quantities. When given in very large quantity, however, they often, particularly the gums, op- press the stomach. Of the decoctions, none seems better than wa- ter-gruel or barley-water. The diet in phthisis ought always to be more or less mucilaginous. To the same head belongs a variety of oily substances which are more apt to oppress the stomach. They are never, perhaps, to be given in large doses, but considerable adv antage is sometimes derived from combining small quantities of them, particularly the spermaceti, with the mucilaginous mixtures used for the purpose of allaying the irritation in the fauces. Such a mixture, with the addition ofa certain quantity of opium appears to be the most powerful means of allaying the cough, and about half a tea-spoon full should be slowly swallowed as often as the irritation to cough is troublesome. In some cases, the extract of hemlock will allay it where opium fails. Upon the whole, however, the latter is by far the most effectual. A bit of gum ara- bic or tragacanth, extract of liquorice, or any other mild substance possessed°of a considerable degree of viscidity, kept in the mouth, often, has a considerable effect in allaying this irritation. The expectoration is often difficult, and sometimes wholly in- terrupted. At an early period, nauseating doses, particularly of -he antimonium tartarisatum, are often the best means of restoring - Hrz the observations on this subject in the draper on nr.'—nonia notha Vor.tr. M 346'" phthisis Pulmonalis. and rendering it easy. At more advanced periods, especially when the temperature and strength of pulse are reduced, the vari- ous preparation of squills and the fetid gums are often employed with advantage. If the interruption of the expectoration depends on the increas- ing debility, the means which have been pointed out for restoring tbe strength will be the most likely to recall it. If it arfs.es, as sometimes happens, from the viscidity of the mor- bid secretion, inhaling the vapour of warm water or gruel in which onions have been boiled, is the best remedy. It has been recom- mended in all cases of difficult or scanty expectoration, to employ vapour impregnated with turpentine, the various balsams,gums, &.c. But the irritating quality of vapour, thus impregnated, renders it a doubtful remedy. Many of the foregoing means often allay the dyspnoea at the same time that they restore the expectoration, and they may occa- sionally be used for this purpose although the expectoration is not suppressed, particularly the squills and gums when there is not much heat, and especially when the dyspnoea suddenly increases without any evident cause. When there is much heat and dry skin antimonial medicines tend to obviate the irritating effect ofthe gums. Many seem to think, that it is only as expectorants and antispas- modics that the gums should ever be employed in phthisis. We have reason to believe, however, that in certain cases, they are otherwise beneficial. For whatever purpose the gums are used, if they increase the heat and oppression, they will do harm. They generally have these effects when there is any considerable degree of hardness in the pulse. I shall have occasion to make some ob- servations on them in speaking of the specifics employed in this disease. For allaying the pain, cough, and dyspnoea, and rendering the expectoration easy, few means are so powerful as blistering and it is generally proper either to keep up the discharge from the same blister for some time, or, what is often more effectual and less trou- blesome, to apply a succession of small blister?. They are more generally applicable in phthisis than any of the medicines just- mentioned. The excitement, even at the commencement, being seldom such as to counterindicate their use. When the pulse is hardj-hWal blood-letting is the most effectual of all means for relieving the local symptoms of phthisis, and should precede blistering. It may be occasionally repeated in the PHTHISIS PULxMONALIS. 347 yearly stages with great advantage, its extent and repetition being regulated by the prevalence ofthe inflammatory symptoms. When the inflammation is inconsiderable, blistering alone is preferable. The effects of blisters though generally less considerable and not :-o speedy, are often more permanent, and always less debilitating. Nothing is more pernicious in diseases of debility, than continued vomiting. I have more than once had occasion to point out the means of allaying this symptom. The saline draughts where the skin is dry, or a mixture of the sulphuric acid, conserve of roses, and peppermint water, when the tendency to sweat is considera- ble, will often succeed. If these fail, a dose of solid opium, or opi- um with camphor, may be tried. Blistering the region of the stomach is often of use. Buf vomiting in phthisis, for the most part, arises from the violence ofthe cough, and is best allayed by the means which alleviate this symptom. No symptom more rapidly reduces the strength, than the sweat- ing which so generally attends the advanced stages of phthisis. The various means which tend to restore the strength, tend at the same time to check this symptom. Dr. Percival observes, that a biscuit steeped in wine, a draught of wine, or a dose of the solution of myrrh, often succeed in checking the sweat. Lime water has been much celebrated for this purpose. The reader will find it recom- mended by Sir John Pringle, Burserius, and others ; but there are no medicines of equal efficacy with the mineral acids, particularly the sulphuric. Some maintain that uie sweating ought not to be whol- ly checked ; but this injunction is unnecessary, as it is hardly ever in our power to do so. I have never seen any bad effects from checking it as far as we can. The relief it brings is never complete and al- wavs transitory, and the harm which it docs is certain. Checking the sweat, it has been said, tends to bring on tbe diarrhoea ; and there may be some truth in this observation ; but we gain little by preveuting the diarrhoea at the expence of the constant recurrence of the sweat. Both are to be checked, as their tendency is equal- i v pernicious. Van Swieten observes, that opium is almost the only thing wliich brings effectual relief in the colliquative diarrhoea of phthisis, and when it is accompanied with griping pains, and tenesmus, he dir rected it to be injected with other medicines by clyster. " Rhu- " barb," Dr. Cullen observes, " so commonly prescribed in every " diarrhoea, and all other purgatives, are extremely dangerous in il the colliquative diarrhoea of hectics. Fresh subacid fruits, sup- " posed to be always laxative, are often in the diarrhoea of hec 340 PHTHISIS PULMONALIS. " tics, by their antisceplic quality, very useful." Dr. White re- commends the columba, and refers to a treatise of Dr. Percival on this medicine, in which are several cases where it checked obsti- nate vomiting and purging, when other means had failed. I have followed those who have trusted chiefly to simple astrin- gents, combined with opium, generally employing either the kino or extract of logwood, and have always found them more or less successful, till at length the powers of life gradually declining, all medicines lose their effect. Whatever other means we employ, some mucilaginous fluid is proper for the purpose of allaying irrita- tion. It may be observed ofthe diarrhoea, as of the sweating, that all means of strengthening the system, generally tend to check it. 1 The menstrual discharge, we have seen, always sooner or later ceases in phthisis. This alarms the patient, and when it happens at an early period, the disease is generally attributed to it. The physician knows that it is merely a symptom of increasing debili- ty, that it is in vain to use any direct means to restore its regular returns, and that could it be restored, its only effects probably would be, that of increasing the debility, and consequently hurry- ing on the fatal termination. It is hardly necessary to add, that avoiding all the exciting causes forms an essential part of the treatment ofa disease whose causes are so numerous and frequently applied; for it appears, from what was said of the causes of phthisis, that every thing which tends to diminish the strength or irritate the lungs may be ranked among them. It only remains to make some observations on the medicines which have been employed as specifics in this disease. I have already remarked that emetics have been employed in this way.* " People at first," Dr. Reid observes, " are apt to be " alarmed, fearing, that by taking vomits every day, the tone of " their stomachs will be injured ; but I can safely affirm, and I " am warranted to do so by the best of all tests, experience, that I " never saw any bad effects from a course of this kind continued " for weeks with proper precautions ; on the contrary, I have " scarcely met with one instance where the general health was " not essentially improved." In the earlier periods, he sometimes used the antimonium tartarisatum, at other times ipecacuanha. * See the observations of Dr. Reid and Dr. Fort Simmons on this disease, a paper by Dr. Senter, in the first volume of the Transactions of the College of- Physicians at Philadelphia, Sec. PHTHISIS PULMONALIS. H19 The sulphate of zinc, as the most speedy, has been'recommended. Dr. Senter used the sulphate of copper with ipecacuanha. Emetics seem best adapted to cases attended with considerable "xcitement, and consequently to the earlier stages of the disea;se. A sufficient trial has not- perhaps been made to enable us to speak positively of the merits of this practice. We know that the relief obtained from emetics in phthisis is'generally transitory, and phy- sicians will not easily admit that their frequent repetition in this disease can produce any effect which will compensate for their de- bilitating tendency. Since the days of Morton, who recommended a variety of bal- sams in phthisis, these have generally formed part of its treatment. Dr. Fothergill was among the first who opposed their use, and they are at present falling into neglect in this country. Burserius, and many others, even the latest foreign writers, still place much reliance on them. Van Swieten observes, that as balsams are very- efficacious in curing external ulcers, they are recommended in those of the lungs. The best physicians, he continues, use the native balsams ; that of Mecca, for instance, Copaiva, and Peru, in preference to the artificial balsams so celebrated by the chemists. Boerhaave also condemns the latter, which have been called bal- sams of sulphur, and are prepared from sulphur and expressed or distilled oils. Sir John Pringle made a full trial of the balsams of Peru and Copaiva, and seems at first to have been prejudiced in their favour; yet he observes, that he has, since the former edi- 'ions of his work, been so often disappointed in their effects in phthisis, that he had wholly laid them aside. " The balsams, " whether natural or artificial,", says Dr. Cullen, "which have '• been so commonly advised in cases of phthisis, appear to me to " have been proposed on no sufficient grounds, and to have proved •commonly hurtful. Along with balsams of all kinds may be •' classed the various resinons gums, which have been recominend- •'ed in phthisis, generally with the same view, and seldom vvilL ''better effects." Dr. White, of York, speaks in still stronger terms, reprobating the balsams of Copaiva, Peru, Tulu, and Ben- jamin, turpentine, opobalsam, gum ammoniac, guaiacum, storax, olibanum, and all their preparations. The observations of these writers are, perhaps, too indiscrimi- nating. We have reason to believe that in some debilitated and languid habits, medicines of this kind may occasionally be useful: 1 have myself made a trial of some of them with good effects. myrrh I have already had occasion to mention. I have also oc 350 PHTHISIS PULMONALIS. casionally used storax combined with opium, with evident advan- tage. Dr. Fort Simmons warmly recommends the balsams of Co- paiva and Peru ; and Dr. Saunders and Dr. Percival speak highly of the effects of myrrh. " I regard this remedy," the latter ob- serves, " as the most useful which modern practice has adopted in " consumptions." Others, however, have not met with the same success from it. Dr. Cullen says, that myrrh has not appeared to him to be of any service in phthisis and in some cases to have proved hurtful. There is the same difference of opinion respect- ing the use of camphor, from which less is to be expected. Tar water has been much celebrated. But the observations respecting it are not sufficiently accurate to enable us to form any certain judgment respecting its effects. I have already had occasion to observe, that all this class, of medicines, when they heat and irri- tate do harm. Physicians in quest of some specific that shall at all times relieve this disease, appear not to have been sufficiently attentive to adapt the means employed to the circumstances of the case, so that the same means have often done both good and harm. Mercury has been recommended as a specific in phthisis, but in general with very little success. Dr. Cullen says, that in many trials which he made with it, it proved of no service, and generally appeared to be manifestly hurtful. Dr. Ryan remarks, that al- though the remedy had never been employed in phthisis, its per- nicious effects in other scrofulous cases would have left little hopes of its proving useful in this disease. The justice of this observa- tion may be called in question. Modern practice has pointed out certain cases of scrofula, in wliich an alterative course of mercury is often employed with advantage. " If there are any grounds," the author just mentioned observes, " for suspecting that the syphilitic virus is the cause of the disor- " der, then mercury is to be administered without further hesita- " tion." If what was said in speaking of the causes of phthisis be just, the syphilitic virus never produces phthisis, except in those very rare cases in wliich a venereal ulcer spreads from the mouth to the trachea and lungs. If syphilis tends to produce phthisis only in proportion as it occasions debility, as appears highly probable, the exhibition of mercury may even be more pernicious in these, than in most other cases. Mercury, indeed, has been chiefly em- ployed in phthisis, where the concurrence of syphilis rendered it necessary : and its effects have generally been such as to deter from the use of it in the former disease. PHTHISIS PULMONALIS. 351 No means employed in phthisis better illustrate a remark just made on the impropriety of an indiscriminate use of any medicine in this disease. In the generality of cases the only effects of mer- cury would probably be that of hastening the fatal termination. Yet in one variety, I have found it the best remedy, and have re* peatedly seen the patient saved by it, after the purulent expecto- ration and hectic fever had come on ; I allude to the cases occa- sioned by induration and enlargement of the abdominal viscera. I have already had occasion to observe, that this cause of phthisis has often been overlooked, which is probably the reason that, as far as I know, no writer has pointed out this variety ofthe disease, as that in which mercury is beneficial. 