UNITED STATES OF AMERICA WASHINGTON, D. C. GPO 16—67244-1 DICTIONARY PRACTICAL MEDICINE COMPRISING GENERAL PATHOLOGY, THE NATURE AND TREATMENT OF DISEASES, MORBID STRUCTURES AND THE DISORDERS ESPECIALLY INCIDENTAL TO CLIMATES, TO THE SEX, AND TO THE DIFFERENT EPOCHS OF LIFE; WITH NUMEROUS PRESCRIPTIONS FOR THE MEDICINES RECOMMENDED, A CLASSIFICATION OF DISEASES ACCORDING TO PATHOLOGICAL PRIN- CIPLES, A COPIOUS BIBLIOGRAPHY, WITH REFERENCES; AND AN %ppenbi% of ^proueb iFcrmttlae: THE WHOLE FORMING A LIBRARY OF PATHOLOGY AND PRACTICAL MEDICINE, AND A DIGEST OF MEDICAL LITERATURE. BY JAMES COPLAND, M.D., Consulting Physician to Queen Charlotte's Lyini;-!]i Hospital; Senior Physician to the Royal Infirmary for Diseases of Children; Member of the Royal College of Physicians, London ; Member of the Medical and Chirurgical Societies of London and Berlin, etc. EDITED, WITH ADDITIONS, BY CHARLES A. LEE, M.Ih 'Co VOL. VII. ^ , 0 7 i^'-J NEW-YORK: HARPER & BROTHERS, PUBLISHERS, 82 CLIFF STREET. 18 52. v. 1 Entered, according to Act of Congress, in tne year 1846, by Harper & Brothers, In the Clerk's Office of the Southern District of New York CONT ENTS. POISONS— continued. Irritating and Depressing ■* Irritant and Alterant - Narcotic - Narcotico Acrid Septic .... Classification of and Index to Bibliography and References POLLUTION—Definition Voluntary - Involuntary Treatment of - Bibliography and References POMPHOLYX Page 433 447 460 474 477 482 483 485 485 488 489 497 497 497 PORRIGO...... PREGNANCY—Pathology and Therapeu- tics of......497 Disorders incidental to 498 Influence upon other Diseases - - 505 Bibliography and References - - 506 PROSTATE GLAND—Diseases of - 506 Bibliography and References - - 512 PRURIGO—Definition - - - - 512 Pathology, Diagnosis, Causes - - 512 Treatment.....514 Bibliography and References - - 515 PRURITUS—Definition - - - - 515 Diagnosis, Treatment, Bibliography - 516 PSO.E MUSCLES — Inflammation and Suppuration of 517 Bibliography and References - - 519 PSORIASIS AND LEPRIASIS—Causes 519 Description of.....521 Pathology and Treatment of - - 526 Bibliography and References - - 531 PUERPERAL STATES AND DISEASES 532 Pathology of - 532 Convalescence from - - 535 Prevention of - - 540 Structural Lesions consequent upon - 541 Spasmodic and Nervous Affections - 546 Puerperal Fevers - 548 Treatment of Puerperal Fevers - - 585 Bibliography and References - 594 PULSE—Historical Notices - - 595 Physiological Pathology of - 596 Semeiological Notices of - - 599 Bibliography and References - - 603 PU RPURA—Definition—Pathology - 604 Description .... - 605 Causes..... - 608 Treatment .... - 609 Bibliography and References - 610 PUS...... - 610 PUSTULAR ERUPTIONS - - - 611 PUSTULE, MALIGNANT—Definition- Causes ......612 Treatment.....614 Bibliography and References - - 615 PYLORUS......615 PYROSIS—Definition—Symptoms - - 615 Diagnosis—Prognosis - - - 616 Treatment.....617 Bibliography and References - - 618 QUARTAN FEVER - - - - 618 QUINSY.......618 QUOTIDIAN FEVER - - - - 618 RABIES.......618 Definition—History—Description - 619 Symptoms.....620 Diagnosis --..-- 625 Cause......627 Pathology......630 Treatment ..... 633 Bibliography and. References - - 640 RECTUM AND ANUS—Diseases of - 642 Malformation—Foreign Bodies - - 643 Paralysis of.....645 Inflammation of .... 646 Abscess of.....650 Ulceration of—Fistula in - - - 652 Prolapse of.....655 Excrescences about .... 657 Strictures of - - - - - 658 Cancer of......661 Bibliography and References - - 663 RHEUMATISM—Definition - - - 663 Acute......664 Sub-acute—Chronic .... 666 Special Seats of .... 669 Gonorrheal.....672 Complications, Extensions, or Metas- tasis of......673 States of the Blood and Excretions in 675 Diagnosis of.....677 Causes of......678 Nature of......680 Treatment of Acute - - - - 683 Treatment of Chronic - - - 689 External Treatment - - - - 693 Treatment of Complications - - 696 Bibliography and References - - 700 RICKETS—Definition—Description - 702 Diagnosis—Prognosis—Causes - - 707 Treatment.....709 Bibliography and References - - 711 ROSE-RASH—Definition—Description - 712 Treatment.....714 IV CONTENTS. RUBEOLA—Definition - - - - 714 Description—Nature of - 715 Treatment—Bibliography, etc. - - 716 RUMINATION, HUMAN - - - 717 History of.....718 Bibliography and References - - 719 RUPIA—Definition—Description of - 720 Diagnosis—Prognosis—Treatment - 721 SALIVATION.....721 SCABIES..... .....721 SCARLATINA RHEUMATICA—Defini- tion ......721 Description of.....722 Causes of......723 Nature—Treatment - 724 SCARLET FEVER—Definition Description of Regular Types and Irregular Forms Complications of Prominent Affections in - Sequelae of State of the Blood in Appearances after Death - Diagnosis - Causes of- Pathological Influences Treatment ... Remarks on Remedies for Bibliography and References - 725 - 726 - 727 - 733 - 735 - 737 - 741 - 742 - 744 - 747 - 751 - 753 - 763 - 767 SCHIRROUS AND OTHER TUMOURS 769 Elements of.....770 Page Chemical Composition of - - - 776 Description of - - - - - 778 Pathological Relations of - - - 784 Diagnosis......789 Prognosis......791 Treatment.....792 Bibliography and References - - 796 SCROFULA AND TUBERCLES—Defi- nition ......797 Diathesis described - 798 Causes of......799 Structure of.....811 Description of.....813 Pathology of.....817 Prevention of.....826 Treatment'.....828 Bibliography and References - - 837 SCURVY—Definition—History of - - 839 Description.....841 Diagnosis......844 Prognosis—Causes of 845 Nature—Prevention of 850 Treatment.....854 Bibliography and References - - 856 SEROUS AND SYNOVIAL MEM- BRANES .....858 SHOCK, VITAL OR NERVOUS - - 858 Causes and Phenomena - - - 859 Diagnosis and Prognosis - - - 861 Treatment.....862 Bibliography and References - - 863 SKIN—Functional Alterations - 863 POISONS—Irritating and Depr: The skin was hot and dry, the pulse frequent, full, and hard. These symptoms gradually sub- sided, and she recovered, although the pain in the head and epigastrium continued long. (Lond. Med. Gaz., xiv., p. 488.) 462. b. The morbid appearances produced by the salts of baryta have not been described as they occur in man. In the lower animals the mucous membrane of the stomach is usually found of a deep-red colour, unless death has taken place very rapidly, and in this case the alimentary canal is healthy. In all the animals which in Dr. Campbell's experiments were killed by the chloride applied to wounds, the brain and its membranes were much injected with blood ; and in one of them the appearan- ces were those of congestive apoplexy. 463. c. The Treatment of poisoning by the salts of baryta consists chiefly in the speedy administration of an alkaline or earthy sulphate, as the sulphate of soda or of magnesia. The poison is thus converted into the insoluble sul- phate of baryta, which, if not altogether inert, is nearly so. But the alkaline sulphates are of but little service where the carbonate of ba- ryta has been taken, unless in procuring the more rapid discharge of the poison by the bow- els. In Dr. Wilson's case, just mentioned, the copious evacuations from the bowels conse- quent on the exhibition of the sulphates were evidently beneficial, and tended to the recovery of the patient. Unless the patient be seen early, any treatment will prove inefficacious. Where the carbonate of baryta has been taken, Mr. Taylor recommends recourse to emetics and the stomach-pump ; or, as chemical antidotes, a mixture of vinegar with an alkaline sulphate. 464. C. Copper, the Preparations and Com- pounds of, have been considered above ($ 205, et seq.) with reference to the corrosive and acute action of these substances when administered in large doses or quantities. But in smaller quantities, or in repeated doses, they act local- ly as irritants of the gastro-intestinal villous surface, and constitutionally as sedatives or paralyzers of nervous and vital power; this latter effect resulting both from the influence primarily produced by them upon the nervous systems, and from their operation, through the medium of the circulation, upon the heart and nervous centres. The cupreous compounds are most likely to act in this way, and in a chronic form, when they contaminate articles of food, as remarked on many occasions. The salts of copper, which are the most frequently adminis- tered in large doses for the purposes of suicide and murder, are the sulphate and subacetate, and these act chiefly as corrosive acute poisons, as stated above (§ 205). But these, as well as the other compounds of this metal, may be so em- ployed or administered as to produce the symp- toms most characteristic of acro-sedative poison- ing.—a. In most instances the gastric symp- toms are similar to, but not so severe as, those attending the corrosive operation of the poison, while the nervous symptoms are of longer du- ration. There are generally burning pain in the throat and stomach, anxiety, vomitings, acute pains and great swelling of the abdomen, but no diarrhoea; afterward painful and difficult deglutition, with swelling of the throat and face, oppression of the pulse, salivation and ul- ceration of the gums, spasms, convulsions, or III 28 ssing—Mineral Acro-Sedatives. 433 paralysis, sometimes jaundice, &c. The irri- tability of the stomach and cramps, or paraly- sis, often continue long, and are attended by costiveness and dysuria or suppression of urine. 465. b. The sub-chloride of copper, oxychlo- ride or Brunswick green, is sometimes formed when common salt has been used in a copper vessel, and in this way, as well as when em- ployed as a pigment, it has given rise to acci- dental poisoning. A boy of three years swal- lowed about a scruple of this salt. Vomiting and coldness of the extremities followed, and continued until death. On dissection there was no change indicative of the action of an irritant poison, excepting slight congestion of the ves- sels of the brain. 466. c. Copper vessels are acted upon by ar- ticles of food or drink, especially if these arti- cles contain saline substances or acids, or be- come acid while kept in these vessels. Thus wines which are more or less acid, substances containing vinegar, or any other acid, soups or broths, especially if they contain vegetable mat- ters, and are liable to become acid, and fatty substances, when kept only for a short time in copper utensils.are not infrequently productive of accidental poisoning. Falconer and others have shown tjiat metallic copper undergoes no change by contact with water unless air be present, when a hydrated carbonate, mixed with oxide, is formed. When an acid, or an oily or fatty matter, is in contact with the met? al, then this change more rapidly takes place, and the liquid or fat acquires a green hue. Hence no acid, oily, or saline liquid should be prepared or kept in copper vessels. Nor should fruits, pickles, or preserves be either kept or prepared in them. The quantity of the poison which may be formed in these circumstances may not be sufficient to produce fatal poison- ing, but they may be quite enough to cause severe gastro-nervous or acro-sedative effects Gmelin was consulted respecting a violent dis- ease which prevailed among a whole brother- hood of monks. The symptoms w:ere obstinate and severe colic, retching and bilious vomitings flatus, costiveness, burning pain in.the pit of the stomach, under the sternum, in the region of the kidneys and extremities,, with paralytic weakness of the arms. He found, on inquiry, that all the kitchen vessels—the pots, pans, milk pail, and butter dishes—were made of cop- per. Similar instances of culinary poisoning have been mentioned by Christison and other writers. 467. d. It is stated by Mr. Taylor, that the use of the alloy called German silver, which is a sort of white brass, consisting of copper, zinc, and nickel, and containing about 50 per cent, of copper, maybe productive of acro-sedative poi- soning where articles, as spoons, made of this alloy, are allowed to remain in contact with acid, oily, fatty, or saline substances. A lady in Paris, in 1838, after having had eels for din- ner, was awakened in the night by headache, nausea, followed by vomiting and colic. Her physician ascertained that the eels had been cooked with butter and vinegar in an earthen- ware vessel; and he found the spoon, which was of German silver, presenting on different parts greenish spots. Chemical analysis show- ed that a poisonous salt of copper had been thus produced ;, and the fact was farther proved by 134 POISONS—Irritating and Depressing—Salts op Potash. polishing the spoon and placing it in a similar mixture. Half an hour afterward green spots were perceived on the spoon, and in twelve hours it was quite green, as well as the butter in contact with it. 468. c. Arsenile of copper, or Scheele's Green, being extensively used as a pigment, both in the arts and in confectionery, has occasioned dangerous effects. Dr. Geoghagan informed Mr. Taylor, that fourteen children in Dublin, in 1842, suffered symptoms of poisoning owing to their having eaten confectionery ornaments coloured with this substance ; and jaundice fol- lowed in two or three of those cases. Three lives were nearly sacrificed at a school near Manchester by the same cause : they suffered from violent vomiting, severe pains in the stom- ach and bowels, and spasms of the extremities. 469. The green colour of the matters vomit- ed, in cases of poisoning by the cupreous com- pounds, has been mistaken by some for bilious vomiting. But this colour is generally owing to the poison, and not to the presence of bile in the vomited matters; for the bile is generally obstructed, and the liver and intestines more or less paralyzed by the influence of the poison on the organic nerves, as shown by the jaun- dice, and by the flatulent and colicky distention of the abdomen in these cases. 470. /. The modus operandi of the cupreous compounds appear to vary with the preparation, with the quantity swallowed, and the state of the stomach at the time, as respects especially the quantity and nature of the contents of this viscus. They certainly produce, as shown above (§ 207), a corrosive action on this organ when taken in large quantities, and in other cir- cumstances favourable to that action; while, in other cases, this action is but slight, the fa- tal issue chiefly resulting from the change pro- duced by them in the nervous system. Their organic action, or the disorganization produced by them locally, is mainly owing to their chem- ical combination with the albumen, or with one or more of the animal tissues. They evident- ly, also, affect the nerves of the part with which they come in contact, altering the innervation of the surface or viscus. They are also more or less imbibed by the surfaces and tissues, and carried into the circulation, thereby farther de- pressing and otherwise changing the irritabili- ty and innervation of the structures, the poison- ous action of the cupreous salts being produced in this way chiefly, especially when given in re- peated doses, or applied to a wound, as shown by the absence of corrosive or other local ef- fects, and by the fact of these salts having been detected in the blood and viscera of animals poisoned by them. Dr. Duncan found that the application of the sulphate to a wound produ- ced death in twenty-two hours, and yet the body appeared everywhere in a healthy state; but Smith and Orfila state that the acetate applied to wounds caused only local inflamma- tion. 471. g. The diagnosis of cupreous poisoning is of some importance, seeing that the symp- toms caused by it closely resemble those pro- duced by arsenic and corrosive sublimate. Ac- cording to Orfila, the first symptom occasion- ed by the compounds or salts of copper is vio- lent headache, which is followed by vomiting and cutting pain in the bowels, and by cramps and I pains in the legs and thighs. Generally there is a coppery taste in the mouth and throat, and I an aversion from the smell of copper. Jaun- dice is a common symptom, and is never ob- served in poisoning by arsenic or sublimate. Fatal cases terminate with palsy, insensibility, and convulsions. This order of the symptoms is, however, by no means generally observed ; for the headache often does not appear until af- ter the vomiting; and the paralytic state, ei- ther of the sensibility or the power of motion, is often early. The chief diagnostic signs on which any reliance can be placed, are the cop- pery taste of the mouth, with a peculiar astrin- gency and watering of the throat, with ulcera- tion in the more chronic cases ; vomitings and eructations of greenish, or greenish-blue mat- ters, and frequently jaundice, or slight yellow- ness of the surface, which, however, does not appear in some cases until after death. 472. Cupreous substances, when taken in mi- nute quantities for a long time, or when used by workmen who are inattentive to cleanliness, according to the observations of Patissier, Mo- rat, and others, are productive of a greenish sallow hue of the countenance; of an infirm and decrepit state of the body; and of severe at- tacks of colic, with partial or slight palsy; the children of persons thus rendered infirm being ricketty and puny. 473. h. The appearances on dissection of fatal cases are most varied and uncertain. In some, the corrosive action of the poison already de- scribed ($ 207) is the most remarkable, espe- cially in the stomach and duodenum. In oth- ers, equally or even more rapidly fatal, little or no structural change of these viscera is observ- ed ; nor even inflammatory appearances of the stomach and bowels are met with. In the ma- jority of instances, however, the alimentary canal is more or less inflamed; and it very commonly presents a greenish hue, especially the stomach, oesophagus, and duodenum. The external surface is generally jaundiced or slight- ly yellow. The blood is of a dark hue, and fluid in some cases, and coagulated in others. The lungs, and the sinuses of the brain are more or less congested ; and the brain is sometimes more vascular than usual. 474. «". The Treatment of the slow or acro- sedative form of poisoning by cupreous substan- ces should be based chiefly on the method sta- ted above (§ 208, et seq.). After the evacua- tion of the poisonous substances as there ad- vised, albuminous and saccharine substances should be given, and irritability of the stomach ought to be quieted, as it tends remarkably to lower the depressed vitality of the frame, by opium conjoined with camphor and creasote, and by external derivatives applied over the ep- igastric region. If inflammatory action be man- ifested, the usual local and general measures indicated by the state and associations of this condition ought to be prescribed. 475. D. Salts of Potash.—a. Ckromate of Potash.— Chrome—Bi-chromate of Potash.__This salt is extensively used in dyeing; yet poison- ing by it is rare; but instances have been re- cently recorded. A concentrated solution of it causes all the symptoms and structural changes of corrosive poisons. In small doses it occa- sions vomiting, diarrhoea, paralysis, and death in the course of some hours. It appears to be POISONS—Irritating and Depressing—Salts of Potash. 435 more or less absorbed, and to depress and oth- erwise affect nervous and vital power. In a case described by Mr. Wilson, of Leeds {Lond. Med. Gaz., vol. xxxiii., p. 734), where a large quantity of this.poison had been taken, the poi- soned person not having been seen until soon after death, the countenance was pale, placid, and composed ; the eyes and mouth closed; the pupils dilated ; no marks of vomiting or diar- rhoea, nor discharge from any of the outlets of the body, nor any stain upon his hands or per- son, or upon the bed linen, or furniture, could be detected. On dissection, a pint of turbid, inky fluid was found in the stomach. The mucous membrane of this organ was red and very vas- cular, particularly about the cardiac orifice. The brain, its membranes, and all the other vis- cera were quite healthy. The contents of the stomach furnished the chromate on analysis. In this case the chrome produced neither vomiting nor purging, and did not act by any irritating influence ; but by its sedative action entirely. Hence it may be viewed as causing, according to the dose, state of the stomach, and other circumstances, either a decided corrosive ef- fect, or an acro-sedative action, or even a pure- ly sedative or fatally depressing operation. The treatment appropriate to poisoning with this salt is recourse to emetics or the stomach-pump, and to the administration of magnesia or chalk, mixed in water. 476. b. Nitrate of Potass.—Tartra denies that this salt possesses any poisonous proper- ties ; and it is stated to have been given, for medicinal purposes, in doses varying from six to twelve or even sixteen drachms in the twen- ty-four hours. {Med. Chirurg. Rev., April, 1844, p. 549.) As it is much employed in the arts, accidents occasionally occur from it; and, in a large dose, as when taken in mistake for some purging salt, seriops or even fatal results may , be produced by it, although its effects are some- what uncertain. Two men swallowed each one ounce of nitre by mistake for Glauber's salt, and almost instantly experienced a sense of coldness in the course of the spine, trem- bling in the limbs, with vomiting and purging ; the stools were bloody. They recovered in the course of a few days. In another case record- ed in the same work, an ounce of nitre was fa- tal in thirty-six hours. (Casper's Wochen- schrift, b. xviii., 1841.) 477. The symptoms and structural lesions pro- duced by a poisonous dose of this salt will appear from the following details : M. Orfila states that a lady took an ounce of nitre by mis- take, and in a quarter of an hour suffered nau- sea, vomiting, and purging; and the muscles of the face were convulsed, the pulse weak-, respiration laborious, and the extremities cold ; but there was a burning pain in the epigastrium. She died three hours after taking the salt. On dissection, the stomach was found inflamed and the villous coat detached in places. Near the pylorus the inflammation approached to gan- grene. A large quantity of fluid, coloured with blood, was found in the stomach. Dr. Geoghe- gan communicated to Mr. Taylor the following case: A man took, by mistake for salts, from an ounce to an ounce and a half of nitre. Se- vere pain in the stomach followed, with violent vomiting, but no purging. He died in about two hours after taking the salt. On examination, a blotfdy mucus was found in the stomach; the villous coat was of a brownish-red colour, gen- erally inflamed, and detached from the adjacent coat in places. None of the poison was detect- ed in the stomach ; but its nature was deter- mined by the analysis of the portion left in the vessel from which it was taken. It is evident that the rapidity of the fatal result in this case was owing to the extent of the local injury, to the shock sustained by the constitution, and to the absorption, in a very short period, of so large a quantity of the salt into the circulation ; this salt being rapidly absorbed, especially in solu- tion, and acting not merely as an irritant, but also as a powerful sedative. 478. c. Sulphate of potass, according to Mr. Mowbray {Med. Gaz., vol. xxxviii., p. 54), is much employed in France as a popular abor- tive, and when thus administered has proved not infrequently poisonous. It has also been employed in this country with the same object, and m one case, at least, with the same results, as shown by Mr. Taylor. In one case two drachms acted most powerfully, and in another four drachms, administered to a lady after her confinement, acted as an irritant poison. An- other lady took, about a week after her deliv- ery, about ten drachms of this salt, in divided doses, as an aperient. After the first dose she was seized with severe pain in the stomach, with nausea, vomiting, purging, and cramps in the extremities. These symptoms became aug- mented after each dose, and she died in two hours. On inspection, the villous surface of the stomach and intestines was found pale, except the valvule conniventes, which were reddened. The stomach contained much reddish liquid, which was found to contain only sulphate of potass. 479. d. Oxalate of Potass.—Salt of Sorrel.— Bin-oxalate of potass is an active poison, owing chiefly to the oxalic acid. It is much employed under the name of " essential salt of lemons," and instances of poisoning have occurred from its having been taken by mistake, some of which have been adduced by Mr. Taylor. The fol- lowing case is recorded by Mr. Jackson : A fe- male, aged 20, took about an ounce of this salt in solution. About an hour and a half after- ward she was found on the floor quite faint, having been very sick. The nature of the poi- son was soon ascertained, and four ounces of mistura cretas were administered. She was then in a state of extreme depression ; the pulse could hardly be felt; the skin was cold and clammy; the lips and face were pale, and rig- ours continually affected the whole body. She complained of a scalding sensation in the throat and stomach, of pain in the back, of soreness of the eyes and dimness of vision. The con- junctivae were injected and the pupils dilated. She was wrapped in warm blankets; ether, tincture of opium and camphor were adminis- tered, and reaction took place. The patient af- terward recovered. Most probably the greatest part of the salt had been thrown off the stomach before she was found. The treatment of this case throughout was as judicious as success- ful.— {Med. Gaz., vol. xxvii., p. 480.)—A lady, recently confined, took by mistake an ounce of this salt. She had scarcely swallowed the dose when she was seized with violent pain in the abdomen and convulsions; she died in eight 436 POISONS—Irritating and minutes. The mucous membrane of the stom- ach and small intestines was found inflamed. A tea-spoonful of this salt was taken for three successive mornings, and produced severe vom- iting ; about an hour after the third dose the patient expired. There was no examination of the body. It is evident from these cases, that this salt is a powerful acro-sedative poi- son, its depressing operation being most en- ergetic. 479*. e. Bi-tartrate of Potass.—Cream of tar- tar is a most useful medicine, even in large do- ses ; but it may be poisonous if a too large quantity be given. I have prescribed as much as two drachms three times in the day, in cases of dropsy connected with obstruction in the liv- er, with great benefit; but this dose should not be continued long, and its effects should always be carefully watched. Mr. Taylor states, on the authority of Mr. Tyson, that a man took four or five table-spoonfuls of cream of tartar, and was seized with violent vomiting and purg- ing, with pain in the abdomen, thirst, feeble- ness of pulse, and a paralyzed state of the thighs and legs. The fluid vomited was of a dark- green colour, and the motions had the appear- ance of coffee-grounds. Death took place in forty-eight hours, and, on inspection, the villous coat of the stomach and duodenum was found highly inflamed; the cardiac portion of the stomach being of a deep-red colour, with spots of black extravasation. This organ contained a thick, brown fluid, coloured by bile. The in- testinal canal was more or less inflamed. 480. /. The nitrate of soda, the sulphate of magnesia, the biborate of soda, the chloride of so- dium, and other salts, which are harmless in small or moderate quantities, are injurious, and act as irritants and depressants when taken in large or excessive doses, especially in states of disease or of constitution which are favour- able to their injurious operation. 481. vii. The Sulphurets of Potassium and Sodium.—The alkaline sulphurets have very rare- ly occasioned poisoning in this country ; but they have caused fatal accidents in France, where they are frequently employed for haths and for the manufacture of artificial sulphure- ous waters. They act as powerful irritants of the digestive mucous surface and depressants of nervous and vital power, exhausting at the same time the irritability of contractile tissues. These latter effects are in great measure ow- ing to their absorption into the circulation. M. Orfila and M. Cayol have recorded cases of poisoning by these sulphurets. The quantity tnken in each of these was three drachms and upward. Two of the cases terminated fatally in less than fifteen minutes; the other patients who recovered were dangerously ill for some days. The rapidly fatal effects of these poisons were probably owing more to the change pro- duced by them in the state of organic nervous influence, than to disorganization of the villous coat of the stomach. 482. a. The symptoms in these cases were burning pain and constriction in the throat, gul- let, and stomach; frequent vomiting; at*first sulphureous, the air of the chamber being taint- ed with the odour of svlphureted hydrogen, and afterward sanguinolent; purging, at first' sul- phureous, afterward mucous and bloody; sul- phureous exhalations from the mouth; acrid Depressing—Tartaric Acid. taste on the palate ; pulse quick, afterward fee- ble, fluttering, and almost imperceptible; fol- lowed, in the cases which recovered, by inflam- matory reaction of the digestive canal, extend- ing to the oesophagus ; and by mortal faintness and convulsions in the fatal cases. 483. b. The structural changes in the fatal in- stances were great lividity of the face and ex- tremities, and loss of the muscular contractili- ty immediately after death. The stomach was red internally, and lined with a crust of sulphur. The duodenum was also red. The lungs were soft, gorged with black fluid blood, and did not crepitate. 484. c. The Treatment seems to consist in the instant administration of any diluent at hand, and frequent doses of common salt. If inflam- mation of the stomach, &c, supervene, local and general antiphlogistic measures and exter- nal derivatives will be required. Dr. Christi- son observes, that the chloride of soda may be called the antidote against this poison, as it de- composes the sulphureted hydrogen which is evolved, the rapid disengagement of which he considers to be the cause of death in the quick- ly fatal cases. The chloride of lime is equally efficacious with the chloride of soda. 485. viii. Tartaric Acid.—Oxalic acid in small doses, and tartaric acid in large quanti- ties, are productive of nearly similar effects. Tartaric acid has, until lately, been regarded as not poisonous ; but an instance lately occurred of this acid having been given to a man instead of aperient salts, in the dose of one ounce, with fatal effect. The whole of this was swallowed at once, dissolved in warm water. He imme- diately exclaimed that he was poisoned, com- plained of a burning pain in the throat and stomach, and compared the sensation to that of being all on fire. Soda and magnesia were ad- ministered with diluent drinks. Vomiting com- menced, and continued until his death, which took place nine days afterward. Tartaric acid was found in the dregs of the cup, and the per- son who made the mistake admitted the act and the substance which he had thus given. On inspection of the body, nearly the whole of the ali- mentary canal was found inflamed. {See Tay- lor, in Op. cit., p. 104.) 486. The Treatment of poisoning with this acid is the same as that for oxalic acid (§ 166), which, when given in smaller quantities than those usually productive of the corrosive action described above (y 160, ct seq.), is partially ab- sorbed, and, with its local irritating operation, occasions also marked depressing and paraly- zing effects ; and either an acute, or sub-acute, or chronic form of poisoning, according to the quantity taken, the circumstances of the case, and the treatment employed soon after its in- gestion. In the slower form of poisoning by oxalic acid, as well as that by tartaric acid, as soon as the poison is removed by vomiting or the stomach-pump, remedial measures should not be confined to the removal of the local irri- tation merely that is produced by it, but ought to be extended to the restoration of the ner- vous and vital powers, which are more or less depressed by the influence of the poison on the * nerves of the alimentary canal, and, by absorp- tion, upon the heart, nervous centres, and con- stitution generally; and with these intentions the means already recommended for the more POISONS—Irritating and Depressing—Necroscopic Poison. 437 energetic acro-sedatives will be found the most successful for the removal of the consecutive effects, and for the slower forms of poisoning caused by small doses of oxalic acid, and by large quantities of tartaric acid. 487. ix. The Necroscopic Poison—Poison im- bibed from recently dead Bodies.—A. Source and Nature of the Poison.—The fluids of bodies recently dead, or that have not passed into an early stage of decomposition, not infrequently produce the most dangerous effects, especially when they come in contact with an abraded surface, or are inoculated in any way. The effects vary with the disease of which the per- son died, with the constitution of the infected individual, and with other circumstances. I have had several occasions of observing and treating the effects of this species of animal poison. Since I first published my views as to the nature and treatment of these effects, in 1823, and again in 1833,1 have been more fully convinced of the accuracy of these views ; and, moreover, they have received the support of experienced observers, and especially of Mr. Travers, in more recent publications. The poisonous action of the fluids of dead bodies is most acutely exerted when these fluids are in- oculated ; but they sometimes act upon the per- fectly sound skin, there being no scratch, punc- ture, or abrasion through which they could be in- troduced, the existence of either of these great- ly facilitating and aggravating their operation. In the observations I offered respecting this poi- son (in the London Medical Repository for July, 1823), I stated, 1st. That this poison is distinct from any other animal poison, generated or transmitted during life ; 2d. That it is different, in its nature and effects, from putrid animal matter; 3d. That it does not appear to exist in the blood, either during life or after death ; 4th. That it is produced during the changes which are more immediately consequent upon the loss of life; and, 5th. That it is present chiefly in the secreted and exhaled fluids on the surface of membranes, especially serous membranes, or in cellular or parenchymatous parts. I then remarked that, as respects the distemper inoc- ulated from another body which has recently ceased to live, and as regards the nature of the animal poison which causes the distemper, and the manner of its operation, it may be inferred that it is produced by the textures before their vital properties and cohesions are quite extinct, because putrid animal matters occasion differ- ent and less dangerous effects; that as all mor- bid poisons possess certain properties bestowed on them by the organic nervous or vital influ- ence of the vessels and structures secreting them, in consequence of previous disease, ei- ther of these parts or of the frame generally, which properties they preserve for a time until the elementary particles composing them enter into different combinations, so may the secre- tions and fluid exhalations occasionally experi- ence, during the period in which organic ner- vous influence and vitality are forsaking the tis- sues which secrete them, such a change as amounts to the acquisition of virulently poison- ous properties, and that these fluids, thus chang- ed, affect the nerves of the part to which they are applied, and, consecutively, the whole frame, the cellular tissue in the vicinity of the glands above the seat of inoculation generally evincing more or less disorganization, and sometimes, also, the integuments, the fasciae and tendon- ous sheaths, the absorbents, or veins, or both, and even the serous surfaces of adjoining cav- ities. This poison being productive of the most dangerous effects, and on numerous occasions, it is of the utmost importance, especially to medical men themselves, that its operation, and its counteraction and treatment, should be care- fully investigated. 488. a. The poison communicated by recent- ly dead bodies has been described, and illustra- ted by the details of cases, by Dr. Duncan, as constituting a form of diffusive inflammation of the cellular tissue, and by Mr. Travers, as occasioning a variety of constitutional irrita- tion. But the doctrine inferred from these de- nominations is too restricted to be applicable to the distemper which this poison develops. Diffusive inflammation of the cellular tissue certainly often exists as a consequence of the contamination produced by the poison; but it is preceded and attended by constitutional ef- fects—by states of the circulation and nervous system—of the most malignant or virulent de- scription. Constitutional irritation is equally present, and is certainly more or less immedi- ately consequent upon the local irritation, im- pression, or alteration, or whatever the local effect may be ; but so are depression of organ- ic and cerebro-spinal nervous power, changes in the states of vascular action and of the blood, asthenic inflammation of the cellular tissue, and often, also, of the integuments, or of the absorbents or veins, or of adjoining serous sur- faces. The truth is, that this poison produces an almost specific effect upon the tissues in the vicinity of glands above the seat of its applica- tion ; but this effect may be limited to the cel- lular tissue, or extended to several other tis- sues ; and it may be confined to the axilla, or extended to more deep-seated parts; it may not implicate, in a visible manner, any of the structures of the arm, although the poison was inoculated in the finger, and the cellular tissue in the axilla is most extensively diseased, no change between these situations being detect- ed ; and it may most virulently affect the ner- vous and vascular systems, and depress vital power and resistance, when the local changes are the least extensive or apparent. 489. b. It is of some moment to know the dis- eases which impart this poisonous property to the recently dead body ; but, as to this, we have no precise information. Although the distemper which is the result has most frequently been pro- duced by the inoculation of the fluids of bodies which had died of inflammations of serous surfa- ces, or of erysipelas, or of puerperal diseases, yet has it occurred also after the inoculation of the fluids of bodies which have died of other visce- ral or inflammatory maladies—of enteritis, pe- ritonitis, &c. More than one person has even been infected by the same dead body, this oc- currence evincing a greater virulence of the poison in that body, owing either to the nature of the disease of which it died, or to the period after death at which the examination Was made. That this has probably depended chiefly upon the former of these causes may be inferred from its frequent occurrence when the body has died of erysipelas, puerperal peritonitis, or other states of puerperal fever; while, on the othei 438 POISONS—Irritating and Depressing—Necroscopic Poison. hand, there is equal, if not stronger, reason to believe that the poison imbibed in dissection is not the result of diseased action, simple or spe- cific, in the living subject, but is altogether gen- erated immediately after death, although cer- tain diseases may favor its generation at this period. That the poison is not the result of the disease of which the patient died, is shown by the facts, 1st. That this poison has been im- bibed during the examination of bodies of per- sons who have died suddenly, and in health, in consequence of accidents; that poisonous ef- fects have been produced by the fluids of a body which has been killed by an accident, or has died of a non-contagious disease ; 2d. That the distemper developed by this poison presents a specific character, differing only in the degree of severity and the extent of the contingent lo- cal inflammation, whatever may have been the malady of which the subject which furnished the poison died. Still, the larger proportion of cases of this distemper have their origin from the fluids of bodies recently dead from inflam- mations, by which an abundant exudation of morbid fluids is accumulated, and in which the thoracic and abdominal viscera are examined and handled. In most instances which have fallen under my observation, the bodies from which the poison was imbibed were still warm when examined, and many of them had died of puerperal diseases. Mr. Travers remarks, also, that the subjects were recent. Not one had been buried ; some were yet warm. Even of those in which demonstration, not inspec- tion, was the object, the bodies were in a per- fectly fresh state; and he remarks a circum- stance, which has also struck me, namely, that when the dissection has been performed before the body has entirely parted with its warmth, a faint and peculiarly oppressive odour is emit- ted, which is disagreeable, not to say revolting, even to persons habituated to dissection, and which not infrequently creates nausea. 490. c. The question may be asked, Whether or not the poisonous fluid may produce its ef- fects when applied to the perfectly whole cutane- ous surface, or only when this surface is punc- tured, or the cuticle abraded, in the part which comes in contact with it 1 I can answer this question in the affirmative from my own expe- rience, and from statements made to me by others in the frequent habit of making inspec- tions. I have seen severe constitutional disor- der of the specific kind produced by this poison in two instances, in which the subjects had died of puerperal disease, the surgeons who assisted me in the examinations, and who thus imbibed the poison, having had no abrasion of the cuti- cle whatever. The fluids accumulated in the serous cavities occasioned, in these two instan- ces, a sensible smarting over the surfaces with which they remained for a time in contact. But I believe that such instances are rare compared with those which are owing to some scratch, abrasion, or puncture of the cuticle.* * The following cases, abridged from Mr. Teavers's work, are remarkable, as they are examples of a distemper, in the local and constitutional symptoms, closely akin to, if not actually identical with, that produced by the poison im- bibed from recently dead bodies, although the poison, in the second and third cases, was imbibed from th,e secretions of the first case while she still lived. 1st Case. A female, while suckling, had a poisoned wound of the finger, follow- ed by pain, fever, and delirium. The pain extended from itself, 491. d. Another question suggests namely, Whether or no this poison »™*a™ the infectious emanation which caused the «"**«- of which the person died; is allied to \sPec,-f.C°n' tagion existing still in the body which has diedm consequence of it? We know that the poison under consideration is frequently imbibed from bodies which have died from puerperal diseases, from visceral inflammations, from erysipelatous and other maladies. But the distemper pro- duced by this poison is not in any respect the same as any of these diseases, there being no farther resemblance than in the febrile disturb- ance present in all of them, and in the vital depression and weak state of vital resistance That small-pox, syphilis, erysipelas, glanders, and even scarlet fever may be transmitted by the recently dead body; and that the power of trans- mitting these specific contagions may be retain- ed by the bodies which have died of them for a considerable but an indefinite time, I believe; but when the body is surrounded by clothes of any kind, this power of transmission is retain- ed by the clothes rather than by the body itself; for, as soon as the latter undergoes decompo- sition, the power of transmitting the specific malady which caused death appears to have ceased, especially if there be a free admission of atmospheric air, because the contagious secre- tions are also decomposed, and, by their decom- position, have lost their specific and poisonous properties. It cannot, however, be inferred that the distemper produced by the poison im- bibed from recently dead bodies is allied to any of the maladies which has most frequently caused the deaths of the bodies from which the poison was imbibed. 492. B. Symptoms.—(a) In some cases, the following is the usual procession of morbid phe- nomena. 1. A few hours after puncturing a the finger up the arm, along the neck, to the tip of the ear. Matter formed within the proper sheath of the flexor tendou of the finger, and the wound in the finger continued to dis- charge freely after the sheath was laid open. Delirium,_ rapid pulse, ™uon produced by the poison is followed by a general disturbance or tumult of all the functions actu- ated by the ganglial or the organic nervous system ; by excessive vascular action, without nervous energy or vital resistance, these states passing into exhaustion, with sinking of vital power, and contamination of the circulating fluids. 506. /. The primary impression of this poi- son is not only irritating, and productive of ex- quisite pain, in many instances, and of inordi- nate excitement in most, but it is also of a de- pressing nature, inasmuch as it often is follow- ed by a numbness in the vicinity of the punc- ture, or by aching, or feebleness of the limb; the local change thus primarily produced being probably a chief cause of the consecutive chan- ges which take place, especially after the frame is infected, in the glands and other structures in the axilla and its vicinity of the inoculated side. 507. g. The constitutional commotion, gen- erally developed from ten to twenty hours after the imbibition of the poison, is displayed by all the organs actuated by the ganglial system, and by the brain ; both the organic and the cerebro- spinal nervous systems evince much disorder, and this disorder is characterized by altered or excited sensibility, and by deficient energy; the functions of vital organs being co-ordinately af- fected, vascular action remarkably excited, and the blood, and all the secretions from it, ulti- mately more or less altered, as in malignant distempers. 508. h. The nature of the constitutional com- motion, of the vascular excitement in this mal- ady, ha6 bejen misunderstood by most practi- tioners and writers, and the character of the pulse misinterpreted; and, because there have been very acute pain, and remarkable frequency of pulse, often with delirium, many have most unwarrantably inferred the existence of sthenic or true inflammatory action, instead of its op- posite, and had recourse to large vascular de- pletions, which have aggravated the pain, in- creased the frequency and weakness of the pulse, and induced or rendered more severe and continued the delirium. Oh! that igno- rance would be less presuming, and not actually inflict the death it is blindly attempting to pre- vent. 509. i. The state of predisposition of the poi- soned person, depending upon temperament, constitution, and the existing health, is most probably influential in developing the primary impression and the consecutive effects, or in aggravating their severity. This has been prov- ed by cases which have come under my own observation, where surgeons, who have aided me in the inspection of very recent bodies, have, without any wound or abrasion of the cuticle, or after such injury, complained only of com- paratively slightconstitutional symptoms, which yielded to treatment, without the local symp- toms having appeared. 510. k. In most cases no morbid connexion can be traced between the puncture, or the point of inoculation, and the subsequent altera- tions which take place in the axilla and vicini- ty : no change is observed in any of the tissues POISONS—Irritating and Depressing—Necrosccpic Poison. 443 between this situation and the puncture or scratch in the finger or hand; unless the change exist in some of the nervous fibriles, and be of such a nature as not to admit of recognition by the unaided senses. The constitutional com- motion is generally ushered in by altered sensi- bility of the poisoned part and of the arm, but is unattended by any visible change, although in some cases the absorbents, either superficial or deep-seated, appear to be affected, and is characterized by its early appearance, and by remarkable physical and moral depression and anxiety, followed by rigours, which are succeed- ed by reaction and excessive nervous and vas- cular excitement, devoid of energy or vital pow- er. The alterations which occur in the axilla and vicinity never commence until the consti- tutional disturbance is produced, generally af- ter the rigours and consequent reaction, and are preceded by exquisite pain, often extending to the shoulder and arm. 511. 1. The inflammatory changes in the ax- illa and vicinity do not take place in some of the most violent and dangerous cases ; the poi- son, apparently, not being intercepted by the glands, and affecting chiefly the nerves and ex- erting its noxious influence upon the nervous systems and constitution generally.* These changes are merely contingent upon the major- ity of cases, and do not constitute the disease ; the constitutional affection not only preceding them, but being also over-proportioned to them. They are, moreover, in some instances, entire- ly absent, as in the first phases above specified (§ 492). I therefore agree with Mr. Travers in stating " that the local inflammatory action is an unessential and subordinate feature of the malady in its severest form ; the disease itself consisting in a direct prostration of the vital for- ces, marked by preternatural excitement and rapid exhaustion." 512. G. Treatment.—It has been justly re- marked by Dr. Colles that, "whatever differ- ence of opinion may be entertained as to the nature of this affection, it will be allowed that, although some few have escaped, yet the plans of treatment hitherto pursued have all proved quite unequal to contend with so formidable a disease." But the plan which he proceeds to advise has nothing to recommend it in prefer- ence to those which have been previously adopt- * The following case illustrates this rapid and violent form of the malady: Mr. E., medical student, punctured his finger in opening a body recently dead. This occurred at noon (of Monday), and in the evening of the same day he found the wound painful. During the night the pain in- creased, and symptoms of high constitutional irritation were present on Tuesday morning. No trace of inflammation, however, was apparent beyond a slight redness of the spot at which the wound was inflicted, which was a mere punc- ture. In the evening he was visited by several physicians, but no local change could be discovered. The nervous sys- tem was agitated in a most violent and alarming degree, the symptoms nearly resembling the universal excitation of hydrophobia ; and in this state he expired at three o'clock on Wednesday morning, forty hours from the injury. (Travers on Const. Irritation, p. 262.) This case, and other instances of a less violent character, seem conclusive of one of two things, namely, either that thW poison acts upon and affects the constitution through the medium of the organic nervous system, or that it is absorbed into the circulation in some cases without inflaming the absorbents or glands, or veins, occasioning the most severe effects upon the nervous system and vital energy, although inflammation of these structures, more especially of the glands and the surrounding cellular tissue, is often produced in consequence of the affection of the nervous system, or of the absorption, or of both. ed, hVindeed, any definite or rational plan had ever been prescribed. The means which had usually been employed consisted of blood-let- ting, general and local, opiates, fomentations, purgatives, &c. ; the blood-letting having been prescribed for the insufficient reasons that the pulse was rapid, and the febrile symptoms and delirium excessive : reasons more correctly in- dicating the propriety of adopting very differ- ent measures. Dr. Colles, knowing that this treatment was most frequently followed by an aggravation of the malady, simply advises cal- omel in doses of three grains every three or four hours, with the intention of quickly exci- ting ptyalism. But, despite of the magic num- ber three, he might consider himself most for- tunate if he succeed at all in this intention, and " fortunate beyond compare" if he succeed ei- ther quickly or with a perfectly favorable issue. 