1 have also employed it with advantage in the incipient stage of phthisis, attended with a scrofulous affection ofthe mesenteric glands. There is reason, I think, to believe, that an alterative course of mercury may tend to resolve indolent tubercles. Cicuta has with much plausibility been recommended for dis- cussing tubercles. It has been so seldom employed in phthisis, however, that its effects are not ascertained. Dr. Cullen, in his lectures on the treatment of phthisis, we are informed by Dr. Ry- an, used to recommend to his pupils a trial of the cicuta and colts- foot, when there was reason to suspect the presence of tubercles. But he did not speak from any trials he had made. Coltsfoot has been employed for resolving scrofulous tumors ; but upon tbe whole, with little success. Amon* the medicines of this kind may be mentioned the kali, which has not perhaps in phthisis met with all the attention it de^ serves. Both the fixed and volatile alkalis have lately been propo- sed as a cure for various forms of scrofula, and the former* to an extent hitherto unknown. I may refer to the works of Burserms and other foreign writers for a variety of specifics employed in this disease. Some of them are innocent, and this, perhaps, is the most favourable ac Count that can be given of them. The lichen islandicus has been much celebrated.! After being steeped in water for some time, it is used as an article of diet in * See a'Trcatise.by Mr. Brandish on the effects]of the fixed alkalis in scro- fula. t Sec Observations on Pulmonary ^Consumption, and the Use. of the Lichen l?!andic*» in that Disease, by J. 13. Resrnaiill :>i* PHTHISIS PULMONALIS. phthisis. I have repeatedly made a trial of it without any advan- tage. The flesh and broth of vipers have ever since the days of Galen been a favourite remedy, and are even recommended in various cases by Mead, Morgagni, De Haen, and others. In this country their credit has only been established among the vulgar. Public expectation has lately been much raised by the proposal ofthe uva ursi. as a cure for phthisis, from so respectable a quarter, that physicians have felt themselves called upon to give it a'fair trial. From the trials I have myself made, and which have been made by others with whom I have conversed, it does not appear to answer the expectations, to which the fortunate termination of some cases, in which Dr. Bourne* employed it, naturally gave rise. The digitalis has been warmly recommended as a specific ip this disease. I have met with a few, and but a few, instances in which it seemed to be of service, out of very many in which I have used it. When haemoptysis attends phthisis its beneficial effects in checking the hemorrhagy are more uniform. An atmosphere in which the usual proportion of oxygen has, by- various means, been diminished, was some years ago recommend- ed as a specific in this disease. In an early stage, and even after the purulent stage has commenced, while the pulse still retains a degree of hardness, any innocent mean's which obviate the in- flammatory tendency are often serviceable. We must sup- pose that the oxygenous part ofthe atmosphere tends to support in- flammation of the lungs, because it has been found that breathing pure oxygen gas excites it. It is needless to enter into any detail of certain ingenious opin- ions respecting the modus operandi of this remedy, and the suppos ed hvperoxygenation of the blood in phthisis. It is enough to say, that any person, who, without prejudice, reviews the symptoms of the disease, will be satisfied that they are fallacious ; and we have reason to lament that many ofthe modes of practice fouuded on them appear to be equally so.t If a lowered atmosphere, as a remedy in phthisis, acts only in the way just pointed out, it is merely to be classed among the means of lessening the inflammatory tendency, many of which are equally certain in their effects, and more easy in their application. * See Dr. Bourne's Treatise on the use of the uva ursi in Phthisis Pulmonalis t See various Publications by Dr. Beddoeson this subject. PHTHISIS PULMONALIS. 353 It would have the great advantages, however, of being more con- stantly applied, and impairing the strength less than any other. May not lessening the proportion of oxygen in the air be of use in certain cases of pneumonia, where the usual means of relief have failed, or the patient's strength is too far reduced to admit of much venesection ? Is there not reason to believe that advantage might arise from the application of oxygen gas to external ulcers, in which the inflammation is too languid ? It is hardly worth while to mention among the specifics in phthisis, the earth bath. It may, perhaps, seem strange, Van Swie- ten observes, that I should ascribe any peculiar efficacy in the cure of phthisis to the effluvia arising from the ground. But I have been informed, by a person highly deserving of credit, that through the whole kingdom of Grenada they attempt the cure of phthisis by the earth bath, and I have since read the same thing in the works of Francisco Solano de Luque, who declares that he used the earth bath with success even in cases deemed incurable. A hole is dug in tbe earth, and the patient put in, covered with earth up to the neck, and left there till he begins to shiver. As soons as he comes out he undergoes a general friction.* * The reader may also consult the end of Dr. Simmon's Treatise on Phthisis. '•''ere he will find some cases in which (his remedy was employed. V01. u, 45 354- CATARRH BOOK IL OF THE PROFLUVIA FEBRILIA. Only one order of diseases remains to be considered, the Proflu- via* the definition of which was given in the general introduction, namely. Symptomatic fever, in which the local affection is an increase of some secretion, not naturally ofa red colour. Under this order Dr. Cullen arranges only two diseases;, Catarrh and Dysentery. If any others have a title to be classed with them they are tbe Cholera and Diabetes. But these are so frequently unaccompanied by fever, at least through the greater part of their course, and often through the whole of it when they terminate fa- vourably, that they cannot be regarded as febrile diseaaes. CHAP. I. Of Catarrh. Catarrh is defined by Dr. Cullen, " Pyrexia saepe contagiosa ; muci ex glandulis membranae nan-. " um, faucium vel bronchiorum, excretio aucta ; saltern hujus ex- " cretionis molimina." He divides it into two species, the common catarrh, which always arises from cold, and the epidemic catarrh, commonjy termed in- fluenza, which frequently, at least, appears to be contagious. With the symptoms and mode of treatment ofthe former, almost every body, whether of the medical profession or not, is acquainted; I shall not, therefore, detain the reader with any particular account of it. Both its symptoms and mode of treatment will sufficiently appear from what will be said ofthe more serious form of the disease. EPIDEMIC CATARRH 'IS* SECT. I. Ofthe Symptoms of Epidemic Catarrh. This disease often comes on like a common cold, hut generally with a more considerable chilly fit, and a greater degree of lassi- tude and dejection ; and frequently after continuing without much change for several days, at length gradually decl ines In other ca- ses, exposure to cold, fatigue, or some other cause of fever produces a sudden aggravation of the symptoms, or this takes place without any evident cause. Sometimes the disease is more severe from the first, the febrile, as well as catarrhal, symptoms being consid- erable, and the patient from the commencement complaining of great sinking and debility. The cough is generally troublesome, and attended with flying pains of the chest, sometimes with a sense of soreness or heat ex- tending downwards under the sternum, or of anxiety, tightness and oppression about the praecordia, which induces the patient to pre- fer the erect posture. The matter expectorated consists of mucus or phlegm, and is sometimes tinged with blood, although inflamma- tion has not supervened, which in the more severe cases is not un- common. In some cases little or nothing is expectorated, and sometimes, though much more rarely, there is little or no cough. In many cases the cough continues after the febrile symptoms have abated, withhoarsness, and sometimes loss of voice. The fauces are frequently affected, often inflamed, as in cynan- che tonsillaris ; in the most severe cases they are sometimes ulcer- ated, and sometimes covered with aphthae. The eyes are otten heavy and inflamed, the face florid, sometimes swelled and bloated. There is frequently a discharge, sometimes profuse, from the eyes and nose, with sneezing and swelling of the eye lids. The dis- charge from the nose, like that from the lungs is sometimes bloody, and in some cases there is a considerable flow of blood from the nose. The patient generally complains of head-ach. increased by the cough or any jolting .i-otion, which, sometimes in the progress of the disease becomes intense. It is often deep-seated and felt in the course ot the frontal sinuses. In some cases the pain is felt chiefly in the face and jaws. A sense of noise in the ears, and deafness, are not uncommon, and tbe taste and smell are often impaired. The patient frequently complains of giddiness and pain on moving 356 EPIDEMIC CATARRlf. the eyes, light and noise being particularly offensive. In some cases there is a degree of drowsiness almost amounting to coma, in others, confusion of head, and even delirium ; neither coma nor de- lirium, however, are frequent. The alimentary canal is often much disordered. The tongue at an early period is generally covered with thick white mucus, which, in tbe progress of the disease, often assumes a brown col- our, and the thirst is frequently greater than usually attends the same degree of fever. Pains in the stomach and bowels are not uncommon, and nausea, vomiting, and diarrhoea occasionally at' tend ; more frequently the bowels are constipated. It has been rtmaiked, that the cough is most severe when the tendency to con- stipation is greatest. Bilious symptoms are not unusual, and a degree of cholera supervenes. The fever is often, but by no means uniformly, proportioned to the catarrhal symptoms. Its most'striking characteristic is depres- sion of strength and spirits, which I have already had occasion to observe is often remarkable from the first attack. In Ihe progress of the disease it sometimes goes so far as to produce syncope, which is seldom attended with danger unless it occurs repeatedly. The pains ofthe head, back, limbs and loins, are also frequently more severe than is usual in the same degree of fever, and there is often a soreness ofthe whole body. It has been remarked that the cough is frequently least sev ere when the pains of tbe limbs are most so. These pains attended with cold shivering alternating with flushings of heat and the sudden prostration of strength, are often the first Fymptoms. There is frequently a great tendency to sweating, sometimes even from the commencement ; in some cases it is very profuse the urine being high-coloured and turbid. The sweating is often attended with relief, but seldom with a sudden termination of the disease. The pulee for the most part is from 90 to 120. At the beginning it is often full and tense, seldom hard. If actual inflammation does not supervene, it generally becomes small and weak in the progress of the disease, and is sometimes in this state from the commence- ment. In old people, in pasticular, it sometimes becomes irregu- lar. The depression of strength and spirits is not always accom- panied with a sinking of the pulse, which on the whole, is often less effected than the other symptoms would lead us to suppose. EPIDEMIC CATARRH. 357' The fever is generally considerable for two or three days. On tbe fourth, for the most part, it begins to abate, hut the loss of ap- petite, languor, and debility, continue much longer, often attended with great feebleness and stiffness of the joints. The duration of the fever, however is various; it is sometimes protracted even for several weeks, and has, though rarely, assumed the intermitting form. The favourable termination is sometimes attended with a bilious diarrhoea. Upon the whole although this disease is often severe, it can- not be regarded as dangerous except in the old and infirm, in whom it is most apt to prove tedious and leave bad consequences. The fever generally runs highest in the young and plethoric. It is often very severe in infants. For the most part tbe danger if best estimated by the degree of cough and dyspnoea. When re- lapses happen they are often more severe than the first attack. Exposure to cold and fatigue are their most frequent causes. They often prove fatal in old people. The chief source of danger in epidemic catarrh is its tendency to produce other diseases. In the young and plelhorc it sometimes occasions pneumonia ; in the old, peripneumonia notha, or apo- plexy ; in the weak and relaxed, typhus. It often induces asth- matic, bilious, and rheumatic attacks in Ihe predisposed. It is less liable to produce phthisis than we should expect. Sometimes it terminates with purulent expectoration without serious consequen- ces, the pus being merely a secretion from the inflamed surface of the bronchiae. It is said sometimes to have produced croup. In exhausted habits it seems often to accelerate the appearance of dropsy, or other diseases of debility, and when it supervenes on any ofthe foregoing diseases, it, for the most part, greatly accele- rates their progress. This is particularly the case with respect to phthisis. It is often a severe disease in those who labour under any species of visceral obstruction. SECT. II. Ofthe Causes of Epidemic Catarrh. All ages and constitutions are liable to this disease. Females ii is said are more liable to it than males. Many alledge that they 3reonly so in consequence of more frequently attending the sick. Puerperal women are said to be most disposed to it. Adults ar* "nore liable to it than children. 358 EPIDEMIC CATARRH. Those who live in high, cold, and damp situations, and those exposed to tbe night air, or to any other cause of ^kmg cold, have been observed to be particularly, subject to it. Whatever debili- tates, appears to dispose to it, bad clothing, a scanty diet, intern* perance, &c. Much difference of opinion exists respecting the way in which this disease spreads. It would appear at first view, that nothing is more easy than to ascertain whether a disease is contagious, yet so great is the difficulty respecting that we are considering, that many ofthe best inlormed confess that they h,.ve not been able to ascer- tain whether it is so or not. " Though I attended to the subject," Dr. Gregory observes, " I am at a loss to decide whether the in- " fluenza was contagious or not. If contagious it spreads by laws, " peculiar to itself."* On comparing together the various facts on the subject, we are almost forced to belive that it does not always spread in the same way, but sometimes by contagion, and at other times, merely as an epidemic. Instances occur in which only one ofa family is seized with it, notwithstanding the freest intercourse ; even those who sleep with the invalid escape it. In some instances a whole family is attacked by it at the same time, and when it spreads from one to another, it appears in some in a few hours, in others in a few days, and in others, not till weeks after those of the same family have been attacked by it; and some escape it while it is in the family, yet have it afterwards. One family has had constant intercourse with another labouring under it, without at all suffering from it. It has been observed that villages in the neighbourhood of, and having constant intercourse with, towns suffering from it, have escaped, while it has appeared in distant towns. And it is not uncommon for it to appear in distant parts of the country at the same time. This observation, however, has been made of other diseases which are certainly contagious, particularly of the plague. Such are the circumstances which would lead us to doubt the contagious nature of influenza. On the other hand there are many well authenticated instances of a family remaining uninfected, till visited by a person labouring under it, and of its then spreading rapidly through the family. It has also been observed in many instances, that those near the sick are most liable to it. And on its first appearance it has often gone through the individuals ofa family in which it first appeared before it 3pread to others, and then first affected those families more imme * Dr. Currie's Med. Reports, ice. second edition, vol. 2. p. 78. EPIDEMIC CATARRH. 