513. The virulent poison imbibed from a re- cently dead body invades the healthy frame with a rapidity and intensity proportionate to the de- ficiency of vital power opposing the invasion ; and whatever means are administered to the person infected by this poison, calculated to lower vital power and resistance, will only ag- gravate the effects by accelerating the absorp- tion, and facilitating the operation of it upon the frame. All animal poisons exert more or less of an asthenic influence upon the healthy body—an influence which is not only morbid, not merely an alteration from the healthy con- dition, but also one of depression, a condition characterized by an imperfect as well as alter- ed manifestation of the functions of life, and tending to the extinction of those functions. But when this primary effect is not so intense, relatively to the powers of life, as to overwhelm these powers altogether, they react against it, oppose it, resist its extension, and often com- pletely overcome it. In many instances the impression made by the poison on the nervous system, and the contamination induced in the circulating fluids, lead to a violent struggle be- tween these changes and the powers which re- sist them ; the struggle ultimately terminating either in the removal of these changes or in the annihilation of the powers which have op- posed them. Now, if I have observed and in- terpreted aright the phenomena produced by the poison in question, this is what actually occurs after the imbibition of it by the healthy frame : first, asthenic and morbid action ; secondly, vas- cular excitement, the morbid influence on the nervous and vital powers still continuing; and, thirdly, disorganization and death, which are rapid in proportion to the invasion of the cause, and the failure of the vital powers of resistance. If it were asked, What are the measures which are most likely to increase not only the first and third of these effects, but also the second 1 I could not hesitate to answer, those very meas- ures which have been hitherto too generally adopted to remove them. It may, however, be contended that the reaction which supervenes requires to be moderated by blood-letting in or- der to prevent its exhaustion ; but I have shown that the reaction is most morbid—is a tumultu- ous excitement, deficient of power or constitu- tional resistance ; that the pulse is that of irri- tation—of what John Hunter would call con- stitutional alarm ; that the blood is not inflam- matory, and the coagulum is not firm; and, SSIN0—Putrid Animal Matters. 444 POISONS—Irritating and Depr moreover, that the rapidity of the pulse, aad the severity of the delirium, and all the other symp- toms are aggravated by this measure; and are of such character, and are attended by such phenomena, as ought to suggest a very differ- ent method of cure. 515. When treating of diffusive inflammation of the Cellular Tissue, I pointed out the means which should be employed, both as prophylactic and curative, in the treatment of this disease when connected with, or consequent upon, poi- soned wounds. Since that article was written, my farther experience has proved the correct- ness of my views, in respect both of the preven- tion and cure of the effects arising from the poi- son imbibed in the dissection of recently dead bodies, as stated in that artiele (y 34, et seq.); and, therefore, I now more strenuously advise the adoptioq of the principles and means of treatment there recommended. 516. a. The prophylactic means should be promptly applied, and should consist chiefly of a ligature applied above the puncture, scratch, or abrasion, when the situation of either admits of its application, or a cupping-glass, or even a common wine or ale glass, may be applied in other circumstances, the air being excluded in the usual way, or suction or pressure may be employed: afterward the wound should be care- fully washed, and a pledgit of lint, wet with spirits of turpentine, placed over it. This ap- plication I have found more efficacious than any other, and it is not productive of any local irritation. When these measures have not been taken, or not taken sufficiently soon, the part wounded should be viewed as still containing a portion of the poison, and be subjected to them, although several, or even many, hours may have elapsed; and the constitutional pow- ers ought to be fortified by means of pure air and generous living. 517. If constitutional disturbance should appear notwithstanding, or if it have already appeared owing to a neglect of prophylactic treatment, it should be promptly met by stimulating diaph- oretics conjoined with tonics ; and by warm or stomachic aperients, conformably with the prin- ciples maintained when discussing the treat- ment of diffusive inflammation of the cellular tis- sue (y 34, et seq.) and of the lymphatics (y 17, et seq.). The decoction of cinchona, therefore, should be given with liquor ammoniae acetatis and full doses of the sesqui-carbonate of am- monia ; and the bowels evacuated by means of a draught with equal parts of the spirits of tur- pentine and castor oil, and of an enema,.con- taining the same substances, with or without ten grains of camphor. These may be subse- quently repeated, according to circumstances. 518. b. The chief intentions of cure are, first, to prevent infection ; secondly, to resist the ex- tension of the mischief if infection have actual- ly taken place ; and, thirdly, to relieve the ur- gent symptoms, both constitutional and local, which usually appear when the disease is fully and unfavourably developed. Theirs* of these having been premised, the second should be en- ergetically employed, notwithstanding the tu- multu ms state of the vascular excitement or the delirium which may be present. The med- icines just recommended ought to be early pre- scribed, and the dose of the ammonia suited to its effects. Instead of the combination of the cinchona now mentioned, the decoction may be given with the chlorate of potass and the hy- drochloric ether; and either of these combi- nations may be aided by the addition of cam- phor, by warm aromatics, by spices, &c., more especially by capsicum, which often prevents or alleviates the sickness and irritability of the stomach, and even the singultus of a more ad- vanced stage of the distemper. If these do not relieve the disorder of the stomach, creasote should be given with camphor, capsicum, and small doses of opium, these medicines being generallv indicated, when restlessness, watch- fulness, "or delirium supervenes. When, how- ever, this last symptom appears, the doses of these substances ought then to be increased, and the morphia substituted for the pure opium or its tincture ; full doses of these being given shortly before bedtime. Morphia or opium, or such of the preparations of opium as may be prescribed for the nervous symptoms of this malady, should be given in a very full dose, and conjoined with camphor or with capsicum or other warm spices, a full dose being given in the evening, and a smaller one in the morning. The infusion or decoction of cinchona may be also conjoined with other medicines, as the bi- carbonate of potash, or soda, or ammonia, and be taken in a state of effervescence with citric acid or lemon juice ; but the carbonate should be in excess, and the warm spices or aromatic tinctures be added. In the advanced stages of this malady, and for the local lesions which su- pervene in the course of it, the treatment should in all respects be such as already advised in the article on diffusive inflammation of the Cellu- lar Tissue (y 34, el seq.). 519. x. Putrid Animal Matter is productive of injurious effects when taken into the stom- ach ; but these effects are much more serious when such matter is applied to an abraded sur- face, or to a wound, and more especially if it be injected into a vein.—A. As to the ingestion of this matter, Dr. Christison well observes, that " to those who are not accustomed to the use of tainted meat, the mere commencement of decay is sufficient to render meat insupportable and noxious. Game only decayed enough to please the palate of the epicure has caused se- vere cholera in persons not accustomed to eat it in that state. The power of habit in recon- ciling the stomach to the digestion of decayed meat is inconceivable. Some epicures in civil- ized countries prefer a slight taint even in their beef and mutton ; and there are tribes of sav- ages who eat with impunity rancid oil, putrid blubber, and stinking offal. How far putrefac- tion may be allowed to advance without over- powering the preservative tendency of habit, it is not easy to tell." Something, however, is due to the nature of the beverages taken along with the articles in this state, and to the pow- ers of digestion and assimilation possessed by those who partake of such food, in enabling them to resist the injurious effects produced by it in othets. 520. B. The exhalations produced by putrid or decaying animal matter have generally been viewed as most noxious, until Dr. Bancroft, the apostle of modern non-infection, endeav- oured to prove, in a most ponderous volume their very harmless nature. The present state of information, and the good sense, not only of POISONS—irritating medical men, but of all competent observers, have completely disproved this absurd and in- jurious opinion. These exhalations are gener- ally more or less noxious, especially when in- haled into the lungs for some time, or in certain states of predisposition to be infected by them, or in grades of considerable concentration, or when dissolved in the humidity of the atmo- sphere. M. Magendie demonstrated that dogs confined over vessels in which animal matter was decaying experienced similar effects to those observed in the experiments performed by him and M. Gaspard upon the introduction of putrid animal matter into the veins. These effects resembled in every respect the putrid form of fever described in the article Fever (§472, et seq.). The fact that putrid effluvia generate fever in man has been sufficiently de- monstrated to require any illustration at this place, and has been sufficiently proved by evi- dence referred to in various parts of this work, and by proofs which have come under my own observation. The instances which have been adduced in opposition to it by Dr. Bancroft, Parent-Duchatelet, and others, prove only that these exhalations are not poisonous in ev- ery case or occasion of exposure to them, and that habit and other circumstances may impart to some persons an immunity from their usual effects. These exhalations have often produ- ced not only putrid or adynamic fevers, but also an adynamic form of dysentery; and in some ca- ses which I was lately called upon to treat, I had every reason to infer that these exhalations may produce dysentery by their action upon the mucous surface of the anus, when resorting to such privies as contain large accumulations of faecal matters, especially during warm sea- sons. An asthenic form of irritation and in- flammation, with adynamic fever, was observed in these cases, the local affection extending from the margin of the anus upward along the mucous surface of the rectum and colon ; and, in three instances, affecting also the vagina and uterus in a similar manner, and with similar discharges. 521. C. When putrid animal matters or fluids are inoculated or inserted into wounds, or appli- ed to abraded surfaces, extensive local inflam- mation of a diffusive or spreading kind, with very low or adynamic fever, is developed, ow- ing to the rapid contamination produced locally as well as in the circulating fluids, and death takes place, unless the mischief be early ar- rested by a very active stimulating, antiseptic, and tonic treatment. The injuries received from dissection of putrid bodies, and by cooks when dressing very high game, are of this kind, they being generally attended by a diffusive cel- lular inflammation and adynamic fever, and are different, in both the local and the constitutional phenomena, from the injuries received in the dissection of recent bodies, although allied to them in many respects. {See Cellular Tis- sue—Diffusive Inflammation of.) Putrid animal matters occasion somewhat different effects, ac- cording to the nature of the matter, the degree of putridity, and the constitution of the individ- ual, but these effects are more or less allied to those produced by poisons which I have view- ed as septic, and classed accordingly. {See Class Septic Poisons.) 522. D. The Treatment of the effects produ- d Depressing—Tobacco. 445 ced by putrid animal matters received into the stomach is in every respect the same as that recommended for the poison of pork or of sau- sages, &c. (y 443, 450). After the offending matters have been evacuated, either by encour- aging vomiting or producing it by the means just advised, creasote may be given with the warm spices already mentioned, and these may be mixed with powdered charcoal or in solu- tions of the chlorides, and taken in doses which the urgency of the case will suggest. If dys- enteric symptoms supervene, these medicines may be conjoined with ipecacuanha and opium, or may be administered in enemata; and the rest of the treatment recommended in Dysen- tery, according to the form which the case may assume, may be adopted. I have lately given, in some dysenteric cases which have been pro- duced by putrid animal exhalations, small and repeated doses of creasote, and a weak solu tion of the chloride of zinc, with marked ben- efit. The chloride of lime may also be given in small, but often-repeated doses, and lime- water, with milk, or in effervescene, or Carara- water, may be used as beverages. The effects caused by the inhalation of putrid effluvia re- quire similar means to those prescribed for the adynamic or putrid forms of fever. (-See Arts. Dysentery and Fever.) The treatment of lo- cal contaminations by putrid matter is not dif- ferent from that about to be recommended for septic poisons. 523. xi. Tobacco.—Indian Tobacco—Lobelia Inflata.— Virginian Tobacco — Nicotiana Taba- cum.—The poisonous operation of these two plants closely resembles that of each other, the latter being the most energetic.—A. In doses exceeding fifteen or twenty grains, the Lobelia causes speedy and severe vomiting, with dis- tressing nausea and sense of sinking at the epi- gastrium ; sometimes purging, cold perspira- tions, giddiness, headache, tremours, and great relaxation and prostration of strength ; failure, with intermissions of the pulse, sometimes a prickly sensation through the body to the ex- tremities, and a smarting in passing the urine. In doses above thirty or forty grains of the pow- der, it produces death in a few hours, if it be not thrown off the stomach by the speedy vom- iting induced by it. The most prominent symp- toms are then, according to Dr. Wood {Lancet, April, 1837, p. 144), extreme prostration, great anxiety and distress, and ultimately death, pre- ceded by convulsions. Fatal effects have often resulted from the empirical use of this plant in America, owing chiefly to its not having been rejected by vomiting, as is sometimes the case. The effects produced by it are the same as those now described when it is administered in an enema.* * * [The Lobelia, or Indian tobacco, is a violent acrid irri- tant, and has occasioned many deaths from its improper use by empirics. The following cases are examples of the fa- tal effects of this article when improperly administered : The sixth volume of the Massachusetts Reports contains an account of the trial of Samuel Thompson for the murder of Ezra Lovett, by administering lobelia. It appears that the patient, being confined by a cold, sent for Mr. T., who gave him three powders of lobelia in the course of half an hour, each of which vomited him violently, and left him in a great perspiration during the night. The next day two or more powders were given, each of which operated by vomiting, and occasioned great distress. In like manner, two other powders were given the subsequent day, leaving the patient in a state of great prostration. Several days after this, finding the patient still worse, Mr. T. gave sc'v- 443 POISONS—Irritating and Di 521. B. Virginian tobacco, in the present state of society, is one of the most important plants in nature, and one of the most deleterious poi- sons furnished by the vegetable creation. In whatever way tobacco is used, whether chew- ed, smoked, or snuffed, habit impairs, and even modifies its effects. Sir B. Brodie found that the infusion of tobacco thrown into the rectum, paralyzes the heart and causes death in a few minutes ; but if the head of the animal be pre- viously removed, and artificial respiration kept up, the heart remains longer unaffected, prov- ing that tobacco disorders this organ through the medium of the nervous system. On her- bivorous animals the effects of tobacco are less marked than on man. 525. a. In small doses, tobacco causes heat in the throat and warmth in the stomach, fol- lowed, especially if the dose be somewhat great- er, by nausea, giddiness, and vomiting. In lar- ger doses, it occasions nausea, vomiting, purg- ing, a distressing feeling of sinking at the epi- gastrium, but rarely any pain. It seldom pro- motes sleep or evinces any narcotic influence beyond what depends upon its sedative action. In poisonous doses, its most remarkable effects are languor, feebleness, great and depressing anxiety, fainting, relaxations of the muscles, trembling of the limbs ; vision and all the sen- ses are enfeebled, the ideas confused. The pulse becomes small, weak, irregular, or inter- mittent ; the respiration laborious ; the surface and extremities cold and clammy. Recovery generally takes place if the symptoms proceed no farther; but if the vomiting continue, or if the purging be frequent, the tendency to faint eral more powders, which produced great distress, and at length ceased to operate. Still more lobelia was adminis- tered, until the patient lost his reason, and became convuls- ed so as to require two men to hold him. To relieve these symptoms, two more powders were forced down, and the patient soon expired. The accused was tried for murder, but for want of suffi- cient evidence of malice prepense, he was acquitted. A very similar trial took place before the Court of Ses- sions in the city of New York, in December, 1837, in which a Thompsonian doctor by the name of Frost was tried for killing a Mr. French, by the administration of lobelia. In this case„lobelia was freely and repeatedly administered, both by mouth and injection; besides which, the patient was repeatedly steamed, and took large quantities of "com- position tea." This course was continued until inflamma- tion of the stomach, bowels, and brain was induced ; delir- ium, with great prostration, took place, and the patient sank, exhausted. On this trial, several botanic physicians testified that lo- belia was not dangerous in any doses. The accused was found guilty, and sentenced to incur the penalty of fine and imprisonment. Another thai of a similar kind took place at Binghamton, N. Y., in May, 1844, which is reported in the New York Journal of Medicine and Surgery for November, 1844, by Dr. Davis. The patient had been complaining for some days. The accused, Dr. Drake, commenced by givuig some medicine to prepare the stomach for an emetic. The next morning he gave at least a tea-spoonful of the seeds of lobelia. About noon, the patient became much distressed for breath : gin- ger te'a was ordered, of which three tea-cups were given ; a decoction of lobelia, containing a quantity of the seeds, was next administered in divided doses : convulsions set in, and the patient expired. On a post-mortem examination, a ta- ble-spoonful of lobelia seeds was found in the stomach ; the mucous membrane of the stomach was softened and much inflamed; the intestines also were much inflamed. The botanic physicians testified that lobelia would not excite in- flammation under any circumstances, and that it does not possess poisonous properties. The accused was found guilty. Other cases could be given to the same effect, all going to prove the dangerous effects of this article when given in considerable doses. (See Bigdew'i Med. Bot, vol. i., p. 181; Phil. Journ. of Pharmacy, vol. v., p. 300 ; vol. ix, p. 98.] pressing—Tobacco—Lobelia. becomes urgent, the features sunk, the muscu- lar powers paralyzed, the pulse progressively weaker, the extremities and surface colder, and covered by cold sweats; and, ultimately, con- vulsive movements, general paralysis, torpor, and death take place. , 526. b. Tobacco is used in various ways, the effects produced by it being remarkably influ- enced by habit in whatever way it may be em- ployed, at least up to a certain amount or dose. In the form of snuff it acts locally chiefly. The habitual use of snuff blunts the sense of smell, and, if it be taken in excess, dyspepsia, with peculiar symptoms, and a cachectic appearance of the surface, are produced by it. Dr. Prout considers the dyspeptic symptoms caused by snuff to be peculiar and severe, and that malig- nant diseases of the stomach and liver are sometimes occasioned by this practice, when excessive or long continued. 527. c. Smoking tobacco in any way produ- ces many of the symptoms described above, if it be long continued by a person unaccustomed to it. Dr. M. Hall detailed a case which near- ly terminated fatally; the subject of it having, for his first essay, smoked two pipes. Dr. Christison refers to two cases recorded by Gmelin, which were fatal; seventeen pipes in the one, and eighteen in the other having been smoked at a sitting. This practice has been adopted by some with the idea that it is a proph- ylactic against endemic, epidemic, and conta- gious diseases ; but there are really no grounds for this opinion. Smoking, especially when very frequently indulged in, weakens the di- gestive and assimilating functions, lowers the tone of the nervous system, imparts a pale, sal- low, and cachectic hue to the countenance and skin, and induces functional disorder of the stomach, liver, and bowels. The soothing and flattering visions with which the practice of smoking feasts the weak and effeminate mind, lead to its adoption by most classes; but it is an enervating and an emasculating luxury ; the offspring of those who indulge in it in excess being weak, puny, or stunted in growth ; or of a nervous, susceptible, and scrofulous conform- ation. It often, also, induces a desire for spir- ituous liquors. 528. d. Chewing tobacco is even a more dele- terious habit than that of snuffing or smoking. It is practiced chiefly by sailors and the natives of the United States of America. In sailors, the sea air probably counteracts its injurious influence; but when commenced in boyhood, as is often observed in this class, it stunts the growth, and in all circumstances it weakens the organic nervous energy and the mental powers, impairing also the powers of application. Per- sons habituated to this mode of using tobacco are irritable, restless, and miserable when de- prived of it, and feel a distressing sinking at the epigastrium. If they continue long to in- dulge in it, they lose their healthy appearance, and, although they may not evince any severe or specific disease, the nervous system__the mental powers especially, are weakened by the habit, and they become prematurely aged and short-lived. [These remarks can only apply to tobacco when employed in excess; for, as aLove remarked, "habit impairs, and even mod- ifies its effects."] 529. e. The application of tobacco to a recent POISONS—Irritant and Alter wound, to an abraded surface, or to sores, is often attended by serious or even fatal effects. Mr. Weston has recorded a case in which the ex- pressed juice of tobacco was applied to the head of a boy, aged eight years, for the cure of tinea capitis. Death took place three hours and a half after the application. Three chil- dren were seized with giddiness, vomiting, and fainting from the application of tobacco leaves to the scalp for the cure of an eruption.— {Ephemer. Our. Nat., Dec. ii., Ann. iv., p. 467.) 530. /. Tobacco has not infrequently been employed fa'ally in an enema. I have witness- ed this result from half a drachm of the infu- sion having been thus prescribed. An instance is adduced in the British arid Foreign Medical Review (vol. xii., p. 562), in which the decoc- tion of twelve grains in six ounces of water, used as an enema, was fatal. Cases of a sim- ilar result from larger quantities of this plant, administered in this way, have been recorded by Desault, Grahl, Cooper, Bell, and others ; and it has not infrequently caused death when thus employed by empirics. The symptoms produced by it, thus administered, are similar to those already described ; nausea, relaxation of the muscles, failure of the pulse, tremours, faintness, cold sweats, and excessive sinking, or fatal syncope, being the most characteristic phenomena. 531. g. The appearances on dissection, as de- scribed by Dr. Grahl, are thus stated by Dr. Christison. Great lividity of the back, pale- ness of the lips, flexibility of the joints (two days after death), diffuse redness of the omen- tum, without gorging of the vessels, similar redness with gorging of vessels on both the outer and the inner coats of the intestines ; in some parts of the mucous coat patches of ex- travasation ; and unusual emptiness of the ves- sels of the abdomen. The stomach was natu- ral, the lungs pale, the heart empty in all its cavities, and the brain was natural. 532. h. The operation of Virginian and Indian tobacco is nearly the same. The action of Vir- ginian,' or common tobacco, is similar to that of foxglove; but it is slightly irritant of the digest- ive mucous surface, and much more paraly- zing, causing more decided relaxation and de- pression of muscular power, with trembling.. It, moreover, acts more decidedly upon the se- cretions and upon exhaling surfaces. The ac- tion of this poison differs from that of Belladon- na, and from that of Stramonium or Hyoscya- mus, in the contraction of the pupil when appli- ed locally or taken in poisonous doses, and in the absence of any affection of the throat, and of delirium or other cerebral symptoms. The influence of tobacco differs also from that of aconite, in its more decided effect upon the mus- cular system, while aconite paralyzes the sen- tient nerves, occasioning numbness and tingling, which are not observed after the administration of tobacco. 533. i. Treatment.—Poisoning by swallowing this plant, or preparations of it, is very rare, a few cases only being recorded. The discharge of the poison from the stomach, by the means usually resorted to, should be as speedy as pos- sible. There is no chemical antidote to it yet known; but Dr. Pereira thinks that the veg- etable acids and astringents, the infusion of nut-galls, of green tea, &c., may be employed ant— Acro-Alterant Poisons. 447 with benefit. In order to allay the vomiting and depression of vascular action, ammonia, brandy, capsicum, and other spices, with small doses of opium; the cold affusion on the head, if congestive or apoplectic symptoms occur; the use of strong coffee; sinapisms over the epigastrium, and the other means advised for the other poisons of this class, are chiefly de- serving adoption. 534. xii. Vegetable Acro-sedatives of dif- ferent species, besides those already noticed, have produced serious effects ; but their oper- ation, and the symptoms they occasion, have not been satisfactorily observed. The chief of these are the following: A. Castor Seeds.— The seeds from which castor oil is extracted contain in the embryo a most active acro-seda- tive poison, a few of them being sufficient to produce violent purging and death. Mr. Tay- lor adduces the following illustration of their ef- fects : A lady, aged 18, ate about twenty of these seeds, one of her sisters ate four or five, and another two. In the night of the evening on which this took place, they were all taken ill. The deceased, who had taken the largest num- ber, felt faint and sick about five hours after- ward, and vomiting and purging came on, and continued through the night. The following morning she presented all the symptoms of ma- lignant cholera. The skin was cold and dark- coloured ; the features contracted, and the breath cold; the pulse was small and wiry; there were restlessness, thirst, pain in the ab- domen ; and she lay in a drowsy, half-conscious state. Whatever liquid was taken was imme- diately rejected, and the matters passed by stool consisted chiefly of a serous fluid tinged with blood. She died in five days without hav- ing rallied. On inspection, a -very large portion of the mucous membrane of the stomach was found abraded and softened in the greater cur- vature. There was general vascularity of the organ, and the abraded portion presented the appearance of a granulating surface of a pale rose-colour, and was covered by a slimy mucus. The small intestines were inflamed, and their inner surface abraded. The two sisters recov- ered. Two or three of the seeds act as a vio- lent depressing cathartic. The irritant poison resides in the embryo, and is not expressed with the oil, which, in its fresh, or non-rancid state, is a mild purgative. 535. B. Iatropha Manihot—Ianipha Mani- hot.—The fresh root, or the juice of this plant has been long known as a violent poison. It produces nausea, vomiting, and purging ; pain, tenesmus, swelling of the body, loss of sight, coldness of the extremities, faintings, and death. Dr. Beck refers to cases in which the juice had produced these effects within an hour. The dissection of one case furnished no alteration, excepting that the stomach was found shrunk to half its natural size. The noxious property of this plant is destroyed by heat. 536. Class VI. Irritant and Alterant Poi- sons.—Acro-alterant Potsons.—This class of poisons is very closely allied to the fifth. It comprises those substances and preparations which, either in acutely or chronically poison- ous doses, not only irritate the digestive sur- faces, but also alter the vital properties and manifestations of the tissues—not so much dy- 448 POISONS—Irritant and namically, as in the preceding classes, as in character or kind. When administered in large doses, the alterative effects may not become very apparent if they produce death in a short period, if they are so given as to prove acutely poisonous; but during their slower or more chronic operation, and during recovery from their acute action, the alterative effects are more fully evinced. Several of the substances comprised under this class are much employed medicinally, and have been, and even still are, prescribed, although much more rarely, so as to produce most injurious effects, owing to the alterant influence exerted by them upon the functions of several surfaces and organs, and not upon the functions merely, but even upon the organization of the structures ultimately and remotely. There are several substances which have been already considered, that pro- duce also an acro-alterative effect, when admin- istered in smaller quantities or in repeated doses. But as these, when employed as poisons or in large quantities, act either as corrosive poisons or as acro-sedative poisons—in the one case cor- roding or disorganizing the tissues to which they are applied, and in the other depressing, or altogether annihilating nervous influence or vital power—I have thought it preferable to treat of them under these classes. Even the same poison, however virulent, does not act in a certain definite manner and specific mode, but in different ways, according to the amount, repetition, or continued exhibition of it; and to the various modifying influences already de- scribed (y 51, et seq.). Poisons are not to be viewed as specific entities, producing certain and determinate results, but as powerful agents affecting nervous influence, vascular action, vital power and resistance, and even the organ- ization of the frame, in varying modes and grades; the more manifest effects furnishing, by their prominent features especially, such characters as enable us to arrange and classify them. And thus we find that many poisons, as corrosive sublimate, the concentrated acids and alkalies, several mineral and other saline sub- stances, and even the vegetable acrids, act as corrosive and acute poisons, and destroy life, chiefly by the intensity of their local action, when taken in sufficient quantity in certain states of the stomach, while the same sub- stances, when administered in smaller or re- peated doses, or in states of greater dilution, or when their exhibition has been too long con- tinued, are fatal, or are injurious, owing to dif- ferent modes of action, and to their remote and secondary effects produced by different chan- nels, their effects having a very intimate refer- ence not only to their quantities and modes of exhibition, but also to the constitution and states of the sufferer at the time. Hence many corrosive poisons, when thus or otherwise exhibited, act as sedatives, or as irritants, or as acro-sedatives, and produce effects similar to those classed under these several heads, or act as acro-alteratives, and operate in nearly similar modes to those substances now about to be noticed. 537. i. Belladonna—Deadly Nightshade.— Atropa Belladonna—Atropia—has usually been classed as a narcotic, or acro-narcotic poison; but although the last stage of poisoning by it is often attended by sopor or insensibility, it is Alterant—Belladonna. not strictly a narcotic, as will appear from the symptoms produced by it. The leaves, roots, and berries of the plant are poisonous, and pro- duce nearly the same effects in equally power- ful doses. On dogs, this plant causes dilatation of the pupil, plaintive cries, efforts to vomit, staggering, weakness of the posterior extrem- ities, frequent pulse, a state resembling intoxi- cation, and death (Pereira). I have seen dan- gerous, and in one instance nearly fatal effects result from the medicinal use of preparations of this plant. 538. A. The symptoms vary remarkably with the dose and the frequency of its repetition, with the mode of administering it, and the constitu- tion of the sufferer. The most rapid appearance, and the most comatose state of the symptoms have followed the administration of an infusion or extract of this plant in an enema. Dr. Scharf states, that four ounces of an infusion of the root injected as a clyster produced coma and death in five hours. In a case to which I was called, the extract had been introduced into the rectum as a suppository, but the exact quan- tity I could not learn. Apoplectic coma soon followed, from which the patient recovered with difficulty, delirium both preceding and following the coma. The poisonous operation of bella- donna is most rapidly and fatally developed, when any of the preparations of it is adminis- tered as an enema. 539. a. The local or irritant action of this plant is not very intense, and is exerted pri- marily upon the upper portion of the digestive canal, especially the fauces and oesophagus, causing dryness and redness of the throat with slight difficulty of swallowing, and but seldom vomitings or purging. In some instances sore- ness of the throat, difficult deglutition, and even aphthous inflammation of the fauces have been more remarkable; and in rarer cases, bloody stools, strangury, and even bloody urine have appeared consecutively, or have accompanied the nervous symptoms. The irritation of, and eruption on, the skin, characteristic of this poi- son, appears chiefly after a frequent or prolong- ed use of small doses of it. This eruption has been observed by me in several instances where I had employed belladonna. It has been likened to that of scarlatina; but it has as fre- quently resembled the eruption of measles. It has sometimes followed the use of the extract in ointments which I have prescribed for irrita- ble states of the rectum or uterus. 540. b. The alterative operation of the prepa- rations of belladonna is varied and uncertain, and is exerted chiefly on the nervous systems, more particularly upon those portions which are most intimately connected with the manifesta- tions of sensibility and intellect. Thus we ob- serve dilatation of the pupils, insensibility of the irides to light, dimness of vision, diminished feeling, vertigo, staggering, delirium, and occa- sional sopor, successively follow the excessive use of them. The alterative operation of this poison on others of the systems or organs of the body is problematical, although the uterine functions have been said to have been influen- ced by it. This plant, especially the tincture and inspissated juice or extract of it is a val uable remedy, not merely as an anodyne but also as an alterative in several diseases •' but if exhibited without due caution, especially in POISONS—Irritant and Altrrant—Belladonna. 449 children, or in hooping-cough, it is liable to be followed by injurious or even dangerous effects. Accidents from this poison most frequently are observed in children, who sometimes eat the berries. 541. The husks and seeds of the berries are very indigestible, and may remain long in the stomach or bowels, whether the case recover or prove fatal, especially if free vomiting has not been early procured. In one case the seeds were vomited towards the close of the third day. {Med. Obs. and Inq., vol. vi., p. 224.) In another case the black husks appeared in the stools after the use of laxatives on the sec- ond day. In several other cases adduced by M. Boucher, fragments of the fruit were vom- ited on the second day, and passed by stool on the third, although actively treated from the commencement. But this can occur only when the fruit has been taken accidentally or by mis- take ; but all cases of poisoning by belladonna are not of this kind. Even the administration of preparations of this plant for medicinal pur- poses may be such as to occasion either dan- gerous or fatal effects, especially in children ; and the juices of it maybe given with felonious intentions. They have been so employed, ei- ther mixed in wine or in other fluids, in the commission of murder; and even to aid the commission of thefts or robberies ; decoctions and infusions of various parts of the plant hav- ing likewise been used for the same purposes, as recorded in numerous works of the preced- ing two centuries. Dr. Christison remarks, that other species of atropa are probably simi- lar in their properties to belladonna. Wilmkr quotes instances of frantic delirium having oc- curred among shepherds, as well as their cattle, from eating the Atropa mandragora, which was used by the ancients in medicine. 542. B. Atropia, the active principle of this plant, is not likely to be employed as a poison. Given to the lower animals, it produced the same symptoms as the berries or the leaves. One tenth of a grain caused in the human subject dryness of the mouth, constriction of the throat, difficulty of swallowing, dilatation of the pupil, headache, and stupor. 543. C. Diagnosis.—Whatever part or prepa- ration of this plant may have been taken into the stomach, or otherwise administered, dilata- tion of the pupil is always observed if the dose is poisonous. This symptom precedes the de- lirium, the character of which is peculiar and diagnostic, especially when viewed in connex- ion with the state of the pupil, and the dryness, soreness, or constriction of the throat. ' The delirium is generally gay, extravagant, pleas- ing, talkative, more rarely furious. It is some- times attended by uncontrollable laughter, and occasionally by loss of voice. Vision is ob- scure, the iris is insensible to light, and the eye- ball sometimes red and prominent. A state re- sembling somnambulism has, in rare cases, been observed. The sopor or lethargy produced in the more severe cases generally does not ap- pear for a considerable time after the poison has been taken. Giddiness first occurs, and is followed by the delirium, which may continue for several hours before sopor takes place ; but in some instances the sopor has occurred more early, and has been followed by delirium. Oc- casionally, even in the same case, the delirium, III. 29 which preceded the stupor, returns when the stupor goes off; and very frequently the stupor is not distinct at any stage, showing that this poi- son should not be classed with narcotics. Con- vulsions are not frequently produced by it, un- less in children; in adults they are slight, or confined to the muscles of the face ; but subsul- lus tendinum, or catching of the extremities, is frequent. The periods at which the symptoms appear vary much. Giddiness may appear in a few minutes, or not until two or three hours, and the affection of the eyes about the same time, or soon afterward. The delirium may be delayed for some hours. These symptoms may continue for two or three days. They gener- ally persist much longer than in cases of nar- cotic poisoning. In some instances these symp- toms, especially the blindness and state of the pupil, giddiness, tremours, and other nervous af- fections, continue several days, or even weeks. 544. D. The appearances after death have not been observed in many instances. In a case described by Gmelin, the subject of it died twelve hours after eating the berries. The body was examined twelve hours after death, and yet putrefaction had commenced, so that the abdomen was swollen, the scrotum and penis distended with fetid serum, the skin covered with dark vesicles, and the brain soft. The blood-vessels of the head were gorged, and the blood everywhere fluid, and flowing profusely from the mouth, nose, and eyes. M. Roques describes somewhat similar changes to the above, and states them to be usually found af- ter poisoning by this plant, especially the swell- ing of the abdomen, livid spots on the surface, exudations of blood, or of a bloody froth from the mucous canals, especially the mouth and nostrils, and sudden and rapid putrefaction, pre- ceded by general intumescence of the body. When the berries, husks, or seeds have not been vomited or passed by stool, they are some- times found in the alimentary canal, and furnish evidence of the nature of the case ; when they have been evacuated, and are detected in the discharges, they assist the diagnosis, which is seldom difficult when any part of this plant has been eaten accidentally, or otherwise adminis- tered. {See M. Roques, Phytographie Mcdicale, t. i., p. 229, et seq.) 545. E. Treatment.—The speedy and complete evacuation of the poison from the stomach, by means of an emetic of zinc, to which capsicum may be added, in order to arouse the paralyzed organ, should be first attempted, especially when the fruit has been eaten. In these cases the stomach-pump ought not to be confided in alone, although it may be required in aid of the emetic, the free operation of which should be duly promoted. The older writers strongly ad- vised recourse to vinegar, and either it or oth- er vegetable acids will prove serviceable after the poison has been evacuated. The cold af- fusion on the head and neck is indicated for the removal of the delirium or sopor ; but it should not be continued too long at a time. In some cases tepid affusion may be substituted for the cold. Dr. Pereira suggests the administration of nut-galls or green tea. I found full doses of camphor and chloric ether successful in a case in which the inspissated juice, adminis- tered by the rectum, proved nearly fatal, tepid affusions having been also administered. 450 POISONS—Irritant and Alterant—Cantharides. 546. ii. Cantharides—Canthans Vesicatoria —the Blister Beetle or Spanish Fly—Cantharidin —Vesicatorin.—Cantharides may be poisonous in any of the forms in which they are employed in medicine—in that of powder, or of tincture, of vinegar, of cerate, ointment, or plaster. Ap- plied topically, they excite the nerves of the part, and irritate and inflame the capillaries, occasion- ing first a sense of heat, followed by pain, red- ness, and slight swelling. They are readily ab- sorbed into the circulation, or their active prin- ciple, Cantharidin ; and, in addition to their lo- cal action, they produce very energetic effects upon the vascular and nervous systems, espe- cially on the spinal cord, and upon the urino- genital organs.—A. Their local action is irritant and inflammatory ; their remote operation is al- terative, exciting, irritating, and inflaming, ac- cording to the amount and repetitions of the dose ; their primary influence being exerted on the nervous systems, their secondary, or consec- utive operation, being produced chiefly through the medium of the blood. They are eliminated by the kidneys, on which, and on the urinary bladder and passages, they produce the effects just described. They are thus closely allied in action to several substances comprised under the class of acrid and corrosive poisons, on the one hand, and to many of those belonging to the excitant and irritating classes on the other. The local action of cantharides is nearly the same wherever they are applied, and their re- mote effects are also the same, whether they are taken into the stomach or applied to the skin denuded of its cuticle, or to a wound, or thrown into a vein. They have destroyed life when taken as an aphrodisiac, or to produce abortion, or accidentally. They are very rare- ly employed to produce murder or suicide. 547. B. Symptoms.—a. These vary with the mode of exhibiting this poison and the quanti- ty of it administered. When it is taken in large or repeated doses, or to an amount sufficient to produce a sub-acute form of poisoning, heat and pain in the throat, stomach, and intestines are experienced. To these are soon added thirst and pain in the loins, extending along the ure- ters to the bladder, with a burning sensation in this viscus, a frequent desire to evacuate the urine, which is passed frequently, in small quan- tity, with difficulty, and sometimes more or less tinged with blood. The pulse is frequent and hard, the skin hot, and the respiration quick- ened. The nervous system is somewhat exci- ted, painful priapism, with or without satyria- sis, being also present. In stiU larger quantity the effects are more acute. A violent burning is felt in the throat, gullet, and stomach, with pain and tenderness in the epigastrium, extend- ing over the abdomen, with sickness and vom- itings. To these are added extreme thirst, and pain in the loins and bladder; dryness and heat of the mouth, sometimes with fetor or with ptyalism; and incessant desire to void urine, the attempts to evacuate it being attended by ex- cruciating pain, and nothing but drops of blood or of bloody urine being passed, and excessive tenderness of the whole abdomen. The heat and constriction of the throat increase, and are attended by distressing difficulty of deglutition. Violent griping pains of the bowels, with purg- ing or with tenesmus, bloody stools, &c, are generally experienced. The difficulty of deglu- tition is often accompanied with a dread of flo- ids, although the thirst is urgent, and the mat- ters vomited consist chiefly of mucus, or flakes of lymph streaked with blood. The priapism is painful and constant, the genital organs be- ing swollen and inflamed. In some instances maniacal delirium, tetanic convulsions, and coma supervene, and terminate life ; in oth- ers the delirium is less marked, giddiness, faintings, sinking of the pulse and vital powers, and other symptoms of gangrene consequent upon acute inflammation, being present. Death is more immediately produced either by the in- flammation and consequent gangrene of the ali- mentary canal, or of the genital and urinary or- gans, or partially of both, or, if the patient live somewhat longer, by the intensity of the ner- vous symptoms. . 548. b. The duration of the symptoms depends upon the susceptibility of the individual to the action of cantharides, upon the preparation of it administered, and upon the treatment. The tincture is followed by a more immediate effect than the powder. Even in fatal cases death seldom takes place before three or four days, and it may not occur until after two or three weeks, from the consequence of the inflamma- tion produced in the alimentary canal, or in the urinary passages, or even in the brain, or spi- nal cord, or their membranes. Sometimes the nervous symptoms do not appear until several days after the ingestion of the poison. The quantity which may be considered sufficient to destroy life depends upon the nature and strength of the preparation. Orfila has seen twenty-four grains of the powder prove fatal; but as abortion was first produced, it is proba- ble that this circumstance not only accelerated, but also aided this result, which occurred on the fourth day. The smallest quantity of the tincture which has caused death is one ounce, the individual having lived fourteen days. But, while smaller quantities may occasion danger- ous or even fatal results, much larger may fail of producing very serious effects, the circum- stances so frequently referred to remarkably affecting the issue. Instances have occurred of blistering plaster having been swallowed by mistake. In one case, half an ounce of the plaster, containing two drachms of the powder, was taken, and death occurred in twenty-four hours {Edin. Med. and Surg. Journ , Oct., 1844), the shortest period in which cantharides have been fatal. 549. c. The application of cantharides to the skin as a vesicant, or external irritant, being very generally adopted, is in many cases pro- ductive of fatal consequences, owing to the se- verity of the local alterations, to the intensity of the inflammation and sphacelation they some- times occasion, and to the spreading of these effects, and, more rarely, to their influence upon the urinary organs and nervous system. The mischief thus produced occurs chiefly in infants or young children of a cachectic habit of body, or in those with either a deficiency or an exu- berance of blood, or when the application is too long continued, or is followed by injudicious topical dressings. It is most likely to occui when the blister is applied on children infected with the more adynamic or malignant forms of the exanthemata, especially measles and scar- let fever and is allowed to remair too long upon POISONS—Irritant and Alterant—Chlorine and the Chlorides. 451 the part, or after redness is produced. The ad- mission of the air to the denuded surface, and the application of rancid ointments as dressings, are also often concerned in producing these se- rious local effects. 550. C. Appearances on Dissection.—In the acute cases, and when death has taken place after a few days, the mouth, oesophagus, stom- ach, and small and large intestines, as well as the kidneys, ureters, bladder, and genital or- gans, have been found inflamed, and even, in rare instances, sphacelated in parts. In an in- stance where an ounce of the tincture had been taken, and death did not occur until the four- teenth day, the villous coat of the stomach was not inflamed, but it was pulpy and easily de- tached ; but the kidneys were inflamed. In the most rapidly fatal cases the powder may be de- tected adhering to the villous coat of the stom- ach. In more prolonged cases, congestion or increased vascularity of the brain, cerebellum, spinal cord, and their membranes have been observed. Ulceration of the bladder in some instances, and even sphacelation of the geni- tals, have been mentioned. 551. D. Treatment.—Cantharides are produc- tive of severe irritation passing into acute or sub-acute inflammation, according to the quan- tity administered; and their absorption is fol- lowed by inflammation of the urinary organs, and by excitement, and sometimes by inflam- matory irritation of the nervous centres. The indications of treatment are hence obviously, 1st. To remove the poison by emetics, and by encouraging vomiting; and, 2d. To allay the inflammatory action in these parts. When the sufferer is seen sufficiently early, and vomiting has not commenced, ipecacuanha should be giv- en in copious emollient and demulcent draughts, and its operation promoted by tickling the fau- ces, by the tepid infusion of chamomile, &c The inflammatory symptoms require general and local blood-letting; but if there be reason to infer that any of the poison still remains on the stomach, the discharge of it should be pro- cured or attempted previously to resorting to depletions, lest absorption be promoted. When blood-letting is prescribed, it should be employ- ed in a decided manner, and aided by demul- cents containing small or moderate doses of camphor and nitre, with opium, henbane, &c. Emollient injections into the large bowels and into the bladder, and warni baths, hip-baths, fomentations, &c, are always beneficial. Oil was once supposed to be an antidote to can- tharides ; but there is no known antidote to this poison ; and oil is now ascertained rather to aggravate than to alleviate the symptoms, by dissolving the active principle of cantharides. 552. Poisoning by the external application of cantharides requires the same treatment as now advised. In these cases, the urinary organs are generally more affected than the digestive canal, and diluents, demulcents, opium with camphor, are chiefly required, unless in the more severe cases, when blood-letting is ne- cessary. But these cases generally soon re- cover, Unless the poison be applied to a very large surface or to a recent wound ; and in these the protection of the surface from the air and full doses of opium are requisite. During recovery the digestive and urinary organs long remain irritable, and the nervous system sus- ceptible ; therefore a bland farinaceous or vege- table diet should be adopted, and continued for some considerable time, and flannel worn near- est the skin. 553. iii. Chlorine and the Chlorides.—A. Chlorine gas produces violent spasm of the glot- tis if it be inspired in a pure state.—a. Mixed with air it causes a sense of tightness of the chest, of suffocation and violent cough, owing to the irritation of the bronchi and spasm pro- duced by it—a state of artificial asthma. [Chlo- rine is apt to produce severe pain in the back part of the head, and a powerfully depressing effect upon the circulatory system, as we have repeatedly witnessed.] This effect, if not ex- cessive, generally passes off with increased mu- cous expectoration. When much more diluted with air, it occasions a sensation of warmth in the chest, and promotes expectoration. As a principal fumigating and disinfecting agent, it is liable to produce injurious effects, when air too strongly impregnated with it is breathed; but it is chiefly in manufactories that it is most likely to be hurtful, although the irritating ef- fects of chlorine are less powerful on those ac- customed to inhale it. Dr. Christison was told by a chemical manufacturer in Belfast, that his workmen can work with impunity in an atmo- sphere of chlorine, where he himself cannot re- main above a few riiinutes. The chief effects produced by inhaling this gas by the workmen are more or less emaciation from the absorption of fat, acidity and disorder of stomach, which are usually corrected by chalk. 554 b. When diluted with air, or aqueous vapour of 116° F., and applied to the external surface, it produces peculiar sensations similar to the stinging of insects, accompanied with copious perspiration and determination of blood to the skin, and sometimes followed by an erup- tion of minute papulae. In a pure form, its ac- tion on the skin is similar, but more energetic. A repeated or prolonged application of the gas to the skin is followed by soreness of the gums and mouth, or fauces, occasionally by slight ul- ceration, and generally by a more abundant as well as altered state of the salivary and biliary secretions. Mr. Wallace believed that it tran- quillizes while it excites nervous power; and Professor Albers, that it is stimulating locally, and antiphlogistic remotely. Many years ago, I examined its operation with Mr. Wallace in London (in 1823), and subsequently in Dublin (in 1834), and inferred that it is locally irritant or stimulating, according to the amount of di- lution, and remotely alterative as regarded ner- vous power and glandular action. Whether in- haled or applied to the external surface, it is absorbed, as shown and ascertained by Mr. Wallace and myself, by the state of the urine. 555. c. Treatment.—It is chiefly owing to its accidental inhalation in too strong a state of di- lution that injurious effects have arisen from this gas. The inhalation of the vapour of warm water, of the spirit of wine, or of ether, has been recommended for the removal of the ef- fects of chlorine ; but Dr. Pereira states, that he has tried these when suffering himself, with- out the least benefit. In a case related by Kastner, sulphureted hydrogen was said to have afforded great relief; but this agent should be used with great caution, as it is itself a pow- erful poison. 452 POISONS—Irritant and Alterant—Compounds of Iodine. 556. B. Chlorate of Potash was supposed to be an active stimulant and antiseptic, and, in large doses, an irritant poison. I have fre- quently employed it since 1816, both in public and private practice, especially in the more malignant states of disease, as an antiseptic, disinfectant, and tonic ; but I have been much disappointed in its effects, which I have not found such as I expected, or by any means cer- tain. It, however, diminishes the fcetor of the excretions, even those from the skin, as evin- ced in the putrid and adynamic states of fever, and it is absorbed into the circulation, from which it is excreted chiefly by the kidneys ; and it may be detected unchanged in the urine. I have employed it in large doses without obtain- ing other effects than nausea and vomiting. It appears to be locally irritant, and remotely al- terative and diuretic. 557. C. The chlorides and the hypochlorides of soda and lime produce effects much resembling those caused by chlorine ; but these vary re- markably with the degrees of dilution. In con- centrated states they are caustic and irritant; in states of dilution, irritant or stimulant, an- tiseptic and alterative. I employed these sub- stances largely in practice, especially public practice, when they were first discovered, and found them useful in dysentery and malig- nant forms of disease ; the secretions and ex- cretions in which they remarkably corrected and improved, while they appeared, particularly when aided by appropriate medicines, to sup- port the powers of life. I am, however, unac- quainted with injury from the administration ■of them. When taken in excessive doses they are most likely to occasion gastro-enteric irri- tation, for which albuminous fluids, the whites of eggs, milk, and oleaginous or mucilaginous diluents are the most suitable remedies. If these salts have been taken in very large quan- tity, emetics or the stomach-pump may be re- quired ; and, after they have been evacuated by these means, these fluids should be abun- dantly exhibited. Acids must be avoided, lest they should disengage chlorinic gas in the stom- ach (Pereira). 558. iv. Iodine, the Compounds of.—The corrosive action of pure iodine, and of strong so- lutions, or rather tinctures of it, has been al- ready considered (y 179, et seq.). It remains only to notice the locally irritant and remotely alterative injurious effects of the compounds of this substance, or of small doses of it, when either too long employed, or given in such forms as produce slow or chronic poisoning. The preparations most likely to produce these effects are the tinctures and the iodides, as the iodide of potassium, or the iodureted iodide, the iodide of sulphur, and the iodide of iron. In some constitutions, any of the preparations of iodine occasion, even before a few doses of ei- ther are taken, and although the doses are very small, remarkably depressing effects, and gen- erally without any signs of local irritation. I have met with several instances of this very unusual and severe effect of these preparations in practice, and in three of these, the prepara- tions of colchicum were also injurious in very small doses. In general, iodine is not hurtful unless the dose is considerable, or be repeated too frequently, or its use too long continued.— a. The irritating operation of iodine is most read- ily manifested by irritable tempe.aments and dyspeptic persons. In these, and in other per- sons in larger doses, it occasions nausea, loss of appetite, cardialgia or heat of stomach, sub- sequently colicky pains, relaxation of the bow- els, diarrhcea, salivation, diuresis, &c. If this substance, or any of its compounds, be still ad- ministered, these effects go on increasing, and are attended by soreness of the mouth, severe colic with diarrhcea, emaciation, rapid absorp- tion of the fat surrounding the mammary glands in females; headache, vertigo, sometimes drow- siness or stupor. When iodine is taken in smaller doses, so as not to cause injurious ir- ritation, it acts as a tonic and alterative, and improves both the strength and flesh. But, if too long persisted in, several of the above ef- fects afterward appear. 559. b. In larger or more frequently repeated doses, the effects are more severe, and amount to what have been designated iodism. These are generally severe vomiting and purging, col- icky pains, thirst, and fever ; a frequent, small pulse, sometimes a dry cough ; cramps of the extremities; rapid emaciation, with, occasion- ally a darker hue of the skin and hair, especially if the iodine has been taken for a long period. In some instances wasting of the mammae or testes, and most of the symptoms of chronic gastro-enteritis. It is rare, however, to meet with instances of these effects from iodine, un- less it have been given in a most imprudent manner, or too long persisted in, and even then something should be imputed to idiosyncrasy. 560. c. In still larger doses the symptoms ei- ther approach, or are identical with, those at- tending the corrosive form of poisoning by io- dine (y 182). When iodinic preparations have either been long continued, or often repeated, especially in large doses, so as to produce not merely an irritant operation, but also a consti- tutional change—a marked alterative effect, va- rious contingent phenomena, of a more or less severe character, referable either to the ner- vous system or to the heart and lungs, are apt to appear, especially stupor, tremours, vertigo, faintness, irregularity of the pulse, alarming sinking, shortness of breathing, restlessness" and even death. In these cases the system may be viewed as saturated with the iodine, notwithstanding that the kidneys have been eliminating it from the circulation, as proved by its presence m considerable quantity in the urine; for it has been detected in the viscera and tissues in such circumstances, and even several days after the administration of iodine had been relinquished. The appearances in fa- tal cases have been already described (v 183). 561. d. The treatment of the more chronic or acro-alterative form of poisoning by any of the preparations of iodine, consists i n the removal of gastro-enteric irritation by local depletions and counter-irritation. Demulcent and mucilagin- ous substances should be given with the prep- arations of opium or of poppy; and starch or emollient enemata, with sirup of poppies or the tinctura opii composita, should be thrown ud from time to time. Warm baths are eenerallv useful The diet should be chiefly farinaceous or amylaceous, with or without milk; and durinc convalescence, the regimen and diet recom- mended for gastro-enteritis and the more inflam. matory states of indigestion ought to be adopted. POISONS—Irritant and Alterant—Preparations of Mercury. 453 562. v. Mercury, the Preparations of. — The poisonous operation of the bi-chlorid* has been already considered ($ 215). But life may be destroyed or put in jeopardy by an excessive or prolonged recourse to any of the prepara- tions of this metal.—A. Fluid mercury is inert when swallowed as long as it retains its pure metallic state ; but it may be slightly oxydized in the alimentary canal, and thus acquire activ- ity, especially if it be long retained in the bow- els. Many years ago it was the fashion to swal- low fluid mercury, and, more recenlly, large quantities of it were often given in order to. re- move obstructions. It rarely, however, pro- duced unpleasant effects from having become oxydized. Zwinger states, that four ounces occasioned profuse salivation four days after swallowing it; and Laborde records the case of a man who retained seven ounces for four- teen days, and was attacked with profuse sali- vation, ulceration of the mouth, and paralysis of the extremities. I was lately called to a man who had taken, some time previously, sev- en pounds' weight of fluid mercury with a sui- cidal intention. His medical attendant inform- ed me that it produced a painful sense of weight and constriction in the abdomen, the body hav- ing been bent forward ; but it caused no farther disorder, and continued to pass off at intervals for some days. 563. It was not unusual, during the last and preceding centuries, to wear belts with fluid mercury around the body for months, or even years ; but the practice was not always devoid of harm ; for, in some cases, profuse salivation, and other specific effects of this metal, appear- ed either suddenly or with great severity. 564. B. The injurious effects of mercurial va- pours have been shown in the article on Arts and Employments, as causing Disease (y 24, et seq.); and the tremor mercurialis, with the sev- eral cachectic and cerebral symptoms associated with it, is there described. This form of shak- ing palsy—tremblement mercuriel—is chiefly met with in workmen whose employments subject them to mercurial vapours. If the emanations still continue to operate, in any circumstance of their evolution, various cachectic symptoms, vertigo, loss of memory, imperfect and un- steady action of the muscles, slight atonic con- vulsions, and even delirium, epilepsy or apo- plexy, terminating in death, are the not infre- quent results. Salivation, ulceration of the mouth and gums, haemorrhages, and emacia- tion are frequently also produced by mercurial vapours. In 1810, the Triumph man-of-war, and a small vessel, received on board several tons of quicksilver at Cadiz. Owing to the rot- ting of the bags the mercury escaped, and the whole of the crews became more or less af- fected. In the course of three weeks 200 men were salivated, and two died. All the lower animals in the vessels—cats, dogs, sheep, fowls, rats, mice, and cockroaches—were destroyed. 565. C. The mercurial compounds are all inju- rious, not excepting even the sulphurets, when taken in excessive quantities, or when their use, even in small doses, is very long continued.— a. The local action of mercurials is irritant and alterant; but the bi-chloride and nitrates, in 6tates of more or less concentration, pass be- yond this state of action, and are, as shown above (y 215, et seq.), caustic and corrosive, al- though, when very much diluted, they, as well as the chlorides, diminish both irritation and vascularity in the surfaces to which they are applied. 566. b. The consecutive and remote operation of mercurials vary with the preparation and the modes of employing it. When taken in- ternally in small doses, they promote all the ab- dominal secretions and excretions, especially the biliary and pancreatic secretions. If the doses be repeated, these effects are not only in- creased, but others are also added ; the mucous surfaces and skin manifest an augmented ex- halation, the gums become red and tender, the urinary secretion is increased, and the catame- nia promoted ; absorption proceeds more rapid- ly, the pulse becomes somewhat accelerated, and the strength slightly impaired. The repe- tition or number of the doses, as well as the amount of each required to produce these chan- ges, vary with the constitution and idiosyncra- sy of the individual, and the amount of action upon the bowels. If the mercurial be continu- ed longer, or after these effects commence, or if the doses be larger than are necessary to produce them, the redness and tenderness of the gums pass into swelling ; the tongue, which was at first broad and soft at its edges, "becomes flabby and swollen ; a coppery taste is perceiv- ed in the mouth, which, with the gums, is sore and tender; salivation, more or less profuse, su- pervenes ; the salivary glands are tender and swollen, the teeth are loosened, the breath be- trays a peculiar odour and fetidity; the pulse is now more accelerated, the strength much impaired, and emaciation more rapid as the sal- ivation proceeds and increases; the quantity of saliva discharged sometimes amounting to several pints in the twenty-four hours. Such may be said to be the first stage of chronic poi- soning by mercurials, as frequently produced formerly for the purpose of curing certain dis- eases, especially the venereal disease ; but now very rarely required either for this or any oth- er distemper. During salivation, the urine, according to Dr. Pereira, does not contain a trace of albumen. The mercurial action alters the secretion of the salivary glands, and causes it to approach more nearly the fluids exhaled from inflamed serous membranes. 567. D. The first stage of poisoning by mer- curials is generally such as now described ; but occasionally other and more serious phenome- na appear after a more or less liberal recourse to any of them, and assume the features of dis- tinct maladies. An acquaintance with these contingent effects of the constitutional action of mercurials is of great importance to the practitioner. They are not so much owing, in most instances, to the preparation employed as to the idiosyncrasy, or the state of health of the individual; a scrofulous constitution, the vene- real taint, and other causes favouring their oc- currence. The maladies which may be ranked under the first stage of chronic poisoning by mercury are, first, what has been called mercurial disease—Morbus mercurialis, hydrargyrosis, ca- chexia mercurialis, &c, and which presents va- rious forms or states; and, second, what has been named pseudo-syphilis, or cachexia syphiloidea, or what is supposed to be syphilis modified by the mercurial disease. 568. 1st. Mercurial disease may be viewed as 454 POISONS—Irritant and Alterant—Mercurial Diseases. the generic appellation of several morbid con- ditions resulting from mercurial preparations— from a few grains only of blue pill or of calo- mel in some constitutions, or from large and repeated doses of these or of other compounds of the metal in others.—(a) Excessive salivation —Ptyalismus mercurialis—Stomatitis mercurialis —may occur from a small dose of any mercu- rial, or from large or excessive doses. It is oftenest met with after small or moderate do- ses, and is then the result of peculiarity of con- stitution. The mouth rapidly becomes violent- ly affected; the tongue is swollen so that it hangs out of the mouth, and prevents the pa- tient from speaking and eating; the gums are tumefied and ulcerated, ulceration often extend- ing to the cheeks; the teeth are loosened or drop out, owing to the sloughing of the gums ; the salivary glands are enlarged, tender, pain- ful, and the surrounding cellular tissue congest- ed or infiltrated ; and the quantity of salivary discharge remarkably increased, sometimes ten or twelve pounds being secreted in the twenty- four hours. With the progress of these symp- toms debility and emaciation make rapid prog- ress ; and, with sloughing of the gums, caries of the alveolar process not infrequently takes place. If the mercury be continued, involunta- ry movements of the muscles, or states of in- complete palsy may appear, and the patient sink from extreme vital depression. Even when the mercury is relinquished, the inordinate saliva- tion and other symptoms may still continue, and be arrested with the greatest difficulty. Indeed, such is the case whenever this effect follows the use of a small dose of mercury, and depends upon idiosyncrasy. In some in- stances, the ulceration and sloughing are fol- lowed by contraction of the arches of the pal- ate, and by inability to open the mouth suffi- ciently. Occasionally the salivary glands be- come remarkably enlarged, tender, and inflam- ed, and the surrounding parts swollen {Parotitis mercurialis), and the mouth ulcerated, before the salivation commences, the salivary dis- charge relieving the extreme swelling and pain of the glands ; but this most frequently occurs when the patient has been exposed to currents of cold air, or to cold and humidity upon the ac- cession of the mercurial action. 569. {b) Mercurial Purging.—Diarrhoea Mer- curialis.—Excessive purging occurs sometimes after a moderate dose of a mercurial; and may arise from an excessive accumulation of bile in the gall-bladder and ducts having been sudden- ly let loose, in which case the evacuations are greenish or dark ; or from an excessive secre- tion of the pancreatic fluid having been produ- ced, and then the evacuations are pale, watery, frothy, or ropy, and are attended by pain, heat, or tenderness in the region of the pancreas. (See Pancreas, Diseases of.) Excessive diar- rhoea after mercury has been ascribed by Die- terich {Die Merkurialkrankheit, Leips., 1837) to a species of pancreatic salivation caused by mercury, and called by him ptyalismus pancrea- ticus mercurialis, or ptyalismus abdominalis, diar- rhoza salivalis, &c. 570. (c) Mercurial fever—Febris mercurialis— F. salivosa—is generally caused by the exces- sive use, or by very large doses of mercury, and seldom appears until after some days. It is attended by dryness of the mouth, redness and swelling of the gums and tongue, great ac- celeration of pulse, with restlessness, headache, hot and dry skin ; swelling or tenderness of the parotids, sometimes extreme, as already no- ticed {Parotitis mercurialis), and loss of appe- tite and nausea. This state of irritative fever generally terminates with a profuse salivation, more rarely with purging or sweating, or with some form of cutaneous eruption (y 574). 571. {d) Mercurial cachexy—Cachexia mercu- rialis—is a more frequent consequence of the prolonged use of mercury, and even of the re- peated exhibition of calomel, than is generally supposed; and, as far as my own observation extends, it constitutes, in various modifications, the most frequent form of slow poisoning by mercury. It is not infrequently produced by prolonged efforts to affect the salivary glands in the treatment of hepatic or other diseases, and is characterised by the usual symptoms of irri- tative fever, without flushings, but with great pallor,emaciation, and manifest anaemia. There are, also, loss of appetite, depression of spirits, disordered bowels, with offensive stools; and occasionally swelling of the salivary glands, redness or sponginess of the gums, or ulcera- tions of them and of the mouth, cheeks, &c, but rarely any salivation. It usually passes al- most insensibly into tubercular phthisis. 572. (e) Mercurial Erethism.—Erethismus Mer- curialis.—This alarming affection, thus denom- inated by Mr. Pearson, has been viewed by Dieterich as adynamic mercurial fever—Febns mercurialis adynamica. Since Dr. Dieterich wrote, one case of it has come under my ob- servation ; and my examination of that case, as well as my recollection of former cases, has not furnished evidence of the, accuracy of this view. The symptoms of this affection are, rap- id depression of strength, with a sense of sink- ing and anxiety, referred chiefly to the pra;cor- dia; with partial or general tremour, frequent sighing, universal sense of coldness, and dimin- ished temperature of the surface. The pulse is small, quick, and weak; the countenance is pale, collapsed, and expressive of anxiety and alarm. ' Vomiting sometimes supervenes, and favours reaction and recovery. In the case just alluded to I could detect nothing, by the aid of the stethoscope, beyond absence of the impulse of the heart, and very weak, frequent, and oc- casionally irregular contraction. A fatal ter- mination has followed muscular exertion. This atlection appears to consist of extreme depres- sion of vital power, and of muscular irritabili- ty, manifested chiefly by the heart, and of .con- gestion of the lungs; and hence it might be more appropriately called Asphyxia curdiaca mercurialis. 573. (/) Neuroses Mercurialcs.—Various ner- vous and mental disorders are sometimes produ- ced by mercury, especially when any of its preparations have been long persisted in, ow- ing to the depressing and alterative action on the nervous systems, probably aided also by other influences. Melancholia, sometimes at- tended by delusions, and various states of par- tial insanity, in which fears of impending or fu- ture calamities more or less predominate and even sway not only the feelings and sentiments, but also the volitions and actions, are not infre- quently produced by a frequent recourse to mercurial preparations. Tremours or trem- POISONS—Irritant and Alterant—Mercurial Diseases. 455 blings {tremor mercurialis), sometimes passing into palsy {paralysis mercurialis), hyponchondri- asis, &c., are also not infrequently occasioned by this cause, and are duly considered at other places. ^74- {g) Various affections of the external surface and of other parts of the body are some- times produced by an excessive use of mercu- ry ; yet it is extremely probable that they are not owing to this cause alone, but to peculiari- ty of constitution, or to some pre-existing taint or local vice. Certain acute and chronic erup- tions on the skin sometimes appear as the ef- fects of mercury ; but are now more rarely met with since severe courses of this mineral have been much less frequently resorted to. Ecze- ma mercuriale, Erythema mercuriale, Lepra mer- curialis, Erysipelas mercurialis, Hydrargyria, are the names which have been given to an acute eruption which has sometimes appeared during a severe mercurial course, and been attended by considerable danger. This affection has been described by Pearson, Alley, Moriarty, Stokes, Spens, Cullerier, Lagneau, Rayer, and others. It generally consists of innumer- able minute pellucid vesicles, which give a dif- fused red appearance to the skin, and a sensa- tion of roughness to the touch : it is generally preceded and attended by more or less febrile disturbance. In two or three days the vesicles attain the size of pin's heads, and the contain- ed serum becomes opaque and milky. The erup- tion soon extends over the body, and is accom- panied by swelling, tenderness, and itching. It usually terminates by desquamation; but a co- pious discharge sometimes takes place from the excoriated surface; and, with the epidermis, forms large flakes. In some instances the hair and nails fall off, and the eyebrows become de- nuded (Pereira). There is also more or less internal disorder, especially tightness and op- pression in the chest, dry cough, with indica- tions of congestion of the lungs and bronchial irritation. Alley saw forty-three cases of this eruption in the first ten years of this century, and of this number eight were fatal; more re- cently Rayer met with only three cases; and Pereira only with two. I have seen only two cases, and these occurred at an early period of my practice. Other cutaneous eruptions have been said to be sometimes caused by mercury, especially a miliary eruption, Herpes, Impetigo, Psydracia, dec.; but this origin is doubtful, and most probably other causes concur, if not en- tirely produce them. 575. A. Congestions and inflammations of va- rious parts, especially of the eyes, or certain tissues of the eye, as -the iris, the retina, the conjunctiva, &c. ; congestions and inflamma- tions of the periosteum {mercurial periostitis), and caries of the bones, especially of the more spongy bones ; and similar diseases of the per- icranium, bones of the cranium and dura mater, have also been ascribed to mercury, but are often owing more to a venereal taint, to the scrofulous diathesis, or to idiosyncrasy, than to this mineral; although exposure to cold, and vicissitudes of temperature and weather in a cold or variable climate sometimes produce those diseases which assume a peculiar char- acter during the mercurial saturation and ac- tion, especially when aided by the constitution- al taints just alluded to. 576. 2d. In this way, also, may be explained the several morbid conditions which are com- prised under the denomination of Cachexia syphiloidea—Pseudo-syphilis. The modes, also, of employing mercury in the cure of venereal or other maladies, and the various grades or states of saturation of the system which these modes induce, may have some influence in pro- ducing various affections of a peculiar or anom- alous character; for it may be anticipated that the large doses of calomel, given in a warm cli- mate, will affect the constitution much less, and somewhat differently from the large inunctions of mercurial ointments, sometimes more or less altered by long keeping, so often employed in this and other cold climates, especially in for- mer times ; and that even the blue pill may be so changed by keeping, particularly in hot and humid countries, as to act differently from the recent preparation. 577. E. Acute poisoning by excessive or large doses of mercurial compounds—by sin- gle or repeated doses—is generally attended by symptoms of acute gastro-enteritis ; but these, as well as the more remote effects, vary with the preparation administered. In general they are altogether the same as are described when treating of the corrosive operation of the salts of mercury (y 216-228), or differ merely in severi- ty, and as respects the liability to any of the consecutive effects just described. 578. F. Intolerance of Mercury.—The injuri- ous effects now described are usually produced by a prolonged or an excessive use of any of the preparations of mercury, excepting proba- bly the sulphurets; but in some constitutions very small doses may occasion excessive sali- vation and some of the other slighter effects, and even a single small dose may bave the same result. When salivation follows a single dose it usually appears on the second or third day, and rarely sooner, but occasionally later. It may, however, appear much sooner, and with great severity, considering the dose, when the preparation, as calomel, is allowed to remain in the mouth for some time. In an instance mentioned by Dr. Bright, five grains of calo- mel put on the tongue in apoplexy, and not washed down, excited in three hours most vi- olent salivation. Dr. Ramsbotham states, that fifteen grains of blue pill, taken in three do- ses, one each night, produced fatal salivation [Med. Gaz., i., 75). Dr. Crampton records a case where two grains of calomel caused ptya- lism, extensive ulceration of the throat, exfoli- ation of the lower jaw, and death. {Trans, of Dub. Col. of Phys., iv., 91.) Dr. Christison says that three drachms of mercurial ointment, applied externally, caused violent ptyalism and death in eight days. {Op. cit., p 379.) I have seen one grain of the bi-chloride divided into twenty doses, of which one was to be taken thrice daily, produce very severe ptyalism be- fore more than two thirds of the grain was ta- ken. I have also seen one grain of blue pill cause very serious ptyalism; and the same quantity of hydrargyrum cum creta occasion most severe diarrhoea, the smallest doses of any mercurial having this effect with that individual. During the present epidemic influenza (1847), nine grains of blue pill, in three doses, caused sloughing, ulceration of the mouth, and extreme prostration in a case to which I was called. 456 POISONS—Irritant and Alterant—Mercurial Diseases. 579. G. On the other hand, some constitutions resist the specific effects of mercury most obstinate- ly. But it must not be supposed that, although the specific effects do not appear, the mercurial has no effect. It may produce some one or more of the injurious effects above described. or it may affect the bowels, and be carried off by diarrhoea, or excite organic disease of the colon or rectum, especially the latter, or occa- sion mental disorder with irritative fever. It has also been erroneously supposed that calo- mel and other preparations of mercury are not injurious to infants and young children, because the specific operation very rarely appears in them. But this is not altogether the case, for the constitutional powers and the digestive or- gans often suffer more or less, although not manifestly, or at the time; and in older chil- dren several of the injurious effects which I have mentioned not infrequently occur, espe- cially ulceration, or even sloughing of the cheeks and gums, and irritative or hectic fever, with re- markable pallor, anaemia, or chronic irritation of the bowels, with enlargement of the mesen- teric glands. 580. H. The diagnosis of mercurial salivation is always difficult, unless the exhibition of some mercurial shortly before the appearance of the discharge be admitted or ascertained. And even when the admission is made, the quantity may be so small as to allow of doubts as to its influence. In certain constitutions, and especially in depressed and debilitated states of such constitutions, after exhausting discharges, and during cold, humid, and north- easterly winds, with more or less exposure to such weather, a small dose of a mercurial may cause excessive salivation ; and, if this dis- charge be attended by much soreness of throat, it is most difficult to determine whether the sal- ivation is actually the result of the mercurial, or merely symptomatic of the sore throat and cold. If it proceed from the mercurial, there will generally be some tenderness of the gums, a soft and flabby state of the sides of the tongue, and it will generally be more obstinate. A patient under my care took, under the cir- cumstances of general health and exposure just mentioned, five grains of blue pill. In two or three days afterward he was attacked with sal- ivation and sore throat. He possessed, how- ever, no constitutional tendency to be affected by mercury; and yet this dose, in his existing state, and from exposure to cold and humidity, appeared to have occasioned the attack, which probably, also, the sore throat aided to develop. When severe and prolonged salivation has been once produced by a course of mercury, a very slight cause may reproduce it a long period af- ter it has ceased. A common sore throat or cold is sometimes alone sufficient to have this effect. But in this case, as well as in others jiot caused by mercury, there is no mercurial foetor; for, although the breath is often very offensive in non-mercurial salivation, the pecu- liar mercurial foetor is absent. A very severe or even dangerous effect may be producd on the mouth by a very small dose of mercurial, when conjoined with or given at the same time as tartarized antimony or colchicum. 581. a. It ought also to be recollected that several medicines and poisons occasionally ex- cite salivation. The preparations of gold pro- duce this effect as certainly as those of mercury. Those of copper have often a similar operation -, and those of iodine and antimony occasionally exert it. Digitalis and prussic acid sometimes occasion the same effect, and even croton oil and opium have increased this secretion ; but this operation, as respects these last, has been loosely observed and recorded. 582. b. Ah idiopathic or spontaneous form of profuse salivation has sometimes been met with, no medicinal or poisonous cause of it having been detected. Several cases of this form have been recorded, and have continued for months, or even for two or three years, many ounces of saliva having been discharged daily; but in many of these eases the mouth was not affected, and other characteristics of mercurial salivation were wanting. The ima- gination may excite salivation. Dr. Christison met with an example of this, which, with other cases of spontaneous chronic salivation, he has noticed in his work. I have seen an instance of profuse salivation follow the contemplation of a disgusting object, but it did not continue longer than a few days. Some of the cases re- corded as instances of idiopathic salivation have probably been symptomatic of chronic or struc- tural disease of the pancreas, as noticed in the article upon that organ. 583. c. Dr. Christison very correctly re- marks, that, in general, mercurial salivation may be distinguished from all other varieties, if its progress has been traced from the first ap- pearance of brassy taste and foetor to the for mation of ulcers and supervention of ptyalism. Its characters are also quite distinct at the time salivation just begins. The foetor of the breath and sponginess and ulceration of the gums at this stage distinguish it from every other affection. But if the mouth is not ex- amined until the ulcers have existed several days, the characters of the mercurial action are much more equivocal. They may not, for ex- ample, be distinguished from spontaneous ul- ceration of the mouth, depending upon general cachexia or unsoundness of constitution, and characterized by extensive ulceration, or slough- ing, with ptyalism and gangrenous foetor. The diagnosis of mercurial salivation demands in all cases much attention, not only in a medical or practical, but also in a medico-legal point of view; and, in both regards, there are other questions connected with it which require a spe- cial attention. 584. 1st. May salivation not appear until a long period has elapsed after the administration of the mercury has been abandoned ? Mercury ad- ministered in small doses is a cumulative poi- son, and often produces no effect upon the saliva- ry glands or gums until a certain amount of sat- uration is produced, this amount varying with different constitutions, or with the same con- stitution at different times. Hence it may be inferred that mercury may accumulate in the system without producing its specific effects, and may still remain, in some instances, for a considerable period, being unexcreted, or only partially excreted, but, before its elimination is accomplished, a change in the state of vital power, or of the constitution, takes place, or some new influence comes into operation and develops the specific action of the mercury existing in the frame. Thus may be explained POISONS—Irritant and Alterant—Mercurial Diseases. 457 the occurrences of salivation not until some months after mercury has been relinquished. Swediaur has met with instances where the in- terval was several months ; Cullerier with an instance where it was three months. 585. 2d. What is the duration of mercurial pty- alism, or how long may salivation continue after the use of mercury has been abandoned? Rare instances of very prolonged salivation have been met with by most practitioners—instan- ces of even several months' duration. But cases have been recorded by Linnaeus, Swe- diaur, Colson, and others of its continuance for periods varying from one to five or six years. These, however, are very rare. Most commonly the mouth and salivary glands return to their healthy states in the course of a fort- night or three weeks; but it is not unusual to observe the period protracted to a month, or even longer. 586. 3d. May ptyalism, and other specific ef- fects of mercury, recur after a complete intermis- sion, or, in other words, reappear after having en- tirely ceased, mercury having been discontinued? I have above (y 580) admitted this occurrence. It has not infrequently been observed by those practitioners who in former days were very conversant with the effects of severe or pro- longed courses of mercury. Dr. Christison believes that the occurrence of salivation after two, or three, or four months have elapsed, without the repetition of mercury, is exceed- ingly uncommon. It certainly is so at the pres- ent day ; but it most probably was not so many years ago, when prolonged and severe courses of mercury were often prescribed ; and that it was not so formerly, the reasons assigned above (y 584), as well as the testimony of Hamilton, Mead, Male, Fordyce, Colson, and others, sufficiently show. 587. 4th. In what manner does small or other doses of mercury prove fatal ? Death may ensue from the mildest preparations, and even from comparatively small doses, generally in conse- quence of severe salivation, or of gangrenous destruction of parts of the mouth and fauces, and the vital depression produced by the min- eral and by the local disorganization. The most obvious manner in which death takes place is by extension of sloughing, or gangrene, of the throat, mouth, cheeks, face, and neck. This re- sult is seldom seen at the present day ; but ca- ses are met with in consequence of peculiarity of constitution, or of large doses given to chil- dren under the belief that they are much less susceptible of the specific effects of this miner- al than adults. In general, when gangrene is the cause of death, it begins within the mouth or in the throat, and spreads from thence until it reaches the face. This is most frequently seen in children. But I have seen the ulcera- tion both commence in and extend to the pha- rynx, and thence to the larynx, producing de- struction of this latter part, and death. Some- times, especially in children, the sloughing be- gins on the external surface, at a distance from ulceration of the gums and mouth, appearing in the course of a few days after salivation. A 6mall vesicle generally appears on the skin, on one or both sides near the mouth, and is suc- ceeded by a gangrenous or sloughing ulcer, which spreads over the cheek, and proves fatal in a few days. In cases of this nature, both the local disorganization and dissolution are the results of the depression of vital power pro- duced by the mineral. When salivation is ex- cessive or prolonged, death may ensue from the exhaustion thereby produced. But even in this case the mercury has occasioned a poisonous vital depression, the first manifestations of which have been the salivation caused by it; but with this depression, and the exhaustion consequent upon the discharge, the changes produced by mercury in the constitution, and the physical appearances and the alterations of the blood, should be taken into the account. Mercury may also excite pulmonary and laryn- geal phthisis, and cause death, as just mention- ed, by the ulceration of the epiglottis and glot- tis, and the attendant exhaustion and hectic. It may occasion a fatal issue by inducing any one of the several affections I have described above (y 569, et seq.) as contingent upon the ad- ministration of mercurial preparations. When the corrosive preparations of mercury have been administered, death is generally the con- sequence of the local corrosive action, of the disorganization caused by them, when taken in large quantity. If this effect is not produced, or is recovered from, they may still cause death from their consecutive effects now described. 588. /. Of the Physiological Action of Mercury. —All the preparations of mercury are more or less readily absorbed and carried into the cir- culation ; but it is not ascertained in what state they are absorbed, or by what particular chan- nel, although the lymphatic and lacteal vessels are most probably the chief media. In what- ever state the mercurial may be when it has arrived in the blood, it evidently accumulates there, and in the solids, to some extent, espe- cially in some constitutions or conditions of the frame, producing, among others, the effects above described. Having arrived in the circu- lation, it is carried out of the system, either without deposition or accumulation in the sol- ids, or after having been for a time thus depos- ited, by means of the several emunctories, more especially by the salivary glands, the skin, the pancreas and liver, the intestinal canal, and kidneys. When the mercurial, owing to either the modes of administration or inaction of the emunctories, accumulates in the blood, the tis- sues may be so saturated with it as to give rise to the changes described, or to admit of the de- tection of it in the excretions, or even in the structures themselves. In whatever state it may exist in the blood, it is so intimately com- bined with this fluid as to escape detection by the ordinary tests, and destructive distillation is generally required. By this means it has been detected by Zeller, Buchner, Schubarth, Colson, Dieterich, and others. In the same way mercury has been found in the secretions and excretions, in the saliva, the perspiration, the urine, the intestinal secretions, and even in the discharges from ulcers, as shown by Chris- tison, Pereira, and the writers just named. Dr. Pereira remarks, that the blackening of the skin mentioned by Harrold, Rigby, and others, as having occurred from the use of mer- cury after the employment of sulphur, shows the presence of mercury in the cutaneous trans- piration. The sulphur and the mercury having been thrown out of the system by the skin, and beyond the sphere of the vital power, had en- 458 POISONS—Irritant and Alterant—Mercurial Diseases. tered into union and formed the black sulphu- ret of mercury, which was deposited on the in- tegument in a pulverulent form. The existence of mercury in the regulinc state, in the organic Bolids, has been asserted by some and denied by others. Wibmer, Colson, Dieterich, Pe- reira, and others say that it has been found in this state in the bones, brain, synovial cap- sules, the pleura, the humours of the eye, the cellular tissue, &c. In what part of the sys- tem reduction is effected is not ascertained, or whether it has occurred during life or after death. I have seen the mercury in the fluid state in bones which have been long in contact with the surrounding earth, and have viewed the reduction as a post-mortem phenomenon; but it may have been otherwise. 589. Mercurials, having been carried into the circulation, and even to some extent into the tissues and organs, as they undoubtedly are more or less, certainly affect the states of or- ganic nervous and vital power, changing not merely dynamically, but also otherwise altering the innervation of the several organs and struc- tures. The alterative influence is displayed, and can be estimated only, by its results, by the ef- fects just described. But in addition to the al- tered state of general innervation, and chiefly as a consequence of it, the blood evinces mark- ed changes. If salivation be easily produced, the blood either shows no very material change at the commencement, or it exhibits merely a slight inflammatory crust. But after salivation has continued some time, the blood becomes darker, coagulates less firmly, and the propor- tion of the coagulum to the serum diminishes. If salivation be protracted, the red globules de- crease in number very remarkably, and anaemia is often very considerable, and always super- venes when salivation is either excessive or pro- tracted. Dieterich says that the electrical con- dition of the blood changes from the negative, the healthy slate, to the positive state. With this change in the blood the soft solids are im- paired in their vital cohesion, and all the exha- lations and secretions from surfaces and mu- cous follicles are increased: The heart and lungs are also more or less affected, as Sir B. Brodie has shown, although more as respects their organic nervous energy, or state of inner- vation, than as regards the structure. The structural changes produced by mercury have been chiefly observed after death from acute poisoning by the corrosive preparations, and have been described above (y 218). 590. K. Treatment.—When the symptoms are those of acute poisoning (y 216), then the treat- ment recommended for that form should be adopted with promptitude and activity (v 221); but the varieties of chronic poisoning by mercu- rials require very different measures.—a. Sali- vation, when either excessive or prolonged be- yond the intentions of the physician, is that va- riety which most frequently calls for aid, the means most successful in removing it bein" also the most beneficial in the treatment of the other varieties of chronic mercurial disease. The patient.should be removed to a large, airy, dry, and moderately cool apartment, about 60° Fahr., and entirely apart from those who are subjected to a mercurial treatment. AH the linen should be frequently changed, and vicis- situdes of temperature avoided. Thus circum- stanced, the remedial means may consist of three classes, which may be distinguished as the antidotal or constitutional, the derivative, and the local, which may be successively or contem- poraneously employed, or in such succession and combination as the peculiarities and form of the mercurial disorder will suggest. 