358 tfiately connected with that in which it first appeared. Such being the facts, it is not surprising that there should be much difference of opinion on the subject. It is natural to form our opinions from »rbat we ourselves see. It has been generally supposed, that the influenza follows the direction ofthe wind, but from the most accurate observations, this does not appear to be the case. It has been observed by some ♦hat animals are more unhealthy during the general prevalence of influenza, and some have imagined that their diseases resemble it, but in general they do not appear to be subject to any particular diseases at such times. SECT. III. Ofthe Treatment of Epidemic Catarrh. In the commencement of this disease, the strict employment of antiphlogistic measures is more uniformly proper than in simph^ fe- ver, but they are not indicated to the same extent as iu the phleg- masiae. In the employment of evacuations in epidemic catarrh, we must always keep in view its tendency to debility.; and in the use of tonic means, the.inflammatory diathesis, which almost al- ways accompanies it. It is generally proper to begin the treatment with an emetic, which is often indicated by nausea. If the febrile symptoms are consid- erable, an antimonial emetic should be perferred, and if they con- tinue with tightness of the chest, but without much depression of strength, the repetition of the emetic is proper. When unattended by actual inflammation the symptoms are sel- dom such as to indicate blood-letting. The excitement can for the most part be sufficiently allayed by abstinence, a cooling diet, the use of cathartics, and antimonial and saline medicines. It sometimes happens that the bowels are particularly languid. Brisk cathartics are then necessary, for it is requisite in all cases, particularly at an early period, to keep up a free action of the bow- els ; but much catharsis appears often to increase the debility without affording relief, especially if the excitement is not consid- erable. Evacuations of all kinds, indeed, generally appear to pro- duce more depression of strength than in other similar cases. From the expectorant power of antimonial medicines, which, when tbe excitement is considerable, should be continued in small doses, they answer a double purpose. When the excitement is not 360 EPIDEMIC CATRARH. much increased, their continued use is apt to induce the sinking and debility so characteristic of this disease. The bed-room should neither be very cold nor very warm, the former increases the catarrhal, the latter the febrile symptoms. Dr. Currie used the cold affusion in his own case, apparently with good effects. The reader will find his account of it in the 77th and following pages of tbe second edition of his Reports. The treatment of influenza is much influenced by the age and habit of the patient, and by its tendency to affect the different cav- ities. If the patient is threatened with pneumonia or phthisis, the means detailed in treating of these diseases should be resorted to4 but our practice must be more cautious in the former case than in simple pneumonia. When the affection ofthe chest is merely catarrhal, if there is nothing in the state ofthe febrile symptoms to counter-indicate the use of anodynes, .they are generally of great use in young people, combined with antimonials. Rubbing a solution of opium on the chest sometimes allays irritation, when taking it internally fails. In old people, in whom the influenza often inclines to peripneumo- nia notha, opiates must be used with caution. When the expecto* rated matter is tough and viscid, and the patient brings it up with difficulty, provided the fever is not considerable, the more stimula- ting expectorants, squills, ammonia, asafetida, seneka, &c. are in- dicated. Even where the fever is considerable, these medicines are sometimes advantageously combined with antimonials, but in general in this case they are too heating, and often render the cough tighter. Blistering the chest is generally of service, and when the inflam- matory tendency prevails, taking blood from it by leeches or cup- ping, as less debilitating, is often better than bleeding from the arm. It has often been remarked that even when the symptoms seem to demand general blood-letting, it frequently does not pro- duce its usual good effects, although the blood shews the buffy coat. In some cases the buffy coat does not appear in this dis- ease, even when the symptoms are such as would lead us most to expect it. ThoBe who have lost much blood either by venesection or hemorrhagy, generally recover very slowly. In old people, we have seen, that influenza is sometimes accom- panied by a determination to the head, which is often relieved by exciting the bowels, making cold applications to the head, taking a little blood from the temples, and blistering the nape ofthe neck. EPIDEMIC CATARRH. 3$ Iflit goes so far as to produce insensibility, it is to be regarded as apoplexy complicated with influenza, and treated accordingly. When this disease is accompanied with bilious or other affec- tions ofthe abdominal viscera, their treatment, in like manner, ii \o be combined with that of influenza, the debilitating tendency of the latter still being kept in view. On account of this tendency, it is generally necessary after the increased excitement and inflammatory symptoms have been sub-, dued, to allow the patient a more generous diet, and in debilitated habits the moderate use of wine. The lighter bitters also are fre- quently used with advantage. At earlier periods, ammonia and musk are employed to relieve the sinking. When the disease has subsided, leaving a considerable degree of debility without any inflammatory tendency, the bark is often of service.* * Respecting epidemic catarrh, the efficient cause is still wrapped up in mystery, and the investigation of it does not promise much advantage ; but facts, which serve to shew its nature and effects on the human constitution are important. The author has justly observed that all ages and constitutions are liable to this disease, and I have observed that it affects people in all situations. Those who are confined to the house, and even to a sick room, are quite as liable to it as those who go abroad. It also attacks persons afflicted with all kinds of chronic disease->; and I think I have seen it combined with Some acute affec- tions. I have observed that when Uiis disease prevails, persons who have it, i re liable to be attacked with the typhus fever, and the symptoms of both dis- eases are conspicuous in such patients. In my note on peripneumonia notha, I remarked that the catarrh assumes a great variety of forms, and affected dillerent parts of the body at different limes. In the autumn of 1790, an epidemic of this kind prevailed in New England, which affected the mucous membrane of the head causing an acrid discharge from the nose, which inflamed the upper lip, having little or no effect on the mucous membranes ofthe lungs and attended with little or no cough. I do not know that it proved fatal to any. In the spring of 1791 a catarrhal af-t fee tion prevailed pretty generally, which affected the lungs severely, and of which many people died, while it produced but little effect on the head. A judicious physician has observed that the spotted fever is a particular form of catarrh. In the winter of 1813, in that part of the country whera the pneu- monia typhoidea prevailed, the spotted fever was prevalent at the same time among children. It was common for the adults in families to have the pneu- monia ; and the children iu the same families to have the spotted fever at the same time, which induced rue to infer that the two diseases were somehow con- nected togetlier. Respecting the treatment of epidemic catarrh, blood-letting is not often n«c?« Ail, but it is occasionally necessary. Kmc-tics, diaphoretics, and opium ar^ \~or. rr. 4fi 362 bYSENTERY. CHAP. 11. 0/Dysentery,. Dysentery is defined by Dr. Cullen, " Pyrexia contagiosa ; dejectiones frequentes, mucosae, vel saa " guinolenta,', retentis plerumque fiecibus alvinis ; tormina ; tenes^ " mus." Dr. Cullen agrees with Sir John Priugle in admitting but one specie's of idiopathic dysentery, considering as merely accidental the circumstances which have been regarded as marking different species ofthe disease ; such as the presence of worms, the dis- cbarge by stool of fleshy or sebacious substances, there being no discharge of blood, the appearance of miliary eruption, &c. There would be no end, il is evident, to species of this kind. SECT. I. Of the Symptoms of Dysentery. DvstNTERY sometimes comes on with the usual symptoms of fe vcr, shivering, and the other marks ofa cold stage, which are succeed- ed by heat and thirst, and soon afterby the symptoms peculiar to the disease. It more frequently happens, however, that an affection ofthe bowels is the first symptom. In many cases the disease comes on with a common diarrhoea, which gradually assumes the form of dysentery. In other cases there are from the first, severe griping, tenesmus and bloody and mucous stools. The febrile symptom; then soon shew themselves, and there is often a very sudden pros- tration of strength. Sometimes the attack is very gradual, wandering pains of the bowels distressing the patient for several days before the dysen- teric symptoms shew themselves, and the fever not making its ap- pearance till some time after this happens. The fever is sometimes a synocha throughout the greater part of its course, more frequently it assumes the form of typhus at an the best remedies in this disease. When the local affection is considerable ; end when it eii'ects the head or lungs, blisters applied near the part affected, are highly useful. N. S. DYSENTERY. 3Gy ■early period, and in some cases it is a well marked typhus from the first. In the worst cases this disease sometimes proves fatal in a few days, during which the patient is reduced to the last stage of debil- ity ; and if he survives many days, the emaciation is extreme, equal to what we see in phthisis. In more favourable cases the debility comes on less suddenly. As the disease often begins with diarrhoea, the favourable change is often denoted by the return of this symptom, the griping and tenesmus abating or ceasing altogether. The diarrhoea generally soon leaves the patient, with no other complaint than a degree of languor and debility, proportioned to the severity of the. preced- ing disease. In other cases, the hardened faeces, which are either wholly re- tained during the disease, or partially excreted in small hard mas- ses, are at length discharged ; and the dysenteric symptoms. without any considerable diarrhoea, gradually abate. The duration of dysentery is various ; the mildest, like the more severe forms, sometimes run their course in a few days, or at most, weeks. Those in which the symptoms are obstinate without be- ing severe, are often protracted for many months. Such is the general course of the disease. Before proceeding to a more detailed view of the symptoms, 1 may observe, thata> the fever in dysentery is not only sometimes the first part of the dis- ease which shews itself, but even now and then continues for some time before the local symptoms appear, and as the degree of fever often seems proportioned rather to some peculiar virulence ofthe con- tagion, than to the local affection, it may seem, that the fever is re- garded as symptomatic ofthe local affection with less propriety in dysentery than in the diseases with which it is classed. But it ap- pears from a variety of facts, that the contagion of dysentery, or the putrid effluvia attending it, may excite a real typhus independently of any local affection ; in which the latter frequently does not appear for some time after the commencement of the fever, and in some cases does not appear at all. Where such a fever, therefore, continues for some time before the local affection shews itself, the case is evident- ly to be regarded as a combination of typhus and dysentery. In the case of simple dysentery we shall find sufficient proof of the gener- al affection depending on the local, the former being constantly influenced both with respect to kind and degree by the state of the local disease, ceasing along with it even when removed merely by 3:4 DYSENTERY. local means ; and again returning, if it be renewed by errors of diet, or any other cause affecting the bowels. When dysentery makes its attack suddenly, it often comes on with great prostration of strength, attended with nausea and vom- iting, and a weak and frequent pulse. More generally after the symptoms common to the commencement of febrile diseases the local affection first shews itself with pain, and mucus and bloody stools. The pain is generally of the griping kind, but varies in different cases, and at different times in the same case.* In other cases, various symptoms denoting derangement in the stomach and bowels, nausea, flatulence, acid eructations, constipa- tion, &c. precede the more characteristic symptoms ofthe disease. sometimes for several days. I have just had occasion to observe, that dysentery is freqently preceded by common diarrhoea. By irritating the intestines and washing off their mucus, diarrhoea seems sometimes to occasion it. The desire to go to stool becomes more frequent ; the griping and tenesmus more severe ; the matter voided gradually changes its appearance, and at length consists wholly of mucus mixed with blood. The quantity of blood in the stools is various. Sometimes it appears only in streakes, sometimes it forms a considerable part of the stool, and sometimes almost the whole of it ; so .that, were it not for the other symptoms, and the darker colour of the blood, the disease might be mistaken for the haemorrhois. From the large quantity of blood sometimes discharged, it has been called the bloody flux. When the stools are wholly unmixed with blood, it is termed dysenteria alba, or morbus mucosus. The natural faeces are often retained during almost the whole course of the disease, and when they do appear they are in small separate balls, which seem to have lain long in the cells ofthe col- on, and have obtained the name ofscybalte. The expulson of these, whether spontaneous or by medicine, is attended with a remission * " Some," Dr. Clcghorn obscn cs, " are seized with a twisting ofthe gut;, :; wliich, as they express it, draws up their bowles into knots, and many, in- '* stead of griping pains which shift from place to place and come at interval.-1, ■•have acute fixed ones in some particular part of the belly, which occasion *; complair.ls as various as their seat, some being attended with stitches about k' the bastard ribs, interrupting their breathing freely, as in the pleurisy; other; '; with a pain reaching from one hypochondrium to the other, cutting them, as <; it were, in two ; while others complain only ofa pain about the pelvis, with " a constant fruitless straining to stool, though the body is for the most part " costive, and discharges nothing but bloody Mime." DYSENTERY. 