591. (a) The constitutional and antidotal means are limited ; but, such as they are, they should not be overlooked ; for, as the injurious effects of mercury, in any of the forms noticed above, often depends upon the actual presence of mer- cury, in some noxious state, in the circulation, and even in the tissues, and not infrequently upon the irritation this mineral causes in the several emunctories concerned in eliminating it from the system, it is important to resort to such means as are the most likely, by combi- ning with it in the blood and tissues, to render it less deleterious, or even inert. There is probably no substance which may be more ben- eficially employed with this intention than sul- phur, inasmuch as it is readily carried into the circulation, and as readily combines with mer- cury, whose injurious operation it thus prevents, the sulphuret of mercury being either inert, or nearly so. Sulphur, therefore, should be given internally, while sulphur baths, both warm and fumigating, or as either may suit the peculiari- ty of the case, may also be called into aid. For- merly the sulphurets were given internally for the removal of excessive salivation, but they are very much inferior to the simple precipita- ted sulphur, and are now employed chiefly in warm medicated baths. Next to the internal use of sulphur may be mentioned the diluted sulphuric acid, taken in quantity sufficient to render the drink pleasantly acid ; but in cases of very long protracted salivation, or when anaemia has supervened, neither it nor any of the other acids, whether mineral or vegetable, has appeared to me to be of any service, unless combined with an oxide of iron. In these cir- cumstances the sulphate of iron may be taken in small doses, dissolved in the drink acidula- ted with the sulphuric acid, or the citrate of iron may be given in fluids containing the citric acid. In treating most of the injurious effects of mercury, the local mischief, in whatever form it may appear, attracts the chief notice, and to it chiefly, and not to the states of the blood and of vital power, which are of the greatest impor- tance, are our remedial measures directed. Va- rious other constitutional means have been rec- ommended ; but there are comparatively few which deserve adoption. The most servicea- ble are the preparations of sarsaparilla ; those of iodine ; the iodide of iron, and some other combinations of iodine with sarza ; the decoc- tion of cinchona, or the sulphate of quinine with sulphate of iron, or common alum, or with the citrate of iron, according to circumstances, or to the amount of debility or of anaemia. In most of the remote or consecutive states of poisoning by mercury, and more especially in mercurial cachexia and affections of the skin and mercurial periostitis, the iodide of potassi um and other preparations of iodide, with sarza &c , will prove most benefic al. 592. (i) The derivative measures which are most serviceable are purgatives and warm baths, and these are serviceable chiefly when salivation has occurred suddenly or unexpect- POISONS—Irritant and Depressing—Stramonium. 459 edly; when it is recent, and the patient not much reduced. In these circumstances, the best purgatives are the neutral sulphates dis- solved in the compound infusion of roses, to which some additional sulphuric acid, and small doses of the sulphate of iron, may be added; these may be administered at intervals, so as to keep up an action on the bowels, or a full dose of precipitated sulphur may be taken at bedtime, and the saline aperient in the morning and at midday if it be required. Warm med- icated baths may likewise be used, or pediluvia. If constipation continue, or become obstinate, other more active purgatives may be required, if a recourse to purgative enemata does not ac- complish fully the object entertained. 593. (c) The local means should have refer- ence to the state and stage of salivation, and of the other symptoms. If salivation be com- mencing ; if it be acute; if it have occurred unexpectedly, or from a small dose of mercury, and be attended by an inflammatory state of the mouth or salivary glands, the topical reme- dies ought to be soothing, and the local excite- ment should be calmed by means of demulcent gargles, containing cooling and anodyne sub- stances, as the nitrate of potash, or the hydro- chlorate of ammonia, with extract or tincture of opium ; or by gargles containing the acetate of lead and acetic acid, with tincture or wine of opium. If the swelling and tenderness around the salivary glands be considerable at the com- mencement, a few leeches, followed by fomen- tations, may be prescribed, and the other means assiduously employed. In the more chronic or atonic stage or state of salivation, the gargles should be astringent and tonic, as the decoc- tion of cinchona, or of oak bark, with alum and sulphuric acid, or with the tincture of krameria. The chlorides, especially the chloride of lime in solution, with creasote; solutions of the chlo- ride of zinc, or of the nitrate of silver ; the tinc- ture of myrrh in camphorated demulcents, &c, may severally be employed as gargles. I have seen strong tar-water of great service when used as a gargle, a weaker form of it having been drank as a constitutional remedy. 594. {d) The other varieties of chronic poison- ing by mercury are benefited most by the con- stitutional or antidotal means advised above (y 591). But, in these varieties, the states of the blood and of nervous energy should receive particular attention. In order to remove the existing depression of vital power, to improve the assimilating processes, and to resist the changes in the blood, especially the progressive anaemia, the iodide of iron in sirrup of sarsapa- rilla, the several preparations of iron, or the min- eral chalybeates, in states of combination which the peculiarities of the case will suggest, and many of the usual vegetable or mineral tonics and antispasmodics, will prove of essential serv- ice. When the nervous system, or even when the mental manifestations betray disorder, the means just mentioned, preceded or attended by the constitutional treatment above recommend- ed (Y 591), are then also required ; change of air and scene, travelling, a dry, bracing air, gen- erous but light diet, aided by occasional recourse to tonics, to chalybeates, to the iodine, and to the natural mineral waters, being also beneficial.* * [The elaborate exposition which our author has given of the various disordered changes induced by mercury, as a 595. vi. Stramonium—Thorn-apple—Datura Stramonium.—Poisoning with this plant is not infrequent, and is generally accidental. But the thorn-apple has been used on the Continent for the purposes of aiding the commission of crimes. The whole plant is probably poison- ous, but the seeds are the most virulent. It is very slightly irritant, its poisonous action being exerted chiefly on the brain and nerves of sen- sation. Its operation nearly resembles that of belladonna. The active properties of the plant reside chiefly in an alkaloid principle, described by Geiger and Hesse, and named daturia or ddturium; and probably partly in an empyreu- matic oil which it contains, resembling that of digitalis. It acts chiefly by absorption, and probably also by its local influence or impres- sion on the«nervous systems; for the applica- tion of the leaves of the plant to burns or sores has occasioned dangerous effects. 593*. a. The symptoms produced by stramo- nium have been most accurately observed and described by Dr. Pereira. In small and grad- ually increased doses, it impairs sensibility, there- by alleviates pain, and hence is anodyne. Al- though it allays pain, it does not usually produce sleep. Dr. Pereira remarks that it has no di- rect tendency to induce sleep, and hence it can- not be called soporific; but indirectly, by allevi- ating pain, it often disposes to sleep. It usu- ally does not affect the pulse : it slightly and temporarily dilates the pupil, and has no ten- dency to cause constipation, but rather relaxa- tion. In larger doses it causes dryness of the throat, thirst, nausea, giddiness, dilatation of the pupil, obscurity of vision, headache, nervous agitation, disturbance of the cerebral functions, perspiration, occasionally relaxation of the bow- els, and sometimes diuresis. In fatal doses the chief symptoms are flushed countenance, delir- remedy and as a poison, supersedes additional matter on the subject; yet on a topic so prolific in relation to a mineral remedy, the use of which has for near a century past been so extensive in the hands of the faculty of American physi- cians, an additional observation or two may be made. In specific febrile disorders, it is well known that Ogden, of Long Island, and Douglass, of Boston, had recourse to mercury before its use for those purposes was made in Great Britain. In the mercurial practice for yellow fever, as it prevailed in Philadelphia in 1793 and in subsequent years, and in New York in 1795, 1798, and in 1803, as adopted by the medical men of that metropolis, great opportunities oc- curred of noticing the action of this powerful agent in a dis- order of acknowledged specific character ; while, the abuse of mercury in syphilitic diseases has been the theme of re- peated remark and of professional notoriety by American prescribers. The reader will do well, on all these subjects, to peruse the valuable volume on the mercurial practice of the United States by the late" Dr. John Warren, of Bos- ton. See, also, the Massachusetts Medical Communications, vol. ii. On this most interesting subject, the use and abuse of mercury, a work of clinical value appeared so long ago as in 1811, entitled a Dissertation on Mercury, by John W. Francis, New York. This elaborate essay contains many details of value relative to the medical history and curative action of this heroic prescription. The author considers the several forms of mercurial erethism as more likely to occur from the external applications of the remedy than from its internal use. He notices the loss of memory for years, arising from the too free introduction of mercurial salts into the system ; and ingeniously contends that mer- cury as a curative agent effects its great design by its uni- versally stimulating or exciting action, and its alterative in- fluence in eliminating specific disease by unlocking all the emunctories of the body. The recent doctrines of Liebic?, now so popular, seem to have been fully broached in this treatise by Dr. Francis. The assimilating principle in elucidation of the action of small-pox, venereal disease, 198. ix. Salts—Metallic corrosive, t) 199. A. Of Antimony, « 200. B. Bismuth, trisnitrate of, v 201. C. Copper, preparations of, y 205. D. Gold, chloride and iodide of, t) 211. E. Mercury, bi-chlonde of, y 216. Nitrates, bi-cyanide, and some other preparations of, y 226. F. Silver, nitrate of, Y 229. G. Tin, the chlorides of, Y 231. H. Zinc, chloride and sulphate of, Y 232. z. Vegetable acrids, Y 234. a. Anemone, the poisonous species of, Y 235. b. Arum maculatum and A. dracunculus, y 236. c Briunia dioica, y 237. d. Caltha palustris, Y 238. e. Chilidonium majus, and other species, y 239. /. Croton tiglium, v 240. g. Cucumis colocynthis, ) 251. p. Juniperus Sabina, <) 252. q. Momordica elaterium, Y 253. r. Narcissus pseudo-narcissus, I) 254. s. Ranunculus, several species of, y 255. t. Rhus toxicodendron, Y 256. u. Stalagmitis cambogioides, t) 257. v. Other acrid and corrosive plants, Y 258. Class II. Depressing and paralyzing Poisons- Sedative Poisons, * 261. A. Acetic acid, in frequent doses, and diluted, y 268. B. Acids, the mineral, frequent doses of the dilute, y 263. C. Alkalies and their carbonates, prolonged use of, I) 264. D. Cold or abstraction of animal heat, Y 265. E. Digitalis purpurea, y 266. F. Lead, preparations of, Y 275.. G. Prussic or hydrocyanic acid, and its compounds, , 289. v ' H. Zinc, oxide of, y 321. /. Vapours of ether and alcohol, t> 322. Class III. Excitants—Stimulants— Exciting and exhausting Poisons, y 323. i. Alcohol, Y 324. ii. Ethers, y 336. iii. Camphor, y 341. iv. Chelidonium majus and C. glaucium, t) 352 v. Heat, in various forms, Y 353. POISONS—Bibliography and References. 483 vi. Ipecacuanha, Y 358. Class IV. Exciting and constringing Poisons- Nervous and muscular Excitants. 6 361. i. Alum, Y 363. ii. Nux vomica and Strychnia, y 364. Various plants containing Strychnia, v 370. iii. Brucia antidysenterica, &c, Y 378. iv. Cocculus Indicus, Y 379. v. Coriaria Myrtifolia, y 381. Class V. Irritating and depressing Poisons—Ir- ritatino and paralyzing Poisons—Acro-Seda- tives, y 3S2. i. Aconite : varieties of A. napellus. y 383 ii. Arsenic and its compounds, t) 393. iii. Colchicum autumnale, y 419. iv. Hellebore and its species, t) 423 v. Food poisons, Y 427. A. Poisonous fish, Y 428. B. Poisonous meats, I) 434. C. Diseased animai substances, fluids, secretions, &<:., t) 444. vi. Mineral and saline acrb-sedatives, y 451. A. The antimonial compounds—Tartar emetic, 458. C. Cupreous preparations and compounds, y 464. D. Salts of potash, y 475. E. Sulphurets, ,481. F. Tartaric acid, Y 485. vii. The necroscopic poison—Poison imbibed from re- cently dead bodies. If 487. viii. Putrid animal matters, Y 519. ix. Tobacco—Indian and Virginian, y 523. A. Tobacco smoking, y 527. B. Tobacco chewing, y 528. x. Other vegetable acro-sedatives, Y 534. A. Castor seeds, $ 534. B. latropha manihot, y 535. Class VI. Irritant and alterant Poisons—Acro- alterant Poisons, <) 536. i. Belladonna, y 537. ii. Cantharides, y 546. iii. Chlorine and the chlorides, $ 553. A. Chlorine gas, y 553. B. Chlorate of potash, Y 556. C. The chlorides and the hypo-chlorides, y 557. iv. Iodine and its compounds, y 558. v. Mercury, the preparations of, I) 562 A. Mercurial vapours, Q 564. B. Mercurial salivation, &c, y 568. C. Mercurial diseases, y 570. vi. Thorn-apple, v 592. )lass VII. Narcotics or stupefying Poisons—Hyp- notics, I) 598. i. Carbonic acid gas, y 600. ii. Carbonic oxide gas, t> 610. iii. Carburetted hydrogen gas—Coal gas, &c, $ 611. iv. Chloroform and the ethers, y 615. v. Cicuta virosa—Water-hemlock, t> 617. vi. Conium—Hemlock, $ 619. vii. Henbane—Hyoscyamus, y 624. viii. Opium, and its preparations, $ 630 a. Opium eating, i) 637. 6. Opium smoking, Y 641. c. Morphia and its salts, (/ 650. ix. Sulphuretted hydrogen gas, y 661. class VIII. Narcotic and irritant Poisons—Acro- Narcotics—Narcotico-Acrid Poisons, y 667. i. Einpyreumatic oils, y 668. ii. Fooi's-parsley, I) 689. iii. Fungi —Poisonous mushrooms, Y 670. iv. Hemlock dropwort. y 680. v. Grain, diseased, y 681. vi. Laburnum, $ 683. vii. Leguminous seeds, y 684. viii. Lolium Temulentum, t> 685. ix. Yew-tree, v 686. Class IX. Septic and disorganizing Poisons, Y 687. i. Remarks on various septic poisons, y 688. ii. The bites of various poisonous serpents, $ 690. iii. The stings of insects, 5.—/. G. Puihn. Materia venenana Regni vegetsbilis, Svo. Dresd., 1785.—/. /. Plenk, Toxicologia, sell Doctrina de Venenis, Svo >'en., 1785— Longmare, in Duncan's Annals of Medicine, vol.ill., 7.-S. Hahnemann, Ueber den Arsenik Vergiftung, ibre Holfe, &c, Svo. Lips., 1786.-/. A'. Halle, G.fthistoriedes Thier.Pflanzen.umlM.ueralicichs.Svo. Berl., 1786.—/o». Skinner, A Treatise on the Venom of the Viper, Cherry- Laurel, &c.: Tiansl. from Fontana, 2 vols. 8vo. Lond., 175,7 —G W. C. von Wtlke, Weber die Giftpflanzen der Krautergarten, Svo. Hal., 1787.-B. Moseley. On Tropical Diseases (Poisons of Serpents, —Disorders INCIDENTAL TO PrEG NANCY. Classif.—General Pathology.—Semiol- ogy.—General Therapeutics. 1. A change is produced in the uterine or- gans by impregnation, which affects, sympa- thetically, the female constitution variously, ac- cording to temperament, diathesis, habit of body, predisposition, and age. The more con- stant and slight changes may be viewed as physiological, or as the natural and healthy con- sequences of the new action imparted to the uterine organs ; those which are characterized by more or less derangement of function may be, with equal justice, considered as patholog- ical. But there are other considerations be- sides these which relate to the physiological and pathological relations of pregnancy that will engage the mind,of the physician when he is required to treat these disorders, to which preg- nancy may predispose, or which it may more di- rectly occasion ; and these considerations have strict reference, not only to the treatment re- quired in the particular circumstances of the case, but also to the effects which such treat- ment may produce upon the state and progress of utero-gestation.% Moreover, the pregnant fe- male is not only liable to certain disorders in- cident to this state, but also to others, in com- mon with the species—to other maladies which attack all who are exposed to their causes. Even in the course of several chronic diseases pregnancy may take place, with or without mod- ification or change of that progress and termi- nation ; and thus the pregnant state is most important in respect of the course, termina- tion, and treatment of diseases which occur III. 32 during its course, as well as of those which had previously existed. The propriety, therefore, of devoting due consideration to the subject cannot be disputed. I have, however, to regret that my limits admit only of a very succinct ac- count of the several topics which the subject comprises. 2. I. The Local and Sympathetic Changes consequent upon Pregnancy.—Impregnation induces a remarkable change in the state of the uterine organs. The nerves with which these organs are supplied experience a more contin- ued state of excitement, and probably even an increased development. The blood-vessels and lymphatics increase in size, and their actions are augmented ; and while these organs become generally more vascular and more excitable, the uterus itself augments in volume with the progress of the contained embryo. The ganglia and plexuses supplying the sexual organs are intimately associated, as I have shown in the article Sympathy, and in the Croonian Lec- tures {published in the Medical Gazette, vol. xl.) by means of communicating branches of nerves, with the other ganglial and sympathetic nerves, and with the spinal cord and its nerves, both sensory and motory, with, in fact, the ganglial and the cerebro-spinal nervous systems, from both which these organs derive their energies, and upon, as well as through the media of, these systems, they produce their numerous and va- ried sympathies. That the uterine nerves, plex- uses, and ganglia experience, with the develop- ment of the ovum of the uterus and of the ute- rine vessels, an augmentation of their size, was an opinion entertained by W. Hunter, and sub- sequently confirmed by Tiedemann and R. Lee. With this remarkable increase of vital action, and of material or structural development of all the constituent tissues of the organ, a more ex- alted degree of sensibility is imparted, through the media of the organic and cerebro-spinal nervous systems, to the whole frame, which thus participates, more or less, in the excite- ment and vital activity of the uterus. 3. When it is considered that during preg- nancy the uterus, and, consequently, its con- stituent tissues, are undergoing a process of de- velopment, which Dr. Montgomery has shown to amount, at the full period of utero-gestation, to 519 times its virgin capacity, and to twelve times its solid substance, it cannot be a matter of surprise that so remarkable a change should be attended by numerous sympathetic phenom- ena, and that this organ, having become the centre of most important vital actions, should also be the source of various influences and de- rangements, manifested both by adjoining a' by remote parts, during the progress of that change and of the development of the embryo with which it is associated. The remarkable increase of the functions of assimilation, cir- culation, and nutrition observed to follow the appearance of puberty is often exceeded du- ring pregnancy; the excitement of the uterine functions, tending more remarkably, than the first evolution of these functions, to develop all the vital actions and manifestations—to in- crease the general sensibility and susceptibility, to augment vascular fulness and plethora, and to promote the several secretions and excre- tions, excepting that excretion furnished by the uterus itself. As consequences of these sym- 498 PREGNANCY—Disorders Incidental to. pathetic changes, and of various predispositions depending upon temperament, diathesis, habit of body, and previous disorder, numerous ail- ments arise in the course of pregnancy, as well as others which this state is nut concerned in producing. 4. Other disorders also occur in the progress of pregnancy, which depend, more or less, upon the mechanical influence which the increased size of the uterus exercises upon the adjoining viscera, and probably also upon sympathetic excitement, or upon irritation, caused by vas- cular determination to this organ. As the ute- rus enlarges within the pelvis, the rectum, neck of the bladder, and urethra experience in- creased pressure, and some disorder of the functions of excretion is often thereby produ- ced, with pain in the back, and various sympa- thetic affections of a transient or varying char- acter. As the uterus enlarges farther and rises above the brim of the pelvis, the urinary blad- der is often pressed upon so as to diminish its capacity, and to occasion frequent calls to pass urine, or even some degree of incontinence of urine. When the womb has nearly or alto- gether acquired its utmost size, the mechani- cal effects produced by it may not be limited to the abdominal viscera, but may extend to the thoracic cavity, occasioning thus disorder of the functions of one, or of several organs. The stomach, duodenum, biliary organs, kidneys, and colon have their functions impeded or disorder- ed ; and indigestion, jaundice, constipation, and pains in the back and loins, and changes in the state of the urine are often complained of. The mechanical disturbance extends upward, the di- aphragm being pressed so high as to diminish the thoracic cavities, and to disturb the func- tions of the lungs, and sometimes also of the heart, occasioning dyspnoea, short breathing on slight exertion, and embarrassed circulation through the cavities of the heart. The pres- sure, also, upon the veins and absorbents with- in the pelvis occasions a varicose state of these vessels, oedema, pains of the limbs, numbness, or neuralgic affections. In some cases, espe- cially in females having a small pelvis or ab- domen, or who have borne several children, the muscular and integumental parieties become relaxed or pendulous, admitting of malpositions of the uterus. 5. If. Affections of the Uterine and Gen- ital Organs and of the Mammae, caused by Pregnancy.—Disorders of related Parts.— k.CEdkma of the Labia Vulvae occurs chiefly in females far advanced in pregnancy—during the 7th, 8th, and 9th months. It disappears immediately after delivery, and is caused chief- ly by the pressure of the gravid uterus, espe- cially when descending into a large pelvis. It is much augmented by a sitting or standing pos- ture, and is characterized by a tense, colourless swelling, of equable density, often pitting on pressure, and by absence of throbbing and of increased heat. The oedematous labia may be attacked with erysipelas shortly before or after delivery, and the utmost danger, or even death, may result; or they may be the seat of simple excoriations. 6. Treatment.—A mild aperient, repeated oc- casionally, the recumbent position, and bathing the parts with a suitable lotion, will generally remove the affection. In some instances, diu- retics may be necessary; or even puncturing the oedematous parts, so as to allow the dis- charge of the fluid. If inflammation or erysipe- las occur, the treatment should depend upon the peculiar features and circumstances of the ca.se. 7. ii. Pruritus of the Vulvae.—This is oft- en a very troublesome affection, and frequently connected with a leucorrhceal discharge [ascar- ides in the rectum], or with an aphthous state of the Vulva and lower part of the vagina, or with a state resembling an eruption of small papulae. It is generally referable to the active vascular determination to the sexual organs, consequent upon impregnation. 8. Treatment. — Lotions of acetate of lead, [hydrocyanic acid], or of nitrate of silver have usually been prescribed for this affection. I have generally added a little vinum opii to these. Lotions consisting only of tar-water will gen- erally prove efficacious. In the summer of 1826 I was consulted by a surgeon in an obsti- nate case, for which the usual means had been employed. I advised a saturated solution of borax in rose-water ; and this proved success- ful. Since I hat time I have generally prescrib- ed this substance for similar cases. Dr. Church- ill states, that a decidedly antiphlogistic treat- ment may sometimes be required ; as venesec- tion, leeches applied to the vulva, and one or two smart purgatives. [Sometimes the stra- monium, belladonna, or creasote ointment will succeed in affording relief] 9. iii. Leucorrhcea is generally caused by the increased determination of blood |o the ute- rine organs during pregnancy, and probably, also, in part, by the pressure of the gravid ute- rus. It sometimes occasions great debility, and increases the aching of the back often com- plained of during pregnancy. It may, when excessive in the early months, cause abortion; but at an advanced period it is not very inju- rious, otherwise than by producing or increas- ing debility. 10. Treatment.—The propriety of removing or suppressing this discharge ought to be con- sidered before any treatment is ordered for it. In many cases, the inconvenience is not so great as to require treatment. But in some instances the discharge is so exhausting as to require to be moderated, if not altogether ar- rested. To strong, plethoric females, and where the disorder proceeds from active deter- mination of blood to the uterine organs, a mod- erate venesection and cooling aperients will prove beneficial. In weak or delicate females, and when the digestive organ's are disordered, the bitter infusions, as those of cheyreita or of calumba, with small doses of the muriated tinc- ture of iron, or with a mineral acid, will he of service. If the discharge occur in connexion with any pulmonary affection, it may be mod- erated by internal remedies; but it should not be arrested by powerful astringents. {See art. Leucorrhcea.) 11. iv. Mknstruation during Pregnancy, or, rather, a periodical discharge of a sanguineous fluid from the vagina, have been occasionally observed. This discharge may occur once or oftener during utero-gestation, and after irreg- ular intervals, but it most frequently takes place at the menstrual periods, and in some instan- ces it returns for three, four, five, or six months, or even lor the whole period of pregnancy. PREGNANCY—Dis Drs. Denman and Hamilton have doubted the occurrence of these discharges, a skepticism the more remarkable considering the great ex* perience of these physicians, and the frequency of the phenomenon according to the observa- tion of very eminent practitioners. Although I have never been engaged in the practice of midwifery, yet I have been consulted in two cases in which this discharge was stated to have occurred regularly during four or five suc- cessive menstrual periods ; and not in one preg- nancy only, but in each of several occasions of utero-gestation. Neither of these patients had ever had an abortion. The discharge was rep resented to have continued from three to four days, to have become paler than usual after the second day, and to have passed into a moder- ate leucorrhcea. It does not appear to be at- tended with any inconvenience to the patient beyond increased aching of the back and loins. The growth of the child is not affected by it; although, judging from the instances which I have seen, the constitution is rendered more delicate ; so that the aphorism of Hippocrates, "that the children of women who menstruate during pregnancy cannot be healthy," appears partly true. The discharge probably proceeds from the vessels of the cervix uteri and vagi- na, in consequence of the more than usual vas- cular determination to the uterine organs du- ring pregnancy, the periodic recurrence being the consequence either of ovarian excitement and influence, or of habit. 12 Treatment, in most instances, is unne- cessary, or nearly so. In one of the two cases which I have alluded to, the lady who was its subject had four children, and this discharge occurred during each pregnancy. Nothing be- yond the recumbent posture, and quietude as long as the discharge continued, was prescri- bed. Three of the four children are living and well, but are of delicate constitutions. Hippoc- rates advises cupping over the mammae, and Mauriceau bleeding from the arm. Neither of the cases which I saw required any depletion. 13. v. Watery Discharges from the Vagi- na have caused some discussion as to their source or sources. The fluid has been refer- red to the glands of the cervix uteri, but they cannot be supposed capable of furnishing so abundant and so clear a fluid; although these glands and those of the vagina often furnish a copious mucous secretion. The fluid is more probably collected between the amnion and cho- rion, or between the chorion and decidua, and evacuated during the advanced stage of preg- nancy, or some time before the commencement of labour. In rare instances, the fluid may be actually the liquor amnii. Dr. Burns remarks, that he has known cases where a considerable discharge of water has taken place after fright or exertion, with subsidence of the abdominal tumour, a feeling of slackness, and irregular pains, and yet the woman has gone to the full time. Other writers have made the same ob- servation. Dr. Davis mentions these discharg- es, especially when they occur " in dribbling quantities weeks and months before labour," as indicative of great consequent danger. But in this other authors do not quite agree with him. The source of the fluid can be inferred only from the quantity and the recurrence of the discharge, and the effect produced upon the rders Incidental to. 499 abdominal tumour. If the discharge be great, sudden, and affecting the tumour, it may be re- ferred to the escape of the liquor amnii. If it be gradual, small in quantity, and does not af- fect the abdominal tumour, it may proceed from the other sources pointed out. 14. The treatment consists in keeping the pa- tient dry, clean, and perfectly quiet. An ano- dyne may be given as circumstances may sug- gest a recourse to it, and the bowels kept gen- tly open by cooling aperients. Injections per vaginam, similar to those advised for leucorrhaa, have bpen recommended, but they are of doubt- ful efficacy ; all perturbations, whether mental, physical, or medical, being much more injuri- ous than beneficial. 15. vi. Dropsy of the Amnion.—See art. Dropsy, § 113, et seq. 16. vii. Rheumatism and Spasm of the Ute- rus have been described chiefly by German and French pathologists. Rheumatism may attack the uterus, as Well as other fibrous struc- tures, although much less frequently than those of more superficial or external parts. It is characterised by severe pain, increased on mo- tion and the contraction of the abdominal mus- cles ; by augmented sensibility and tenderness; and by symptomatic fever and restlessness.— a. It is caused by cold, currents of cold air, and the usual causes of rheumatism acting upon a rheumatic diathesis. Velten states that it was observed during an epidemic of rheuma- tism ; and Wigand, Joerg, and others, that it was caused by the projection of the clothes, during advanced pregnancy, by the enlarged abdomen, producing exposure of the lowpr part of the body It may occur at any period of gestation, but is much more frequent in the lat- ter months. The slighter states of it are very probably, as Dr. Churchill suggests, what have commonly been called " false pains." 17. b. Symptoms.—The milder attacks con- sist chiefly of shooting pains in the region of the uterus, occurring at intervals, and either limited to a small space, or affecting the organ more generally The severer attacks occur often suddenly, and without any apparent cause; are attended by violent pain in the region of the uterus, the duration and the character of the suffering distinguishing them from the com- mencement of labour, even although there may he distinct contractions of the uterus, and slight dilatation of the os uteri. In the milder forms there is little or no constitutional disturbance; but the more severe are attended by quickened pulse, hot skin, sleeplessness, and restlessness. Rheumatism of the uterus is generally accom- panied with spasm, or irregular contraction of the organ, which is sometimes extended to the lower limbs. The irritation is occasionally, also, propagated to the bladder, causing frequent and painful micturition, and to the bowels, oc- casioning colic, tenesmus, or diarrhcea. "The motions of the child are a source of great tor- ment, owing to the increased sensibility of the womb; and from some sympathy with the mother, it not infrequently happens that these motions are peculiarly lively." 18. When the affection occurs during par- turition, Wigand, Dezeimeris, and Churchill state that the ■l.itural pauis are arrested, or be- come ledious, ineffective, sudden or interrupt- ed, and more distressing than usual. The pa- 500 PREGNANCY —Disorders Incidental to. tient is hot, thirsty, and irritable or restless ; the pulse being quick, and either full, soft, and undulating, or small and hard. The uterus is very tender, the weight of the bedclothes occa- sioning much pain ; and the cervix and os ute- ri are often tender and painful on examination. If the case be left to itself, the pains become weaker, or suspended for hours. If the patient falls into perspiration and sleep, the natural pains recur, and delivery is favourably termina- ted.—(Churchill.) 19. c. The diagnosis between rheumatism and inflammation of the uterus consists in the more limited and continued pain of inflammation, and in the more sudden, spasmodic, and paroxysmal character of the pain bf rheumatism. It is not improbable that some cases, occurring in the eighth or ninth months of pregnancy, are mere- ly spasmodic paroxysms, or irregular contrac- tions of the body of the organ, and not truly rheumatism affecting its structure. 20. d. The prognosis is generally favourable, when the patient comes early under treatment; but if she be neglected, abortion or premature labour may follow the continuance of the attack, and the repeated contractions of the uterus and spasm attending the complaint. Slight dilata- tion of the os uteri usually attends the period of severe suffering; but this part regains its natural state upon the subsidence of the attack. Joero states that the child is less frequently injured by rheumatism than by inflammation of the uterus. 21. e. The treatment consists of venesection varying in amount from six to twelve or six- teen ounces, when the patient is young, strong or plethoric, and when there is fever with a hard or full pulse ; of sedatives and diaphoret- ics ; and of anodyne enemata. Opium with ipecacuanha may be given at bedtime, or Do- ver's powder; and, after opening the bowels by a suitable aperient, an emollient and anodyne clyster should be administered. An opium or belladonna plaster may be applied over the ab- domen or loins ; and diaphoretics should be ad- ministered at intervals, conjoined with an opiate or some other narcotic. The warm embroca- tion containing spirits of turpentine, with a con- siderable proportion of the wine or tincture of opium, may be applied over the abdomen. If the attack occur at the commencement of par- turition, this embrocation, without the opium, will generally prove efficaoious. The bowels ought to be kept quietly open, so as to prevent faecal accumulations; and the diet duly regu- lated. 22. viii. Inflammation of the pregnant Ute- rus.—Inflammations of the womb in the unim- pregnated state, and after delivery, are descri- bed in the articles Uterus and Puerperal Dis- eases. I have merely to notice such peculiar- ities as hysteritis presents during gestation. As may be anticipated from the physiological conditions of the uterus, inflammation attacks the impregnated organ more frequently than the unimpregnated, although less so than after delivery.—a. It is caused by exposures to cold, by injury, by concussions of the trunk, by the abuse of spirituous liquors, and by the exten- sion of inflammation from adjoining parts. Hysteritis during pregnancy and after delivery, as observed in the metropolis, is chiefly caused by the abuse of spirituous liquors, more espe- cially of gin. It is said to be most frequently observed in the sanguine and irritable temper- aments, and scrofulous diathesis, and seldom to occupy the entire uteru.s, unless in the very early months. In the latter months of preg- nancy, it is more limited, affecting chiefly the lower portions or cervix. At earlier periods it is commonly seated in that part to which the placenta is attached. The inflammation is seat- ed in the muscular structure, but the peritone- al coat may also be implicated; in which case partial or limited adhesions may form between the fundus or body of the uterus and adjoining parts, as I have observed in several instances. 23. b. The symptoms are a severe, constant, or aching pain in some part of the abdominal tumour, increased upon pressure, upon sudden motion, walking or descending stairs quickly, and by the movements of the child. It often extends to the back and groins. Sometimes dy- suria, or a frequent desire to pass urine, or te- nesmus, or pain on going to stool, is complain- ed of. More or less sympathetic disturbance is produced, especially heat of skin, quickened pulse, thirst, nausea, or vomiting. " If the dis- ease be very limited, the child may escape in- jury, and gestation be completed ; but if more extended, the foetus will probably perish in ute- ro, or be prematurely expelled." Unless the disease be completely removed, and the womb restored to a healthy condition, the consequen- ces during parturition may be very serious. Dr. Gason informed Dr. Churchill that, in three cases of inflammation of the womb during preg- nancy, rupture took place during labour in the exact spot previously diseased. Dr. E. Murphy states that most instances of rupture of the ute- rus may be traced to lesions either previously existing or produced by inflammation. The wife of a respectable tradesman, for whose fam- ily I was often consulted, complained of hyste* ritis at an advanced period of pregnancy. She had had several children, and her constitution was much injured by gin-drinking. She sunk almost instantly upon delivery from sudden and profuse flooding. Inspection of the body was not allowed. 24. c. Hysteritis during pregnancy may ter- minate, 1st. In resolution, the patient going her full time and being safely delivered ; 2d. In ef- fusion of lymph and the firm adhesion of the placenta to the uterus; 3d. In softening of the structure of the organ, favouring rupture or dan- gerous or fatal hemorrhage; 4th. In the pro- duction of an abscess or small abscesses in the inflamed portion of the uterine parietes; and, 5th. Even in gangrene, as described chiefly by the German writers on diseases of the uterus. 25. d. The prognosis, as shown by these ter- minations, ought to be guarded, especially when the disease occurs in females addicted to the use of spirits, to whom it is frequently fatal in one of the ways now indicated. 26. e. The treatment should depend upon the habit of body, strength, and habits of the pa- tient, and upon the extent and severity of the local symptoms and of the constitutional affec- tion. Although the local suffering is generally less severe than in rheumatism of the womb, the constitutional disturbance is greater and a more decided and prompt treatment is often required. In other respects the treatment is much the same as recommended for rheuma- PREGNANCY—Disorders Incidental to. 501 tism of the organ. Local vascular depletions are generally beneficial; and calomel, camphor, and opium are also of service. In other re- spects the treatment should be the same as advised for inflammation of the womb in the other articles comprising it. {See Uterus and Puerperal Fevers.) 27. III. Affections occurring sympathet- ically during Pregnancy.—The general sys- tems and the more remote organs may experi- ence more or less disorder in the course of preg- nancy, arising either directly from the altered state of the uterus; or indirectly, as from faecal accumulations in the large bowels, that are apt to form during the earlier periods of gestation. —i. The Digestive Organs often experience more or less disorder. The slighter or less im- portant of them may be only mentioned.—A. Toothache is frequently complained of, but is owing to the common causes of the affection ; for it is not usually felt when these causes have not existed before conception ; pregnancy, ei- ther directly or indirectly, aggravating merely a pre-existing evil. The bowels generally re- quire moderate but repeated doses of stomach- ic aperients, and afterward anodynes, locally and internally, preparations of iron, narcotics, and antispasmodics, &c. The question as to the propriety of extraction, or of other painful operations for this complaint during pregnancy, may be considered as set at rest by having re- course to ether or chloroform inhalation. 28. B. Salivation is sometimes troublesome; but it is rarely of great importance. It will generally be moderated or removed by a judi- cious use of stomachic or cooling aperients, by cooling and astringent gargles, and attention to the states of the gums and teeth. Rinsing the mouth often with tar-water, or with muci- laginous fluids containing creasote or spirits of turpentine, will generally be useful, and also benefit the teeth and gums. Capricious or mor- bid appetite is not infrequent during pregnancy; but this topic suggests nothing of any impor- tance in addition to what I have stated in the article Appetite. If, however, carried to an extreme, it may, as well as frights and violent mental perturbations, affect the development of the foetus. 29. C. Nausea and Vomiting generally occur at some period of gestation—most frequently from the third to the sixth week after concep- tion, although occasionally only a few days after this act; and sometimes not until the seventh or eighth month of gestation. At the earlier periods these symptoms are merely sympathet- ic. In the latter months they may, in some measure, be caused by the pressure of the ute- rus.—a. The patient usually finds her stomach uncomfortable on rising in the morning, and the discomfort soon amounts to nausea or vom- iting. Whether the stomach be evacuated or not, the nausea ceases after a few minutes or within an hour; and, after some delay, break- fast is taken with the usual or good appetite, and without subsequent inconvenience. These attacks are renewed every morning for six weeks or two months, when they gradually subside. In some cases, vomiting does not occur until a full meal is taken. It may also take place at any time of the day, or in the evening. Instead of gradually ceasing about the third or fourth month, or after quickening, it occasionally continues during pregnancy, causing great distress and some risk. If car- ried beyond certain limits, it may occasion mis- carriage. When vomiting follows a meal the constitution of the patient languishes from a want of due nourishment as well as from the continued irritation, the patient even sinking from inanition or exhaustion. Several instan- ces of this issue are recorded in the works re- ferred to in the bibliography. When the prog- ress of pregnancy is arrested by the death of the foetus, then the vomiting ceases spontane- ously. Instances have occurred of an internal organ, the uterus, stomach, &c., having been ruptured by the violence of the vomiting. The matters thrown off the stomach may be thin, watery, glairy, colourless ; or consist partly of bile, or of blood. In severe cases they are greenish or blackish, owing to an admixture of bile or an exudation of blood. The vomiting is generally attended by tenderness at the epi- gastrium, prostration of strength, a weak, small, quick pulse, constipated bowels, and sometimes a loaded tongue. 30. b. The causes of the serious cases of vom- iting during pregnancy have not been duly in- vestigated even by those physicians who be- lieve themselves the sole depositories of the knowledge of female maladies. Writers on these maladies have not even shown whether or not this vomiting may not result from dis- ease of the uterus or of the ovum ; and they have not always attended to the existence of disease of the liver and biliary apparatus, or of the duodenum and pancreas, or of the stomach itself; or to the presence of scybala, or of ir- ritating substances locked up in the cells of the colon. They even furnish no information as to the states of the kidneys or of the ovaria— so little has a division of labour hitherto tended to advance this department of medical science. Cases, however, have occurred when danger- ous or fatal vomiting has been caused chiefly by lesions seated as just stated, or by retained irritating matters, pregnancy merely developing and perpetuating a sympathetic disease, which in most of its morbid relations had previously existed, but had been latent, until it became ag- gravated or excited by the change in the ute- rine organs. 31. c. The diagnosis of vomiting should not be overlooked, with reference to its dependence or non-dependence on pregnancy. The chief circumstances indicative of its dependence on this cause are its occurrence and daily recur- rence in connexion with the disappearance of the catamenia, the speedy return of appetite and of the appearance of good health in the in- tervals, the changes apparent in the nipple, are- olae, and in the mammae, and the absence of any sign of disease of the stomach itself, or of any other organ. 32. d. Treatment.—In slight cases, and espe- cially during the early months, little or no treat- ment is necessary: time will remove the dis- order. But the bowels should always be kept gently open, as any accumulation in the large bowels aggravates the complaint. If nausea be distressing, and unaccompanied with vomiting, an ipecacuanha emetic will often be of use at an early period of gestation ; and, after having evacuated the bowels, the infusion of calumba or of cheyreita may be given. If the patient • " 60S PREGNANCY—Disorders Incidental to. be very robust or plethoric, a moderate bleed- ing will be serviceable at the commencement; but at a later period, or when she is reduced by the duration of the disorder, it is inappro- priate. Gentle stomachic or cooling aperients, suited to the circumstances of the case, are generally beneficial. The most useful are, the confection of senna with magnesia, [lemon- juice], the infusions of calumba and of senna with tartrate of potash, with an aromatic spirit; the compound infusion of roses with sulphate of magnesia, a little dilute sulphuric acid, and tincture of orange-peel; and, if the bowels are not much confined and the sickness more ur- gent, from a scruple to half a drachm of sul- phate of magnesia with fifteen grains or a scru- ple of rriagnesia, and four or five drops of tinc- ture of opium, in spear-mint water, taken once, twice, or thrice daily. In several cases, the nausea or the vomiting is aggravated or per- petuated by acidity, especially if flatulency is complained of. The infusion of calumba, with magnesia and ammonia, is then very beneficial. Small morsels of ice are sometimes of use. 33. In more severe cases, the application of embrocations over the stomach, or mustard poultices, or terebinthinate epithems, or blis- ters may be resorted to. When the matters thrown off are acid, acrid, or attended by flatu- lent eructations, powdered charcoal, magnesia, ammonia, or other alkalies are severally of use. The hydrocyanic acid may also be given ; or creasote, either in pills or in mucilaginous mix- tures. The several preparations of opium or of morphia, conjoined with other medicines— either those already enumerated, or warm aro- matics and spices, as capsicum, aromatic con- fection, &c.—are sometimes of service ; and embrocations or epithems with laudanum over the stomach afford relief in the more urgent circumstances of the case. During the use of these means, the bowels ought to be preserved in an open state, either by such aperients as are most likely to be retained qri the stomach, or by laxative and anodyne clysters. When the bowels are sufficiently evacuated, starch enemata, containing sirup of poppies or tbe compound tincture of camphor, will then be of service. In all circumstances the horizontal posture ought to be adopted, and strict atten- tion paid to diet, the patient's desire for arti- cles of food being indulged, if there be no rea- son to the contrary. When all other means fail, and the case admits of the measure, the induction of premature labour may be contem- plated, or even attempted.* 34. D. Heartburn, Pyrosis, spasmodic and colicky pains are often complained of during pregnancy, and are severally relieved by ant- acids, conjoined with tonics, antispasmodics, and anodynes, and by a due promotion of the intestinal secretions and excretions, as just ad- vised for nausea or vomiting, or as they are more fully directed in the articles Indigestion, Colic, Pyrosis, and Stomach. 35. E. Constipation of the bowels is very common during pregnancy, and always aggra- vates the disorders of the stomach, which have been noticed above.—a. It is caused in some instances by the pressure of the gravid uterus [* We have known two cases where it was necessary to resort to this measure, and where it proved successful, sa- ving, beyond doubt, the life of the patient.] on the rectum and sigmoid flexure of the co- lon ; by impaired action of the bowels in oth- ers, owing to vital and vascular determination. to the uterus; and not infrequently it is in- creased by the impaction of hardened faeces in the cells of the colon. Faecal accumulations in the cells may exist, and may even endure for weeks or months without the constipation being remarkable; and in this way many of the disorders of pregnancy may be produced or aggravated ; not merely those already mention- ed, but also headaches, restlessness, watchful- ness, colicky pains in the abdomen ; weight, flatulence, and distention in this cavity ; hem- orrhoids, and sometimes diarrhcea or tenes- mus. If these ailments continue or increase, owing to the retention of faecal collections, in- flammation of the bowels or dysentery, or abor- tion may supervene. If constipation, and the collections of faecal matters in the bowels con- sequent upon it take place during the latter months of gestation, or he retained until the period of delivery, the diseases incidental to that period are very readily produced. 36. b. The treatment consists of the occasion- al recourse to the aperients already mentioned; to rhubarb and magnesia; to the infusions of gentian and senna, with such adjuncts as may suggest themselves ; to confection of senna with sulphur and magnesia; to castor oil or olive oil taken in small and frequent doses ; to the compound rhubarb pill, with extract of hen- bane and Castile soap, and sometimes, also, a a little ipecacuanha ; to emollient and laxative enemata; or to soap or oleaginous clysters. In obstinate cases more active means may be employed, with due reference to the situation of the patient; and for these I must refer the reader to the article Constipation and Cos- tiveness. 37. F. Diarrhoea is often met with during pregnancy as a consequence of improper food, &c, and of neglect of the bowels, or of consti- pation. It may be kept up by the presence of hardened faeces in the cells of the colon.—a. It may occur at any period of pregnancy, and may arise from cold, from mental perturbation, from the state of the secretions and excretions, and without any assignable cause. The acidity consequent upon imperfect digestion often oc- casions it. Very recently I was consulted re- specting a case which resisted absorbents, as- tringents, tonics, opiates, &c. The patient ac- cidentally mentioned her addiction to the use of immoderate quantities of sugar. This sub- stance was interdicted, unless in small quanr tity; and within three or four days afterward the same medicines as were previously taken without benefit removed the complaint. 38. b. The treatment consists of small doses of hydrarg. cum creta with Dover's powder; or of small quantities of rhubarb with ipecacu- anha and dried sub-carbonate of soda • of ipe- cacuanha with the extract of hop, or with the compound soap pill ; of cretaceous mixture with compound tincture of camphor, or tinc- ture of hop ; and of flannel clo.hing worn next the skin, and suitable diet. (See, also, art. Di- arrhoea.) 39. G. Jaundice is not of frequent occur- rence dur.ng pregnancy. .It may appear at any period of gestation, but more frequently during the latter months, and in females who have had • PREGNANCY—Disorders Incidental to. 503 several children, or are advancing in life. It generally continues until after delivery. It may be caused by the pressure of the gravid uterus, but more frequently by some one of the several pathological conditions assigned in the article Jaundice. The symptoms vary with these con- ditions ; and the treatment should have strict reference to them, as well as to the stage of pregnancy and other peculiarities of the case. Although laxatives, or even chologogue purga- tives, may be cautiously employed and repeated more or less frequently, yet active cathartic or other heroic measures should not be prescribed If nausea or vomiting occur, or diarrhcea, the remedies advised above for these may be em- ployed ; and the more urgent symptoms, as pain and spasm, should be palliated by means of narcotics, &c. If the symptoms indicate ac- tive congestion or inflammation of the liver, bleeding and other antiphlogistic means must be adopted. 40. ii. Various Disorders of the Heart and respiratory Organs sometimes occur during pregnancy. These are apt to appear in hys- terical or nervous females, and during a first pregnancy. — A. Faintness, fainting, or full syncope, is most apt to occur at the period of quickening, but it may take place at any pe- riod, or may recur occasionally or frequently. Delicate and weak females are most liable to it. " Towards the end of pregnancy, fainting is regarded with much suspicion, not so much for the immediate consequences as for its effect upon convalescence after parturition." (Churchill.) It may prove a serious affection if it depend upon passive dilatation of any of the cavities or orifices, or other organic disease of the heart: lesions which consultation will detect. 41. B. Palpitations of the Heart are often connected with faintness or syncope, either of these preceding or following the other ; and both affections often depending upon the pres sure of the gravid uterus upon the digestive or- gans, and of these latter upon the diaphragm. The embarrassment thus occasioned to the cir- culation through the heart is often increased by collections of flatus in the stomach, and even in the oesophagus, as well as in other parts of the digestive canal, these collections being often retained by spasm of adjoining parts of the ca- nal. These symptomatic affections are usual- ly caused, developed, or aggravated by mental emotions and perturbations, by errors in diet, by startling noises or occurrences, by disordered states of the stomach and bowels, and by a sus- ceptible and hysterical diathesis. The treat- ment is nearly the same /or both affections. During the paroxysm of faintness the patient should assume the horizontal position ; during that of palpitation, the sitting. Antispasmodics and stimulants are beneficial for both, especial- ly those which are prescribed for Hysteria. Between the attacks, tonics, restoratives, qui- nine or cinchona, the bitter infusions or decoc- tions, stomachic aperients, with due attention to diet and regimen, will generally prevent a re- turn of disorder. 42. C. Cough and Dyspnoea may occur in the early months from sympathy. Either of these may then assume an hysterical charac- ter, the cough depending chiefly on sympathetic iiritation of the larynx or trachea, and dyspnoea arising either from the same cause or from af- fection of the bronchi or respiratory nerves. In these circumstances, both cough and dyspnoea are nervous, spasmodic, or hysterical. But in the advanced stage of gestation, both affections may be caused and continued by the pressure of the gravid uterus, and aggravated by flatu- lence, indigestion, and costiveness. The diag- nosis should, however, be established by means of the stethoscope and percussion, and by an attenfive consideration of the several rational symptoms, lest these symptoms proceed from pneumonia, bronchitis, tubercular disease, or some other malady that has supervened or been developed in the course of pregnancy. When these affections are merely nervous and sympathetic, the treatment should be antispas- modic and anodyne. The bowels ought to be freely evacuated, and kept duly open ; and acid- ity of stomach and flatulence prevented by means of tonics, antacids, and carminatives, as already advised, the diet and regimen being duly regulated. If these affections occur in full and robust females, they may be connected with pulmonary congestion, and then blood-let- ting is requisite. When the cough is severe, the use of narcotics and anodynes is of service, in order to moderate it and to diminish the risk to the foetus. If it be attended by dyspnoea, pain, or fever, or by adhesive or glairy expec- toration, blood-letting is also proper, with anti- monial and other diaphoretics. 43. D. Haemoptysis may occur with or with- out either or both of the affections just noticed. It is not often observed, for pregnancy more frequently removes than induces this com- plaint. When, therefore, it is met with during pregnancy, it should be viewed as a most se- rious evil, and the means advised for hemor- rhages promptly employed, according to the state of the case, especially blood-letting, cup- ping over the back or thorax, acetate of lead with opium, digitalis, acids, antimonial diapho- retics, turpentine epithems applied over the chest, &c. 44. iii. Disorders of the Nervous System during Pregnancy.—A. Headaches are fre- quently experienced during utero-gestation, and chiefly by two classes of constitution : 1st, by the delicate, nervous, hysterical, and those de- ficient in blood ; 2d, by the plethoric and ro- bust. In the earlier months the nervous char- acter of headache is most pronounced, in the later months the congestive or plethoric. This latter form is often connected with impeded circulation through the heart and lungs, in con- sequence of the pressure of the gravid uterus, and in this case more particularly it is aggra- vated by indigestion, flatulency, and costive- ness. The nervous form of headache is often limited, as to the vertex—the clavus hystericus —or to one side—hemicrania. It is oftener felt in paroxysms than without intermissions; and it is unattended by flushings of the face, heat of scalp, or injection of the conjunctivae. Con- gestive or plethoric headache is attended by flushing, increased heat of scalp, injected eyes, a sense of throbbing, distention or fulness, by intolerance of light and sound, and it usually commences in the forehead, and extends equal- ly to both sides ; it is also continued and some- times increased by a meal; while the nervous variety is relieved by a meal and by stimuli.. 504 PREGNANCY—Disorders Incidental to. 45. The treatment is different in either case. The nervous form requires stimulants, antispas- modics, and tonics ; as ammonia, camphor, va- lerian, cascarilla, &c. ; the congestive, moderate blood-letting, general, or local, according to cir- cumstances, purgatives, diaphoretics, &c. In all cases, the diet and regimen ought to be suit- ed to the form of headache which is complain- ed of, and the uses of all stimulating or resto- rative beverages either allowed or disallowed accordingly. 46. B. Sleeplessness is sometimes a dis- tressing complaint of nervous, hysterical, and delicate females, especially as pregnancy ad- vances. It is most liable to affect those who shut themselves in-doors, and deprive them- selves of exercise in the open air, and who sleep in too warm and ill-ventilated chambers, or with too much bed-clothes. It is often attend- ed by restlessness, by anxiety respecting tri- fling matters, and ultimately by despondency, and even by hypochondriasis. It is also inti- mately allied, and often associated with, nervous headaches. It is much more rarely associated with plethoric headache. 47. Treatment.—Besides the means already advised for nervous and hysterical headaches (v 45), I have seen decided benefit result from a'draught at bedtime, containing a drachm of the tincture of hop, with five or six of the car- bonate of ammonia, or from twelve to twenty grains of the carbonate of potash, or soda, or magnesia. When the sleeplessness is attend- ed by indications of plethora and active deter- mination of blood to the head, and with the usual indications of congestive headache ($ 44), then vascular depletions, purgatives, and other antiphlogistic means, and low diet, are required. 48. C. Despondency and Hypochondriasis are not infrequent in hysterical females, espe- cially during a first pregnancy, and more espe- cially in unmarried females. In married fe- males, these moral affections are most com- monly seen in the delicate constitution and hysterical diathesis, and are often attributable to no other exciting cause than the contempla- tion of the future pains and contingencies of child-birth, or the private contrarieties and anx- ieties of married life. In the unmarried, nu- merous and painful reflections serve to develop these mental conditions, and even to carry them on to a state verging on insanity, and subver- sive of due control. In many such cases, the sentiments and emotions excite the cerebral circulation, and this in its turn augments the despondency, or carries it beyond the limits of sane judgment and conduct. 49. The treatment depends upon the peculiar circumstances, moral and physical, of each case. If the despondency proceed from fears of the dangers of child-birth—a cause which seldom exists alone—a true statement of the small amount of that risk will generally allay such fears ; for there are very few females, however inexperienced, who indulge such fears after knowing the truth, especially when their hopes are excited and promoted by affection. If the disorder of the mind is truly nervous or hyster- ical, agreeable society, change of scene and of air, gentle exercise, mental occupation of a pleasant kind, healthy air, and restorative treat- ment will generally remove it. If the temper- ature of the scalp, the appearance of the eyes and countenance, and the action of the carot- ids, indicate increased determination of blood to the head, then moderate bleeding, especially if the patient be strong or plethoric, cold spon- ging the head frequently, mild purgatives, de- rivatives, warm clothing on the lower parts of the body, and light, digestible food, will be re- quisite, with such other means as the peculiar- ities of the case may suggest. 50. D. Convulsions during pregnancy as- sume one or other of these forms—the hyster- ical, the epileptic, or the apoplectic. The first of these is confined to utero-gestation, and is much more frequent during the early months than at an advanced stage. It is chiefly de- pendent upon the vital excitement and vascu- lar determination to the sexual organs, and af- fects chiefly the weak, delicate, and hysterical constitution. The character and treatment are in all respects the same as described in the ar- ticle Hysteria. Epileptic convulsions are the most frequent forms of convulsions at an ad- vanced period of pregnancy, and the apoplectic during or after parturition. They are fully dis- cussed in the articles Convulsion (y 27-88) and Epilepsy. 51. E. Painful Affections of the MammjK —Mastodynia—often commence during preg- nancy, with pricking or tingling sensations in them, followed by shooting pains, with slight soreness of the nipples and increased size of the mammae themselves, and especially of the glandular structure. The pains may be either of a neuralgic character, and owing to sympa- thy with the increased excitement of the ute- rus, or altogether consequent upon the stretch- ing of the fibrous envelope by increased devel- opment of the glandular structure. In the lat- ter months the pain is often dependent upon active vascular determination, which may go on to inflammation and abscess. 52. The ien£ consists of fomentations, or frictions with oleaginous and anodyne liniments, or emollient poultices. In many cases no treat- ment is necessary. In the severer attacks, if these means fail, anodynes, cooling aperients, and antimonial diaphoretics may be prescribed: blood-letting, general or local, is seldom requi- red, unless great tension, enlargement, or in- creased heat exist, and then the application of a number of leeches, or even venesection, should not be delayed, especially in plethoric females, lest active determination and conges- tion should go on to inflammation and its usual consequence, abscess. (See art. Mammje.) 53. F. Various other symptomatic Disor- ders, and even structural diseases, occasion- ally supervene in the course of pregnancy, ow- ing either to the sympathy existing between the parts affected or to the pressure of the gravid uterus. To the former of these states anomalous affections of the organs of sense, es- pecially of sight and hearing, altered sensibili- ty of various parts, occasional spasms, slight attacks of singultus, eccentricities of conduct or of sentiment, &c, are chiefly owing. To the latter cause, hemorrhoids, incontinence, or retention of urine, varicose veins, cramps or spasms of the lower limbs, oedema, anasarca, as- cites, &c, are chiefly to be referred, and are noticed in their relations to the pregnant state in the articles in which these several maladies are described. PREGNANCY—Disorders Incidental to. 505 54. III. Influence of Pregnancy upon the Course, Termination, and Treatment of Chronic or Pre-existent Diseases.—A. Va- rious pre-existent maladies have no influence in preventing conception ; a very few have even the effect of favouring the act, especially tuber- cular and scrofulous diseases, when not very far advanced ; glandular enlargements, slight hem- orrhages, hysteria, &c. Several of these mal- adies, indeed most of them, and especially those now named, are either altogether arrested in their progress, or impeded or rendered latent, owing to the vital determination to, and increas- ed vascular action developed in, the sexual or- gans, and to the salutary influence exerted thereby throughout the ceconomy. Pulmonary affections, especially tubercles in the lungs and haemoptysis, are generally arrested, if not too far advanced ; the pulmonary symptoms often almost disappearing during the continuance of pregnancy; but, soon after parturition, they often re-appear with much greater severity, and sometimes with various associations. When pregnancy occurs at an advanced stage of phthi- sis, the disease is only partially abated, or ren- dered somewhat more latent; and in this case, not only is the child born with tubercles al- ready formed, as I have ascertained by inspec- tion in three instances, but the mother sinks in a short time after delivery, with remarkable in- crease of the pulmonary symptoms, either gran- ular degeneration of the kidneys, with anasar- ca, ascites, &c, or delirium, or some other complication, besides the more common one of colliquative diarrhcea, rapidly appearing, and accelerating a fatal issue. When the pulmo- nary symptoms are only slight, the tubercles not having gone on to softening, then not only may pregnancy arrest the farther progress of the malady, but also may subsequent lactation, if duly managed so as not to impair the strength, exert a similar preservative influence, until pregnancy again recurs ; and thus the disease, which had appeared before marriage, and had even been attended by haemoptysis, be kept at bay for several pregnancies, or until the cessa- tion of child-bearing, when it generally reap- pears and runs its usual course. I have seen a lady who had experienced an attack of hae- moptysis before marriage, have nine children, and enjoyed tolerably good health, and, having ceased to become pregnant, die of consumption two or th ree years after the birth of her last child. 55. Although pregnancy thus arrests the prog- ress of chronic maladies in most instances, yet, if these maladies- are of so severe a character as not to be removed altogether, as some of them are, by this state, and by the changes in- duced by it in the frame, they may be very re- markably aggravated after parturition, or du- ring the last stage of gestation. Epileptic sei- zures may be rendered fewer or slighter during pregnancy, .especially in the earlier periods ; but they may be more severe at an advanced period, or even fatal during parturition. Para- lytic affections, even hemiplegia or paraplegia, may be complete, and yet the patient become pregnant, bear a child at the usual period, and even become pregnant several times ; but there is an increased risk of apoplectic seizures or convulsions during advanced pregnancy and during parturition. Pregnancy has generally a beneficial effect upon hysteria, leucorrhcea, and dysmenorrhoea, but there are not infrequent ex- ceptions; and in several other diseases so many circumstances tend to vary the results, provi- ded pregnancy actually occur in their course, that nothing precise can be advanced respect- ing them. .During chlorosis and anaemia, par- ticularly the former, pregnancy may not take place; but if it occur in either, a very benefi- cial change generally results. 56. B. As to the management or treatment of pregnancy thus occurring during chronic maladies but little can be said. The suggestions of good sense, guided by pathological knowledge, will point out what ought to be done and what avoid- ed, in the different and ever-varying circum- stances in which medical advice will be requi- red. In most instances, officious interference will be more prejudicial than beneficial; and the operations of nature, aided by suitable diet, pure, temperate, and dry air, and a gentle pro- motion of the several vital and excreting func- tions, will do more than any plan that can be laid down. Heroic or even active remedies should be avoided. They are out of place in these cases, and are only employed by charla- tans and pretenders in and out of the pale of the profession. In these, as well as in other circumstances, it is not only the probable good which may be done, but the possible evil also which may follow, that should engage our minds and guide our determinations as to the use of any remedy and the adoption of a particular plan of cure. 57. IV. Influence exerted by Pregnancy on the Production, Course, and Treatment of , Acute Maladies.—A. During pregnancy, the increased manifestations of vital action throughout the frame tend to ward off many of the slighter causes of disease, and even others of a more energetic kind, which would have, in other circumstances, been productive of dis- ease, fail of causing it, or cause it in a less de- gree, during this state. Various epidemics have been observed to affect a smaller propor- tion of pregnant women than of others, and even endemic diseases have been less frequent among them. Epidemic diseases of a malig- nant character, or those which often assume a malignant form, as smallpox, scarlet fever, measles, erysipelas, typhous and adynamic fe- vers, are liable to become not only malignant, but rapidly fatal when they attack pregnant fe- males, although this class of females are less predisposed to them than others. If these mal- adies appear at an early stage of gestation, abor- tion is likely to occur, and the danger is there- by increased; if they appear at an advanced period, or shortly before parturition, premature labour often takes place, and a fatal issue very frequently results soon after delivery. Other acute diseases, as inflammations of any of the viscera, although occurring less frequently in pregnant than in other females, are also attend- ed by much increased risk, not only of abortion, but even of dissolution ; although the danger is, upon the whole, not so great from these at- tacks as from exanthematous and malignant fe- vers. Hippocrates (Aphorism., L. v., 30) says, that " pregnant females seized with an acute disease never recover." This inference, how- ever, is too general, for recoveries take place, in some instances, from most of the acute mal- adies which have been now enumerated, but 506 PROSTATE GLAND—Inflammations of. the danger is always great, even in cases of in- flammation of the respiratory organs or pleura; and it is not less so, if not even greater, when inflammation of other important or vital organs takes place during pregnancy. 58. B. The treatment of acute maladies at- tacking pregnant females should be appropriate to the nature of the disease, to the pathological conditions of the case, to the progress it has made, and to the circumstances of the patient and the stage of her pregnancy. In most epi- demic, or exanlhematous, or febrile maladies which are not truly inflammatory, violent or perturbating remedies should be avoided ; vas- cular depletions, the promotion of the abdom- inal and cutaneous excretions, and due support of the vital powers being severally prescribed, as the nature of the disease and the circum- stances of the case may require. In every in- stance the malady should be carefully watched, remedies cautiously administered, and the vari- ous offices of the nurse assiduously performed. The numerous details which a due discussion of this subject might involve are beyond my limits. They will readily suggest themselves in practice to the observing physician, who will act in all things appropriately to the peculiar circumstances both of the disease and of the patient. Bibliog. and REFER.—Hippocrates, Tvvaucttiiiv, Op., p. 600.— Galen. De Causis Sympt., i., 7.—Pliny, Hist. Nat., xxiii., 56.—Ac'tius, xvi., 10.—Paulus Mgineta, 1. i.,c. 1.— Sydenham Edit., p. 4. Mr. Adams has given references to several of the ancients, and has added the following direc- tions, given by Aspasia (apud Aitium, xvi., 12) for the management of pregnant females: "Women who have conceived are to be guarded from frights, sorrow, and all violent mental perturbation. They are to avoid gestation in carnages, severe exercise, inordinate breathing, and blows about the loins ; also the lifting of heavy-loads, dan- cing, and sitting on hard seats. Likewise afl acrid and flatulent food and drink are to be avoided. All discharges of blood, from the nose or hemorrhoids, are dangerous in trie pregnant state. Moderate and wholesome food, gesta- tion in a sedan, gentle walking, soft friction, and the exer- cise of spinning are proper. About the eighth month, which is the most critical period, the diet is to be more contracted, and the exercise increased. If the bowels are constipated, owing to the compression of the rectum by the enlarged uterus, laxative food is to be given, such as ptisan and mal- lows. In the ninth month the regimen is to be of a relax- ing nature, and for this purpose the tepid bath is to he fre- quently taken, for it has great effect in rendering parturi- tion easy."—Avicenna, Canon., 1. iii., 21, 2, i.— Haly Ab- bas, Pract., 1. i., c. 19.—Primerosiu*, De Morbis Mulierum, 1. iv., c. 2.—F. Rauchinus, Tract, duo de Morbis ante Par- turn, in Partu et post Partum, &c Lugd. Bat., 8vo, 1644. —Hirliz, in Holler's Biblioth Med. Pract., vol. ii., p. 237. —R. a Castro, De Universa Mulierum Morborum Medicina, &c, 3tia, ed. 4to. Hamb., 1688.— Mauriceau, Des Mala- dies des Femmes Grosses. Paris, 1824. vol. i., p. 178.— Manning, On Diseases of Women, p. 328, et pluries.—R. Manningham, Aphorism. Medica; quibus tarn bona quam mala valetudo Mul. praecipue Utero-gerentium depingitur, 12mo. Lond., 1756.—Triller, De Regimene Gravidarum et Puerperarum. Vrtel., 1757.—Astruc, Maladies des Femmes, t. v.—C. White, Treatise on the Management of Preg- nant and Lying-in Women, 8vo. Lond., 1773.•—L. Leake, Practical Observations on Child-bed Fever, Uterine Hemor- rhages, Convulsions, and such other acute Diseases as are most fatal to Women during Pregnancy, 8vo. Lond., 1774. —C. L. Mursinna, Abhandlung von den Krankheiten der Schwangern, cal collec- tions in the large bowels, or of dyspeptic dis- orders.— (b) Pruritus urethra: is often a very troublesome affection. Itching of the extrem- ity or course of the male urethra is most fre- quently caused by calculus or gravel in the blad- der, or by irritation of the prostate gland or stricture of the urethra. In females it is con- nected either with calculus in the bladder, or with leucorrhcea or uterine disorder.—(c) Pru- 616 PSO^E MUSCLES—Inflammation and Soppuration of. ritut vulva is often a most distressing affection. It is seated chiefly in the labia majora, but it frequently implicates the clitoris and nymphae, or even extends up the vagina. It is usually caused by ascarides in the rectum, by disorder of the catamenia, by leucorrhcea, by self-pollu- tion, and by hemorrhoids. It is not uncommon during the periods of puberty and the cessa- tion of the menses, and especially during preg- nancy.—(d) Pruritus ani is often a very trou- blesome and obstinate complaint, and is most annoying soon after retiring to rest. It is usu- ally caused by ascarides in the rectum, by hem- orrhoids, by fistula ani, by neglect of cleanly habits, by morbid states of the intestinal secre- tions, especially of the mucous follicles of the rectum, and by irritation or congestions of the prostate gland and vesiculse seminales. It is often complained of by persons of sedentary occupations and habits, and by those who sit on soft and warm cushions. The itching, al- though occurring independently of any visible eruption, when repeated or protracted, often occasions slight excoriations and thickening around the margin of the anus. 4. ii. Diagnosis.—Pruritus can be confounded only with prurigo, from which it is distinguished by the absence of any visible eruption, unless such redness, or excoriation as may result from scratching, and the mechanical irritation em- ployed to remove or relieve this annoying sen- sation. 5. iii. Treatment.—This should be directed to the removal of the morbid condition of the vis- cera, upon which the pruritus depends. This is most effectually accomplished by occasional doses of spirits of turpentine and castor oil, and by enemata of the same, so as fully to evacuate all accumulated or morbid matters from the bowels. Afterward the lotions I have pre- scribed for Prurigo (y 12), especially the lead lotion with opium; diluted vinegar or lemon- juice with creasote; a weak solution of bi- chloride of mercury with some hydro-chlorate of ammonia; or the solution of the biborate of soda. Attention should be directed, in the treatment of the pruritus of females, to the state of the uterine functions, which ought to be duly promoted ; and when congestion of the uterine organs, or of any of the abdominal vis- cera, is present, especially if the patient be young and plethoric, or if the parts become hot or excoriated, then local depletions, followed by hot fomentations, are required. The diet, regimen, and treatment are in most respects the same as advised for Prurigo. Biblioo. and Refer. — Oribasius, Morb. Curat., Hi., 22. — Alsaharavius, Pract., xxii., 8. — Aviccnna, Canon., iv., 7, 3, 6.—Paulus jEgineta, by Adams, 1. iv., sect. 4.— Thilenius, Medic, und Chirurg. Bemerkungen, b. i., p. 287. —Schneider, in Annalen derHeilkunst. Jun., 1811, p. 490. —Cheze, in Bulletin de la Faculte de Medecine. Paris, 1812, p. 157.—Journ. des Progres des Sc. Med., t. xiii., p. 264.—E. Wilson, Practical and Theoretical Treatise on the Pathology and Treatment of Diseases of the Skin, bvo. Lond., 1842, p. 272. PSOjE MUSCLES—Inflammation and Sip- pub ation of. — Syno.v. Psoitis, Auct. Lat. Psoite, Inflammation des Muscles lombaires, Fr, Entziindung der Lendenmuskeln, Germ. Psoas abscess; Lumbar abscess. Classif.—III. Class, I. Order. (See Pref- ace.) 1. Dsfin.—i. Nosolog.—Pain in the loins, gen- Jfu% on one side, commencing and existing insidi- ously, but often becoming severe, and extending to the hip, thigh, and knee-joint, caused by inflamma- tion and suppuration, the pus collecting around the muscles, and descending with more or less tumour, either under Pou part's ligament or in some other direction. 2. ii. Patholog.—Inflammation of the cellular tissues surrounding the psoct lumbar and adjoin- ing muscles, generally originating in caries of the bodies of the vertebra, or in inflammation of the intervertebral substance, the muscles themselves ultimately becoming disorganized, and the purulent collection gravitating in the course of the cellular tissue, and opening or forming a tumour as above and as hereafter stated. '3. I. The Causes of Psoas or lumbar abscess are, the scrofulous, the rheumatic, and the gouty diathesis ; a cachectic habit of body, tubercular changes or deposites in the bodies of the ver- tebrae ; caries of the vertebrae, especially the lumbar; inflammation of the intervertebral sub- stance ; violent exertion of the lumbar muscles, external violence, severe strains, or sudden jerks or twists of the loins ; currents of cold air on the back or loins ; and ulcerations of the caecum extending to the peri-caecal cellular tis- sue. Caries of the dorsal or lumbar vertebrae, or inflammation of the intervertebral spaces are the most common causes of psoitis and lum- bar abscess. Of nineteen cases detailed by Abernethy, only two were independent of dis- ease of the spine. He observes, that the gen- eral opinion of surgeons, in which he entirely concurs, is, that lumbar abscesses most fre- quently arise from diseases of the vertebrae; and they should certainly all be treated as if such were their origin. 4. II. Symptoms.—Psoitis sometimes occurs suddenly, and the patient complains of pain in the loins, especially on one side. Walking be- comes troublesome ; the thighs can be neither raised nor extended without pain. The disease sometimes commences gradually, with pricking pains, which, becoming more severe, extend to the hip, and to the thigh, and even to the knee- joint. Sometimes the progress of inflammation is so insidious as hardly to be noticed, until the mischief appears in the form of a purulent col- lection. According to the extent of vertebral disease and the degree of inflammation does suppuration appear early or late; but the ab- scess which is formed generally assumes a chronic state, and is of a symptomatic character, as it is consecutive of inflammation and caries of the vertebrae. The chronic abscess, termed psoas or lumbar abscess, commonly forms in con- sequence of disease of the vertebrae of the back or loins. Matter Is secreted around the dis- eased vertebra;, and then descends through the loose cellular tissue covering the muscles along the side of the pelvis into the thigh. It may take a course towards the back, or may go in various directions either within or without the pelvis. The pus formed about the seat of ca- ries remains there for a longer or shorter time, especially in the cellular tissue. As the pus collects and increases it forms a cyst, which descends, and lengthens as it inclines to either or to both sides of the vertebral column. As the pus accumulates it pushes onward the lower end of the cyst, which, if it meet with any ob- stacle, spreads out, but contracts when pressed on by the adjoining parts, and dilates again PSO^E MUSCLES—Inflammation and Suppuration of 617 when relieved from pressure, until it at last arrives at the place, when it projects or breaks. In the route which the purulent matter thus takes, the psoae and other lumbar muscles are inflamed, pressed upon, partially absorbed and disorganized, owing to the extension of the in- flammation and purulent infiltrations to them and their connecting cellular tissue. 5. The abscess most frequently protrudes be- low Poupart's ligament, and it generally ex- tends or opens at a greater or less distance from the original seat of disease. It may, however, point or open into the caecum, into the colon, or the rectum, or in some part of the back, or in the loins just above the sacrum; or it may make its way to the hip, or the groin, and pro- ceed even down the thigh in the direction of the large vessels. As the matter is seated behind the peritoneum, and as it generally gravitates according to the position of the body, it very rarely perforates this membrane and becomes effused into the abdominal cavity. As the purulent matter increases and presses upon, or otherwise implicates, or even inflames the larger veins, nerves, or arteries, so are the symptoms either of phlebitis, or of neuritis, or of artereitis, according to the situation and ex- tent of the abscess, not infrequently superin- duced, and complicated with the advanced prog- ress of the disease, in addition to the primary lesion of the spine. I have repeatedly met with these complications, which have greatly aggra- vated the sufferings of the patient. If, du- ring its increase, the abscess breaks external- ly, or is opened so as to admit the air, pus is discharged, at first without smell; but it sub- sequently becomes offensive, and the hectic symptoms more marked. The powers of the patient sink, and the stomach becomes irrita- ble. In some cases the aperture either closes, and matter again collects, or it contracts, and remains fistulous for a considerable time. 6. III. Diagnosis.—(a) During the formation of matter the patient suffers pain in the loins, and walking is painful. When the abscess is not large, the usual symptoms of suppuration may be absent, or so slight as to escape obser- vation. Night or morning sweats, emaciation, and other hectic symptoms, however, generally appear or increase with the progress of the complaint. When the purulent collection has increased so as to form an external tumour either in the groin or in the loins, or near the anus, a movement may be perceived in it upon coughing. When the matter has gravitated towards the thigh or anus, the tumour is less- ened by the recumbent posture. If the patient has suffered continued pain in the loins for four, five, or six months ; if he has difficulty in ex- tending the thigh, especially when putting his legs together ; if he feels' pain and tightness in the groin, and increase of pain on attempting to exert the limb, or when the psoas muscle is either put on the stretch or exerted, then this disease should be Suspected, even although no external tumour has yet appeared; but if such tumour is present, there can be little doubt of its nature. 7. (b) Psoas abscess, when protruding under Poupart's ligament, may, as Mr. South ob- serves, be mistaken for femoral hernia, especially as it dilates on coughing, and partly subsides when the patient lies down. But it is generally of larger size than femoral rupture, and the fingers cannot be at all thrust around it, as they partially may behind the hernial sac. The chief distinctions, however, are the long con- tinuance of pain in the loins previously to its appearance, the persistence of that pain, and the remarkable increase of pain produced by attempting to extend the thigh, especially back- ward, or the entire inability to do so. "When the abscess appears in the loins, there is no difficulty in determining its character by its his- tory, and by its dilatation on coughing. Pulsa- tion may sometimes be communicated to it from the adjoining large vessels;" and thus it may be mistaken for aneurism, if the history of the case and the existing symptoms be not atten- tively investigated. 8. (c) The diagnosis between psoas abscess and disease of the hip-joint is not always, al- though it is frequently, easy. It has been well pointed out by Mr. Coulson (Oh Disease of the Hip-joint, 4to, Lond., 1837, p. 72), and nearly as follows : 1st. In psoas disease, the patient gen- erally complains of dull or of severe pain in the loins, which is increased by the upright posture, and by every motion of the limb, particularly on extending it: in diseased hip there is no fixed pain in the loins; it is felt more in the vicinity of the hip, and especially in the knee. 2d. In the whole course of psoas disease there is no deviation in the natural situation of the trochanter, and no difference in the length of both limbs; in diseased hip, on the contrary, this is always the case. 3d. In psoitis and lumbar abscess the patient cannot turn the foot of the affected side outward without in- creasing the pain ; in diseased hip the foot is generally turned outward. 4th. On taking a deep inspiration, on coughing, crying, and in the erect posture, the fluctuating swelling either in front of the thigh or on the nates increases, and exit of matter, if the abscess be open, is facilitated ; but in abscess of the hip-joint nei- ther phenomenon is observed. 9. IV. Prognosis.—The prognosis of psoitis, especially when the inflammation has gone on to abscess, is extremely unfavourable. Pro- fessor Colles states, that not one patient out of fifty recovers from it; and that, in the course of his practice, he has not known five cases in all recover. He never knew a case get well where a surgeon interfered at all with it. In my own practice, I know only of two recov- eries. For these no surgical aid was required beyond the formation of an issue in the back or loins. When psoas abscess is complicated with tubercles in the lungs, or with paraplegia, or with phlebitis or neuritis, instances of such complications having occurred in my practice, the case is then hopeless. I may, however, add, that psoas abscess may become compli- cated with hip-disease, a case of this associa- tion—the latter supervening on the former- having been under my care ; or hip-disease may give rise to psoas abscess, as shown by Dr. M'DoWELL. 10. V. Treatment.—This disease usually ap- pears so insidiously, and advances so slowly, that it has proceeded in most cases beyond the influence of treatment before medical aid is re- quired. When it is recognised at an early stage, and especially when the lesions of the vertebrae are not far advanced, or the inflamma- 518 PSOiE MUSCLES—Inflam: :mation and Suppuration of. tion consequent upon them has not given rise to much suppuration, then reasonable hopes may be entertained from the use of appropriate means. If the powers of the patient be not re- duced, if there be no sign of anaemia, or of im- paired vascular action and tone, the application of leeches, or cupping in the vicinity of the ver- tebral lesion, according to the state of the case, should be prescribed, and aided by stomachic aperients and cooling diaphoretics, with suitable attention to diet and perfect quietude. After sufficient local depletion, I have generally di- rected either of the following embrocations to be applied to the back or loins by means of flan- nel, and renewed once in the twenty-four hours if it be found to agree; the sensations of the patient, the state of the pulse, and a careful observation of all the symptoms guiding the physician : No. 325. R. Linimenti camphors comp.; Linimenti tere- binthinae; Linim. saponis cum opio, aa, Jj.; Olei cajuputi, 5j. Tfl- Fiat embrocatio. No. 326. R. Linimenti terebinthinte; Linimenti cam- phors comp., aa, f jss. ; Olei olivae, 3iij.; Olei cajuputi, 3j. 111. Fiat embrocatio. 11. If these embrocations fail, after local de- pletions and other constitutional or suitable means, to arrest the progress of the disease, open blisters in the vicinity of the part or is- sues ought to be ordered, and kept freely dis- charging ; while an alterative and restorative influence should be exerted on the constitution by a course either of the iodide of iron with sarsaparilla, or of the iodide of potassium and liquor potassae, with compound tincture of bark and fluid extract of sarsa ; or of the bichloride of mercury, in either the compound tincture or decoction of cinchona. I have alternated short courses of these, varying them according to circumstances, during the operation of the ap- plications, issues, &c, advised to be applied near the diseased vertebrae, and often with marked benefit. I have prescribed iodine for this disease since 1322. 12. Several surgical writers, even Aber- nethy, Cooper, Dupuytren, Lawrence, Pear- son, Chelius, South, and others, have directed their attention and their treatment chiefly to the consecutive abscess. But if the abscess be not large, if it be not complicated with para- plegia, or if it occasion no distressing symp- toms, as it sometimes does, by its pressure on nervous, venous, or arterial trunks, or large branches, it should not be officiously interfered with ; the external drains, &c, placed near the diseased vertebrae, the constitutional means prescribed above ($ 11), and such other aids as stomachic aperients, &c, as .the peculiarities of the case may require, being the remedies most deserving of confidence. If these means succeed in even partially removing the spinal disease, the consecutive abscess, if not large, will either diminish or become absorbed, at least in some instances, as in two of those which have come under my care, and for which the above treatment, without opening the ab- scess, was pursued. In one of these cases the treatment sometimes consisted, during the in- tervals between courses of the above medi- cines (v H), chiefly of full and regular doses of either morphia or opium, which also were occasionally given with these medicines. 13. When the inflammation terminates in suppuration, and an abscess is formed, Che- lius remarks, that the absorption of the matte* may be procured in some cases, although rare- ly, by issues or perpetual blisters in the loins, and by general treatment, which promotes the abdominal functions and the patient's strength. Dupuytren observes, that these abscesses may remain for years, and the pus either be absorb- ed, no trace of them remaining, or, after a time, they may increase, the skin covering them be- coming inflamed and giving way. In rare in- stances, the pus may drain away and not be reproduced, or, after a longer or shorter time, it may be converted into adipocerous matter. These, however, are favourable terminations of rare occurrence. Much more frequently the abscess goes on increasing, either until it in- flames and bursts the skin at the most prom- inent point, or until it opens Into one of the hollow viscera, or until the distressing effects produced by it, as already adverted to, create a necessity for opening it. 14. Mr. South observes, that issues are most important aids in the treatment of psoas ab- scess, either before or after it has opened of it- self or been punctured, and that no circum- stance should prevent a recourse to them. He advises the issue to be made on the side of the spine opposite to that where the abscess is seat- ed. If presenting in one of the lumbar regions, the issue should be made at the outer margin of the quadratus lumborum of the opposite side; but if there be abscess in both lumbar regions, issues ought to be placed above and below them. If the swelling appear at the top of the thigh, an issue may be made on the same side, or in both sides of the spine, but never over the spine, nor over the abscess itself, for very obvious reasons. The issue should be made the size of a sixpence, with caustic potash, and it will generally enlarge to that of a shilling : one, or both, should be kept freely open and discharg- ing, as just advised, while the constitutional and restorative powers ought to be promoted by the means recommended above. 15. Much difference of opinion exists as to the propriety of opening psoas or lumbar ab- scess, or of waiting for the self-evacuation of it. My own observation leads me to state, that there are cases for which surgical interference is either unnecessary or injurious ; while there are others for which it may be most beneficially employed, if not for a cure, at least for the al- leviation of the sufferings of the patient, and prolongation of life. When required, the open- ing should be made, as advised by Mr. Aber- nethy, so as entirely to prevent the entrance of air through the aperture, otherwise inflam- mation of the sac, increased hectic, offensive discharge, and sinking of the powers of life will ensue. An opening thus carefully made, and subsequently managed as carefully, will often prevent those painful complications ob- served in the advanced course of the malady, and to which surgeons have not sufficiently ad- verted. The occasional inflammation and ero- sion of vessels adjoining the purulent collec- tion, and the distressing symptoms which re- sult, as well as the not unusual implication of a nervous trunk, or of some other important part, may be prevented, or even alleviated after their appearance, by opening the abscess be- fore it has become so greatly distended as to complicate the case and increase the sufferings PSORIASIS and LI of the patient. Mr. South has given a good digest of surgical opinions on this topic, with his own advice, and to his translation of Che- lius's system of surgery I refer the reader re- specting it. I should, however, add that, wheth- er the abscess be opened or not, the issues and constitutional treatment Ihave recommended, with opium and other aids, and alternated, mod- ified, or changed, as circumstances may require, ought to be persisted in throughout the disease. Bibliog. and Refer.—Ludwig, De Abscessu Latente. Lips., 1758, v.—Haller, Biblioth. Chirurg., ii., p. 629.—De Haen, Rut. Med., part iv., p. 135.—P. Pott, Chirurgical Works, 8vo. Lond., 1783, vol. iii.—Smith, in Med. Facts and Observat., vol. iv.—Plenciz, Acta et Observat. Med., p. 159.—T. Kirkland, An Inquiry into the present State of Medical Surgery; 2 vols. 8vo. London, 1783, vol. ii.—/. Pearson, Principles of Surgery, 8vo. Lond., 1788.—Latta, Practical System of Surgery, vol. i. and iii., ch. 3.—Meckel, De Psoitide. Halie, 1796. —Salzb. Med. und Chirurg Zeitung, 1801, b. ii., j). 210—X F. Vogel, Chirurgische Warnehmungen, b. ii., p. Q.—Tomlinson, in Med. Observ. and Inquiries, vol. v., p. 163.—Wilson, in Lond. Med. and Phys. Journ. July, 1802.—Ricardo, in ibid. Sept., 1802. —/. Abernethy, Surgical Works, 2d ed. Lond., 1815, vol. ii., p. 137.—A. Cooper, Lectures in Lancet, vol. ii. Lond., 1824.— W. Lawrence, in ibid., vol. i., 1830. — Dupuytren, Lecons Orales, t. i.—S. Cooper, Surgical Dictionary, Lum- bar Abscess—M'Dowell, in Dublin Journ. of Med. Sciences, vol. iv., p. 9, et seq. (Abscess communicating with the Ilium, and opening externally near the Spine of the Ilium; also, Cases of associated Hip Disease and Psoas Abscess.)— IV. Coulson, On Dis. of the Hip-joint, 4to. Lond., 1837, p. 71.—IV. O. Chalk, in Lond. Med. Gazette, vol. xxviii., p. 103, 146.—/. M. Chelius, A System of Surgery. Transla- ted, with Additions, &c, by /. F. South, 2 vols. 8vo. Loud., 1845, vol. i., p. 185. [Am. Biblioo. and Refer.—See Mott and Townsend's Velpeau, Am. ed. of South's and Chelius's Surgery, Reese's Cooper, Gibbon's Surgery, M'Clellen's Surgery, and Am. Med. Journals.] PSORIASIS AND LEPRIASIS.—Synon. PsoRiAsrs, irupiaccc (from ipupa, scabies, itch) ; Impetigo, Scabies, Celsus. Impetigo, Sennert, Plenck. Scabies sicca, Plater, Hoff- man. Psoriasis, Vogel, Swediaur, Willan, Bateman. Lipidosis psoriasis, Young, Good. Dartre, Dartre furfuracie, Fr. Kleinaussatz, Germ. Dry Tetter, Dry Scall. Lepriasis, Lepra, M-irpa (from lEirpbc, scaly, rough). Leuce, Alphos, Impetigo, Vitiligo, Cel- sus. Impetigo cxcorticativa, Avicenna. Lepra, Sauvages, Sagar, Cullen, Willan, Young, &c. Lepidosis lepriasis, Good. Le.pre, Fr. Dartre squammeuse, Alibert. Aussats, Germ. Scaly Leprosy, Leprous Scall. Classif. —4. Class, 8. Order (Cullen). 6. Class, 3. Order (Good). ii. Order, 2. Genus (Willan and Bateman). III. Class, I. Order (Author). 1. Defin.—A chronic inflammation of the skin, either limited to a particular region or extended more or less over the surface, appearing first with slight elevations, which change into scaly patches ; the patches of psoriasis being of different sizes, not depressed in the centres, but with irregular and very slightly raised edges; those o/Lepriasis being generally rounded, slightly depressed in the centres, and surrounded by slightly raised and red- dish circles. 2. Both Psoriasis and Lepriasis or Lepra were considered as modifications of the same disease by most of the ancients, and they are treated of by Paulus ^Egineta by the terms " Leprosy and Psora." He states that " both these affections consist of an asperity of the skin, with pruritus or wasting of the body, hav- ing their origin from a melancholic humour. But leprosy spreads over the skin more deeply in a circular form, throwing out scales which EPRIASIS—Causes. 519 resemble those of fishes ; but psora is more su- perficial and variously figured, and throws out furfuraceous bodies." (Translated by Adams, vol. ii., p. 15.) Mr. Adams concludes his re- marks respecting the views of the ancients as to these affections as follows: '" It will be re- marked that the Leuce of the Greeks, the leuce and fourth species of impetigo of Celsus, and the albarras of most of the Arabians, are the same as the lepra vulgaris of Drs. Willan and Bateman ; that the alphos of most of the Greek authorities and of Celsus, and the morphia alba of most of the Arabians, correspond with the lepra alphoides of our English nosologists ; that the melas, alphos niger, and common lepra of the Greeks, Celsus's third species of impetigfc and his melas, and the morphia nigra and im- petigo of most of the Arabian translators, apply to the lepra nigricans of our modern arrange- ment ; and that the psora of the Greeks, Cel- sus's second species of impetigo, and the sca- bies of Octavius Horatianus, and of most of the Arabian translators, comprehend both the psoriasis and scabies of Willan and Bateman. Since many of the ancient authorities speak of scabies as being infectious, they must have ap- plied the term to the true itch, with which it is not likely, as Raye-r. maintains, that they, were wholly unacquainted. The earlier modern wri- ters, as those of the Schola Salernitana, Pla- terius, Guy of Caultac, and Lanfrancus, jum- ble together the Latin and Arabian names, so as to produce no ordinary degree of confusion." (Op. ctt.. vol. ii., p. 21.) 3. I. Causes.—The causes of the several va- rieties of both Psoriasis and Lepriasis are the same, or the same causes are common to both these species.—A. The predisposing causes are chiefly hereditary conformation, the melanchol- ic temperament, and an habitual languor and weakness of the circulation in the integuments, with dryness of the skin. These affections oc- cur at all ages and in both sexes, but some- what more frequently in adults and in those advanced in life. The influence of sex is not great, some writers stating that they are more frequent in females, others in males. They are both constitutional maladies, and are often connected with disordered abdominal func- tions, both at their origin and in their course. They are sometimes connected with the gouty and rheumatic diathesis, and they may appear at any season, but more frequently in spring and autumn : lepriasis oftener in autumn. Pro- longed or neglected dyspepsia; inattention to the states of the bowels and of the intestinal . secretions and excretions ; the habitual reten- tion or accumulation of faecal matters, improp- er and insufficient food ; mental anxieties, and sexual excesses also predispose to these erup- tions. ^ 4. B. The occasional exciting causes are the use of salted, dried, smoked, or otherwise pre- served meats and fish ; the frequent use of shell-fish ; irregularities and improprieties of diet, the use of pork or the flesh of the wild boar, bacon, hams, &c.; drinking cold fluids when the body is perspiring; vicissitudes "of temperature and weather; poor, innutritious, or unwholesome food ; exposure to cold or moisture, and living in low, damp cellars or lo- calities ; prolonged anxiety of mind; the fre- quent use of heating and stimulating food, sau> 520 PSORIASIS AND LEPRIASIS—Causes. ces, spices, condiments, pickles, preserves, acids, or spirituous liquors ; debaucheries or excesses of any kind ; the want of sufficient personal cleanliness ; and the irritation produced by va- rious substances employed in several of the useful arts. 5. The contagious or non-contagious nature of these eruptions has long been a topic of dis- pute, especially as they appear in countries bordering upon the Mediterranean Sea. My friend and colleague, Mr. Dendy, has consider- ed the subject very fully in his unpublished work on these maladies, which he kindly al- lowed me to peruse ; and concludes that in this country they are not contagious. Willan has observed that psoriasis guttata and annulata af- fect several children about the same time in large families and schools, especially those who sleep together; and the same remark is made by Mr. E. Wilson and others. The simulation of contagion must, however, arise from the con- stitutional predisposition to these eruptions un- doubtedly existing in some families, and from the simultaneous operation of the same exci- ting causes. The topic, however, deserves far- ther investigation. 