365 uf the symptoms, particularly ofthe frequency of the stools, grip- ing and tenesmus. Such are the most common appearances in dysenteric stools. Substances ofa fibrous or membranous appearance are often observ- ed in them, which have been regarded as portions of the internal coat of the intestines abraded ; but Zimmerman remarks, that they are very seldom of that nature, and generally consist of inspissated mucus. The internal coat ofthe bowels, he admits, is sometimes abraded, but so late in the disease, that instead of having a mem- branous appearance, it is changed into a putrid thin pus, the bowels becoming ulcerated ; or is so mixed with blood and mucus, that it is impossible to distinguish it. Wc are not always, however, to infer that the bowels are ulcer- ated when we observe purulent matter in the stools, which is not uncommon, particularly in protracted dysenteries. We have rea- son to believe, that in the majority of cases it is secreted from the irritated and inflamed surface ofthe intestines, without ulceration. Small masses ofa substance resembling fat, are sometimes found in the stools, the nature of-which does not seem well ascertained.* The various substances passed by stool are occasionally dischar- ged by vomiting. It is not uncommon in dysentery for worms to be passed in both these ways.f The matter rejected by vomiting * " As to the white substances," Sir John Pringle observes, which I compare "to suet, I do not know whether they are the same which Hippocrates call< " caruncul?e, but they are plainly described by Aretseus and Caelius Aurelianu?. '' and have since been taken notice of by later writers, under the nameofcor- " porapinguia, and variously accounted for. Although I have frequently seen " them, I had neglected to examine them till the autumn of 17b2, when Dr. k' Huck and I visited a patient ill of dysentery, who voided such substanct- " We preserved one of them, and were both satisfied that the object of our c:- " quiry was nothing but a bit of cheese, though the patient assured us after- " wards he had tasted none from the beginning of his illness, which had been ot " above a fortnight's standing." Sir John Pringle concludes, that tliev orig- inated either in bits of cheese which had passed from the stomach before the illness, or were formed from milk, the use of which the patient had continued. It is more than probable that they are not the carunculae, of Hippocrates, sincv. Degner and other writers mention both these substances and small Meshy bodie- which they term caruncula;. Zimmerman thinks that they are both formed from inspissated mucus, but adduces noprcofof his opinion. t In 1743, we are informed by Huxham, that a dreadful dysentery raged, \u which worms were passed even by adults and old people. Pringle, Monro, amj jfhcrc, mention worms discharged by vomiting. S6ti DYSENTERY. is generally more or less bilious, sometimes, though rarely, stereo* raceous.* As the disease advances, the stools often become sanious, and of a dark brown or black colour, with an insupportable cadaverous fetor, affording a very bad prognosis, and often indeed indicating the presence of gangrene. Very frequently at an early period, and sometimes throughout the greater part of the disease, they have little or no fetor, but a faintish disagreeable smell. Sydenham mentions cases under the name of dysentery, in which there were no stools. They cannot, however, be regarded as de- serving this name, and must be referred either to the head of colic, or enteritis. The various symptoms of derangement in the prima; viae attend throughout the progress of the disease, and the flatulence sometimes increases to such a degree as to occasion a real tympanitis. The mouth is foul, the patient complaining of a bitter taste ; the tongue white and covered with tough mucus, or rough and dry, at length becoming black, Aphthae frequently appear about the root of the tongue, and sometimes spread over the internal fauces. When we were considering eruptive fevers, 1 had occasion to ob- serve how much eruptions are influenced by the state ofthe stomach and bowels. It even appeared that disorders of the alimentary canal are not unfrequently their exciting cause. Hence it is, we have reason to believe, that dysentery is so frequently accompani- ed by eruptions of different kinds. The miliary eruption, in parti- cular, is a frequent attendant on it.| By an attention to the local symptoms, we may sometimes de- termine what part ofthe intestines is affected. If the small intes- tines be the seat ofthe disease, the pain is often very acute ; and the patient complains of its twisting round the umbilicus ; the sick- ness and vomiting, and the pain and flatulence of the stomach, are more urgent than when the disease is confined to the large intes- tines ; the faeces are not passed immediately after the griping, and if blood or purulent matter is passed, they are more intimately- mixed with the other parts of the stool. Hiccup sometimes supervenes early without affording a bad prognosis, which it always does when it comes on at a late period, * See the observations of Degner, (De Dysenteria Biliosa) and others. tDegner describes a singular eruption which appeared in one of his patients, blotches and hard black tubercles, like the true pestilential carbuncles, which terminated in a fatal sphacelus. DYSENTERY. 36*? and when the other symptoms are unfavourable. When hiccup appears early, and proves obstinate, it may be suspected, that in whatever part of the intestines the disease is seated, it is pretty high in the abdomen. When the disease has its seat in the large intestines, the pain, ac- cording to Burserius, is more obtuse. But Sir John Pringle re- marks, that in general the irritation of the stomach and higher in- testines is attended with more sickness in proportion to the griping, and that when the griping is very acute without sickness, it is probable that the disease is in the large intestines. The tenesmus is then most urgent, the stool more quickly follows the griping, and the blood and purulent matter is less mixed with the rest of the excrement. Sometimes both the large and small intestines partake of the dis- ease. This circumstance, together with the intestines constantly changing their place, the sympathy which subsists between differ- ent parts of them, and there being in some measure differently situ- ated in different people, often renders it very difficult, with any certainty, to determine the seat of the disease. There are cases of dysentery unattended by fever. In these, however, the affection ofthe bowels is slight, and of short dura- tion. In many cases, we have seen, the fever is a synocha. This is particularly the case in the young and robust, and when the dis- ease is produced by the use of fermented liquors, or cold. When the excitement runs high, the danger is considerable, the debility which succeeds being pi oportioned to it. But it is greater when debility attends from the beginning. Even in the early sta- ges the debility is often such as to occasion syncope. It sometimes happens, that the pulse is natural for the first days. Wo cannot, however, confide in this, especially if the strength is much reduc- ed. In such cases, about the third or fourth day the pulse be- comes frequent, and often very suddenly begins to intermit. The state of the various functions is the same as in simple fever, except where it is influenced by the local affection. There is often a painful strangury from the commencement of the disease, and the urine is sometimes wholly suppressed for several days. The fever in dysentery is not always continued ; it sometime^ assumes the tertian type, and in many cases remits irregularly. Well marked remissions, and still more intermissions of either the local or general symptoms, are favourable. They can only be depended on, however, when they arc of considerable duration. jor, DYSENTERY. As the fatal termination approaches, the various symptoms' ol ex- treme debility^ gradually shew themselves. A lienteric purging sometimes conies on, whatever is taken being passed with little change ; the pulse becomes extremely frequent, small and irreg- ular ; the skin is bedewed with cold, clammy, and partial sweats ; the extremities become cold, and the pulse it length ceases. It sometimes happen-, that after these symptoms the patient lives for several days, the pulse and natural heat gradually returning. When the pain and tenesmus remit, the anxiety and restlessness in- creasing, with dark coloured and offensive stoob, and a hippocra- tic countenance, we are assured that gangrene has taken place. It is not uncommon here, as in gangrene of the intestines from other causes, for the patient to retain his senses to the last. We may look for a favourable termination, when the fpbrile symptoms are mild, some degree of appetite remains, and the pa- tient is little troubled with nausea ; when the pains are not very- severe, nor the stools very fetid ; when, the emaciation, weakness and anxiety are not considerable ; and above all, when the pa- tient enjoys sleep, and the skin is soft and moist. The favourable diarrhoea, in wliich dysentery often terminates, like that which pre- cedes death, is sometimes lienteric, though seldom in the same degree. Dysentery rarely terminates in recovery in so short a time as it sometimes proves fatal ; seldom in less than twelve or fourteen days. Protracted cases may prove fatal either by the symptoms suddenly increasing, or in consequence of the strength being gradu- ally exhausted. But in these, the symptoms being milder than when the disease is more rapid, the danger is generally less. The bowels seem sometimes to acquire a habit (if the expression maybe used) of retaining the faeces, and the disease is protracted even for years, the patient being constantly harrassed with pain, mucous and bloody stool-, fever and want of appetite, under which he gradually sinks. In such cases some part ofthe intes- tines is often ulcerated. The lower parts of the intestines are generally the last that recover their tone ; the tenesmus of- ten remaining a considerable time after all the other symptoms have disappeared. This has been ascribed to the remains ofthe morbific matter ; but Sir John Pringle seems to ascribe it to the true cause, the soreness of a part which has been so much inflamed and excoriated in the course ofthe disease, and which is still fre- quently irritated. " That the tenesmus which succeeds dysen- " tery." he adds, "may be sometimes owing to an ulcer, is as- DYSENTERY. 369 "* serted by Morgagni, but he gives only one instance of it in his " practice." Various diseases of debility, particularly ofthe stomach and in- testines, follow dysentery, especially when long protracted ; ob- stinate diarrhoea, or lientary, dyspepsia, pains of the bowels, &c. Degner says, that some of his patients after recovering from dysen- tery bad a discharge of chyle with the faeces ; and others almost an insatiable hunger. I have seen a case in which permanent stricture of the rectum followed long protracted dysentery, where the irritation from acrid stools had been very great. If the pa- tient has been much reduced, dropsical symptoms often succeed this disease, which may sometimes be removed by tonic medicines and a proper attention to diet and exercise. , SECT. II. Of the Appeatances on Dissection. We generally find the intestines inflamed, often more or less sphacelated, and sometimes ulcerated ; they are sometimes of a dark or even black colour, for a great part of their course without either ulceration or gangrene. * The inflammation sometimes extends through almost the whole tract ofthe intestines, and even spreads to the stomach, which has also been found gangrenous. The coats of the intestines are often much thickened, and here and there tender as if half putrid. , The villous coat is frequently abraded, though not so often as once supposed ; sometimes it seems quite dissolved into a greenish putrid mass. When the villous coat is consumed, the vascular generally appears full of turgid vessels, as if well injected with red wax. The internal surface of the intestines is often covered with bloody slime of an extremely offensive smell, and sometimes there is no excrementitious matter, even in the form of scybalae, in any part of them ; the digestive powers seeming to have been wholly suspended for some time before death. The large intestines are most frequently affected with gangrene and ulceration. Blood is often passed in considerable quantity when no appearance of ulceration can be found after death ; so * Dr. Baillie's Morbid Anatomy Vol. ir. 1? 370 DVSENTERY. that Sir JolenJP?jngle and Zimmerman conclude, that in general the blood flows from the debilitated mouths of the vessels which open on the internal coat ofthe intestines ; and the gangrenous state of this coat often extending so for along the canal without actual ulcera- tion, favours the opinion. The intestines are often found enlarged, the effect of repeated distension from air. From this cause, together with the flaccidity occasioned by, the tendency to gangrene, the colon in particular has often been so much distended, that the appearance of its cells, and even ofthe ligaments which form them, has been almost whol- ly obliterated. The ligaments are sometimes found iua gangrenous state, and adhering loosely to the outer coat ofthe intestine. When gangrene has not destroyed the texture of tbe parts, con- strictions are often found, particularly in the large intestines, often of considerable extent. These are supposed by the generality of writers to cause dysentery by retaining the natural faeces, which, by lying in the intestine, are formed into hard masses, occasioning much irritation and an increased secretion of mucus. The relaxa- tion of these constrictions readily accounts for the highly offensive and putrid stools which are so often, the forerunner of death. Sir John Pringle, Dr. Cleghorn, and some others, mention the appearance of small flat tubercles in the large intestines, which look like the confluent smallpox.* Such are tbe appearances observed in the intestines of those who die of dysentery. Dr. Cleghorn informs us that in some cases, the ulcers were not on their internal but external surface. In a few, he observes, there were small abscesses in tbe cellular membrane of the peritoneum, contiguous to the colon and rectum ; the con- volutions ofthe intestines frequently adhering to each other, or to parts in their neighbourhood, i With regard to the other abdominal viscera, they are often sound. The ine-entery anl mesocolon, even when the intestines ajv gangrenous,are sometime- loaded with fat. The author just mentioned observes, that in two cases which he saw, the omentum was almost t ntiruly. wasted, the small remains of it being quite black, and purulent matter was found iu the abdomen. The gall _* Liuncrus i*nd Zimmerman alio mention this appearance. The writer* mentioned in the text think il a very common attendant, particularly on conta- £inui-'dysentery, and thai its m.l liavmg been more generally mentioned by writers, arises from its being concealed by the blood and mucus, which so fre- cently bc;.mcar ihe inte lints iu dysentery. It i-> unnoticed both bv Uonctu* and M'ligagni- DYSENTERY. 