6. I have observed these eruptions more fre- quently in unmarried than in married females. They are often dependent upon impaired di- gestion and assimilation, and upon equally im- paired function of the-skin, kidneys, and intes- tinal canal, the blood thereby abounding in im- perfectly assimilated chyle and in effete mate- rials. I have seldom observed them in females whose catamenial discharges were quite reg- ular and sufficient, these discharges, when healthy, being manifestly depurative as respects the circulation, and no mean preventive of chronic cutaneous eruptions. Many modern pathologists have viewed both psoriasis and le- priasis as symptomatic of gastro-intestinal irri- tation. That there is more or less disorder of the digestive canal in most cases of both these eruptions must be admitted; but it does not strictly follow that this disorder consists of in- flammatory irritation. It is generally function- al merely—a defect of function as much as dis- order of function, the digestive and assimila- tive derangement and the cutaneous affection proceeding from the same source, viz., impaired organic nervous power, the cutaneous disorder only being the last of the series of functional and morbid changes. 7. Every arrangement of the scaly eruptions must necessarily be, to a certain extent, con- ventional, and be based on the more prominent phenomena and differences which they present. The chief points of difference have thus become the most familiar, as being the most commonly noted and represented, wliile the gradations by which the one variety and species pass into the other are so far kept out of view as to be ei- ther overlooked or unacknowledged. That this is the case more especially with the three spe- cies of scaly eruptions to which the terms of pityriasis, psoriasis, and lepra have been applied is not to be doubted by any one whose knowl- edge of them has been acquired from observa- tion, and not from writers who have been more anxious to create distinctions than to trace resemblances. That these three species of eruption do not merely present points of re- semblance in most cases, and even of identity in others, but also originate in the same or sim- ilar causes, will be farther admitted. Nor are their causes only the same, their constitutional nature, their associations, and their tendencies are also the same or closely similar. Still, it becomes necessary to describe those differen- ces which may be remarked in their external characters, and which enable us to recognise as well as to classify them. The intimate con- nexion subsisting between these eruptions is shown by the circumstance of their presenting, in some cases, the distinct features of psoriasis in one part, and in another part those of lepri- asis ; and it occasionally happens that pityriasis of very long duration, or tbe acute or inflam- matory form of that species, when it becomes very chronic, assumes the form either of pso- riasis or of lepra, while lepra of long duration often passes into the form of psoriasis invete- rata. The three species of eruption, moreover, require the same constitutional and local treat- ment. For these and other reasons mentioned when treating of tubercular leprosy, or the lep- rosy of the Arabians and Middle Ages (see art. Leprosy), I have viewed lepra as merely a spe- cies belonging to the same genus as psoriasis and pityriasis; and have treated of psoriasis and lepra in connexion, their causes, patholo- gy, and treatment being the same.* * My colleague, Mr. Dendy, whose experience in th« treatment of these eruptions is very great, has endeavoured to clear up the confusion, existing even down.to the present day, respecting squamous diseases. He has arranged pso- riasis, lepra, and the inflammatory form of pityriasis u species constituting one genus, " Lepriasis," and has assign. ed to each species what he considers its synonyme in an- cient and modern authorities. His views, as well as hu descriptions, are most deserving attention. ] give his ar- rangement, but I lake the liberty of placing his species, " Lepriasis furfurans," or acute pityriasis, before the othei more chronic and severe species, consisting of psoriasis anJ lepra. LEPRIASIS.'— Svnon. Zaraab, H.—Kouba, Kuba, Al- kauba, Ar.—Ae-fai, Gr.—Lepra, W.—Lepidosis lepriasis, G.—Scale-skin, Leprosy, Scaly Leprosy. Species i. Lepriasis Furfurans.—Synon. Aharati, Ar. — Tinea, Porrigo, Dartre furfuracee, Al. — Tcignt amiantacee ; Pityriasis, W.—Pityriasis acuta, R. Spec. ii. Lepriasis Guttata.—Synon. AA0o$, Gr.—Al- phos, C. — Lepra alphoides ; Psoriasis guttata. W. — Dartre squammeuse orbiculaire, Al.—Lepriasis albida, G. —Psoriasis disereta, R.—Guttated dry scatt. Spotted leprosy. Spec. iii. Lepriasis Annulata.—Synon. Book; Be- hag, H.—Bohak, Bolhor, Ar. (Translated pearly or dull white leprosy.)—Ampui, Gr.—Lepra Gracorvm, vitiligo, C.—Lepra Vulgaris, W.—Dartre squammeuse arrondie, Al.—Psoriasis circinnalus ; Lepidosis lepriasis, G.—Le- pra; Leprosy; Greek leprosy. Var.— Centrifugal; Crescentic ; Gyrated. Spec, iv. —Lepriasis Diffusa. —Syno.n. Saphat, H. (Translated spreading dry scall.)—Sahafati, Ar.— topa XtirpiaSns, Gr.—Scabies, sicca, s. Crassa, Itch.—Psori- asis diffusa, XV.—Psoriasis confluens, R.—Lepidosis Pso riasis, G —Dry scall; Scaly tetter. Var.—Confluent, &c. Spec. v. Lepriasis Inveterata.—Synon. Baheretk I*- bena, H. (Translated plague of leprosy)—Beras begas, At.—Acikt), Gr.—Agria.—Bright white leprosy.—Lichen agrius. — Pellagra. — Acrodynia.— Psoriasis inveterata, W".—Dartre squammeuse invelere: Lichenoide, Al.— Le- priasis Candida, G.—Inveterate dry scall. Var.— Scabida ; Indurata; Prominens. Spec. vi. Lepriasis Livida— Synon. Baheretk cecha, H.— roopar, Gr.—Beras asved, Ar.—Melas, C.—Lepra nigricans, W.—Lepriasis nigricans, G.—Black albarai. —Black morphia.—Dusky or black leprosy. Spec. vii. Lepriasis Syphilitica. Synon.— Leprt Syphilitica, Psoriasis Syphilitica, W.—Syphilide pustu- le use, Al.—Syphilides, R.—Syphilitic lepra and psoriasis. —Scaly syphilis. 1 The capital letters following the synonymes represent the authorities. Al. Alibert.—Ar. Arabians.—C. Celsus.__ G. Good. —Gr. Greeks.— H. Hebrews. — R. Raver.__W. Willan. PSORIASIS AND LEPRIASIS—Description of. 521 8. II. Description.—i. Psoriasis Guttata. — Synon. Lepra alphoides; Lepriasis albida, Good. Psorias-is discreta, Rayer. Dartre squam- meuse orbiculaire, Alibert. Lvrriasis guttata, Dendy. Gutlated dry scall.—Psoriasis, even in this the mildest of its forms, is often preceded or attended by symptoms of indigestion, lassi- tude, and inaptitude for physical or mental ex- ertion ; but these are often so slight as to be overlooked. In this variety numbers of small, distinct elevations or papulae occur, sometimes appearing at first of the size of a pin's head, their summits soon becoming covered with a minute scale of a dull white colour. These elevations are generally, at first, from two to three or four lines in diameter, irregularly cir- cumscribed, and generally rounded. They in- crease somewhat in size, but always remain distinct, with the skin sound between them. When freed from the squamae on their sur- faces, they appear red and irritable, forming rounded spots or patches, from two to four or five lines across; and are slightly prominent, and of a brownish red hue. These patches oc- casionally heal, like those of lepra, from the centre to the circumference ; and in this case they present slight depressions in the centres, and acquire a yellowish dusky tint. The scales formed on their surface are reproduced as soon as they are removed. As they decline, the patches often are transformed into segments or arcs of circles ; and when quite, removed the skin presents small stains of a grayish brown or yellowish hue in the spots occupied by them. 9. This variety is seldom accompanied with much pruritus, unless when the body is heated by exercise, or by stimulating or heating food and drink. It may be confined to the hairy scalp, face, trunk, or extremities; or be dis- seminated over these regions, appearing either at once upon all of them, or upon each in suc- cession. The patches or spots are generally irregularly disseminated, being crowded in one situation, and thinly scattered in others; but they are more numerous in the line of exten- sion in the extremities than in that of flexion. Guttated psoriasis appears most frequently in spring and autumn, and often disappears in summer or in winter. It may thus recur for many successive years. It is not infrequent in children, and is more quickly evolved in them, often with slight fever. It is more prevalent in adults than in children and old persons. It often presents characters intermediate between psoriasis and lepra. It sometimes coexists with one of the other forms of psoriasis, and I have seen it associated with pityriasis. When it affects the fingers, it often implicates the nails. 10. ii. Psoriasis Diffusa. — Synon. Psoria- tis conflucns, Rayer. Lepidosis psoriasis, Good. Lepriasis diffusa, Dendy. Spreading dry scall; tcalhj tetter.—a. In this variety the patches are uf large size, of variable extent, and irregular form. They are developed either by a number of small elevations, like the preceding variety, which run together and form one continuous patch, or by a papular roughness of a patch of the epidermis and congestion of the subjacent dermis, or by several patches, which speedily increase in size and coalesce. In each of these modes the patches may require two or three weeks to be fully formed. The surface of each is usually then of a dull red colour, rough, and slightly elevated above the surrounding skin, intersected by furrows which correspond with those of the epidermis, and often fissured by several deep chaps. The patches are covered by numerous thin epidermic scales, the remo- val of which is rarely followed by any fluid ex- udation. The eruption often assumes the char- acters of the guttated or discrete variety over different parts of the body, and the diffused form around the joints and extremities. 11. Diffuse psoriasis may occur in a single patch, of various sizes, or in several and upon any part of the body; but most frequently on the fore-arms, or about the elbow and wrist, and, unlike lepra, chiefly the fleshy parts of the limbs. Its duration is always chronic; even its mildest states may continue for weeks or months, and the severest forms may remain for months or years. 12. Diffuse psoriasis, when extensive, is oft- en preceded by symptoms of constitutional dis- order ; especially indigestion, costiveness, lan- guor, and debility, which frequently subside as the eruption is developed, but which often re- cur. The eruption is generally attended by slight pruritus, and by pain and tenderness af- ter the removal of the scales, or when the patches are fissured or chapped. It occurs chiefly in adults and the middle-aged. 13. b. This variety has, in rare instanees, as- sumed a gyrated form—Psoriasis gyrata, or that of narrow bands, or curved or tortuous lines. Biett describes it as long, narrow, tortuous stripes, resembling worms; and sometimes bending into rings, occurring generally on the back, or trunk of the body. These stripes are covered by very delicate epidermic scales, which exfoliate, and are reproduced as in the other forms of this variety. They are attend- ed by a slight pruritus, and but little inconve- nience. In very rare cases the eruption as- sumes an annular form, especially about the neck and face of delicate persons, and is very slight: 14. c. In children, diffuse psoriasis is occa- sionally seen in a sub-acute form—Psoriasis in- fantilis, Willan. It appears from two or three months to two or three years of age. It is more acute, is attended by more pruritus and smarting, and is much more rapid in its prog- ress than in adults. The surface of the patch- es, which are often large, is intersected by nu- merous fissures or chaps, and often excoriated by friction ; the excoriations exuding an ichor- ous fluid, which dries into hard scabs of con- siderable size. In infants and children this eruption may be attended by phlyzacious pus- tules, by a morbid secretion from the nostrils, by loss of the hair of the eyebrows and the eyelashes when the forehead is affected, 'and by hardened elevations of a reddish hue. 15. iii. Psoriasis Inveterata.—Synon. Le- priasis Candida, Good. Dartre Squammeuse lich- enoide, Alibert. Lepriasis inveterata, Dendy. Inveterate dry scall.—When either discrete or confluent psoriasis has continued months, or years, or sometimes after the more inflamma- tory form of pityriasis has persisted long, espe- cially when the eruption is hereditary, or oc- curs at an advanced age, or attacks a debilita- ted or shattered constitution, or is consequent upon protracted functional disorder of the di- gestive organs, then the eruption assumes the 522 PSORIASIS AND LEPRIASIS—Description of. form thus named. It may be regarded as an aggravated form of psoriasis diffusa. Inveter- ate psoriasis usually extends over a large sur- face, occupying the most of the limbs, and of the trunk; the face, the palms of the hands, and the soles of the feet being free. The skin is thickened, congested, hot, dry, and harsh. It is stiff, fissured by deep cracks, and covered by epidermic scales and scabs, which are thrown off in great abundance. Pruritus is very trou- blesome in this variety, and is increased by the heat of bed and by a heating regimen. The thickening of the integuments restrains the motions of the limbs and flexions of the joints. When the surface "is abraded or excoriated by friction or otherwise, a fluid exudes which con- cretes into scabs. When this eruption affects the scalp, the scales collect in numbers ; and when they are removed, an ichorous fetid ex- udation takes place from the reddened surface. When it extends to the hands, the nails are re- markably affected; but in some cases I have observed the affection of the nails without the fingers being otherwise implicated, and have imputed the disease of the nails to the infection of the fluid exuded, from the surface scratched by them. The constitutional disturbance may be but slight even in the severest cases, par- ticularly in respect of febrile symptoms. But the functions of the stomach, liver, and bowels are often languid and torpid, and the several depurating actions impaired. The duration of this variety is always prolonged and indeter- minate. In old persons it continues for the rest of life. 16. Local States of Psoriasis.—(a) Pso- riasis may occur primarily on the hairy scalp; but it is more frequently consequent upon the eruption in some other part, or upon neglected pityriasis. It is oftener seen in the distinct form ; much more rarely in the confluent. In rare instances it has extended over nearly all the scalp, extending to the forehead in a line parallel with that of the hair. The inflamma- tion sometimes attacks the bulbs of the hair, which become detached in the patches affected. 17. (b) The face is rarely affected alone, the eruption generally appearing also in some oth- er part. The patches on the face are usually red and furfuraceous, the scales being light and thin. On the eyebrows and eyelids it appears, as everywhere else, by the formation of papu- lae. The eyelids become stiff, and slightly fis- sured or chapped, and these changes are fol- lowed in children by the loss of the ciliae and the hair of the eyebrows. It rarely affects the lips, as true psoriasis, but generally in a form that more strictly belongs to pityriasis. 18. (c) Psoriasis genitalium is not infrequent, and either the prepuce, or the scrotum, or the labia majora vulva may be the seat of the erup- tion. In either of these situations it presents the characters already described. It seldom appears in any of these primarily, but generally in connexion with its occurrence in other sit- uations. It may, however, be consequent upon prurigo or pruritus of these parts. In the pre- puce this eruption is often obstinate and severe and is sometimes attended by thickening, pain- ful exudations of blood and fissures, and phy- mosis. Psoriasis in this situation may be as- sociated with psoriasis of the scrotum, which is often most obstinate, and assumes the invet- erate form, or with psoriasis palmaris. As re- spects the characters of the eruption, there are no differences produced by these localities. But swellings of the inguinal glands are often caused by the appearance of the eruption in these situations ; and care should be taken not to confound it with venereal affections. 19. (d) Palmar psoriasis—Psoriasis palmaris__, may be either distinct or confluent; but in ei- ther form the elevations are generally broad, of a pale reddish hue, and the seat of much heat and itching. If the elevations are numerous they become painful, and interfere with the pa- tient's occupations. In the confluent form the palm of the hand swells, and presents a uni- form brownish red colour. As the eruption becomes more chronic, the heat and itching are less troublesome, the cuticle covering the ele- vations grows thicker, acquires ayellowish hue, dries up and becomes friable, and at last of a dead white on the surface of the patches. The epidermis then cracks, and is detached either spontaneously or by the nails of the patient, and leaves a new epidermis, through which the corion appears red and vascular. The epider- mis surrounding the diseased patch also under- goes a change, being thicker than usual, of a dirty yellow tint, and subsequently becoming dry or mealy on the surface. It finally exfo- liates irregularly, at first adjoining the older patches, and then in the flexuses of the joints and natural folds of the palm. The desquataa- tion is always irregular, and very different in appearance from that of the next variety, the psoriasis-palmaris centrifuga; but, like it, and even more constantly, is attended by linear fis- sures, which penetrate to the quick in the lines of the palms, and by smaller cracks or fissures which extend less deeply. 20. (e) Centrifugal palmar psoriasis is less common than the preceding. It begins in the palm by a single elevated spot, solid, and of small size, upon which a small white scale is formed. Around this elevation a series of red eccentric circles are produced, each in succes- sion, and are covered by epidermic scales, which exfoliate. As these circles appear, each successive one is more eccentric, until the whole palm is implicated, and each undergoes desquamation. Squamous patches also appear on the palmar aspects of the fingers. The pal- mar integument is reddish where the exfolia- tion of the scales has taken place, is thickened, and fissured by numerous chaps, some of which, upon opening the hand, which is painful and stiff, sometimes exude a little blood. 21. Both these forms of palmar psoriasis are of long duration, they seldom continuing for a shorter time than several months, and often persisting for years. They often decline in summer and autumn, and are exacerbated in winter and spring, for a number of years. Pal- mar psoriasis is sometimes complicated with psoriasis genitalium in either sex. A modifica- tion of it sometimes affects, although much less frequently, the soles of the feet—psoriasis plan- taris; but the severity of the symptoms is less in this situation, owing probably to the struc- ture of the plantar integument, and to the pro- tective coverings of the part. Fissures in this situation are much less apt to occur, and are smaller when they occur. 22. (/) A variety of psoriasis diffusa occa- PSORIASIS AND LEPRIASIS—Description of. 523 sionally affects the backs of the hands, and is called grocers' itch, because it is often seen in persons engaged in this trade; but it also often attacks bakers, laundresses, and others. It be- gins with two or three squamous elevations, which often spread until the whole back of the hand is covered. The integument at length presents numerous dry and painful fissures over or near the wrist and the articulations of the metacarpal bones and first phalanges of the fin- gers. This variety is distinguished from con- fluent and chronic lichen of this part by the cir- cumstance of the latter always commencing in an eruption of small papulae. 23- {g) Psoriasis of the Nails—Psoriasis Un- guium.—When the disease affects either the upper or the lower extremities, the nails are often attacked, even although neither the fin- gers nor the toes may be affected. But the af- fection of the nails never occurs without some other part being attacked. It is most frequently associated with psoriasis guttata of the hands or arms. The nails, when diseased, become yellowish or tawny ; thickened and irregular in their structure ; rough, ragged, and brittle, and often bent over the ends of the fingers. A cheesy-like matter is sometimes formed at the roots of the nails, or between the roots and the matrix, as at the extremity of the papillary "sur- face, these parts sometimes becoming unusual- ly vascular, and giving rise to thickening, &c. 24. (h) Psoriasis is often complicated with vis- ceral disorder, as already noticed, and some- times with lepra or pityriasis. It has also been seen associated, especially in children, with ec- zema impetiginodes, vesicles and purulent points appearing amid the thin squamae covering the patches of psoriasis. At a later period these patches become excoriated* and form thin, la- mellar, yellowish scabs like those of eczema. This association is not infrequent in children during the period of teething, and occasionally at a more advanced period. 25. iv. Psoriasts Lepr^eformis.— Synon. Lepra ; Lepriasis. Lepra Gracorum, Auct. Lepra vulgaris, Willan. Psoriasis circinnatus ; Lepidosis lepriasis, Good. Lepriasis annulata, Dendy. Psoriasis orbicularis; Dartre Squam- meuse arrondie, Alibert. Scaly leprosy; Greek leprosy.—This chronic squamous eruption is characterized chiefly by its consisting of circular and slightly-raised patches, which are speedily covered by thin, semi-transparent, epidermic scales, the patches being prominent at their edges, and somewhat depressed in their cen- tres, and the scales being thrown off and re- placed by successive formations. Lepra is oc- casionally confined to the knees and elbows, and it generally appears first in these situations, or, rather, immediately below them. In most cases it affects both legs or both arms at the same time. It is apt to extend by the succes- sive formation of new scaly patches along the arms and thighs, to the breast and shoulders, and to the lumbar and lateral regions of the abdomen. The patches are sometimes more numerous, large, ,and prominent on the lower part of the trunk. The disease rarely extends to the hands or hairy scalp. The patches which appear on the head are usually of a small size. They are seen near the outer angles of the or- bits, whence they spread along the eyebrows to the forehead and temples. When lepra extends to the hands or fingers, the nails and the matri- ces of the nails are often affected in a similar manner to that described above (y 23). Every- where the patches are apt to coalesce by their corresponding edges; but the originally orbic- ular form of the aggregate patches is partially preserved in the arcs of circles which are seen in the circumference. 26. A. Lepra vulgaris commences with small, smooth, solid elevations of a dull red hue, around which numbers of other reddish, prom- inent spots, about a line in diameter, are evolv- ed. The surface of the elevations become cov- ered in two or three days with thin whitish scales. In four or five days the elevations spread, having thrown off the small spangle- like scale from their summits, and are attended by a sense of heat, tingling, or pruritus. They then enlarge rapidly by the extension of their circumference, which is raised and red ; while the centres become depressed and paler than the margins. As the scales exfoliate others are produced, and are of a glistening or opa- lescent, or of a pearl-gray or pale yellow tint. The squamae are not evenly spread over the surface of the patches, and they are detached partially and irregularly. After their fall, the ' skin which they covered looks red, shining, and somewhat raised. They are superposed, es- pecially in the circumference of the patches, and thus become thicker and thicker, so as to form prominent layers. Even when small, the patches are never covered by a single scale. When they are recent, the corion does not pre- sent lines corresponding to those of the cuticle^ but when they are older such lines are observ- ed, and are often increased to wrinkles, which correspond with small indentations or ridges in the inner surfaces of the scales. However de- tached from the inflamed surface, a fresh forma- tion of scales takes place. 27. The cure of the orbicular patches of lepra begins in the centres, and extends to the cir- cumference. After the detachment of the squa- mae the skin acquires, when they are not re- newed, a grayish tint, with a shade of yellow. At a later period, the ring bounding the patches is narrowed progressively fromwithin outward; the circle at last is broken in one or more pla- ces, and the spot, ultimately disappears entire- ly. (Rayer.) 28. Lepra is seldom attended by any febrile disturbance, or other disorder than impaired digestion, assimilation, and excretion. The ap- petite is usually good, and generally greater than the powers of digestion. It occasions no farther inconvenience than slight itching upon getting into bed, or upon changes of tempera- ture. But when the patches are extensive or numerous, or when the inflammation of them is increased by a heating regimen, the patient feels so much burning or stinging pruritus as often to disturb repose. When the patches surround the joints they cause stiffness, and occasionally are attended by small painful fis- sures. The disease is always of considerable duration; it often continues for years, some- times for life. I am now attending a lady who has been afflicted with it extensively for up- ward of forty years, although she has always had the advantage of the best medical advice. 29. B. The variety denominated Lepra al- phoides by Willan is merely a milder form 524 PSORIASIS AND LEPRIASIS—Description of. than the preceding, the squamous patches re- maining of small size, and seldom exceeding a few lines in diameter. The spots increase slowly, are slightly prominent, and rarely run into one another. They form almost exclu- sively on the joints and extremities, and differ from the patches of lepra vulgaris chiefly in the small size and whiteness of the scales which are formed. They are commonly met with in children and delicate persons, and are not easi- ly distinguished from psoriasis guttata. Sev- eral other modifications are sometimes observ- ed in the form, disposition, and extension of the patches, depending upon their seat and the constitution of the patient; but these are too numerous to describe. Some of them so close- ly resemble psoriasis as hardly to be distin- guished from it. When this variety affects the scalp or pubic region, it often occasions much pruritus or inconvenience ; but it rarely affects these situations exclusively. The squamae in these situations are generally yellow and fur- furaceous, and are without the glistening mi- caceous hue they present on the knees or el- bows. 30. C. Lepra nigricans is a comparatively rare form of lepra, and is met with only in ca- chectic and broken-down constitutions. The form and distribution of the patches are the same as described ; but the patches are not so large, and are generally without the central de- pression. Instead of beingof dull red or rose- colour, they are of a livid or bluish brown hue. Mr. E. Wilson states that the scales are so thin ps to allow the lividity of the surface to be seen through them, are easily detached, and leave behind a tender and frequently an excoriated surface, from which a morbid serous fluid, often mixed with blood, is poured out. This exuda- tion hardens into an irregular and friable crust. This variety is particularly annoying when it affects the scalp. It occurs chiefly in persons whose occupations expose them to the vicissi- tudes of the weather, and to a precarious diet, with fatigue and watching, and excesses in spirituous liquors, &c. 31. v. Psoriasis et Lepriasis Syphilitica. — Synon. Squama Syphilitica.—Lepra Syphi- litica, Psoriasis Syphilitica, Willan. Syphilide pustuleuse, Alibert. Syphilides Squammeuses, Rayer. Lepriasis Syphilitica, Dendy. Scaly Syphilis. — Secondary syphilis assumes every species and variety of cutaneous eruption ; and no species more frequently than psoriasis and lepriasis in all their forms. Mr. Dendy states, that the most common form of scaly syphilis is that of irregularly scattered spots, which, how- ever, become occasionally confluent, and some- times three or four forms or distributions of scale are seen in the same subject, viz. : folia- ceous lamina on the scalp, guttated and diffused psoriasis with indurated scales on parts subject to pressure, heat, or friction, as the palms, soles, axillae, scrotum, and labia vulvas ; psoriasis lep- raformis, or lepra, on the breast, abdomen, and thighs ; and very rarely an extensive psoriasis diffusa, as a syphilitic eruption. 32. A. Psoriasis guttata syphilitica commences in a copper-coloured, livid, or violet spot, at first extremely small, usually becoming from six to eight lines in diameter, and, when extending to the scalp, assuming a greenish olive or dull yellowish hue. The spot is flatter, softer, and smoother than the incipient papulae of commoii psoriasis, and less squamous, having little or no defined edge ; or it may be sometimes larger or redder, more defined, and less squamous. The spots or patches are often more ovoid than circular ; the diseased cuticle on their surface is usually more furfuraceous, still adhering te- naciously, and it is of a dull violet or yellowish hue, rather than white. When the scales are detached they are of dirty pearl gray, the livid colour being imparted by the subjacent tissue. After one or two exfoliations the squamous character often diminishes, and, under mercuri- al influence, disappears in three or four months. If a syphilitic treatment fail, they will degener- ate, the squamous character changing to that of a blotch, or even to superficial ulceration. In some cases, Mr. Dendy remarks, that in the centre of the scale a sort of pustular or ulcerated character is observable, even in an early stage, very similar to the moist crusts of eczema. This is never seen in the common forms of the non- syphilitic eruption. 33. B. Another form of scaly syphilis is that of a dusky or brownish, livid, circular spot, the centre slightly fissured and foliaceous, the cuti- cle detached, as it were, around the disk, and thus forming a white margin. This form nearly resembles ecthyma syphilitica. (See art. Ecthy- ma, v 6.) In both these forms of syphilitic scales, ulceration of the throat is often also ob- served. 34. C. The annular syphilitic scale, or syphilitic lepra, is less defined than the common circular lepriasis ; the margins are slightly raised, the scales are dusky rather than white, and more annular. " In some cases the guttated and an- nular forms become one elevated, brownish, red mass, here and there spotted with scales."— (Dendy.) 35. D. Syphilitic scaly spots usually appear from five to ten weeks after the subsidence of a chancre. " Mr. Carmichael believed it to be the sequence only of that ulcer which was marked by indurated edges—the true Hunterian chancre." Mr. Dendy does not think that it is thus limited, for he has seen it consequent upon primary pustules which had speedily subsided, and both consequent upon and coexistent with almost every primary form of the syphilitic mal- ady. 36. The most common seat of scaly syphilis is on the forehead, " corona veneris," and the breast. When, however, the patches speedily arise during acute or often-recurring primary disease, especially in depraved constitutions, they often appear first in the vicinity of the organs of generation, and are then more defined. The character of the patches or spots is, how- ever, much altered by the treatment, especially by external applications. 37. The spots of simple lepra are generally larger and rounder than those of syphilitic ori- gin, the latter being much more rarely conflu- ent and united into broad bands and patches than those of the former. Scaly syphilis is, however, much modified by locality. When it is seated in the axilla, or between the toes, it is moist, whitish, and very offensively fetid. Sometimes, also, fissures form, and the cuticle peels rather than drops off. On the scalp it assumes a greenish livid hue. On the palms and soles it is usually guttated. The spots, PSORIASIS AND LEPR however, are not so distinct as in other parts, the cuticle, on being detached, also appearing more horny and yellowish ; and in this situation exfoliation is often very protracted. If fissures form, and the feet and hands are subject to much pressure, they become deeply ulcerated. If the matrix of the nails become affected, painful or phagedenic onyxis may follow. (Dendy.) 38. E. Infantile scaly syphilis is almost inva- riably marked by snuffling from the child's birth. The skin is of a dirty yellow or waxen hue, with numerous brownish pink spots, presenting a sprinkling of a gray or brownish white dust, which is often most abundant on the circumfer- ence of these spots. The disease may resem- ble, also, the livid spots already described, even at a very early age ; but more frequently an as- sociation of these differently tinted spots are observed on the face and hands. 39. III. Diagnosis.—The differences between the species of scaly eruption have often been exaggerated, or the extreme points of difference have been chiefly adduced and placed in bold relief by most of the writers on diseases of the 6kin, believing that the Enumeration of minute distinctions and the recognition of modifica- tions of the external characters would evince a more intimate knowledge of their nature than a display of their relations, not only with one another, but also with the state of the digestive, the assimilating, and the excreting functions, and of the circulating fluids. The devotion to "specialities," with the view of attracting the public by the presumed advantages of, and by the superior knowledge assumed from, a divi- sion of labour, was first manifested in modern times by the writers on skin affections; and, like all others devoted to a single craft, who adopt merely a minute segment of the great cir- cle of medical science for their practices on the public, rather than for its proper cultivation and improvement, they merely partially advance the trivial and the mechanical to the detriment of profound or comprehensive views, and they fail in the recognition of extensive morbid relations. While a few local distinctions or mechanical contrivances are paraded as proofs of a superior acquaintance with the adopted subject, their narrowed powers of mental vision fail to recog- nise much more important relations and mat- ters, the sources from which the local mischief proceeds, and the varied sympathies which ei- ther produce,, or are produced by, the object of exclusive adoption and cultivation, a cultivation resembling merely the superficial scraping of the soil by the hands of savage ignorance, not the deep ditching, the draining, and the manu- ring of applied science. The human microcosm cannot be advantageously studied in one of its parts only, nor can its states, affections, or structural lesions be either understood or rem- edied by confining our inquiries and our means to a particular or limited locality, even although that locality is the seat of disease. The animal body is one and indivisible, no one part being independent of another—no single system, or organ, or tissue, being disordered or diseased without implicating more or less the functions, and even the organization of several, or even of all the rest. Hence it is that no division of labour which has been adopted in medical prac- tice in ancient times, since the ages of the Pharaohs, down either to the modern days of IASIS—Description of. 525 the higher and more regular grades of empiri- cism, or to the lower degrees of quackery and imposture, has tended to advance medical sci- ence or to raise the respectability of our profes- sion. On the contrary, all such divisions, all adoptions of a single member, organ, or viscus for special practice or study, have lowered, in proportion to the degree of division, our science to a craft, and sunk the physician to an empir- ical practitioner: they may have enriched the charlatan, but they have degraded the profes- sion. 40. Those who have taken the eruptions of the skin under their protection, or the "Derma- tologists," as they have dignified themselves, have generally laboured to point out the ex- treme distinctions which may exist between the several forms or cases of scaly eruption ; limiting, however, their distinctions to the form, the size, the tint, and the thickness of a scale ; and to the form, size, hue, and condition of the tissue underneath. Their distinctions have been always local, and without reference to the states of the assimilating and depurating func- tions, and of the circulating fluids and excre- tions. Even the most important of all local distinctions have been neglected ; for they have failed to show whether the scales are an exu- berant formation of cuticle—are diseased cuticle hastily formed and as hastily thrown off—or are merely a thin albuminous exudation on the in- flamed surface, that becomes alfered by the action of the oxygen of the air, and thrown off by the local morbid action and the state of its vital and vascular relations ; or in how far va- rious states or appearances of these scales de- pend upon a morbid cuticular formation, or upon a modified albuminous exudation, upon the pro- duction by and upon the skin of an oxidized albumen. 41. The diagnosis of scaly eruptions is there- fore hardly to be regarded as respects the sev- eral forms which they assume, because shades of difference, too slight and too varied, and ever varying, to admit of description, are even more common than more marked distinctions ; but it may be entertained as regards other erup- tions with which the squamous may be con- founded, upon a hastji or imperfect view, and if the history, progress, and morbid relations of the case are not observed. The chief differ- ences which exist between the leprous and other species of psoriasis are, that generally in the former the patches are circular, with raised margins and somewhat depressed centres, the scales being moderately thick and slightly adhe- rent ; while in the other species the patches are irregular, not depressed in their centres, and are covered by thinner and more adherent scales. Psoriasis guttata, however, very near- ly approaches to the leprous species, especially to the alphoid variety, the distinctions now stated existing in some respects, and the patch- es of the latter being generally of larger size. Pityriasis may be confounded with psoriasis; indeed, it 13 but slightly different, either in local characters or in pathological relations, from the several species of psoriasis ; so that pityriasis, psoriasis, and lepra may be justly viewed as species of one genus. The distinction between pityriasis and the other species consists chiefly in the more superficial affection of the skin in the former, and in the smaller size and more 526 PSORIASIS AND LEPRIASIS—Pathology and Treatment of. furfuraceous character of the scales. The in- teguments, moreover, are often chapped or fis- sured in the latter, and but rarely in the former. Lichen'circumscriptus, with its annular clusters of papulae, fading towards the centre, may some- times be mistaken for leprous psoriasis, espe- cially in process of cure ; but the existence of the former is shown by the presence of marginal papula?; whereas in the latter the inflamed surface, denuded of its scales, is smooth and devoid of papulae. Tinea annularis, or ring- worm, at certain periods of its progress, either at the commencement or the end, when the crusts fall off and leave behind red annular- shaped patches, may be mistaken for lepra of the scalp, especially if there are patches on oth- er parts of the body. But the one is as rarely seen on the body as the other is on the scalp ; besides, the favous pustules of the former will indicate its nature. It should be recollected that several varieties of squamous eruption may exist in the same case, and that it may be asso- ciated with other eruptions, as with tinea. 42. IV. Prognosis.—The several species of this eruption are more or less obstinate. The prognosis depends much upon the-condition of the patient, and the duration, species, and state of the eruption. Even the mildest forms are apt to return after having disappeared, upon the recurrence of the causes, regimen, and diet especially, which first occasioned it. Psoriasis guttata, although not a severe form, is yet very obstinate, and is apt to return after disappearing. The diffused variety is still more obstinate, espe- cially in debilitated, old, or cachectic persons; and the inveterate form often resists all treat- ment, particularly in those unfavourable circum- stances. The same prognosis applies to the different forms of the leprous species. It is rare- ly attended by danger, and in young subjects it is often cured ; but in adults and aged persons it is always very rebellious, and often incurable, although treatment may restrain its progress and palliate most of the more annoying symp- toms. The existence of an hereditary predis- position to any of the species of scaly eruption militates strongly against a perfect cure, espe- cially in patients advanced in life ; for, even if almost or altogether removed, it seldom fails to return. The syphilitic scaly eruptions, when not associated with serious disease of the throat, or of the periosteum,' or of the joints or bones, and not advanced to extensive ulceration, will generally be removed by appropriate treatment, unless the disease be developed in the scrofu- lous diathesis, or is connected with an abuse of mercury, when a less favourable opinion of the result, as respects the constitution and vital organs, should be entertained. 43. V. The Pathology of Scaly Eruptions has been imperfectly, if, indeed, at all consid- ered. These eruptions have been viewed as altogether local, and their obvious dependence upon the state of the circulating fluids most un- accountably overlooked. Many years ago (in 1822) my attention was attracted to the state of the blood by a case of psoriasis, for which I had prescribed venesection, and found the serum remarkably milky or whitish-coloured. Since then other cases have furnished evidence of a superabundance of insufficiently assimilated chyle, of albumen, and sometimes of fatty mat- ter in the blood of patients severely affected with either of these eruptions. It is very obvi- ous that impaired function of the liver and di- gestive canal, as well as of other assimilating organs, will be followed by the presence, if not by the superabundance of imperfectly assimi- lated chyle, and chyle-globules in the circula- tion ; and that equally impaired excreting func- tion will occasion a state of excrementitial plethora ; the imperfectly assimilated and the effete materials thus accumulated in the blood exciting and perpetuating irritation of the capil- lary circulation of one or other of those emunc- tories whose office it is to remove these mate- rials from the circulation. Irritation of the cutaneous surface having gone on to inflamma- tion of a slow and chronic form, and the blood abounding with albumen, a state of capillary action and a material are thereby furnished for the formation of the scales which are so abun- dantly produced on the inflamed surface, and which is rarely, excepting at the commence- ment of the eruption, an altered state of the cuticle, and a morbid reproduction of it, but an exudation of albuminous lymph from the dis- eased capillaries that is modified by the state of the blood and the local action, and by the oxygen of the air, so as to form the several varieties of squamae observed in this genus of eruption. This view of the nature of squamous eruptions shows the impropriety of employing local or external means solely or chiefly in the treatment, and of thereby shutting up a safety- valve in the economy opened by the course of functional disorders; and it accounts for-the occasional supervention of serious visceral dis- ease upon the suppression of the cutaneous eruption. It also suggests the use for these and similar eruptions of such means as shall most effectually remove the disorders of the digestive, of the assimilating, and of the ex- creting functions, upon which these eruptions are chiefly dependent, and the impropriety of prescribing external means otherwise than as aids to internal and constitutional treatment. 44. VI. Treatment. — The circumstances which require especial attention, before the in- tentions of cure are determined upon in each case of scaly eruption, are the following: 1st, The habit of body, diathesis, age, and employ- ment of the patient. 2d. The indications of dis- order of the digestive, of the assimilative, and of the depurative functions in connexion with nervous and vital power. 3d. The duration and character of the eruption, the causes in which it originated or tend to perpetuate it. These last circumstances' should be viewed in con- nexion with the previous diet, mode of living, &c, commonly adopted by the patient. These particulars being ascertained, the states of those suffering any form of the eruption may be ar- ranged as follows, as/urnishing the chief bases for therapeutical intentions : First, as regards habit of body, &c, indications of plethora, or of anamia, and of digestive and excreting derange- ment ought to be carefully observed, and the Several associations of these states. Second, as respects the duration and appearances of the eruption, the amount and character of the in- flammation, and the discrete or confluent, or syph- ilitic form of the eruption ought to be noted; and, Third, the state of vascular action, generally and locally, and of constitutional power. These data having been obtained as accurately as pos- PSORIASIS AND LEPRIASIS—Treatment of. 527 sible, and with due reference to the states of the )lood and of the functions of waste and supply, the intentions are, 1st. To remove what- ever disorder may exist in the quantity or qual- ity of the blood, and in vascular action ; 2d. To restore the digestive and depurative functions* as being subsidiary to the first indication ; and, 3d. To correct the morbid action on the skin by rational local means. 45. Viewing the cure of scaly eruptions as being thus dependent, at all times during treat- ment, upon a due exercise of the several vital actions, especially those of digestion and depu- ration, and upon a sufficient, but not an exuber- ant supply of wholesome food, the application of these indications of cure should be accom- panied with strict attention to diet and regimen, as noticed in the sequel, and with a careful avoidance of the several predisposing and ex- citing causes (y 3, et seq.). 46. A. If the patient be plethoric, strong, or young, and the eruption copious, red, and not of long duration, and more especially if the pulse present sufficient tone, local and general action not being impaired or asthenic, then blood-letting, according to the peculiarities of the case, should unhesitatingly be prescribed ; and in healthy, dry, and country localities, if the patient has lived fully or richly, it may be re- peated, according to the effect produced by the first. After bleeding, an active antimonial emetic ought to be given, and its operation freely pro- moted. When the stomach is quieted, the bowels, and, through them, the liver, .should be freely evacuated by chologogue and stomachic purgatives. At first, and on several occasions afterward, a full dose of calomel, with some purgative, ought to be prescribed, and its free operation promoted by an enema containing spir- its of turpentine and castor oil, or some other cathartic. These should be repeated according to circumstances, but sufficiently often to pro- cure not only an entire evacuation of all crudi- ties and accumulations,'but also an increased discharge of all secretions and excretions from the digestive canal, and, through the medium of it, all effete or injurious materials from the blood 47. B. When the patient presents no indica- tions of vascular plethora or of increased action, and the patches are not very irritable or much inflamed, then blood-letting may be omitted, or a small blood-letting only prescribed. In the metropolis and large manufacturing towns,/vas- cular fulness and excitement are not generally such as require more than a small, or a local bleeding only; and not infrequently a state of anaemia, requiring opposite means to this, is met with in connexion with scaly eruptions.