371 bladder is often much distended with bile, which is generally of a darker colour than usual. The liver, spleen, pancreas, and kid- neys have been found flaccid and enlarged, more rarely, diminish- ed in size and indurated. They are sometimes gangrenous or con- sumed with abscesses. The following description affords a striking picture ofthe effects of this disease. " Although the body was opened the next day, " the smell was intolerable, the intestines were wholly mortified " and the stomach partly so. The coat ofthe liver was putrid, " and in its substance were several abscesses containing a purulent " or ichorus matter ; the spleen was likewise corrupted."* There is seldom much change to bo observed in the thoracic vi-i era. Sir John Pringle mentions a c.j->e in which the diaphragm, ascended as high as the third rib, probably from the distension of the intestines, yet the lungs were sound. In some cases, however, as in one related in the 31st Epistle of Morgagni, the lungs are found in a very diseased state. The blood is generally of a dark colour, and partly coagulated in the ventricles of the heart. From the above state ofthe abdominal visccra.t we have reason lo believe, that death is generally occasioned by inflammation of the intestines running lo gangrene. When the pulse is frequent and small and the pain severe with nau.-ea ami much tenderness of the abdomen, we may be assured that inflammation has super- vened. SECT. III. Ofthe Causes of Dysentery. The ancients were acquainted with dysentery, but most oftiieui used the word in a vc\y vague sense ; Hippocrates, Galen, and many others, applying it as a general term for all kinds of fluxes or hemorrhagies ofthe intestines ; others confining it to express an ulcer of some part of the alimentary canal. Sydenham and Willis seeA to be the first who employed the term in the way we now do. Dysentery is more a disease ofthe warm, than the cold and tem- perate climates, and most freqently appears towards the end of summer and in autumn. Huxham is among the few writers who. *Sir John Pringle's Observations on the Diseases ofthe Army. + See Rocderer de Morbo Mucoso, p. 155etseq, 372 DYSENTERY. met with an epidemic dysentery in spring. It is most apt to make its appearance when the summer is unusually warm and the autumn moist ; and the cold of winter generally tends to check its progress. It has sometimes, however, made its appearance, and proved very fatal after moderate heats, and sometimes it has con- tinued through a great part of the winter. Weak and exhausted habits are most liable to it. This observa- tion is most applicable to the worst forms of dysentery,, which par- take so much of putrid fever, that Dr. Blane considers the disease as a fever of this kind, the affection of the bowels being only symptomatic. With regard to the occasional causes of dysentery, many main- tain that there is but one, contagion ; and that the other occasion- al causes only favour its operation. Of contagion in general I have already had occasion to speak at length ; it will only be necessary here to make a few observa- tions, particularly applicable to the disease before us. The con- tagion of this disease, like that of most others, extends but a short way around the sick. Rut its chief source islhe excrement; for the mere smell of it, as Zimmerman observes, has often com- municated the disease to men in health, and even to beasts. And it would seem, that the more fetid the excrement, the more conta- gious is the disease. It may be propagated, the author just men- tioned thinks, by clothes or'furniture which have never been in contact with the sick, provided they have been exposed to the ef- fluvia arising from the patient's body, and still more to those from the excrement.; and as I have had occasion to observe of other dis- eases, the person who wears, the infected clothes may escape, while the disease is communicated to those with whom he asso- ciates. It is a remark of Sir John Pringle, however, that dysen- tery often spreads more slowly, and is of a less infectious nature, than most other contagious fevers ; so that in the milder epidem- ics, as in that described by Sydenham and Willis, its contagious nature has passed unnoticed. This observation by no means ap- plies to the worst forms of it. Degner and others mention epi- demics not less infectious than the plague itself. Like many other contagious diseases, dysentery is sometimes communicated to the foetus inutero. The manner in which dysentery is propagated points out some ofthe means of checking its progress. Public privies are the most certain means of spreading it. It is not even proper to confine many sick to the same privy, as the constant application of the DYSENTERY. 37o contagion not only renders the disease more dangerous to the pa- tient himself, but to all that are near him. Tbe excrement should be regularly buried. In camps attention should be particularly di- rected towards detecting the sick, who use every means to con- ceal a disorder which excludes them from the comforts of society, and seldom betake themselves to bed till they have infected many of their companions. But for the various means of preventing the spreading ofthe disease, I must refer to the first volume.* If the other causes, to which dysentery has been ascribed, are not capable of exciting the disease, independently of contagion, they certainly add to its power; it is therefore of great conse- quence to avoid them in endeavouring to check the progress of the disease. A bad diet seems to be a principal cause of the greater virulence of dysentery among the lower ranks. A debilitated habit, how- ever induced, may have the same effect. I have had opportunities of pointing out how much the severity of other contagious diseases is increased by it. Another cause of its frequency among the lower ranks, is their keeping their persons and houses dirty. Zimmerman even goes so far as to attribute to this cause alone the contagious nature of dysentery. Foron its first appearance he remarks, as it attacked many at the same time, it seemed to proceed from a cause which acted more generally than contagion could be supposed to do, and seemed only to become infectious in proportion as cleanliness was disregarded. h Many have been led wholly to ascribe dysentery to certain states of the bile, from the stools being frequently bilious ; from an un- usual quantity of bile being often found in the intestines and gall bladder of those who die of it, and that generally ofa dark colour, implying a vitiated state of this fluid ; and from dysentery pre- vailing most in those countries where bilious affections are most common. No particular state of the bile, however, seems connect- * A vomit and gentle cathartic, Zimmerman remarks, seem often to pre- vent the disease in those who are exposed to its contagion. Those, it has been observed, who eat little,' drink less, and do not take their drink cold; who keep up the perspiration, especially during the night, by covering themselves all over with bed clothes ; either escape the disease, or have it slightly. Fa- tigue, vexation, and fea^tlispose to dysentery as well.as.other contagious dis- eases. There is every reason to believe, that tonic medicines, by strengthen- ing the alimentary canal, tend to pjeveut this disease. See Sir G. Baker's Treatise de Dysenteria. oU DYSENTERi. ed with the disease ; and in cholera and other diseases we see the bile variously changed in quantity as well as quality without in- ducing it. By others it has been ascribed to other kinds of acrid matter in the intestines. But there seems in many cases no evi- dence of any acrid mattertill the disease itself has produced it Ir- ritation of the intestines, however, kept up by bile, worms,* flatu- lence, acid, &c. may terminate in dysentery ; and that such caus- es are favourable to the operation of itscontagion, and tend to in- crease its virulence, every day's experience evinces. Almost every writer on the diseases of the army informs us, that lying in the fields and doing duty in all kinds, of weather are peculiar- ly favourable to the appearance of this disease. Here, as in other instances, cold is most pernicious when it alternates with heat, which is probably one of the causes of the unwholesomeness of warm moist weather, the vapour.exhaled during the day being condensed occa- sions dampand chilliness in the evening. Hence it seems to be, that dysentery often rages at the same time with remitting and inter- mitting fevers, and that these diseases are frequently combined.t Whatever share putrid effluvia may have in the first production of the disease, they never fail to increase its violence, and render it more infectious. Dr. Donald Monro, whose experience was ve- ry extensive, wholly attributes its production to obstructed per- spiration and exposure to putrid effluvia. It is very doubtful whether (as Zimmerman seems to suppose, and as the great effect of the excrement in propagating the disease has induced many to believe) dysentery, like common typhus may arise from putrid effluvia alone. The constant affection of the bowels must incline us to believe that there is something specific in its contagion. It was observed in treating of contagion, that we have reason lo believe that contagious diseases are at first produ- ced by a concurrence of several causes. Thus we find, that a ve- ry simple concurrence of causes is sufficient to occasion typhus, wliich afterwards spreads by its own contagion. It seems proba- ble from many observations, that taking cold, a diet of difficult di- gestion, irritation from bile, &c. which would in ordinary circum- stances occasion diarrhoea, may, when the patient is exposed to putrid effluvia, produce dysentery. , I have had occasion lo observe of the plague, typhus, and some other contagious fevers, that few other diseases appear, while thev * See Dr. Huxham's account of the Epidemics of 1743. + See the observations of Sir John Pringle, Dr. Donald Monro. Sec. DYSENTERY. 375 are prevalent, and those which do, partake of their nature. The same observations have been made respecting dysentery. While the dysentery raged, Dcgner observes there was hardly any other disease lo be met with except diarrhoea and one or two cases of small pox. I knew very few, he adds, that during this time were con- fined to bed by any other disease but the dysentery. Most wri- ters on this disease make similar observation-. Intermitting and remitting levers, in particular, are apt to partake of dysentery. Analogous to this observation is that of Sydenham, that the epi- demics of the same year bear some resemblance to each other. We find lhat the worst kinds of dysentery, in which the fever is typhus and the stools very fetid, are often preceded or followed by putrid fever-. SECT. IV. Ofthe Treatment of Dysentery. The treatment of dysentery, Dr. Cullen observes, for want ofa proper view ofthe nature of the disease, seems to have been in several respects fluctuating and undetermined. He therefore ex- plains what he conceives its nature to be. Although Dr. Cullen's opinion of its depending wholly on a preternatural constriction of the intestines, is far from being established, it may be regarded as the,most probable ; and as it serves to connect the'different parts ofthe treatment, it may be useful to keep it in view. It does not, however, lead, a priori, to the whole of the treatment which has been found most successful ; and might even surest an early and free use of opiates and other modes of practice, which are found to be hurtful* We cannot, therefore, agree with Dr. Cullen, in re- garding the removal of the supposed constriction of the intestines 5 the indication on which the whole treatment rests. Sir John Pringle and many.other of the best writers seem tohave regarded our knowledge of this disease, as too confined to admit of »ur laying down indications of cure. But although we are not warranted, perhaps, to lay down any, implying a knowledge of it^ proximate cause, it does not seem difficult, by attending to the effects ofthe means found beneficial, to form such as may be very useful in conducting the treatment. A review of theie mean- seems to lead to two indications, which comprehend the whole ot the treatment : to procure the evacuation ofthe natural lances ; am' when this indication is answered, to re More tone to the bowels. 376 DYSENTERY. The former is answered by preventing or removing irritation and other causes which impede the action of the bowels or render it ineffectual in expelling the faeces ; and by increasing the action of the stomach and bowels by cathartics. The circuuistances which, besides irritation, tend to prevent the relaxation of the bow- els, seem reducible to the two heads of increased excitement and debility. It is ofthe first importance in this disease, that every thing which tends to irritate the stomach and bowels should be avoided ; the diet, therefore, ought, with the exceptions afterwards to be pointed out, to be ofthe mildest kind ; and we must, at the same time, as far as we can, expel the morbid contents of the primae vise, and al- lay or prevent the irritation occasioned by those which we cannot remove ; for whether irritating matter in the prima; viae has occa- sioned dysentery or not, it always attends it. The use of emetics is chiefly confined to the early periods. They are particularly indicated when the stomach is loaded, espe- cially, if, at the same time, the excitement is considerable, with a dry parched skin. At the commencement, the excitement is sel- dom so low as to counterindicate them. Their effect is not merely that of emptying the stomach and preventing the introduction of irritating matter into the intestines ; they determine to the skin, thus tending both to allay the fever and relax the bowels. When the stomach is much loaded, emetics are often employed with ad- vantage as late as the tenth, twelfth, or fourteenth day. As might be inferred, a priori, from the purposes which they seem to serve in this disease, their frequent repetition is seldom proper, and often does harm.* The antimonium tartarisatum and ipecacuanha are the best emetics in this disease. They should be given in small and repeated doses, that they may partly pass the pylorus before -•exciting vomiting, unless the symptoms of oppressed stomach are urgent. The preparation of antimony, termed the vitrum anti- monii ceratum, has been celebrated as an emetic in dysentery, but is now, on account of the roughness and uncertainty of its opera- tion, very generally laid aside. To render cathartics effectual, we must, as far as we can, re- move the different causes just mentioned, impeding their operation in this disease. * For the use of emetics in dysentery the reader may consult the works of the different authors I have had occasion to mention, particularly those of Sir J. I'ringle, Dr. Cleghorn, Dr. D. Monro, Dr. Cullen, and Dr. Zimmerman, of vhose work a translation from the German is given by Dr. Hopson DYSENTERY. 37-; If after the operation of the emetic there is reason to believe that the stomach is still oppressed, we must endeavour to correct the of- fending cause. When the breath and eructations are sour, anti- acids are necessary ; when there is reason to suspect a preva- lence of bile, acids, particularly the vegetable acids, must be em- ployed. The only means we possess, if we except opiates, of defending the stomach and intestines against irritation, are, mucilaginous and oily deuiulsions. The latter seem to be the most effectual, but they are most apt to oppress the stomach. They are better adapted to clysters. In preparing oily clysters, the oil should be rubbed with a sufficient quantity of mucilage to make it mix readi- ly with the milk, of which the remaining part ofthe clyster should be composed. These means relieve the pain and tenesmus, and seem to act partly by lining the internal coat of the intestines, and thus defending them against the acrimony of their contents, and partly as a warm bath, by their bulk, warmth, and blandness, sof- tening and relaxing the bowels. When, notwithstanding these means, the irritation and griping are severe, we must call in the aid of external applications, parti- cularly the warm bath, fomentations, and blisters. The first is strongly recommended by Sir George Baker. When the general warm bath is inconvenient, the semicupium is often used with ad- vantage. Fomentations of the abdomen, and flannel dipped in brandy and sprinkled with pepper applied to it, are also frequent- ly serviceable. A large blister applied over the abdomen is more effectual than any of these means ; but in the milder cases, so se- vere a remedy is unnecessary. Concerning the exhibition of opiates in this disease, there has been much difference of opinion. But there are few writers on dysentery who do not warn against the early usa of them.* After * I have always looked upon it, says Zimmerman, as dangerous to give opium in dysentery, before the fuel which feeds the disease is burnt out. " Si astrin- " gentia et opiata prtepropn dantur, (Huxham observes,) mox gravisshm.' :; accedunt tormina, stomachi aegritudo, singultus, aphtha, tandemque intesti- " norum spKj ius, queni cito mors excipit." Lieutaud, Dr. Blane, Sir John Pringle, and many others might be quoted to the same purpose. Even Dr. Cullen, whose opinion ofthe disease seems to point out opium as the principal remedy, observes, that !>y sccasioning an interruption of the action of the small intestines, it favours the constriction of the colon, and thereby sometimes ag- gravates the disease, and that if the use of it supersede the employment of purg- atives, it commonly does much mischief. I believe, indeed, he adds, that it is only the neglect of purging that renders the use of opiates necessary. Vol. it. 43 5U DYSENTERY a free evacuation by cathartics, opiates are often of great service** especially in the evening, for the purpose of procuring sleep, and they are the more beneficial at this time, as the pain is generally most severe in the night. It has been observed, indeed, that if opium allays the local symptoms, it occasions a proportional in- crease ofthe febrile. But the latter effect is seldom considerable, unless it be exhibited before a proper relaxation ofthe bowels, or while the excitement is great. At whatever period of the disease it is given, its tendency to con- stipate must be carefully obviated. Some have proposed combin- ing a cathartic with the opiate, expecting that while the cathartic ob- viates the constipating effect of the opium, it may counteract the irritating quality of the cathartic. This plan, however, has not been so successful as might have been expected. It has been found better to give the cathartic alone, and the opiate after its opera- tion. Nauseating doses of emetics, indeed, of which I shall pre- sently have occasion to speak more particularly, are often advan- tageously combined with opium. By this combination, however, we have it less in view to move the bowels than to take off the ten- dency to spasm and promote perspiration.* The hyosciamus has not, as far as I know, been recommended in.- dysentery, although its anodyne and gently laxative qualities seem eminently to adapt it to this disease. I have employed it with advantage in cholic, in which it is recommended by Dr. Cullen. Opiates are often given with great advantage, in clysters, in this disease. The intolerable irritation in the rectum natural- ly suggests them. When the motions were so frequent that mere emollient clysters could not be retained, Sir John Pringle generally added from 20 to 60 drops of laudanum to each, or more if it was necessary, provided it did not affect the head. Mr. John Hunter, (the author just mentioned, informs us) often used antiseptic anodyne clysters with the best effects. He made the first trial with four ounces ofa strong decoction of bark, with some grains of opium dissolved in it. He afterwards used with success a decoction of the tornientil root and of oak bark in the Same way. The clysters were repeated if returned without al- laying the tenesmus. Some medicines are warmly recommended as means of allaying the griping, the operation of which it is not so easy to explain, un- less we allow that their bulk, warmth, and gently tonic power may ' Sec the observations of Dr. D. Monro, and Dr. Brocklesby. DYSENTERY. 379 liave the effect. Among the chief of these are lime water and an infusion of camomile flowers.* Other similar infusions are re- commended for the same purpose. We have reason to believe, that the warm water is the chief part ofthe remedy. It is almost always beneficial, and some have trusted to it alone, and it is said with great success.t For the purpose of allaying irritation in dysentery, there are few means more powerful than the horizontal posture. I have known cases yield in this posture which had resisted every remedy, while the patient was allowed to sit up. AVhen the excitement runs high, it is difficult effectually to move the bowels in this disease. The same means which fail during in- creased excitement, often succeed when it has been ruduced. To allay it, therefore, is, both on this accouut, and because nothing tends more to debilitate, an indication of great importance in tbe commencernen t of dysentery. The means of allaying irritation just considered, form an essen- tial part of those of reducing excitement; but it is often necessary- to have recourse to more active measures. It is to be recollected however, that less is to be feared in this disease from an excess, than from a deficiency of excitement ; the more powerful means of reducing it, therefore, must be used with caution. Emetics and cathartics are employed for other purposes; the same may be said of diaphoretics ; blood-letting, therefore, is the only evacuation recommended wholly with a view to lessen excite- ment. Many speak of blood-letting as necessary at the commencement of dysentery, as proper if all the remaining strength ofthe patient will bear it.J They seem to expect from it some essential change in the state of the local affection. If inflammation of the bou cl.s always attended the commencement of dysentery, this expectation *Dr. D. Monro gave the lime water mixed with milk, which proved ser- viceable to some ; in other cases it failed. The infusion of camomile flowers seems preferable to lime water. Sir John rringle says, that for mitigating the gripes and expelling wind, he has found nothing equal to fomentations and drinking camomile tea. And Zimmerman observes, that next to opium he found the infusion of camomile flowers the best means of alleviating the pains.. Dr. Monro and others make similar observations. t See the observations of Zimmerman, and Sir J, Tripgle; also those of Huxham, Degner, Tissot, 4c, X Akenside J)e Dysenteria Commsntarius, Lieutaud's Synopsis, 4c 380 DYSENTERY. would be just. But when inflammation does attend dysentery, it is the consequence not the cause ofthe disease, and seldom super- venes early. Besides, the authors just alluded to mention symp- toms as warranting the employment of blood-letting, which do not indicate the presence of inflammation. Inflammation ofthe intestines is known here, as in other cases, by the great severity of the pain, and tenderness of the abdomen, and by a frequent, small, feeble pulse, more or less hard.* In the last stage of dysentery, enteritis is often unaccompanied with its usual symptoms, and in many cases the tendency to gangrene is so great, that it supervenes on a degree of inflammation too slight materially: to affectthe state of the symptoms. I had occasion to explain in the introduction to this volume, why, in very debilita- ted states of the system,, gangrene often supervenes on slight de- grees of inflammation, the inflammation then bearing the same an- alogy to passive hemorrhagy, which inflammation with a strong vis a tergo, bears to active hemorrhagy. In such cases, it is evident, that blood-letting would only add to the evil. It would seem that when there is no inflammation, the propriety of blood-letting is ascertained in the same way as in simple fever, by the degree of excitement; we must recollect, however, that in proportion as the due action of the bowels is obtained with great- Crdifficulty in dysentery, a less degree of excitement warrants its employment. It frequently happens in this disease, that the abdomen, or par- ticular parts of it become very tender, the patient complaining on the slightest pressure, without the other symptoms of enteritis. Local blood-letting, as I have often witnessed, is then attended with the best effects. With regard to the employment of refrigerants as a means of les- sening excitement, there is little to be added here to what I have frequently had occasion to say. Nitrate of potash, given in any considerable quantity, is apt to irritate the bowels. Saline draughts in the state of effervescence, and acetate of ammonia, are perhaps the best of this class of medicines in dysentery. Their gobd ef- fects in this disease are to be ascribed, perhaps, more to their dia- phoretic than refrigerant quality. * " Nor were we discouraged," Dr. D. Monro observes, " from bleeding in " the beginning by the low, quick pulse, which often attended the disorder ; " and we frequently found the pulse rise as the blood flowed from the vein. " But when the sick were low and weak, without much pain or fever, and the "puke was soft, we were more sparing of the vital fluid." Why, it may be asked, was blood-letting recommended in the latter case ? DYSENTERY. fc;8j When the indication is to lessen excitement, the diet must be such as shall co-operate with the forgoing means, mild and diluent. In- dependently of increased excitement, indeed, this diet seems par- ticularly indicated by the state of the bowels in dy.-entery.* The drink should always be tepid. Such are the means of moderating excitement in dysentery ; but the morbid state of the bowels is less frequently supported by in- creased excitement than by debility, the means of preventing and removing which form an essential part ofthe treatment of this dis- ease. The debility, we found, is sometimes considerable from the commencement. In general, however, this is only the case in tbe more advanced stages. Our view.is to support the strength with as little irritation as pos- sible. I have already had occasion to observe, that the diet in dy- sentery should be mucilaginous and diluent. When debility pre- vails it must be nutricious. A full diet of animal food is too irri- tating, and too low a diet may induce a fatal debility. It must be adapted to the state of the symptoms, the patient's habit, the na- ture of the epidemic, and the duration ofthe disease. In all cases, perhaps, which have not been of long duration, the mildest diet is proper. The patient should be confined to gruel, sago, pana'da, &c. the quantity being regulated by the appetite. Sir George Baker and many ethers even forbid the use of chicken broth at the commencement. Where the fever is slight, and there is reason to dread much debility, Dr. Akenside recommends not only different kinds of broths, but the milder kinds of animal food in a solid form. Few practitioners, however, admit of so full a diet. Sir John Pringle says, that he formerly used to permit dysenteric patients to take a little mutton broth, but finding even this hurtful he has since for bidden it. Dr. Cleghorn, Dr. D. Monro, Dr. Zimmerman, &.c. make similar observations : were I to speak from my own experi ence, I should say. that it is only in those cases of dysenters which are so protracted as to assume the chronic form, that any kind of animal food is proper, and in these the mildest only should be used. Fruit has frequently been regarded as a cause of dysentery, anu consequently avoided in this disease, not, however, it would ap- pear on sufficient grounds. Zimmerman observes, that grapes were an excellent remedy in the epidemic dysenteryr. Sir George Baker says, that those who had taken an unusual quantity ofthe ' See the observations of Sir J. Pringle, Zimmerman, II r.ham, Derner &■*. 382 DYSENTERY. summer or autumnal fruits either wholly escaped the dysentery, or had it in a very mild form. Dr. Cullen thinks the use of fruits should be chiefly confined to the beginning of the disease. It is only, he observes, in the more advanced stages that the morbid acidity of the stomach seems to prevail, and requires some reserve in the use of acessants. Fruit is particularly indicated when there is much bile in the primae viae. Of the use of wine in dysentery, I shall presently have occasion to speak. With respect to tonic medicines the tendency of this disease to inflammation has deterred many from employing them at any pe- riod, and at an early period they are generally hurtful, even where the debility is considerable. When dysentery, however, has been of long standing and has occasioned much debility, or is com- plicated with typhus or with intermitting fever, the bark seems often to have proved eminently useful. Sir John Pringle re- commends it with the serpentaria, when the fever is ofa malignant nature.* Lauter, in his Historia Med. Bien. observes, that when the fever remitted, the urine depositing a laterititious sediment, however irregularly and however short the remissions, he immedi- ately had recourse to the bark,which he gave in substance. Scarcely, he observes, had the patient taken half an ounce when the stools became less frequent, the griping was allayed, the tenesmus, which formerly baffled all means which could be employed, almost wholly ceased, and the pulse at length lost its unusual frequency. Dr. Cullen, Dr. Cleghorn, and many others, make similar observa- tions, t * " In 1760," he observes, " Dr. Whytt wrote to me, that in this bad state. w of the dysentery, when the mouth and alimentary canal were threatened with " aphthae, and even sometimes after they had appeared, he had successfully " given the bark, having first made such evacuations as the case required or " the patient's strength could bear, by blood-letting, vomiting with ipecacuan- u ha, and purging with rhubarb. That to a pint ofa strong decoction ofthe " bark he added three drams or half an ounce of confectio japonica, and order- *' cd two spoonfuls every four hours of this medicine without any other, except " some laudanum at bed time. That when by the continued use thereof the " body became costive he then gave rhubarb, and after that, went on with the ia be used with caution ; the Bristol waters have been celebra- ted for the same purpose, but have lost much of their reputation. For so e time after the disease the patient should were flannel next the skin, pass a go ;d deal of time in the horizontal posture, if he is too weak to walk, ride on horse back or in a carriage, accor- ding to his strength, and carefully avoid taking cold. When there is reason to suspect that the disease has left an ulcer of the. intestines, balsams, particularly the balsamum chiae or copa- ivae, rubbed with oils, have been employed, though seldom with success.