— a. For the former of these cases emetics and purgatives are indispensable, and for the latter they are not the less so; but the purgatives should be either conjoined with chalybeates or vegetable tonics, or alternated with them, so as to improve the powers of digestion and assimi- lation simultaneously with the evacuation of in- jurious matters. MM. Cazenave and Schedel remark, that " when the patient is young and vigorous, and the disease pursues a rapid course, the skin being hot and inflamed, and the pulse full and quick, then venesection, simple baths, diluents, strict regimen, and quiet are neces- sary." To these, however, I would add emetics and purgatives, as above advised (§ 46). In old and feeble persons, or in constitutions broken down by privation or excesses, in whom there is either but little inflammation, or inflammation of an asthenic or cachectic character, a course of tonics should be directed, and either alternated with or followed by purgatives and other ener- getic measures, according to the peculiarities of the case. 48. M. Biett, although he says nothing as to exhibition of an emetic either at the commence- ment or in the course of treatment, strongly recommends a purgative course, especially when the disease is recent, and the patient young or robust. He advises calomel every morning, fasting, in four-grain doses, either alone or with the same quantity of jalap. Sometimes sulphate of soda or sulphate of magnesia, taken in a considerable quantity of a bitter infusion, is very beneficial; and occasionally a more ac- tive purgative, as colocynth, scammony, gam- boge, &c., may be employed. The choice should be guided by the conditions of the patient and of the eruption, and by the effects of the medi- cine previously employed. M. Biett advises the calomel and the other purgatives to be con- tinued daily for several weeks—for two months —if they do not produce a complete cure within that time. If salivation or other specific effects of the calomel appears this substance may be omitted or the dose reduced ; but this effect would Seldom appear, and will not delay the cure. It is often necessary, or even advanta- geous, to suspend the treatment for three or four days, and then renew it. I have generally pre- ferred to combine the calomel with rhubarb, and sometimes also with magnesia ; or to give the calomel alone, much less frequently, and soon afterward a full dose of sulphur and magnesia ; or the pilula hydrarg., chloridi comp. with soap and extract of colchicum at bedtime, and sul- phur ,with magnesia in the morning. When sulphur is prescribed with magnesia, an aro- matic powder may be added, and the medicine continued once or twice daily, so as to keep up a free evacuation from the bowels for several weeks, the tepid or vapour bath, or other exter- nal means about to be stated being also em- ployed in aid of them. 49. b. The tincture of cantharides, administered in any mucilaginous diluent in doses gradually increased from five"to fifteen or twenty or thirty drops for a dose, was much praised by Biett , and, as M. Rayer observes, occasionally causes the rapid disappearance of the eruption, espe- cially of the leprous form, when not severe, or only recent and limited in extent. But if taken in larger doses, it may, although it relieves or removes the eruption, excite inflammation of the digestive or urinary organs, or of both. 50. c. The arsenical preparations, especially Fowler's solution, has proved very efficacious in scaly eruptions, and I have found it more certain in its effects than almost any other single.medicine. But the' good effects have seldom been permanent, or even so progressive as to effect a cure in the more severe cases, unless the diet be carefully regulated. There is often, also, a liability to a recurrence of the eruption after it has been removed by too large or too frequent doses of any arsenical prep- aration ; but this liability exists in most cases, and is to be met only by a most careful avoid- PSORIASIS AND LEPRIASIS—Treatment or. 528 ance of the exciting causes. MM. Cazenave and Schedel state, that as psor.as.s is often more obstinate than lepra, the remedies es- pecially arsenic, should be pushed faither for the former affection; and that a permanent cure, without any dangerous resultsmay be obta ned by the judicious admin.stra 10of arsenical preparations. M. Biett also enter- tafns a sSr opinion. These preparations should not be given oftener than twice daily and the dose ought not to be larger than three drops at first, nor increased beyond ten or twelve In many cases they should be given after a full meal, especially when the dose is large, and when the course is protracted ; and, unless the dose is very small, an intermission in the use of the medicine for three or four days should be directed. The following is the mode in which I have usually prescribed arsenic for the cure of psoriasis : No. 327. ft. Lkmoris Potassae Arsenitis, flljij. »d ^v.; Liquons Potassae, m*v. ad TKxxxv. ; Extr. Fluidi sarzs comp., 31.: Tinct. Aurantii, 3J- I"f«V Gentians Comp., 31. Aq Cinnamom., Jss, M. Fiat Haustus bis quotidie sumendus. 51. I believe that large or too frequent doses of arsenical medicines are not only more injuri- ous to the constitution, but actually much less beneficial, as regards the eruption, than either very small or very moderate doses. This cir- cumstance will account for the not very favour- able opinion expressed by Dr. A, T. Thomson re- specting them. He observes, " That notwith- standing the powerful influence of arsenic in psoriasis inveterata, I have met with cases which resisted it, even when administered in the largest doses. In some cases erysipelas has accompanied the use of the arsenical solu- tion, in which case the remedy should be sus- pended until the erysipelas be removed, and afterward renewed in smaller doses." (P. 67.) 52. d. Dr. Thomson adds, "That the medicine on which the greatest confidence may be placed in psoriasis is the liquor potassa." He com- mences with thirty drops in two fluid ounces of the bitter almond emulsion twice a day, " and gradually increases the dose of the solution to eighty or even one hundred drops. If the pa- tient be delicate, the infusion of yellow cincho- na or of cascarilla is substituted for the almond emulsion ;" and he has found the hydrargyrum cum creta in doses of six or eight grains, at bedtime, a useful aid to this practice. I have employed a similar treatment, but could rarely succeed in getting the patient to take so large doses of the solution as he advises ; indeed, I view them as injurious to the digestive organs and kidneys. I have seen marked advantage derived from it conjoined with the .iodide of potassium, and taken either in a bitter infusion or in one of the decoctions advised for this eruption. 53. e. The bi-chloride of mercury, taken in the decoction of cinchona, or of sarsaparilla, or of dulcamara, has been also recommended, and is beneficial in slight or recent cases; but has failed in every case of inveterate or of pro- tracted leprous psoriasis in which I have tried it. Dr. A. T. Thomson states, that he has found the combination of iodine with mercury Che most successful of any mercurial preparation for this disease. " The biniodide, in doses of a sixth to a fourth of a grain, exerts almost a specific influence upon the morbid state of the skin ; and when given at the same time as the iodide of arsenic, and aided by blood-letting, it has rarely failed in curing the most inveterate cases." As the acrimony of the preparation has disturbed the alimentary canal, he has usu- ally combined it either with opium or with co- nium, carefully avoiding ptyalism. As, how- ever, he has usually combined the biniodide of mercury with the iodide of arsenic, it is difficult to determine what share each may have had in the cure. He prefers this preparation of arsenic to the liquor arsenicalis. The dose of it, at first, ought not to exceed one tenth of a grain ; and in no instance should it be carried beyond one third of a grain. " Its obvious ef- fects are quickness and hardness of pulse, with slight puffiness of the lower eyelids ; but gen- erally, before these symptoms display them- selves, the disease has begun to yield. The symptoms which indicate a necessity for redu- cing the dose are, heat of the mouth and fau- ces, anxiety at the praecordia, pain at the epi- gastrium, or griping. If, besides these, there is tension, with stiffness around the eyes, ery- thema of the face, thirst, white tongue, the edges and tip of a florid red hue, and a quick pulse, the medicine should be suspended for some days. If nausea, cough, vertigo, or sali- vation supervene, it should be left off altogeth- er. The employment of any arsenical prepa- ration is inadmissible, if it cause an uneasy sen- sation in the chest from the first." 54. The reason of the failure of arsenic in the cure of leprous and inveterate psoriasis is, in many cases, the large or too frequent doses in which it has been prescribed; the poisonous effects of the arsenic being thereby produced before sufficient time is afforded for the devel- opment of the alterative operation of the min- eral. Most writers who have depended chiefly on arsenic for the cure of scaly eruptions have advised small or moderate doses, and a pro- tracted course of it. Girdlestone, Biett, Rayer, Willan, Bateman, and Erichsen ad- vise from two to three drops twice a day, up to seven or eight, this dose not to be exceed- ed, and the course to be persevered in, if none of the injurious symptoms just noticed be oc- casioned by it. 55. /. Recently, a preparation of arsenic, io- dine, and mercury has been strongly recom- mended for the most obstinate and inveterate cutaneous eruptions by Mr. Donovan, under the name of the " Liquor Arsenici et Hydrargy- ri Iodidi." The composition of this solution is as follows: Water, one drachm; arseniotis acid, one eighth of a grain ; peroxide of mercury, one fourth of a grain ; iodine, as hydriodic acid, about three fourths of a grain. Twenty min- ims, three times a day, have been considered as a proper dose with which to commence a course of it, and forty minims, thrice daily, as the lar- gest dose. I have prescribed this solution in many cases ; but I consider the dose here ad- vised as very much too large. If the tongue be at all foul or loaded, an emetic, followed by two or three doses of calomel and rhubarb, or jalap, ought to precede a course of it; and at first, from five to ten minims, twice or thrice daily, and very gradually increased to twenty or thirty, at the utmost, will be sufficient. This solution is most serviceable when the liver ifl PSORIASIS AND LEPRIASIS—Treatment of. 529 torpid or loaded, and in the strumous diathesis. It, as well as the biniodide of mercury, is very efficacious in the syphilitic scaly eruptions. Mr. Dendy recommends the occasional use of the warm nitro-muriatic foot-bath during the course of this solution. 56. As to the use of arsenical preparations in psoriasis and lepra, Mr. Erichsen very justly observes, that they should not be given until the disease had assumed a chronic or inactive character. As long as there is inflammatory redness, heat, or irritation of the patches, they ought not to be employed, as the irritation of the arsenic will augment these symptoms. Be- sides, during the earlier periods of the eruption, a cure may be effected by the antiphlogistic and other means I have above advised, espe- cially by depletions, emetics, and purgatjves, with strict attention to diet and regimen. It is only, therefore, in very indolent, or exten- sive squamous diseases, and after other reme- dies have failed, that any of the arsenical prep- arations should be prescribed ; and in all cir- cumstances they ought to be given cautiously, and their effects closely observed ; for, if pre- scribed too largely, or too long, they may in- jure the constitution much more than the con- tinuance of the eruption, which in many cir- cumstances admits of palliation merely, and not of complete cure. 57. g. There are various other medicines that have been prescribed, internally, for the scaly eruptions. The chief of these are, the decoctions of dulcamara, of gvaiacum, of mcze- reon, of elm-bark, the infusions of nettles, of marsh rosemary, the decoctions of sarsaparilla, sulphur, and the sulphurets, or the milk of sul- phur conjoined with magnesia, or with either of the alkaline carbonates, and the aethiop's mineral and other preparations of antimony. Either of these infusions or decoctions may be made the vehicles for the administration of oth- er more active agents, as the liqupr potassae, with or without the iodide of potassium, the li- quor iodidi arsenici et hydarargyri, the liquor hydrarg. bichloridi, &c. In some obstinate ca- ses of psoriasis, after morbid secretions and excretions have been evacuated, I have lately resorted to the use of spirit of turpentine, inter- nally and externally, prescribing this substance either alone or with oleum ricini, in doses of half a drachm, or of one drachm, twice or thrice daily, and, after two or three days, the occasion- al application of an epithem, or embrocation of this spirit over the part chiefly affected. The turpentine ought to be discontinued as soon as it irritates the kidneys, but persisted in if it acts gently on the bowels. It will be taken with little inconvenience on the surface of a little milk or coffee. I have occasionally pre- scribed tar-water, internally as well as exter- nally. It will be found a medicine of consider- able power in this and other cachectic disor- ders, if appropriately employed. Pitch, tar, and the turpentines have been recommended inter- nally and externally for squamous diseases, and generally in the form of pill when administered internally, tar and the turpentines being render- ed more or less consistent by means of magne- sia. They are sometimes of service ; but they often, in this form, pass into the large bowels undissolved, become excrementitial, and hence have little effect. Ill 34 [Dr. Emery, of the Hospital St. Louis, had his attention turned to the investigation of the dif- ferent products of tar as remedial agents in the treatment of skin diseases, on account of the successful results he obtained from the use of tar, and because of the unpleasant odour it gave forth. Various preparations were had recourse to, the most valuable of which proved to be the concrete naphthaline, which Dr. Emery tried in fourteen cases. In two cases, one of psoriasis gyrata, and the other lepra vulgaris, it failed in effecting any good; in the remaining twelve it proved more serviceable. Eight of these were men, and four women. In two of the cases, lepra vulgaris of from fifteen months to two years' duration, arsenical and iodic prepara- tions had been previously tried ; in the young- er patient the arsenic at first seemed to do good, but the improvement soon ceased. An oint- ment prepared with two scruples of concrete naphthaline to thirty of lard was applied, caus- ing the scales to fall off", leaving the skin of a violet colour, with white circles around. A perfect cure was effected in six weeks, and al- though three months have passed since, there has not been any relapse. In four other cases the men were labouring under inveterate pso- riasis ; in one of them it had existed sixteen years, and had resisted arsenical, iodic, and mercurial treatment. The tar ointment was had recourse to, and with decided advantage, but the man becoming impatient on account of his business, an ointment of naphthaline, twice the strength of that used in the preceding ca- ses, was spread on compresses, and applied over the diseased parts night and morning. The man was cured in six weeks. When the ointment was applied too strong, it caused a burning heat, which was soon removed by emoll- ient baths and poultices. The other six cases were also instances of psoriasis cured by the naphthaline ointment. Dr. Emery states, that this remedy has an unpleasant odour, which passes off, and it is apt to irritate the skin and cause erysipelas, if it be not carefully watched.] 58. C. The state of the constitution, as well as of general and local action, should guide the phy- sician in the choice of remedies, which ought to be chiefly antiphlogistic and evacuant, in the acute or early stage, and alterative and depura- tive in the chronic or advanced states. In many cases, however, alteratives and depurative rem- edies require to be combined with tonics and even with chalybeates; especially in cachectic habits, and when the eruption assumes a livid or dusky hue. In these, the iodide of potassi- um with the carbonate or solution of potass and sarsaparilla, or tonic infusions, or the io- dide of iron with sirup of sarsaparilla, or the bi-chloride of mercury in the tincture or decoc- tion of bark, with tincture of serpentaria, or the fluid extract of sarsaparilla, will generally be of great service ; and, if a cure be not effected by these, aided by external means (Y 61, et seq.), then the preparations of arsenic, or the combi- nations of arsenic, iodine, and mercury, may be resorted to, as above recommended. 59. D. The syphilitic varieties of squamous eruption should be treated with strict reference to the history of the case, and the means which have already been employed and the period of their employment. Several severe oases of this eruption, some of which had either gone 'RIASIS—Treatment of. 530 PSORIASIS AND LEP on to extensive ulcerations or become compli- cated with disease of the throat, or the bones or joints, have at sundry times come under my care. For these there are certain remedies, which, if judiciously employed, may be viewed as specifics.—a. The oldest and not the least efficacious of these is the bi-chloride of mercury, prescribed either in the manner recommended by Van Sweiten, or given dissolved in alcohol, and taken in water with the hydrochlorate of ammonia, or in decoctions of sarsa, &c, or pre- scribed with the decoctions or infusions, or tinctures of cinchona, serpentaria, &c. When the eruption and its antecedent symptoms have not been attacked by a mercurial course, then the bi-chloride should be given in decided do- ses, and preferably soon after a full meal, ei- ther in the form of a pill and in gradually in- creased doses, as advised by Van Sweiten, or as just recommended, in either of which com- binations it may be taken in the intervals be- tween meals. Salivation, unless it be slight, need not be produced ; although the specific ef- fects should be continued for some time ; when either of the other remedies next to be noticed should be prescribed, if the eruptions have not nearly or altogether disappeared. 60. b. The next specific remedy for this spe- cies of eruption is iodine. I believe that this substance, or any of its preparations, had not been prescribed for any form of syphilitic dis- ease when first I ordered it in the summer of 1825, the formulae, as well as an ioduret of sul- phur, having been prepared by Mr. Morson, the eminent operative chemist. At first I employ- ed the iodine either in the form of a weak tinc- ture, or in combination with potash, or the io- dide of potash with the addition of pure iodine. Subsequently I preferred the' iodide of potash, conjoined with liquor potassae and sarsaparilla ; full doses of Plummer's pill being taken at bed- time. The iodides of mercury have more re- cently been employed for this eruption, and are generally beneficial; but they are not superior to the treatment which preceded them. They are, however, advantageously given in the form of pills at night, or night and morning, the io- dide of potass being taken during the day, with liquor potassae and sarsa. In the syphilitic spe- cies, also, Mr. Donovan's solution is an excel- lent remedy, and may be advantageously adopt- ed in the more protracted cases. 61. E. The internal and external use of miner- al waters, either natural or artificial, and of sim- ple or medicated baths, will generally promote a cure. It is preferable, however, not to have recourse to these until morbidly increased ac- tion and vascular or excrementitial plethora is removed by depletions, emetics, purgatives, an- timonials, &e. But this end being attained, the sulphur waters of Harrowgate, Leaming- ton, Moffat, Crofton, and of other springs in this country *, or of those of Bareges, Caute- rets, Bagneres, Bagnoles, &c, on the Conti- nent, will be employed with great advantage. A frequent use of warm ,baths, the patient re- maining in them for a considerable time, and using gentle friction over the affected parts, will often be of service. A small quantity of the sulphuret of potash may be added to the bath. If the eruption be attended by much itch- ing, the biborate of soda dissolved in the water :vill prove very beneficial. Dr. Duffin recom- mends the immersion of the part, especially when the extremities are chiefly affected, in warm artificial Harrowgate water ; or the dis- eased parts to be washed or fomented with it twice or thrice daily, for fifteen or twenty min- utes each time ; and a mixture of equal parts of the,weak citrine and tar ointments to be applied after each fomentation. The following formula is given by him for the preparation of this wa- ter: Sulph. magnesia?, sij.; supertart. potassae, gr. x. ; sulphat. potassae cum sulphure (or sal polychrest), 3ss. These are directed to be dis- solved in twenty-four ounces of warm water, and used for a wash or fomentation. I have lately employed a wash or fomentation, either warm or tepid, with tar-water, containing bi- borate of soda dissolved in it. 62. If the scales adhere or are accumulated in crusts, sulphureous vapour baths, followed by frictions, or gently stimulating ablutions, or fomentations, with a solution of the biborate of soda, or with a little liquor potassae, will be of service. The application of steam or vapour, with or without the fumes of sulphur, is always of use. Lotions of diluted alcohol, of solutions of sulphuret of potass, or the decoction of dul- camara, will aid the exfoliation. When the scales are removed, Bateman and Thomson rec- ommend the unguentum picis, or the unguen- tum hydrargyri nitratis, diluted with the cera- tum plumbi compositum, or with simple oint- ment ; or, which is better than either, an oint- ment composed of equal parts of these two oint- ments. The ointments which I have preferred are the ioduret of sulphur ointment (gr. xij. or xj. to fj.), the calomel ointment (3J. to §j.), the oint- ment of white precipitate, the zinc and lead oint- ments conjoined, and the several ointments of the nitrates of mercury and of the iodide of mercury. These last should, however, be employed more or less diluted. The ointments containing ei- ther of the iodides are most suited to very ob- stinate cases, the others for slight or recent ca- ses. The iodide of sulphur ointment was first employed by the author in 1825. The oint- ments should be applied at night and washed offin the morning with a saponaceous or alka- line lotion (as 3iij. of liquor potassae in fvij. ss. of water), after which a solution of the bi-chlo- ride of mercury in dilute alcohol (gr. ij. in 51. p.) may be applied slightly by a sponge over the part. Besides these ointments, others, with the acetate or phosphate of mercury, with the sulphate and deutoxide of antimony, with an ioduret of ammonia (3J. to sj.), with camphor, or with concrete naphthaline (two to four parts to thirty parts of lard), have severally been rec- ommended by different writers. A principal advantage derived from ointments is the pro- tection of the inflamed surface from the action of the air, to which very insufficient attention has been directed in the treatment of cutane- ous inflammations. Therefore, after the sur- face has been cleaned by any of these oint- ments, they should be washed off, and some gelatinous, albuminous, or gummy preparation applied to it, so as to exclude the air, as advis- ed for Pityriasis (v 27); and this preparation should be allowed to remain as long as it an- swers this purpose, when it should be removed by fomentations and ablution, and reapplied until the parts are completely restored. I have lately employed for scaly eruptions a lotion of PSORIASIS AND LEPRIASIS—Bibliography and References. 531 one part of Glycerine, to three, four, or five parts of water, with marked benefit; and Dr Glover has recommended Iodoform externally (33s.—31. to the fj. of cerate), and internally, in doses of two or three grains twice or thrice daily.* 63. As I have shown in the article Pityriasis, the chief causes of the obstinacy of scaly and other cutaneous eruptions, are, 1st. The action of the air, from which they are not sufficiently protected during the treatment; 2d. The want of due attention to the state of the assimilative and depurative functions of the blood ; and, 3d. Insufficient restrictions on diet and regimen. But, even when a cure is obtained, or nearly obtained, a relapse or a return of the eruptibn is a frequent occurrence—a relapse generally pro- ceeding either from the causes just specified, or from a premature relinquishment of treat- ment ; a subsequent return of the disease re- sulting from the same causes as produced it at first, or from inattention to the several digest- ive and excreting functions. Both these un- favourable contingencies are most likely to oc- cur when the functions of the several abdomin- al organs have not received due attention du- ring the treatment, and a restoration of them to the healthy state has not been effected ; and also when the healthy conditions and colour of the parts affected have not been completely re- stored before the successful means were re- linquished. These two causes, especially when acting simultaneously, with errors in diet and regimen, are most influential in producing re- lapses, and returns, at more or less remote pe- riods, of scaly eruptions; and they are of great- er importance than they have hitherto been considered. 64. The local forms of psoriasis and lepra, men- tioned above (§ 16, et seq.), require chiefly the adaptation of the general and local treatment already described to the circumstances of each case.—(a) Psoriasis palpebrarum will often be benefited by the application of three or five leeches behind the ears, and by a lotion con- sisting of a weak solution of the nitrate of sil- ver, or a lotion of sulphate of zinc, or diluted tincture of iodine, to the part. The calomel ointment, or the zinc ointment, or a diluted ni- trate of mercury ointment, may be severally applied in this and the other local forms of the eruption.—(b) For psoriasis genitalium, emoll- ient local baths, and the use of the lotions and ointments just mentioned, are most beneficial. If these forms be attended, as they usually are, with much itching or irritation, a solution of the bi-borate of soda in tar water, or in some emollient fluid, containing creasote, applied as a lotion, or by a sponge, will generally give re- lief and remove the eruption. Sulphur and cin- nabar fumigations are usually successful when the scrotum or anus is implicated—(c) For pso- riasis palmaria, after soothing the parts with local baths of the decoction of bran, &c, oint- ments containing the iodide of sulphur, or the iodide of mercury, or the other ointments al- ready mentioned, may be employed in aid of the constitutional remedies recommended. In the more chronic states of psoriasis palmaris, Mr. Wilson advises a spirituous lotion of bi- chloride of mercury, followed by water dressing. 65. The mineral acids have been favourably [* Gun cotton dissolved in ether is on,e of the best appli- cations in these cases.] mentioned by some writers; but I have seldom observed much benefit derived from them, and have even believed them to have been some- times injurious. In a few cases, however, af- ter a due evacuation of accumulated secretions and excretions, the liver still continuing torpid, the nitro-muriatic acids given internally and employed externally have appeared of some use; and the sulphuric acid has occasionally been added, with marked advantage, to the neutral sulphates, dissolve^ in bitter infusions, and taken in quantities sufficient to keep the bowels freely open. Dr. C. Smith and Dr. Cu- min, however, are of opinion that dilute sul- phuric acid possesses considerable efficacy in the treatment of squamous eruptions ; the lat- ter physician believing that the acid is decom- posed, and that the system is thereby impreg- nated with sulphur. This may be the case when the quantity taken is small or very mod- erate ; but in some experiments I found that the dilute acid, when given in large and fre- quent doses, could be detected unchanged in the urine. Acids, however, ought to be em- ployed with caution, and with strict reference to the excretions, especially the urine and its saline constituents. 66. The diet and regimen are of the greatest importance in the treatment of all the scaly eruptions, and are often more beneficial, if strictly enforced, than even medical means. Animal food should be used sparingly; and pork, veal, ham, dried or smoked .and preserved meats ; fish and shell-fish, especially fried and rich fish; rich sauces, doughy articles, pastry, or pie-crust; pickles and preserves; heating and stimulating beverages, especially spiritu- ous and malt liquors, coffee, punch, acid wines, &c.,.ought to be constantly avoided; and su- gar, butter, and sweet or acidulated articles very sparingly taken. The remarks offered on this topic in the article Pityriasis (y 34), a spe- cies of the eruption now treated of, strictly ap- ply to the treatment of these eruptions. Bibliog. and Refer.—Hippocrates, De Usu Humido- rum. Epidem., ii.—Galen, Method. Med., xii.—De Caus. Sympt., iii., 6.—Oribasius, Morb. Curat., 1. iii., 58.—Celsus, L>e Med., 1. v., 28.—Actuarius, Meth. Med., ii., 11.—Paulus JEgineta, Trans, by Adams, iv., 2.—Avicenna, Canon., iv., 7, 2, 9.—Haly Abbas, Theor., viii., 26.—Pract., iv., 4.— Mercuriali, De Morbis Cutaneis, 4to. Venet., 1585.—M. Czanakius, Encomium Scabiei ad Scabinos Reipublicse Sca- bianae, 12mo. 1627.—Sennertus, Med. Pract., t. i., cap. 30. — Mead, Medicina Sacra, cap. ii. — Turner, Treatise on Diseases of the Skin, 8vo. Lond., 4th edit., 1731.—D. Ly- sons, Practical Essays, dec, 8vo. Bath, 1772. (On Elm Bark in Cutaneous Diseases.)—J. F. Carrere, Trait6 de la Douce Araere dans les Dartres, 8vo. Paris, 1789.—Vogel, De Cognosc. et Curand. Homin. Affect. CI., viii., s. 699.^- Sauvages, Nosolog. Method. CI., x., ord. 5. — Linnaus, Amismt. Acad., vol. viii., p. 285.—Et Dissertatio de Lede Palustre. Upsale, 8vo., 1775.—Lorry, De Morbis Cutaneis, 4to. Paris, 1777, p. 365.—Falconer, Memoirs of the Med. Soc. of Lond., vol. iii„ p. 369.—/. C. Smyth, Medical Com- munications, vol. i., p. 191, 8vo. Lond., 1784.—Meckel, De Lepra Squamosa, 8vo. Hals, 1795.—Moriarty, A Treatise on Mercurial Lepra, 12mo. Dublin, 1804.—C. H. Wilkin- son, Remarks on Cut. Diseases, Svo. Lond., 1822.—Willan, On Cutaneous Diseases, 4to. Lond., 1811, p. 36.—Alibert, Maladies, de la Peau, fol. Paris.—/. W. Perkins, Boston Med. and Surg. Journ., No. 182.—Et Journ. des Progres, &c, t. xvii., p. 272.—F. S. Bidon, Reflect. Pratiques sur le Mai. de la Peau appel. les Dartres, 4th ed. Paris, 1828. —Duffin, On Squamous Disorders, in Edin. Med. and Surg. Journ., vol. xxr, p. I.—T. Bateman, Practical Synopsis of Cutaneous Diseases, 7th ed., by A. T. Thomson, p. 35.— Plumbe, Practical Treatise on Diseases of the Skin, Svo, 2d ed. Lond., 1827.—M. Good, Study of Medicine,.vol. iv., p. 457.—Chevalier, Joum. de Chirnie Med. Mars., 1826.—Richter, Specielle Therapie, &c, b. vi., p. 440.— Rayer, Trait6 des Maladies de la Peau. Transl. by Willis, bvo. Lond., p. 631.—Et Diet, de Med. et Chirurg. Prat., 532 PUERPERAL CONDITIONS—Predispose to Disease. art. Lcprt—J. L. Alibert, Descript. des Mai. de la Peau, Observees A l'Hopital St. Louis. &c, fol: Pans, 1825 — L. A. Struvc, Synopsis Morb. Cutan. secundum Classes Genera, Species of vanet., Ac, fol. Berl., lb'29.—R. Wil- lis, Illustrations of Cutaneous Diseases, 35, p. 199.—E. Wilson, Pract. and Theor. Treatise on the Diag , Pathology, and Treatment of Diseases of the Skin, Svo. Lond., 1842. p. 214. — Th. H. Burgess, Manual of Diseases of the Skin. From the French of MM. Cazenave and Schedel, Svo. Lond., 1842, p. 200. —Et Diction, de Med., 2d ed., art. Psoriasis.— W. C. Dendy, On the Causes, Nature, and Treatment of Lepra and Psoriasis, fol. Lond. (with plates).—And a Treatise on the Cut. Dis. incidental to Childhood, Svo. Lond., 1627.—/. E. Erichsen, in Lond. Med. Gaz., vol. xxxii., p, 197.—R. M. Glover, in Monthly Journ. of Med. Sciences. Feb., 1848, p. 578. [Am. Biblioo. *nd Refer.—American editions of Rayer, Green, Cazenave and Schedel (by Bulkley); Good, Phimbe, Bateman, &c, and reviews and medical journals already noticed.] PUERPERAL STATES AND DISEASES. —The Pathology of Parturition. — Dis- eases INCIDENTAL TO THE PUERPERAL STATES. Classif.—General Pathology.—Special Pathology. 1. Several of the diseases incidental to par- turition and to convalescence from this act are discussed under their special denominations; and to these I shall refer as they successively take their places in the group of maladies usu- ally called "Puerperal." In this place, there- fore, it chiefly remains to discuss, 1st. The path- ological relations of the puerperal state ; and, 2d. The very dangerous and often malignant maladies incidental to it, which are not treated of under oth- er heads. That a view of the pathological re- lations of the puerperal state, impartially ex- hibited, and without reference to peculiar doc- trines, will be of use, it is hoped, in guiding the inexperienced during their intercourse with the deviations from the more common procession of morbid phenomena which will occasionally be met with by them, is only a reasonable ex- pectation ; and hence an inducement to under- take the labour which a faithful exhibition of this view involves. 2. I. The Pathology ok the Puerperal States.—i. Of the State of the Female at the most advanced or full Period of Preg- nancy.—The changes, as well as the principal deviations from the healthy state, during ute- ro-gestation, are described in the article Preg- nancy, and under various other heads. It only remains to notice the slate presented by the fe- male economy when gestation is approaching, or has reached its full period. The uterus then has attained its utmost size; and it then en- joys a copious determination of blood for the nourishment and growth of the fcetus, and for the preservation of its own augmented struc- ture. The distended uterus, especially in a first pregnancy, presses more or less, accord- ing to the size of the female and the capacity of the abdomen, upon the other viscera, espe- cially on the urinary bladder, the kidneys, the rectum, and large bowels, the liver and biliary apparatus, and stomach; and, consequently, the descent of the diaphragm is impeded, and con- gestion of the lungs is favoured. But the pres- sure also influences the circulation through the large venous trunks, and often, in some degree, through the heart and lungs ; hence arise con- gestion of remote parts, especially of the veins of the lower extremities, often followed by cedema, and congestion of the sinuses witbii the cranium, with the dangerous consequencei of this condition. The effects produced by the large size of the uterus are very much aggra- vated if pressure upon the lower bowels be al- lowed to interrupt the regular process of fteca- tion and excretion, and if this cause or indi- gestion should give rise to flatulent collections in any portion of the alimentary canal. 3. With the increased development of the pregnant uterus, the peritoneal envelope of the organ, and even the ligaments experience a re- markable change, and are inordinately stretch- ed, so as to favour the supervention of inflam- mation, especially upon the removal of the dis- tending cause, when additional influences come into operation. With the ascent of the fundus of the uterus, the omentum is more or less dis- placed, and carried upward ; its exact position and influence upon adjoining parts varying with the quantity of adipose substance it may contain. 4. It is obvious that changes of the position and condition of the viseera must influence more or less the functions performed by these viscera ; and that, both during the progress of these changes and at their consummation, va- rious disorders, noticed under Pregnancy, are liable to appear ; that the secretion and excre- tion of urine should be disturbed or impeded, or even arrested, the functions of digestion and assimilation-disordered, the intestinal secre- tions and excretions interrupted, and sensibili- ty and motion materially disturbed. At the full period of gestation, the circulating and res- piratory organs, and still more the nervous centres, owing to the congestions to which they are exposed at this period, are severally liable to the most serious attacks as soon as the congestion, in which these attacks origi- nate, is carried to the pitch requisite for their development. 5. In connexion generally with the changes now mentioned, if not always dependent upon these changes, the nervous system generally acquires increased sensibility and susceptibility of impression ; and, through the medium of this system more directly, and through that of the vascular system more indirectly, the whole frame intimately sympathizes with the uterus, independently of the mechanical effects pro- duced by it upon the other viscera. The ner- vous development of this organ, and the vascu- lar determination to it, influenced by the ner- vous organization, renders the womb the centre of numerous sympathies and the source of many morbid phenomena, all which increase and be- come more prominent with the progress of pregnancy, and still more manifest at the full period, during parturition, and for some time after delivery. The activity of the nervous in- fluence, and of the vascular circulation of the uterus at an advanced stage of pregnancy, in- fluences remarkably the conditions of both the nervous and the vascular system generally, not- withstanding the various pathological condi- tions tending to impair the energy and sensi- bility of the one, and the tone and action of the other—notwithstanding interrupted excretion, and the various circumstances favouring ex- crementitial contamination of the blood, and congestion of it in venous trunks and sinuses. 6. ii. Of the Changes taking place durin8 the Parturient Process, and their Inflo- PUERPERAL CONDITION ences in causing Disease.—The uterus, hav- ing completed its function of foptal develop- ment, or having carried this function as far as is consistent with the health and subsequent safety of the mother, experiences that state of action which is the best calculated to preserve both the child and the parent from injury and disease. But during this action, and the chan- ges in the nervous and vascular systems which it more or less remarkably produces, various morbid conditions are apt to appear. The pain- ful contractions of the uterus, although occur- ring only at intervals, tend to excite or react upon the nervous systems generally, but more remarkably upon the spinal cord, and through it upon the brain. These contractions also tend to diminish the flux of blood to the uterus, and to determine it in greater quantity to the brain, and thereby to change a pre-existent state of passive congestion into active and in- creased congestion, or to carry a condition of the vascular system, which was insufficient to produce acute disease, to that pitch which in- stantly develops such disease. 7. The uterine actions, although often thus productive of seizures depending upon the states of the cerebro-spinal nervous centres, especially as regards the circulation of these centres and the peculiarities of that circulation, are yet independent of these states. This fact is undeniably demonstrated by the occurrence of uterine action independently of the will, and during abolition of the functions of the cerebro- spinal system ; by natural parturition taking place during paraplegia as well as hemiplegia, and as shown recently by the regular progress of the parturient process, while sensibility and voluntary motion are abolished by the inhala- tion of ether or of chloroform. It is obvious that the muscular contractions, and the pain- ful excitement of the uterine nerves during par- turition, will occasionally develop morbid ten- dencies in the nervous system when these al- ready exist, owing either to hereditary or to acquired predisposition, and consequently that convulsive or apoplectic seizures, or phrenitic or maniacal attacks will occasionally appear during this process ; the convulsive seizure presenting more or less of the apoplectic, of the epilectic, or of the simply convulsive char- acter, according to the predisposition and pe- culiar circumstances of the case ; the mani- acal attacks rarely appearing during parturition, although frequently after this process. Con- vulsive-seizures are not confined to parturition, for they occasionally take place previously to, as well as after, this process; but during it they are more apt to assume an apoplectic or epileptic, or a mixed form—in consequence of the greater liability to active congestion of the brain and spinal cord during the parturient act —the apoplectic being characterized by pro- found coma and stertorous breathing, with slight convulsions, the epileptic by the violence of the convulsions, by frothing at the mouth and injury to the tongue. (See articles Con- vulsions, Puerperal ; and Insanity, Puerpe- ral.) 8. Certain changes in the uterus itself may take place during pregnancy, or even may have existed previously, and may arrive at a danger- ous or even fatal termination upon the acces- sion or in the course of parturition. Thus in- S—Predispose to Disease. 533 inflammation may have attacked a portion of the pregnant uterus and occasioned softening, or impaired action and tone, or even a greater lacerability of that portion, in consequence of either of which changes rupture of the uterus, or dangerous hemorrhage may take place du- ring parturition ; or, if either of these do not supervene, inflammation of the uterus, or of its veins or sinusest or peritonitis, or puerperal fe- ver, may follow delivery, the previously dis- eased state, and the exhausted tone and con- tractile power of the organ especially favouring the occurrence of these maladies. 9. There are various circumstances connect- ed with parturition productive of disease ei- ther of the uterus or of adjoining and associa- ted parts. The interferences arising out of im- patience and want of confidence in the efforts of nature, a premature or inconsiderate, or a too "long delayed recourse to medicinal or me- chanical aids of parturition, and the injury which these may occasion either to the uterus or to parts in the vicinity, or even to both, are among the most influential causes of disease, not only of the parts thereby injured.but of the frame generally through the media of the ner- vous and vascular systems. The means which have recently been recommended for the pre- vention of pain during parturition, although quite competent to the production of this re- sult, cannot be viewed as altogether innocuous. Several instances have already occurred, evin- cing not merely dangerous, but actually fatal effects from recourse to them. A fatal issue may certainly be prevented from taking place immediately from these means ; but the chan- ges which may terminate fatally cannot be so readily prevented in all cases, and at the same time accomplish the intention for which they are employed. These anaesthetic agents have been demonstratively shown not only to de- stroy, sensibility for a time, when inhaled for a short period, but also, in comparatively short periods of inhalation, to produce congestion of the lungs, a manifest change in the state of the blood, and even a rapidly fatal result. That these agents, when adroitly and cautiously ad- ministered, may hot occasion any inconvenience subsequently to their inhalation maybe the case, in nine out of ten instances in which they have been employed, will be readily admitted, but the tenth instance may be one of serious puerperal disease, of convulsions, or of mania, or of fe- ver, or of congestive pneumonia, or bronchitis, owing to the previous state and predisposition of the patient: events which cannot be anti- cipated or guarded against by the physician. Pain is often salutary as respects its effects, and especially in enabling the oeconomy to re- sist, and to rally against, the depressing ope- ration of shocks upon the vital influence ; and, when neither its violence nor its continuance is productive of injury to the constitution, or of exhaustion of vital power, to endure it is preferable to the annihilating of sensibility by an agent which acts so remarkably, and so im- mediately upon the chief manifestation of ani- mal life, arrests the usual processes of nature, and even terminates existence itself if employ- ed a.few seconds longer than is required to de- stroy this the highest function of living crea- tures. [On the other hand, it is not to be forgotten MS—Predispose to Disease. 534 PUERPERAL CONDITIOI that very serious consequences often happen from the shock produced by pain itself, as in a severe surgical operation, or from parturient throes, and that there may be less danger in overcoming these pains, and thus preventing the shock, than in allowing them to go on un- impeded. There is a choice of evils, and, if possible, we are to select the least. We have been led to believe, from what we have observ- ed, that the general employment of anaesthetic agents in midwifery is inexpedient, being not unattended with danger. Dr. J. C. Warren has very justly observed, that there is no parity be- tween the abolition of pain in surgical opera- tions and the abolition of the pains of labour, the former being only a part of that general law for preservation against injury, in consequence of which, whenever a foreign body threatens to impair the integrity of an organ, pain is pro- duced, and the organ is instinctively withdrawn from the contact. While, therefore, there is nothing contrary to the laws of nature in the removal of pain from surgical operations, that which regulates the pains of labour is a general law, its final cause being sufficiently plain to show its utility, if not its necessity. It would certainly seem, a priori, that the use of so pow- erful an application through the whole period of a natural labour would, in proportion to the term of that labour, increase the dangerous tendency to organic excitation ; and when this period is very protracted if might bring on dis- tressing derangements of the stomach, brain, spinal marrow, or uterus, besides in many ca- ses suspending the uterine contractions. Dr. W. is of opinion that the cases in which ether or chloroform can be properly resorted to in mid- wifery should be exceptions; such as, 1st. In a natural labour, when the pains are uncommon- ly severe, especially the terminating pains in a first parturition. 2d. During limited periods of labours prolonged by a preternatural cause. 3d. When, from the peculiarity of constitution, the patient cannot without danger support the usual amount of suffering. 4th. For the pur- pose of obtaining relaxation in irregular con- tractions of the uterus, as the hour-glass con- traction after delivery. Ou the contrary, there are other highly re- spectable accoucheurs who advocate the gen- eral use of anaesthetic agents in midwifery prac- tice, as Professors Simpson, of Edinburgh, and W. Channing, of Boston, Mass. The former states that he has employed chloroform in al- most every case of parturition for the last six months or more, not only without danger, but without any unpleasant symptoms. The testi- mony of Dr. Channing is also to the same ef- fect. The conclusion, then, to which we are forced to come, in consideration of all the facts before us, is, that in properly-regulated doses, anaesthetic agents, like other powerful narcot- ics, as morphia, &c, may be administered not only with safety, but with the highest advan- tage, provided there be no contra-indicating cir- cumstances, and due attention be paid to con- dition, age, temperament, sex, and constitu- tion. We have found a small inhaler the most convenient method of giving chloroform, so as to regulate the dose with proper exactness. In this vessel place fifteen to twenty drops of pure chloroform, and let the patient inhale it care- fully ; if the dose is not sufficient, add ten or fifteen drops more, whicr will usually be found an ample quantity to annul sensibility, if not consciousness.] 10. iii. Of the State of the Female after Parturition, and its Influence in favouring the Occurrence of Disease.—In estimating the state of the female upon delivery, the pre- vious conditions now passed in review, those just antecedent to parturition, and the act of parturition itself, ought to be held in recollec- tion. The pressure produced by the gravid uterus upon adjoining viscera, and the effects of that pressure, as shown above (y 6, et seq.), are now suddenly removed. The vitality of the frame has sustained some degree of shock from the violent contractions of the uterus, the expulsion of the fetus, and the detachment of the placenta, as well as from the sudden loss of blood, and the removal of pressure and dis- tention. The internal surface of the uterus, moreover, resembles that of an extensive wound, especially where the placenta was attached to it; while the peritoneal surface of the organ, and the positions and physical conditions of the several abdominal viscera, are now more or less changed. The general results of these con- current changes are not severely felt by robust or sound constitutions, beyond what may be viewed as a slight shock to the vital energy, attended by more or less exhaustion conse- quent upon the pains, the uterine action, and the loss of blood ; but this result in these con- stitutions amounts not to disease ; it is merely a state of vital exhaustion, which nature soon repairs, but Avhich readily favours the develop- ment of disease whenever any of the causes to which puerperal females are often exposed comes into operation. It is different, however, with females who are otherwise circumstanced, especially with the delicate, the insufficiently nourished, and the morally depressed. If there exist a deficiency or poorness of blood ; if fae- cal accumulations have formed in the large bowels; if the patient be nervous, hysterical, or subject to sudden or epileptic seizures; if she entertain fears of her state, or anxieties as to the present or future ; and if she be exposed to the impure air of a low, miasmatous, damp, and close chamber or locality ; or to the con- taminating and infectious air of an hospital; or to any of the numerous causes whjch induce the diseases incidental to child-bed, then the ef- fects, whatever may be the especial form which they assume, will be most serious and often fatal. 11. In proportion to the severity of shock produced by the parturient act upon the vital energy, and to the susceptibility of the nervous influence and sensibility of the patient, will the liability to the supervention of puerperal mala- dies be great. Mania, watchfulness, headache, convulsions, imperfect contractions of the ute- rus, or an impeded return of the organ to the size proper to the time which has elapsed since delivery; suppression of, or irregularities in, the lochial discharge; suppression of the se- cretion of milk, &c, may severally follow se- verity of shock, especially when heightened by marked susceptibility and sensibility; and these latter will in their turn be greatly aggravated by large losses of blood relatively to the condi- tion of the vascular system, even although no other malady be superinduced. After consid- PUERPERAL CONDITIONS—Convalescence from. 535 erable hemorrhage, also, particularly when vi- tal exhaustion is remarkable, or when the mind is anxious or depressed, morbid emanations strongly impress the nervous system, and read- ily pass, by endosmose, into the pulmonary cir- culation. The contractions of the uterus being then also inefficiently produced, the lochial dis- charge is partially retained and rapidly altered; and, thus altered, it is partially imbibed by the vessels opening on the internal surface of the uterus, inflaming these vessels and venous si- nuses. . But the matters retained in the uterus may not merely inflame these vessels, they may also contaminate the organ itself; and being imbibed and absorbed into the circulation, contaminate also the whole mass of blood, with or without manifest change in the uterine ves- sels and structure ; and, moreover, after such contamination, superinduce remarkable consti- tutional effects and structural lesions of those parts especially which have undergone the more evident alterations as to position and condition during the successive stages of gestation and parturition. 