* I had occasion to make some observations on ulcers of the intestines in speaking of enteritis. For removing the tenesmus, which so frequently remains after the other symptoms, small mucilaginous and anodyne clysters, with occasional gentle cathartics to evacuate any irritating matter that may still be lodged in the alimentary canal, are the best means. * See Dr. Monro's Obs. on the Dis, ofthe Army, and Dr. Mead's Monjfa e'i Precept. Med. cum NotisWintringhami, vol. i, DYSENTERY. J8& Dr. N. Smith's Note on Dvshnterv. As tbe author has not mentioned Dr. Moseley's treatise on dys- entery, and as he has not adverted to the mode of treating that diseases with sudorifics, I have added for the benefit of those who may not have the book within their reach, the whole of the first part of Dr. Moseley's treatise*on dysentery, which contains his the- ory of that disease, and mode of treating it, and at the end I have added the recipe for making his vitriolic solution. As Dr. Moseley's book on dysentery has been in the hands of some ofthe faculty in this country a considerable number of years, they have had opportunities of putting his theory to the test of practice; and several judicious practitioners have declared in its* favour. Since I first read his treatise, the dysentery has been epidemic several times, and I have had frequent opportunities of contrasting his mode of treatment with that of others, and am decidedly of opinion that it is the best I have been acquainted with. N. S. On the Dysentery. " The dysentery or bloody .flux having been a disease so destruc- tive to soldiers in camps and garrisons, and a constant attendant on all military operations, it is a medical inquiry of the utmost im- portance to investigate the disease, on every occasion, with the greatest attention, in hopes of finding some method to put a stop to its devastation. *" When this treatise was first published, separately, in England, it was remarked in a literary journal, that curing the dysentery by sudorific medicines, was not a new doctrine ; and since the first edi- tion of this book appeared, the same journal observes, that ' promot- ' ing perspiration after the intestines are well emptied, is the usual 'mode of treating the disease, and the only effectual way ofcur- " ing it.' But that I ' seem to place too much efficacy insudori- ' fics.'t " Another of these literary journals suggests, that the disease, $?om yielding easily to my sudorific treatment, was' a peculiar * Critical Review for February 1788. f Monthly Review for June 1788. 390 DYSENTERY. * epidemic, and suspects strongly that this plan would not sue- ' ceed so well in this climate."* The authors of these remarks appear candid, but less fortunate than in some others which they have honoured me with. If they had given the subject due consideration, the former would have known that no person before me, ancient or modern, has ever men- tioned as a system, treating the dysentery, after the primae viae have been cleansed, with sudorifics only ; and from enquiry among practitioners in London, or any where else, that it is not ' the usual ' mode of treating the disease.' The latter gentleman, from my words, had no reason to suppose it was * a peculiar epidemic,' to which I was applying the doctrine, but to the various epidemics of a long series of years. And though it is not hitherto * the usual * mode of treating the disease ;' yet I foretell that it will be so, wdienever any severe epidemic shall make its appearance, and will be ' the only effectual way of curing it.' I have the satisfaction to assert from my own experience, that it does succeed well in * this ' climate,' and in every other climate of Europe, where the prac- tice has gained and is gaining ground faster than could reasonably be expected, considering what piles of venerable absurdity stand in its way, surrounded by an host of idolaters defending their su- perstition. " It is a subject in which the welfare of mankind is deeply inter- ested, and often the glory and honour of a nation. If the cause of humanity was not alone a sufficient motive to induce to this re- search, we need bqt turn our eyes on the political field; there we may behold the best concerted measures defeated by its influence. The page of military history weeps less for the slain in battle, than for those who have fallen victims to this calamity. " We have greatly to lament^hat the labours of medical writ- ers have hitherto met with so little success, and that their best en- deavours have only shown how little we know, and how much we have to learn in treating this disease. " Happy shall I be if the following observations may contribute to remove some of the many difficulties which present themselves, and induce a farther prosecution ofthe subject, until the disease is brought under the command of the most improved and certain practice. " The word Dysentery, in Latin, Dysenterta, and in Greek AvotvTiftct, is derived from JVs, with difficulty, and entera, the iri- *Monthly Review for June, 1788. DYSENTERY. 3& restints; importing a difliculty, or a disturbance of the functions of the intestines. " The Dysentery is termed by the Latin writers, diflicultas intes- h'norum ; Celsus calls it tormina ; Galen, 'eyfutaii ctTepm ; Ca> lius Aurelianus, Rheumatismus cum ulcere ; and it is thus de- scribed by Hippocrates, in lib. 3. cap. 5; de Victus Ratione Sano- rum. 'Ox«t*» & S-egfUtnefMeii t»v cm/wres, xxtctpTis fynttx yevyTxt, re fi tlTtpoi %Vereti, kxi itxtvrxi xxt ^i»xfi>fttrcu cufmruhx, revro oe ewsvre^tn xtOttTtu, iavn.x$ «v t« «r«povTi Myu, rots xvpius tvoftot^tf&tvccs ovo-tvTipixs ctxovtiv, on rqpuuvovrTif tjj$ Wfao-aj/«gi(*s ttrspm EAx«o"* Dr. Cullep, DYSENTERY. 39? far, and much abuse of it has arisen in hot climates, from respect to his authority and character. Il has been supposed also by the same professor, that the appli- cation of cold air, as a sedative,by abating the re-action of the vas- cular system, maybe useful in some circumstances of fever ; but he* does not venture to pronounce in what. This dangerous conjecture, too, wc have seen followed, by the extravagant custom of exposing patients indiscriminately in fevers and fluxes, almost sub dio, and the mischief it produced disregarded. A moderately cool temperate air is proper and necessary in ev- ery species of fever ; but if any thing beyond that degree is meant, it cannot be supported by any reasoning that applies to the small pox ; though this gave rise to the speculation, and many experi- ments on it in the southern parts of Europe. The small pox fever is sui generis, and terminates in phlegmons ; it requires a treatment of its own ; for example, cooler air than is required in a state of health is necessary ; raising a sweat is pre- judicial, and often changes the distinct into the confluent sort. On the contrary, in fevers their solution is commonly by sweat; cold air applied, as in small pox, impedes that solution, and changes an intermittent into a remittent, or both into a continued fever. The preceding paragraph will not be deemed digressive, as it ds necessary to elucidate my subject. It is not my intention to dispute the auxiliary aid, that may oc- casionally be drawn from various purgatives, and even from vari- *>u> astringents, in certain conditions of the dysentery', diarrhoea, or tenesmus ; or from rhubarb, absorbents, and correctors, in un- important complaints ofthe bowels, originating there from acrimo- ny and crudities ; but to recommend a practice for removing ep- idemical dysenteries, by means adequate to, and that correspond with their general cause. It will occur to every practitioner (,;s my intention here is the use of sudorifics) that I mean a careful continued course of them, to keep up a sweat in extent proportioned to the violence of the dis- ease ; and not the trifling way of giving them in small doses, whilst the patient is exposed, and their operation neglected. It will occur also, that the sudorific employed must be suitable to the nature of the flux ; the Stage of it, and the habit ofthe patient. When I propose a method for the cure of this disease by a course Af sudorifics, I am aware of no objection that can possibly attend the novelty of the doctrine ; excepting that it wants the sanction of the trthers of physic, and has to oppose the errors and prejudices of 4 oo DYSENTERY. custom. But facts must strpport it, where this disease is most for midable, from the important consideration that success in war, the safety of possessions, and the protection of commerce, depend on the preservation of soldiers and sailors ; among whom the flux has ever been found to make the most dreadful havoc in the East and West Indies, and on all service in hot climates. Though 1 have had a succession of opportunities in my private practice sinc,e the year 1768, to prove the extent of tbe doctrine I advance ; I have also had many opportunities to prove its efficacy, in that degree of dysentery, which is no where to be seen but in military camps and garrisons, for which reason I shall illustrate the subject with a short account of the bloody flux, as it raged among the troops in Jamaica, in April 1780, and particularly in the camp at Castile fort, with the method that I followed in the treatment. This flux will appear to want almost all the usually conceived remote causes of a dysentery ; but it will be found with the im- mediate one, common to all. The state ofthe human frame for some time prior to the above period, undenvent a multitude of diurnal transitions, from the ab- sence, or presence of a violent sea breeze ; the weather was now remarkably dry, hot for the season of the year, and at times sultry. It was impossible to use the least exercise without being heated ; and it was almost impossible to get heated without being immedi- ately chilled by the breeze.* It is the soldiers' life to be much exposed, and it is his custom to be careless of himself; when he is fatigued or heated, he hastens to cool himself in the breeze, or night air, and perhaps throws off his clothes, and often lies down and sleeps in that condition. If he is wet,! e dries his clothes, linen, and skin together. By these means, perspiration, the great fountain of health in hot climates, is suddenly stopped, and febrile strictures occupy the whole surface :>f the body. A flux following these data, must distinguish itself by an inflam- matory diathesis ; and its progress will consequently be rapid. The general symptoms were a chillness in the beginning, suc- ceeded by feverish heats, gripings, and fequent small motions; sickness of the stomach, and sometimes retchings, copious purging soon followed, with green, brown, or yellow watery stools; these * When the breeze is vislent, and what is call*! fiery, it checks perspiration, when people are exposed to it, in an inactive situation, making the skin dry and parched, and causing a feverish tendency. DYSENTERY. 401 were uow mixed with or succeeded by great discharges of blood ; several ounces of pure arterial blood were voided in a stream, ev- ery ha If hour, or hour, and some patients bled to death in this manner. The stools varied in foetorand appearance, according to the periods ofthe disease, and as they were more or less retained. A considera- ble degree of fever brought on the disease, and accompanied it with some ; with others butnittle. Small, bloody, slimy stools continually harrassed the patient in the last stages, particularly at nights. The tongue was greatly furred, and sometimes ofa brown, or black colour. Apthae appeared but seldom. This is the gene- ral account of those who experienced the violence of the disease, and survived the first week ; but many who were seized at the set- ting in of the flux that spring, perished in three or four days. The curative indications are to cleanse the intestines, and to cause a revulsion to the surface of the body. When the disease is rapid, the cure depends on performing these things as speedily as possible. Experience having shewn that the common methods and medi- cines hitherto used, fall far short, in violent dysenteries, of obtain- ing the important point of revulsion, ii proper time, and support- ing il; the practice will still be deficient, if we cannot find means adequate to these purposes. The inductive considerations are, to bleed as often as it can be done with safety ; to cleanse the primae viae ; to check the impe- tus with which the circulation is determined on the intestines, dis- tending and bursting the coats of the distributing branches of the mesenteric arteries; to remove the spasm from the vessels of the surface of the body, and to cause a diversion there ; all these must be done immediately, that the revulsion may be effectual. Bleeding being an operation of great consequence in the flux, the cure is generally begun with it, repeating it as the symptoms au- thorise. There are but few instances where it may not safely be done in the beginning of the disease ; observing only " non qua " aetas sit, sed quae vires sint."* The necessity is obvious where tbe patient is plethoric, with much fever, full pulse, and severe pains. After bleeding, a vomit of ipecacuanha is to be given ; which commonly relieves the stomach from a load of acid, poraceous, bi- lious impurities But our great expectation from vomiting is, that its action on the muscular fibres of the stomach, forces open the ex- * Cc!-. Lib. II. Cap. 10. Vol. ir. 51 402 DYSENTERY. treme arterial capillaries, forwards the circulation to the surface 0/ the body, and induces to sweat. This, the invariable effect of vomits, has not been noticed by the ancients ; and has never been by the moderns applied to the end I propose in the cure of intes- tinal diseases. An opiate, after its operation is necessary. After the vomit and opiate, it is proper t6 empty the bowels, but with caution, in case the patient be w^ak ; and in such a manner as not to increase the determination of the blood there, and to di- vert it from the surface ; for then we should lose the ground gained by the vomit, and counteract our principal design. An antimonial that acts much upon the skin, and purges at the same time, is what I always use. The primae viae being cleansed, and the revulsion begun, it must be supported by sudorifics, that the disease may be thrown off by sweat; this will be effected by uniting an opiate with a diaphoret- ic, and administering it as occasion requires. Laudanum and an- timonial wine combined, is a medicine that causes little or no irri- tation, and is a pleasant and certain diaphoretic. It is generally necessary in the flux, when a sweat is intended by antimonial, or other emetic medicines, in small doses, to add laudanum, to take off their irritation, by which means their doses and effect may be greatly extended. James's Powder is admirably calculated to answer the first in- tentions in this disease; it possesses this great advantage, that though it shall effectually cleanse the primae viae, properly given, if never fails to excite a plentiful sweat, and its effects terminate on the skin. This double operation, if I may so call it, perhaps has made it so decisive in obstinate fevers. When the diaphoresis is begun, I cover my patient, if a soldier, with a blanket, (which no soldier, should be without) and take care that no wind is admitted directly upon him. I do not suffer him to uncover himself, but order whatever he wants to be brought to him, aqd supply him copiously with warm barley-water, mint, sage, balm, or oat-meal tea ; and now and then give him a basorf of gruel, or thin flour pap, with a spoonful or two of good sound white wine in it, as free as possible from acidity. When the sudorific process has been successfully continued, all (he symptoms grow milder; and if the patient break out in a rash or efflorescent eruptions, or boils, the disease will soon be removed, Should it be objected, that uncovering and exposing the patient, while sweating, when he rises to go to stool, is an inconveniency which militates against my doctrine, I answer that where there ar« DYSENTERY. 403 proper attendants and utensils, the patient need not be exposed nor move from his bed ; and that when once a complete and uni- versal sweat is raised, the necessity for exposing the patient at all will soon be at an end, as the disease sometimes suddenly disap- pears. In the West-Indies, in the presence of several ofthe officers of dif- ferent regiments, who were desirous of being spectators of a fact so interesting to the army, a soldier has been taken in the worst condition ofthe disease, with blood running from him as in a he- morrhage from a wound, and in the utmost agony, I have given him three grains of the common Glass of Antimony, finely prepared and made into a small pill; this perhaps has operated upwards and down- wards ; but in promoting its operation to the skin, those other op- erations ceased, and a violent sweat has ensued, which was kept up by warm herb teas, and now and then small doses of laudanum, which may always be given with safety, and without any of its usual inconveniences, while the patient is sweating, which is a fact worthy the attention of practitioners ; even the iir^t stool, af- ter the sweating has been raised, has been less bloody, and the third or fourth frequently scarcely tinged. Such is the power of revulsion. If the flux continue obstinate, and the sweats do not go on kind- ly, it will not only be requisite to carry off the morbific humours by a dose of the antimonial purgative, but repeated vomits of ipeca- cuanha are to be given. In this case, the circulation has not been .enough diverted from the intestines, to produce a full and sufficient diaphoresis ; it is therefore necessary to give a fresh impulse to the fibres, by the action of vomiting ; for in vomiting the action of the stomach and the contraction of the abdominal viscera, force the blood to the surface, and upper parts of the body. Another cause of obstinacy in the flux, is indurated faeces, lodg- ed in the intestines ; and though the patient shall have been re- peatedly purged, and taken nothing but fluids during his illness, it is amazing what scybalae, or lumps of excrement will sometimes be brought away, by a repetition of the antimonial purgative, after an interval of several days ; for which reason, when the sweat? have been plentiful, the pulse moderate, and the flux still continues, we may suspect this to be the case. The extraordinary appearance these balls of excrement sometimes acquire from a long retention among the diseased secretions, has induced some writers to whim sical suppositions concerning their cause, and component prir; ciples. 404 DYSENTERY. rringle says, he does pot know whether those lumps, which have the appearance of suet, are the same which Hippocrates calls -<■=, and avoided division-- founded on the causes oi di.-"a':-, both iv^-ar.ng to eta in ^..-l-tai.t with the natua. of nt.soh.-y. See vol. 1 [•. 1 •.: ! 't. i I omit V-lh--)d'-.ca. ;,i ruugc ^>.y Dr, CuUi-n as o 'equela of rheumatism. both f.u- reason- r ■• ^ :n"titi.>ncd, (sec l"'..lc?uioi^ rnui In-eause it is never a II- l>ril<:i'i-i .i-. FIN I.- DR. N. SMITH'S APPENDIX. Ofthe Modus Operandi of morbid poisons, and other exciting cause of disease. Since the humoral pathology has been exploded, andthediscov cry of the absorbent system by anatomists, the opinions of physi- cians, respecting the causes of diseases, have changed in many respects ; and what was formerly attributed to morbific matter, and certain changes in the fluid has often been attributed to the op- eration of the absorbent system, in taking up and carrying into the circulating fluids from various sources such matter as produces dis- ease. In this way ithas been, and still is supposed by many, that all the morbid poisons enter the system and produce their effects. Another opinion is, that those causes of disease, such as contagion, and other morbid poisons, produce their effects by what has been called sympathy; that is, by an impression made on some part of the living system ; their effects are propagated to other parts ofthe body, without the poison ever being carried beyond the part touch- ed by it. As in most cases of disease, especially when it becomes general. we have to prescribe rather for the effects of the cause, than to re- move the cause itself: It may perhaps be thought unimportant. whether we adopt one or the other of these opinions. This may be true in general, but still 1 think there is no errour in theory, but: what is liable to produce an errour in practice ; therefore it is of some importance to settle this question rightly. That the absorbent system is of great importance in the system, cannot be doubted. The mouths of the absorbent vessels open every where ; on all the surfaces, in the cavities, in the body, and throughout all the cellular substance. By their activity, while their action is unimpaired, they take up all the superfluous fluids which are thrown out on these surfaces by the exhalent v essels ; and also ■>11 the superfluous fluids which are thrown into the cellular sub 57 loO MODUS OPERANDI OF stance. If in a healthy state of this system large quantities of watery fluid are thrown into the cavities ofthe body, it is soon re- moved by this system of vessels, and the general health of the sys- tem remains unimpaired. So likewise large quantities of fluids may be injected into the cellular substance, and quickly removed in the same manner. Even fluids impregnated with poisonous sub- stances will be absorbed, without producing any sensible effects on the system. I once, in attempting to inject a sinus on the knee joint, threw into the cellular substance more than half a gill of a solution of corrosive sublimate, which must have contained nearly two grains of that medicine ; this was soon absorbed without pro- ducing the least effect on the system. The water of an hydrocele, by a rupture ofthe sack, is often poured into the cellular substance of the scrotum, with a considerable quantity of blood, and all this is absorbed in a few days, without any injury to health. So far the action and office of the absorbent system is established beyond a doubt. But that this system of vessels reaches the sur- face of the body, and is capable of taking up fluids from thence, has been doubted. Within a few years, Dr. Mussey, a pupil of mine, and since that, d young gentleman from Albany, whose name I do not recollect. undertook some experiments iu order to settle this question. The method they adopted was to immerse themselves in a bath of warm tyater coloured with madder for several hours, and afterwards tc examine the urine to see if it was coloured by the madder. The experiments were conducted very much alike, and the results were very similar. The urine was in a small degree coloured with the madder. But before we allow those experiments to be conclusive in establishing the absorption by the skin, we must take notice of some circumstance attending them. In both instances, the expe rimentors lay in the bath'several hours, and after all, the urine was but slightly affected by the colouring matter. Another circum- stance which should be noticed is, that the first urine passed after coining out ofthe bath, was not coloured at all, and the effects oi the bath on the urine, was wholly over in less than 36 hours. Now I apprehend that the facts stated by the experimentors re- specting the effects of the bath, may fairly be explained without supposing the skin naturally to possi-s the power of absorption. The scarf skin or cuticle, is an inanimate substance, and is affected by warm water like other dead animal matter; that is, it is soft- ened, and by long maceration is loosened and separated from the ',\iU< vera, and when in this state the fluid in which the bodv j- MORBID POISONS. 451 immersed would come in contact with the mouths ofthe active ab- sorbents, so that we might reasonably expect the result from those experiments which 1 have stated. Notwithstanding those experi- ments, I am still inclined to think that the cuticle is to set bound? to the absorbent system, as well as to defend the nerves and blood vessels from the contact of such substances as are liable to excite morbid action. However we may determine this point, still it may be a question where poisons are actually inserted below the scarfskin, whether they produce their effects by making an im- pression on tbe nerves and blood vessels ofthe part, and in that way commencing their effect, or whether they are actually taken up by.the absorbent vessels, and carried into the circulating fluid. I confess there is great difliculty in settling this questiou by de- monstration, and, perhaps we may not be able to decide it, except it be by analogous reasoning. I think, however, by carefully at- tending to all the circumstances of diseased actions, it will lead us to a probable solution of those difficulties. In the first place, it may be observed of the causes of diseased action, that they produced their ultimate effects on the system at very different periods of time ; in some, after they are applied, the effect is instantaneous, and in others, several years elapse be- fore the effect is produced.. In those cases, where the effect is in- stantaneous, there could hardly be time for the cause to operate through the medium ofthe ahsorbents ; and in those cases, where the effect was delayed more than one year, we should think, that if the matter were absorbed, it must be worn out long before the effect was produced; for in one year, the whole of the fluid must be changed many times. One circumstance which should be noticed here, is that in cases of bites from rubid animals, though, the effect is not produced for many days after the wound is inflicted, the general effect on the _ ystem is always preceded by a peculiar irritation in the part, where the poison is inserted. It would be difficult to account for this on the supposition, that the effect was produced by absorp- tion ofthe virus ; for if it were actually absorbed, why should it produce irritation so long afterwards ? From this fact we should rather infer that the virus made an impression on the sensible fi- bres of that part; at first obscure and imperceptable, and at length increasing so as to effect the whole system. Another fact, which has been considered as proof of the absorp- tion of poison, is the effects of Cantharides, \yi\en applied to the 452 MODUS OPERANDI Ot skin on the urethra. Dr. Cullen says, that the acrimony ot the can- tharides is absorbed and carried into the circulating fluids and is again concentrated in the urine and irritates the urethra in pas- sing with the urine. To this it may be objected, that in cases of excoriation ofthe skin similar to the effects produced by the flies, tbe same effects on the urethra are produced. Sore nipples in nursing women will produce the same effects ; and the application ofthe child to the breast irritating the tender papilla, will often bring on a fit of strangury. It has also been observed that where certain substances are inserted below the skin, and which generate disease, such as the contagion of small pox, the lymphatic glands, situated between the part, where the matter is deposited, and the body, swell and become tender. The same also takes place in cancers. This circum- stance has been considered as a proof of absorption. But to this. it may be objected that the same swelling of the glands is caused by punctured wounds, where no poison is inserted. This fact has been noticed by Dr Crookshank. And in the case of cancers, this swelling of the glands is as often observed in tumours of a schirrous nature, before they ulcerate, as after; and in some cases the secondary tumours arise more remote from the body than the original ; several of wliich 1 have seen. The disease called hectic fever, which is always symptomatic, and arising from ulcers, some where in the body, has also been considered as proof of the doctrine of absorption. I dqi, not know that we can bring a direct proof to the contrary, but there are sev- eral facts to be noticed, which render it very doubtful, and would rather incline us to believe that it proceeds from another cause. I have witnessed many cures in which large collections of matter have been absorbed without producing any such effects, and in- stead of causing any disease, the system was relieved, or rather be- gun to mend as soon as the absorption commenced. But those, who support the doctrine pf absorption, say that, it il v essary the ulcer should be open, and air admitted to the matter ii order to give it a peculiar acrimony, which fits it for producing hectic fever. To this I would object, that many open ulcers of prodigious ex- tent do not produce that effect, while others, of but small surfaces, produce it in a high degree. The circumstance which has favour- ed the doctrine of absorption, and the opinion that it depended on contact ofthe air with the matter, is, that in cases of lumbar abcess and other large collections of matter in various parts ofthe body, no hectic fever is produced till the abcess is opened, and then it MODUS OPERANDI, &c. 453 comes on suddenly. But by carefully attending to all the circum- stances of such cases, we may, I think attribute this effect to other causes In such large collections of matter, there is, till opened, a great pressure ofthe matter on the whole surface ofthe abscess, and of course the matter collects, or increases, very slowly ; but wten the abscess is opened this presure is taken off, and tbe secretion of matter (for the surface of the abscess is a secreting organ) is great- ly increased; so much so, that it will secret more matter in one day, after opening, than in weeks or months before. Of course the action of the secreting surface is greatly increased ; the action is also changed, for the matter is of a different quality, after it is. opened, from that which was discharged at first. Therefore it is more probable that the hectic is the effect of the peculiar action of the ulcerated surface, than that of the absorption of matter. Upon the whole, on a careful review of all the facts which have been stated relative to the effects observed on the operation of those causes of diseased action, it appears that some of them operate too instantaneously to be brought about by absorption, while others produce their effects at such a distant period of time from their ap- plication, that it will be impossible to account for their operation upon that principle. Besides many of the effects which have been attributed to ab- sorption have certainly been produced without it, and therefore i? is rather unphilosophic to suppose that the same effects would b* produced by different causes. (Among the objections I had brought forward against the doctrin* of absorption I have not adverted to the opinions of some, which are, that though the absorbents will take up bland fluids, they will not receive poisonous matter that would be injurious. There is good reason, however, to believe that the absorbents do exercise a kinr' pf elective attraction on fluids presented to them.) FINIS. CATALOGUE OF MEDICAL BOOKS, FOR SALE, BY COOKE & HALE. HARTFORD. inatomy from the Encyclopedia, 8vo. $2,00—Abernethy's Surgery, 8vo.2,00. \hirnethy's Observations on the Head. 1,00 Ahbert on Intermittents, 8vo, 2,50,—Anatomical Examinations 1,87 Assalini on the Plaugue 1,00—Accum's Analysis of Minerals 1,00. Accum's Chcymistry. 2 vols. 8vo. 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