12. Thus, after parturition, the female frame is particularly open and liable to be invaded by the most influential causes of disease : 1st. By mental excitement and impulse, and by moral depression. 2d. By the inhalation of morbid effluvia, proceeding either from other diseases, or from the decomposition of-animal discharges and secretions, or from the other sources gen- erally productive of infectious emanations. 3d. By the absorption from the cavity of the uterus itself of retained and partially decomposed dis- charges. 4th. By infectious matters retained in the foul bed-clothes, mattresses, or beds in which the female is confined. 5th. By the re- tention and, absorption of altered secretions and excretions, or of faecal matters from the alimentary canal; and, 6th. By interrupted se- cretion and excretion, the blood being altered more or less, owing to the accumulation in it of morbid or excrementitial materials. 13. iv. Of Convalescence after Parturi- tion.—A. The natural Course of Convales- cence.—a. The shock consequent upon deliv- ery soon subsides when it is moderate and the patient obtains a few hours' sleep, if all dis- turbance or excitement be prevented. In pro- portion to the subsidence of this effect upon the vital power, the comfort and repose of the patient return, and nervous symptoms or vas- cular excitement are prevented. As the shock subsides and exhaustion is diminished, so are the several secretions and excretions, with the new secretion of milk, re-established. The cir- culation, as indicated by the pulse, which was excited or increased in frequency during the progress of labour, falls below the natural stand- ard immediately after, and continues below it during a few hours. After varying somewhat for the following fourteen or fifteen hours, the circulation becomes slightly increased on the secretion of milk ; and, when this secretion is established, it generally continues about the natural state. 14. b. The uterus contracts more or less firm- ly immediately after delivery, so as to reduce it, in the more energetic cases of contraction, to about the size of the infant's head. This contraction, 1st. Prevents hemorrhage; 2d. Empties the cavity of the uterus, and prevents the lodgment of coagula; 3d. It constricts the uterine vessels and sinuses, evacuates their contents, and prevents their tendency to im- bibe fluids, which may be retained in the cavi- ty of the womb; and, 4th. It diminishes the afflux of blood to the uterus. The contraction and diminishing size of the womb proceed, al- though not regularly, or without recurrences of slight relaxation, until about the eighth, or ninth, or tenth day, when it descends into the pelvis. Previous to the eighth day, its state may be as- certained through the relaxed abdominal pari- etes ; but afterward the fundus only can be felt above the pubis, and in six or seven days it can no longer be detected.' This diminution of bulk is not altogether attributable to contrac- tion, but to absorption in part, and in no small degree to the exclusion of the supply of blood, and to the pressure, by the contraction of the uterine fibres, of the fluids from the vessels and the interstices of the structure. It may, how- ever, be doubted whether absortion is concerned in lessening the size of the womb aftef delivery, the lochial discharge probably contributing to this result. 15. c. The condition of the internal surface of the uterus, after delivery, is a matter of inter- est. " For several days after parturition, when no disease of the uterus has supervened, its lining membrane is coated with a yellowish brown, dark red, or ash-gray coloured layer of no great thickness, which seems to be formed chiefly of the fibrine of the blood, with small portions of deciduous membrane." The part to which the placenta was attached is raised above the surrounding level: its surface is un- equal, resembling in this respect a granulating ulcer ; its size is wonderfully reduced. In this situation dark-coloured coagula are found seal- ing up the orifices of the uterine sinuses, and frequently extending into the veins. The struc- ture of the uterus is found to be less dense than natural, and the fibres more distinct. The os and cervix uteri axe covered with ecchymoses, as if severely bruised; and sometimes small la- cerations are observed on the edge. The ori- fice remains open for some days, but gradually closes. The vagina soon recovers its former calibre; considerable heat and soreness of it are experienced ,for only a short time, unless the head of the child have remained long in the pelvis, of the lochia be very acrid, when they are prolonged or pass on to inflammation of a more or less severe character. The vulva also resumes its natural capacity in a shorter time than might be expected. (See Churchill.) 16. d. After-pains require no mention at this place, as they are considered under that head. (See art. After-pains) The lochia is merely a continuation of the discharge of blood which attends delivery, and proceeds from the vessels exposed by the separation of the placenta. For three, or four, or five days it continues of a red colour; but it is much thinner, and more wa- tery than blood, and it is not coagulable. It then sometimes becomes yellowish, retaining its serous consistence; but it most frequently changes successively to greenish, yellowish,. and, lastly, to a turbid appearance. The quan- tity and continuance of this discharge vary re- markably. Of the former no estimate can well be formed; the latter varies much; but the discharge seldom ceases altogether in a short- 536 PUERPERAL DISEASES—Convalescence from. er period than three weeks, unless in conse- quence of disease, or continues longer than a month. Its suddpn disappearance, and even its short duration or scanty quantity, are im- portant symptoms of puerperal disease. 17. e. The several secretions and excretions are more or less affected during the puerperal states. During parturition the perspiration is abundant, but diminishes gradually after deliv- ery ; but it usually continues free, and has a faint, sickly odour, until convalescence is fully established, when the skin presents its usual state. The urine varies in quantity with the abundance of perspiration and of fluid ingesta, and also with the state of the bowels, which also vary, owing to their previous conditions and other circumstances. The milk is secreted im- mediately, or soon after delivery. A serous fluid, approaching to, but in some respects dif- fering from true milk, is generally secreted for some time before parturition ; and occasional- ly true milk is secreted during labour, although rarely with first children. In this case the mother can suckle immediately after delivery. But more frequently the milk is not secreted for eighteen, or twenty-four, or thirty-six hours, when the breasts enlarge and stinging pains shoot through them. As the parturient shock passes off, and the contracted state of the ute- rus diverts the vascular determination from this organ, the secretion of milk commences and increases. 18. /. With the development of this new function a general disturbance of the system, constituting what is termed the milk fever, is produced. The severity and duration of this disturbance are influenced chiefly by the cir- cumstance of the woman's nursing the infant or discouraging the secretion of milk, and by the state of the bowels and of the other secretions. At first, or about the second or beginning of the third day, the mammae are heavier, larger, and tenser, and the patient has slight chills or rigours, followed by heat of skin, soreness of the breasts, and acceleration of pulse. With these symptoms the secretion commences, at first slowly and with difficulty, but afterward more freely. As the secretion becomes more abundant, the above symptoms abate, and in two or three days disappear. The milk first secreted is thicker and richer than that which follows, and acts as an aperient to the infant. (See art. Lactation.) 19. B. Deviations from the natural and healthy Course of Convalescence after De- livery.— Dr. Hamilton justly remarks, 1st. That when there has been unusual suffering during labour, the usual changes after delivery cannot be expected to proceed in a healthy manner, because the exhaustion of sensorial power must more or less paralyze the actions of every part of t*he system ; 2d. That the vio- lent pressure to which the parts concerned in the mechanism of labour have been subjected must occasion a tendency to inflammation; and, 3d. That the violent and continued actions of the respiratory organs must render them li- able to derangement. But, however influen- tial these causes may prove in occasioning de- viations from the ordinary course of convales- cence, there are others not the less so, and these consist, 1st. Of disorders previously ex- isting, or occurring during pregnancy; 2d. Of peculiarity of constitution or predisposition; 3d. Of mental agitation and moral influences; and, 4th. Of numerous circumstances occurring, and of causes coming into operation after de- livery. 20. (a) The nervous shock may be so very se- vere as to create alarm. The patient has the aspect of a person in a state of collapse or ex- treme exhaustion. The countenance is ex- pressive of anxiety; the senses are either mor- bidly acute, ort what is still worse, unnaturally dull; the pulse is very rapid, small, and weak, or very slow, laboured, or irregular; and the respiration is hurried, panting, and often more frequent than accords- with the state of the pulse. Between this more extreme state of vital shock and the natural state there are nu- merous grades; and even in the slighter states reaction may be long deferred, or may take place imperfectly, or even excessively. In the more extreme states of shock, death may oc- cur in a few hours, without any attempts at re- action being made, the vital sinking proceed- ing until life is terminated.* 21. Dissection, in these cases, detects no le- sion to account for death. Dr. Churchill re- marks, that of several cases of this kind which he has seen, one was tedious, but terminated naturally, and two others were instrumental deliveries. A due estimate of the nervous shock is of great importance in severe cases ; for in most instances the progress of conva- lescence is in inverse proportion to the amount of this disturbance. In some persons slight circumstances increase, in a wonderful degree, the susceptibility of impression ; and, if this be overlooked, very serious results may follow. 22. (b) The state of the pulse is of the utmost importance after delivery. If it continue fre- quent or very quick, one of two, or even three, things is to be apprehended, even although no other untoward symptom may exist, namely, hemorrhage, internal or external, or the acces- sion of inflammation, or of puerperal fever. Dr. Churchill observes that, in almost all the cases of flooding after labour, he has found the pulse remain quick, and perhaps full, up to the oc- currence of the attack. He might have extend- ed the observation to inflammations and puer- peral fevers; seeing that the phenomenon is equally applicable to them and to the com- mencement of lactation, to after-pains and to the retention of coagula, in some constitutions. The remark of Dr. John Clarke that no wom- an should be considered as safe whose pulse exceeds 100 is certainly just; and I may add, that if the pulse exceed 110, then the risk of puerperal fever or of internal hemorrhage hav- ing commenced, is very great; and a careful examination of all the symptoms of the case should be made, and the coming mischief anti- cipated, and, if possible, prevented. 23. When, with increased quickness of pulse, it is found that the uterus has not decreased so far in size as might have been expected from the time that had elapsed since delivery, or [* We have known several cases of death from nervous shock after child-birth even as late as the second or third week, in vefy delicate females, and where no morbid chan- ges could be found after death. In two instances the fatal result was caused by strong mental excitement when in a very feeble condition; syncope succeeded, from which the patient could not be roused. These cases require very great caution, in order to guard against accident.] PUERPERAL DISEASES-Trea that, having been diminished, its bulk has in- creased about the fourth or fifth day, then in- flammation of the womb or of its vessels may be expected to declare itself, if it have not al- ready done so, by increased tenderness, by less firmness of the uterine tumour, by the diminu- tion of the lochia, and by the sensations of the patient. These symptoms may, however, be occasioned by the retention of coagula in the womb ; which, if retained long, or if not thrown off, by means which will aid the contractile ac- tion of the uterus, may cause inflammation or puerperal fever. As tenderness may accom- pany severe .after-pains, it is proper to distin- guish between the tenderness thus produced and that which depends on inflammation; and this may be effected by ascertaining whether or no the tenderness continues in the intervals be- tween the pains and contractions which occa- sion them. If it does continue, inflammation should be suspected, especially if the pulse be quick, and if the lochia has suddenly become scanty or suppressed. 24. (c) The lochia rarely deviates from the usual condition without exciting some degree of anxiety in the mind of the patient and phy- sician. This discharge may cease a few hours after delivery, after the birth of a still-born or putrid child ; and, although putridity of the fe- tus may be viewed as risking the healthy con- dition of the uterus, yet the membranes may have protected this organ, so that no unpleas- ant symptoms appear. The lochia may also be very scanty, yet of the usual duration, as when flooding has occurred ; and in this case no farther mischief may appear, although a greater predisposition to some other puerperal malady is thereby developed, as puerperal fever or mania, &c. This discharge may be, on the other hand, excessive, either as to the quantity within the usual time, or as to the prolonged duration of it. After having decreased in quan- tity and changed in colour, it may suddenly in- crease, or become even excessive. This is usually caused by sitting up too soon, or walk- ing about; or by the expulsion of a clot which may have obstructed the passage of the dis- charge through the os uteri. If the lochia change suddenly from a paler to a redder col- our, or if a red colour return after it has disap- peared, the accession of secondary hemorrhage should be dreaded and guarded against. The passage of the discharge into uterine leucor- rhosa, which may be permanent, will sometimes occur, and ought to be prevented. The lochia may assume an acrid and a very offensive state. It is then of a dark or green colour, very pro- fuse and watery, often so acrid as to excoriate the parts, and always very fetidl These con- ditions of the discharge are often a sign of dis- ease, but they often also are caused by the re- tention of a small portion of the placenta, or of coagula, either in the uterine cavity, or in the extremities of the veins and sinuses, or by portions of the decidua which putrify and come away. 25. (d) The bladder and urethra may suffer considerably after labour, especially when pro- tracted, and be excessively tender; and redness and tenderness may extend to the vagina and vulva. This state is often productive of dis- tressing strangury, sometimes with considera- ble fever. LTMENT OF CONVALESCENCE FROM. 537 26. C. Of the Management- of Convales- cence from Parturition.—{a) For the natural course of recovery, the recommendations of Ham- ilton, Clarke, Smellie, Burns, Churchill, and others accord in every respect, and are nearly the same as those which will be here adopted. The patient, after delivery, should be kept for some time in a state of perfect quiet. The room ought to be slightly darkened, and very few persons, except the nurse, admitted. Little or no talking ought to be permitted, unless in an under-tone, and no whispering. The con- versation and demeanour of all should be cheer- ful; and no ill news, frightful stories, or un- seasonable communications related. Mental excitement or emotion of every kind is liable to be injurious. The horizontal position must be strictly preserved, and sleep invited. After a few hours' sleep the nervous system will re- cover from its shock. The state of the pulse ought to be carefully watched, and excitement of it viewed attentively in connexion with every sign or symptom of disorder, as it is generally the first to indicate the approach of disease. " Immediately after delivery, it is proper to ap- ply compression to the abdomen, by means of a broad binder. This is useful, in the first place, to fix the uterus, and secure its steady contrac- tion ; and, secondly, to encourage the contrac- tion of the abdominal parietes. The binder should extend from the ensiform cartilage to the pubes, and be carefully applied for ten days or a fortnight." Immediately after the expul- sion of the placenta, a warm napkin ought to be applied to the vulva, and changed at short in- tervals. "This will afford relief from the smart- ing pain consequent upon the passage of the child. After some hours, when the patient is recovered, the external parts should be washed with tepid milk and water, containing a small portion of spirit. This must be repeated twice a day, not only for the sake of cleanliness, but to aid in restoring the parts to their natural state."—(Churchill, &c, Op. cit., p. 253.) 27. The horizontal posture ought to be unde- viatingly observed ; and however the exact position may be changed, the horizontal state should never be departed from until permitted, and never until after the fourth or fifth day from delivery. The after-pains require such atten- tion as is advised in the article respecting them. The lochia needs no farther attention than that the napkins should be changed sufficiently often, and. that they be applied warm, and so as to prevent the admission of air, especially cold air, to the tender parts, and the action of the air on the internal surface of the vulva. The air in the chamber ought to be preserved in a fresh and moderately cool state, and a fire kept up in order to promote a renewal of air in the room. The hed-clothes ought only to be sufficient to afford a comfortable degree of warmth. 28. Micturition should be attempted as soon after delivery as may be felt to be requisite— in from five to eight hours—and it should take place as nearly in the horizontal position as possible. Dr. Hamilton advises the patient to turn round upon her knees, by which any coag- ula accumulated in the vagina will readily be expelled. If micturition be neglected too long, the bladder may be paralyzed, or inflammation may attack it and extend to the peritoneum, or convulsions may be excited by its over-disten- 538 PUERPERAL STATE—Treatment of Convalescence from. tion, as I have witnessed in two instances. If any difficulty in evacuating the bladder exist, a warm fomentation to the vulva, or the intro- duction of the catheter, will remove it. It is the more important that the urine should be voided when the patient complains of pain in the lower belly, with a desire to pass it, and when the la- bour has been severe or instrumental. 29. The bowels may remain quiet for twelve or eighteen hours after delivery ; and if they are not moved at the end of this time, a dose of castor oil, or of senna, or of rhubarb may be given, and, if necessary, repeated. The fre- quency of repetition must depend upon the state of the bowels previously to delivery, and upon the presence of signs of faecal accumulations. Dr. Hamilton remarks, that " unless it be un- equivocally ascertained that the bowels have been regularly cleared previous to delivery, a dose of castor oil, or of aloes, with some nar- cotic, if necessary, ought to be given as soon as the woman has recovered from the shock of la- bour, and the appearance of the stools particu- larly examined." lfindurated faeces be present, the purgative should be repeated every ten or twelve hours, until the bowels are completely unloaded. When the reduction of the bulk of the uterus is tardy, purgatives are more espe- cially required, or an enema, containing the spirit of turpentine and castor oil, may be oc- casionally administered. 30. If the breasts become hard and painful, warm fomentations, frictions with warm oil, or with a slightly stimulating liniment, and a dose of a purgative medicine are usually advised and repeated for those cases where the milk is to be discouraged, the woman not intending, or not being capable of suckling the infant. As soon as the secretion commences, the child should be put to the breast, in order to facilitate the dis- charge of the milk and to prevent distention. It is better, as Dr Churchill advises, to do this, even if the patient should not suckle her infant, as it will aflbrd relief. When she is not to suckle, she ought to have every second or third day, according to her strength, till the secretion of milk ceases, and the tension of the mammae subsides, a dose of some purgative, as rhubarb or senna, with a neutral salt. She ought not to leave her bed, even to have it made; before the fifth day; and, if she be a delicate subject, she should strictly preserve the horizontal position for several days longer. Premature exertion, and inattention to position and to suitable diet, are the chief causes which combine with im- pure air, foul beds and bedding, and mental emo- tions to produce the maladies consequent upon parturition. 31. The patient's diet should consist chiefly of gruel, arrow-root, sago, rice, milk, whey, pa- nada, weak black tea, with dry toast or biscuit, and very little butter for the first three or four days. When the vascular excitement attending the commencement of lactation has subsided, and no disorder is observed, broth, chicken, mut- ton, or other light articles of diet may be taken on the seventh or eighth day; and wine and water, preferably claret, may be allowed in a day or two afterward. 32. (b) Deviations from the ordinary progress of convalescence ought to be promptly attended to and cautiously treated.—a. If the vital shock be extreme, or even severe, small doses of opium, with camphor, ammonia, or musk, should be frequently administered, and the quantity of each duly proportioned to the frequency of ex- hibition and the urgency of the case. These substances are preferable to wine or brandy, as they procure sleep, quiet the pulse, and prevent the subsequent reaction from being excessive; while the latter may occasion fever, or dis- tressing headache, or even mania. In this emergency perfect moral and physical quietude should be preserved. As the shock subsides, suitable nourishment and restoratives are re- quisite. 33. /3. Increased frequency of pulse ought al- ways to excite suspicions and the strictest in- vestigation. If the patient suffer from gastro- intestinal irritation, the cause.of frequency is thereby manifested, and blue pill, or the gray powder, with Dover's powder, should be pre- scribed, and repeated according to circumstan- ces. If faecal matters have accumulated in the bowels, the purgatives and enemata already mentioned are required. If the quickness of pulse still continue, the states of uterine con- traction and of the lochia ought to be examin- ed, with the view of detecting the commence- ment of disease in the uterus or its appendages, or in the peritoneum. 34. y. An acrid or morbid state of the lochia is apt to occasion irritation, excoriation, or even inflammation of the vagina and vulva, with smarting and itching. In this case extreme cleanliness, frequent bathing, warm diluent va- ginal injections, lotions containing lead, or the black-wash, or the sulphate of zinc may be em- ployed ; the simply diluent injections being first used, and the others subsequently or after the lochia has become scanty, or about to disappear, lest suppression of the discharge should be pro- duced. The injections ought to be warm, and, if the lochia be very offensive, a small quantity of creasote, or of chloride of lime, or chlorinated soda may be added. During the treatment, the binder above recommended should be duly and carefully applied. When the lochia becomes excessive or prolonged, nutritious diet, tonics, as the preparations of cinchona, or quinine or cha- lybeates, or the tincture of the muriate of iron, ought to be allowed after a due time from de- livery has elapsed. When the discharge be- comes excessive, or changes in colour after having nearly ceased, the patient should be con- fined to the horizontal posture. In all these circumstances, and especially when the lochia is excessive, prolonged, or likely to pass into uterine leucorrhcea, the occasional administra- tion of an enema containing oil of turpentine, or embrocations with this substance, applied either above the pubis or over the sacrum, will be of service. 35. v. Of the Influences and Agents favour- ing, predisposing to, or exciting Puerperal Disease.—The same causes may produce any of the acute maladies incidental to the puerperal state ; the particular malady being determined by the peculiar combination of causes and of circumstances aiding the development of the ef- fects of these causes by the constitution, habit of body, and state of the patient previous to and during the parturient process, and by the chang- es consequent upon delivery; by these last more especially than by others. The remarks which have been offered above on the several changes PUERPERAL STATE—Treatment of Convalescence from. 539 and varying states and circumstances tending strongly to predispose the female frame to the invasion of the exciting causes of acute disease, will sufficiently show the marked liability to such disease which these changes and states create, even in the more favourable circum- stances in which she may be placed. But when it is considered that, with these successive changes, various mental emotions have been and continue in operation—fear and anxiety in most cases, and the most depressing of the moral sentiments in some—these changes must be viewed as receiving therefrom the most im- portant aids towards the development of serious morbid effects. To these, moreover, are often added the influences of diet and regimen, not always the most suitable to the successive states of advanced gestation and of parturition, and more especially to the period immediately following delivery; the still more active agency of close, impure, and miasmatous air, of foul exhalations, and of imperfect ventilation ; and the contingent operations of infectious effluvia variously generated and as variously conveyed and propagated. 36. Among the poorer classes, and even among the richer in some localities, the moist, putrid, and contaminating emanations from the numerous sources with which all cities and large towns more or less abound, are productive of the more malignant of the maladies incidental to the puerperal state. These sources have been fully described, and their influence shown in the articles Infection and Pestilence, pro- tection from. But the most malignant operation of a foul or contaminated air is shown in lying- in hospitals, where every patient which enters them, at certain seasons or times, is seized with puerperal fever, or some other acute and often fatal disease. If the wards of a lying-in hospital contain more than four beds; if these wards are placed too close to each othei, if they be not lofty and ventilated by a thorough cur- rent, by open fire-places, and by fires; if they be too closely shut during cold and moist states of the air ; if the discharges be not quickly re- moved, and the cloths imbibing the lochia be not frequently renewed ; and if the bed-clothes and bedding be not perfectly clean and duly purified, the more malignant forms of puerperal disease will soon make their appearance, owing to the generation of a morbid, an infectious, and a contaminated effluvium, by puerperal females and by their discharges, in too confined and in- sufficiently ventilated apartments. This efflu- vium, when once generated, may be conveyed by the clothes, or by other media, and may in- fect others so circumstanced as to be contami- nated by it. Of this fact I have known numer- ous proofs, which will be noticed in the sequel. 37. There is every reason, moreover, to be- lieve that lying-in hospitals are not the only source of the fevers which render these institu- tions a greater curse than a benefit to the com- munity ; for I have seen reasons for inferring, that the foul air extricated from the numerous sources of impurity, contamination, and death with which this city and others abound, and which I have described under the heads refer- red to above, especially when undiluted by due ventilation, or when accumulated in a humid, still, and confined atmosphere, and when ad- mitted to and acting upon the recently delivered female, will so depress organic nervous power, and so contaminate the circulating fluids, as to develop puerperal fever of a malignant charac- ter, which may, in its turn, generate an efflu- vium productive of a similar malady in other puerperal females when communicated to them. 38. The contaminating effluvium, or infect- ed atmosphere, productive of the more violent states of puerperal diseases, and the sources from which such effluvium proceeds, cannot be disputed ; but its modes of invasion and. opera- tion are not quite so manifest. 1 believe, how- ever, from what I have observed in the differ- ent circumstances in which this effluvium or contaminated atmosphere has been generated, that its modes of invasion and operation differ materially according to the concentration of this cause, and to the circumstances favouring its invasion in one way in preference to anoth- er. Thus, in the more concentrated state of the effluvium, as generated in the crowded wards of a lying-in hospital during a cold and humid state of the air, and when due ventilation was prevented, I have seen females without any complaint, and dead within twenty hours after- ward ; and on dissection neither the uterus nor its appendages, nor the peritoneum, has pre- sented any manifest lesion, or any change more evident than that of other organs ; the chief alteration being a fluid and dark state of the blood, some congestion of the lungs, and enor- mous flatulent distention of the elementary ca- nal. (See hereafter.) In these cases, which were observed as closely as I was able, I at- tributed the intensity of the operation of the poison to its being respired with the air, to its operation on the nervous system and blood, to its contaminating the fluids, and to its impair- ing not only the crasis pf the blood, but also the vital cohesion of the tissues, as evinced upon dissection, even before the body had en- tirely cooled. 39. In other circumstances, when the mor- bid or poisonous effluvium appeared to be less concentrated, and to be productive of a less malignant or less rapidly fatal disease, and where there was less crowding, and better ven- tilation of the wards, the effects were different both as to their procession and as to their issue. The appearances after death were varied, and were most remarkable in the peritoneum, or in the uterus, or in the uterine sinuses, or in the veins of the uterus and its appendages; and, in respect of these cases, I have doubted wheth- er.or not the poisonous effluvium or emanation had invaded the frame through the respiratory organs, or by the vulva and vagina, or by both avenues. It may be viewed as a somewhat extravagant notion to suppose that an agent disseminated in, and conveyed by, the air can contaminate or infect the frame by the latter avenue—by the vagina. But if the effects of the admission of even pure air into the cavity of an abscess, and the difficulty of preventing this admission on occasions of opening psoas and lumbar abscesses, and of puncturing empy- ema, be duly estimated, the probability of air finding admission by the vagina to the uterus will be admitted, especially when the states of these parts for some days after parturition is considered. If, then, the air already poisoned or contaminated thus finds its way into either the vagina or the uterus—an avenue much more 540 PUERPERAL DISEASES—Prevention or. patent than the opening into a chronic abscess, &c.—it will necessarily occasion, in the puer- peral state, effects even more remarkable than when admitted into other cavities ; for the al- ready infected air will contaminate not only the discharges retained in these situations, render- ing them still more injurious and infecting, but also the surfaces with which they come in con- tact, and which, as respects the uterus, resem- ble those of a recent wound, and, as regards the vagina, are excoriated, tender, or inflamed. 40. If the production of dangerous states of puerperal disease by this local contamination be admitted, the very intimate connexion be- tween certain forms of puerperal fevers and erysipelas will be farther demonstrated thereby; while, on the other hand, this admitted connex- ion between these maladies will evince the high probability of this mode of infection and con- tamination. It is extremely probable, more- over, that the vital depression produced by the foul air respired by the puerperal female, or even by an infecting effluvium communicated by the clothes of an accoucheur, will so influ- ence the state of the recently-delivered uterus as to give rise to farther changes : 1st. To im- perfect contraction of the uterus and impaired tonic action, and to the slow return to the nat- ural states of the vagina and vulva; 2d. To an altered, contaminating, or morbid state of the lochia; 3d. To a more marked disposition to the absorption of such parts of this altered dis- charge as may be retained in the uterus or va- gina; and, 4th. To the prominent changes ob- served after death in the uterus, its appendages, and peritoneum. 41. vi. The Causes of the serious nature OF ALL, AND THE VERY DANGEROUS TENDENCY OF some, Puerperal Diseases, will readily appear from what I have already advanced respecting the changes experienced by the female frame in connexion with the puerperal state, and the nature of the influences and agents to which the female in this state may be exposed. The shock which the vitality of the frame has re- ceived during parturition, its manifest effects on the nervous system of some females; the predisposition to fever, mania, or convulsion which it occasions ; the sudden removal of dis- tention and of pressure ; the as sudden change in the state of the vascular system, as respects both fulness or deficiency, and distribution or determination of blood ; the continuance of weakening discharges and of depressing men- tal emotions ; the alterations in the secretions and excretions ; and the organic disposition of the sexual organs and adjoining tissues and vis- cera to experience structural change during the puerperal states—all and severally tend to im- part a serious or dangerous character to the diseases which occur during these states. 42. But it is not only to the changes which the female constitution undergoes in the puer- peral states that the severity of the diseases incidental to those states are to be imputed, but also to the nature of the causes which pro- duce these diseases, and to the pathological changes which necessarily follow, if they be not arrested by prompt and active measures at an early period of their progress, and before the fluids become contaminated, and the predispo- sed structures disorganized or altered. The diseased, also, with which puerperal females are affected, whether those following the ope- ration of the common or physical causes, of those induced by the imbibition and absorpiion of morbid secretions or excretions, or by infec- tious effluvia, are seldom simple or uncompli- cated—are not confined to the nervous system, or to the vascular system, or to the sexual or- gans, or even to several of the abdominal visce- ra—but extend to all the general systems, im- plicate both the nervous and vascular systems, change the vital and physical conditions of the blood, and affect, in a more or less prominent manner, the generative organs and peritoneal surface, which in many cases manifest the great- est amount of organic lesion. It is obvious that diseases of so complicated and general a character, affecting the chief factors of life, changing the conditions of vital fluids and of vital organs, attacking the frame at that period of existence, and in that condition, which are the most liable and open to their invasion, and in which the vital energies are the least capa- ble of resistance, will, in these circumstances, make a rapid, a dangerous, and often a fatal progress. 43. vii. Of the prevention of Puerperal Maladies.—The remarks which I have offered above on the management, both of the natural course of convalesence after delivery and of the slightest deviations from it (§ 26-34), and on the chief causes of the most important of puerperal diseases (§ 35, et seq.), will have al- ready shown what the chief means of preven- tion are, and that they should have strict refer- ence to the management of convalescence and to the treatment of those early deviations, as well as to the careful avoidance of those more noxious causes to which puerperal females may be exposed. Indeed, an early and judicious treatment of the slighter deviations from the usual progress of convalescence, and avoidance of the infectious or contaminating causes, con- stitute the chief means of prevention that can be adopted. Yet there are certain of these causes, and more especially of the sources whence they spring, which receive insufficient attention, and until lately have received no at- tention at all, even from those who consider themselves expert beyond all others, especially in matters which they view as their own par- ticular province, and as being above all the rest most important. I believe that the chief sour- ces of puerperal fevers, particularly of their more malignant forms, are lying-in hospitals, in which not only a very large proportion of those who are received become infected, but also from which the infection is carried abroad, not solely by the females who go out, but also by the clothes of the dead and of those who recover, and by the persons and clothes of the medical attendants. The charitable would much more wisely and humanely contribute their bounty for the promotion of cleanliness and comfort in the chambers of the poor, and for enabling the objects of their bounty to be delivered in their own houses, with requisite and healthful appliances and aids, than in caus- ing them to be transported to sources of con- tamination, contingent infection, and in no very small proportion, even of death. 44. The importance of removing, and of avoid- ing, when removal cannot be attained, the sev- eral sources of infectious effluvia which have PUERPERAL DISEASES—Sang been mentioned under the several heads already referred to, was not the less obvious because it was so generally overlooked previously to the appearance of those parts of this work in which the injurious effects of these sources of con- tamination were treated of; and even now they have not received the least attention as re- spects their influence in causing the more im- portant maladies incidental to the puerperal state. The nature, the number, and the con- centrated agencies of these sources are now too manifest to require description ; but there is at least one to which insufficient attention— or, indeed, no attention at all—has been direct- ed, namely, the impure state of the bedding used by many persons of the middle classes, and of those below them, although not the poorest. The beds, consisting chiefly of feathers or wool, always of animal substances—having imbibed the effluvium and perspiration of the persons who have slept on them during many years, or even during generations, without .having once undergone purification—have become more or less contaminated by the continued use ; and it cannot, therefore, be a matter of surprise if, in certain occasions of prolonged occupation, and in some atmospheric conditions, an efflu- vium should be evolved from them productive of infection or contamination to the susceptible and predisposed puerperal female. That a con- taminating effluvium is actually evolved from foul beds in these circumstances, I believe, be- cause I have seen proofs of this cause of dan- gerous disease ; and hence more notice should be taken of this source of human, and especially of puerperal infection, than it has hitherto re- ceived. It is not improbable that puerperal fe- males are not the only sufferers from this cause, and that puerperal fevers are not the only dis- eases which may occasionally originate in this source, but also that erysipelas, typhoid fevers, and other febrile and infectious maladies may often be produced by the same causes, both in the wards of an hospital, and in the close and impure sleeping apartments and beds of the poorer classes, and even of those next above them, when the infection becomes more gener- ally diffused. 45. II. Of the local and functional Dis- eases incidental to the Puerperal State.— Several of these diseases are treated of under distinct heads. Phlegmasia dolens, puerperal convulsions, uterine hemorrhages, and puerperal mania have separate articles assigned to them. (See arts* Convulsions, § 27, et seq.; Hemor- rhage, Uterine, and Insanity, Puerperal). The disorders incidental to the mamma and to the secretion of milk are considered in the arti- cles Lactation and Mamm^. It therefore only remains for me to notice at this place certain lesions of the sexual and adjoining organs which are apt to occur, during and subsequent to par- turition, and the fevers to which puerperal fe- males are liable. 46. i. Structural Lesions consequent upon Parturition. Classif.—IV. Class, IV. Order (Author). 47. A. Sanguineous Tumour of the Vulv^;. Sanguineous tumour of the labia, Churchill.— Sanguineous extravasation into the labia, Crosse. —Effusion of blood into the cellular tissue of one or of both labia is of rare occurrence. It has been observed and described by Macbride, Mait- uineous Tumour of the Vulvae. 541 land, Denman, Burns, Merriman, Dewees, Hamilton, Crosse, and others. 48. The effusion may not be limited to the vulva, but may extend into the pelvis, and downward to the perinaeum. ' It may occur du- ring labour, previously to the delivery of the child, as in Dr. Maitland's case, but much more frequently immediately afterward. The tume- faction is generally sudden, and increases rapid- ly. The size varies much, and has even reach- ed that of a child's head. Dr. Churchill, quo- ting M. Schedel, states, that as much as six or seven pounds of blood have escaped. 49. a. It is caused by the rupture of some ves- sel or vessels, by the pressure of the child's head while passing through the pelvis ; and most probably the ruptured vessels have been in a varicose or disordered state previously. " Dr. Burns supposes some of the vessels of the nymphae to be ruptured ; Dr. Dewees, that the vessels of the vagina give way; and Drs. Davis and Campbell, the pudic vein."- But there is not sufficient reason to assign it to any particular vessel. It most probably arises from the rupture of several small varicose veins. This lesion has usually followed natural la- bours. 50. b.' Symptoms.—The patient's attention is first directed to it by the swelling of the labia, and by a sense of weight and of bearing down. On examination, one or both labia are found distended, sometimes enormously, and the la- bium everted, so that the tumour appears par- tially covered by the mucous membrane. The colour is livid, or nearly black. The parts are extremely tender, and the pain is very great. The tumour increases rapidly until it covers the vulva and the perinaeum. Dr. Churchill states, that a considerable degree of fever is present; the pulse becomes quick, the skin hot, and the head pained ; there is sometimes, also, delirium. Retention of urine, from the pres- sure of the tumour on the orifice of the urethra, increases the distress. The patient lies on her back, scarcely able to move, with the thighs widely separated, unable to bear even the pres- sure of the bed-clothes (Dewees). After a few hours, relief is obtained by the rupture of the labium, which always takes place on its inner surface, and by the discharge of blood. A small portion of this surface begins, to slough, and part of the blood escapes ; but, some co- agula remaining, the wound becomes offensive from their decomposition. The slough and re- maining coagula are afterward thrown off, and the parts generally heal by degrees. 51. The rupture of the tumour rarely takes place during the labour; but in this case, as well as- in others where it occurs before the blood is coagulated, the hemorrhage is so great as to occasion fainting, or even death, as in the instances adduced by Phillipart, Crosse, Nae- gale, Schedel, and,others. If the tumour be very large before the birth of the child, it proves so serious an obstacle as to require surgical in- terference.. This tumour cannot be mistaken for hernia; the rapidity of its appearance, the period of its occurrence, its size and colour suf- ficiently distinguishing it from hernia. It has been mistaken for the distended membranes, and punctured with this idea; but the bag form- ed by the membranes can be isolated from the labia and traced up to the os uteri. Besides, URE OF THE LTtERUS AND VaGINA. 542 PUERPERAL DISEASES—Rup- this tumour generally does not occur until after delivery. 52. c. The treatment is evidently to give as early an issue as possible, after the blood has coagulated, to the contents of the tumour. If the risk of hemorrhage before coagulation be considered so great as to prevent an opening being sooner made in the tumour, the urine ought to be drawn off, and an enema, with an ounce or an ounce and a half of oil of turpen- tine, administered. In no case should this en- ema be withheld, and rarely ought an incision into the labium be delayed longer than two or three hours. When the small coagula infiltra- ting the cellular tissue causes an offensive dis- charge, then lotions with vinegar, water, and creasote, or with chloride of lime, or charcoal poultices, may be employed. If hemorrhage con- tinue, or return, the turpentine clyster should be repeated, and compresses, moistened with oil of turpentine, applied. The bowels ought to be kept open, and the febrile and other symp- toms treated according to general principles and the peculiarities of the case. 53. B. Laceration of the Perineum.—This accident is varied in extent. Where it is slight, it may not materially interfere with the com- fort of the patient, but when it is extensive it is a cause of almost constant distress. It oc- curs most frequently during first labours.—a. " The exact situation and extent of the rupture vary with the cause and the circumstances of the case. 1st. It may Commence at the ante- rior border and extend to the sphincter ani, and this is the most frequent extent. 2d. The rent may involve the entire perinaeum; and extend through the sphincter ani, laying the cavities of the rectum and vagina into one. 3d. The central space of the perinaeum is sometimes ruptured, leaving the anterior edge and the sphincter ani untouched." Both the child and the placenta may pass through this central lace- ration, or completely per anum. 4th. The rec- to-vaginal septum, sphincter ani, and part of the perinaeum may be torn, so as to permit the passage of the child, leaving the anterior por- tion of the perinaeum entire. 54. b. The causes are deviations from the or- dinary mechanism of parturition ; malconform- ation of the passages, or of the soft parts ; ex- ostosis or tumours in the pelvic cavity ; ex- cessive violence of the pains, and the too rapid passage of the head of the fcetus; great breadth, or extreme rigidity, or great weakness of the perinaeum ; malposition of the child's head, or malpresentations; and mismanagement or want of care, especially when instruments are used. Thus it will appear that this accident cannot always be prevented. 55. c. The symptoms and consequences of lace- ration depend upon the extent of it. If the in- jury be slight, no ill effects may probably re- sult ; but if it extend to the sphincter, the pa- tient complains of want of support, and is lia- ble to procidentia of the womb. If the recto- vaginal septum be torn, the state of the patient is most distressing. The faeces, for some time at least, pass through the vagina involuntarily ; and the utmost attention to cleanliness is re- quired, but cannot always prevent most dis- tressing annoyances. When slight, the rent commonly contracts, and heals without inter- ference, after a short time. Even when the recto-vaginal septum is torn, partial union may take place, and leave only a fistulous opening. Dr. Burns remarks, that a valve may ultimate- ly be formed, so that the patient may be partly relieved of her infirmity. But frequently the lochial discharge passing over the wound pre- vents the natural process of cure, and the torn surfaces become callous, or degenerate into ul- ceration iii consequence. 56. d. The prevention and treatment of this ac- cident are fully discussed in works on midwife- ry and surgery. To these I must refer the reader. But I may remark, that slight cases require only cleanliness : the part will heal of itself, and the patient may not even suspect what has occurred. Even when the laceration is more considerable, all that may be required is, to give at first one or two active purges, and afterward allow the bowels to become costive, to observe strict cleanliness, and to keep the patient in one position, so as to preserve the edges of the wound in contact. If these means do not succeed, a binder may be passed around the hips, and a pad on each side of the perinae- um, so as to preserve the edges of the wound in apposition. Sutures of different kinds have been employed, and have succeeded in rare in- stances. After sufficient purging, it may be advisable to give opiates, so as to cause cos- tiveness for a few days, and thereby to aid in the restoration of the parts. The catheter must be passed twice or thrice daily, and means used to absorb entirely the discharge. The diet should be spare, and chiefly farinaceous. Perfect qui- etude is necessary. In the various circum- stances in which a failure, partial or complete, of the above means may occur, the assistance of the surgeon and mechanist will be required. 57. C. Rupture of the Uterus and Vagi- na.—This fatal occurrence may take place du- ring parturition, during pregnancy, and at an advanced period of life, of course unconnected with pregnancy; this last being the rarest. Dr. Churchill adduces statistical details of this accident, from which it appears that Dr. Collins met with thirty-four cases out of 16,654 ; that sixty-five cases occurred in an ag- gregate of 42,768 patients, or about one in 657. Dr. Burns says, that it happens about once in 940 cases. It is not so often met with in first as in subsequent pregnancies. Of seventy-five cases, nine occurred in the first pregnancy, fourteen in the second, thirteen in the third, and thirty-seven in the fourth and subsequent pregnancies. 58. a. Causes.—1st. During gestation, it may arise from that form of extra-uterine pregnan- cy called interstitial fostation; the ovum being retained, in passing the Fallopian tube into the uterus, between the uterine fibres, where, as it grows, it occasions the absorption of that por- tion of the uterine parietes, which at last give way, and allows the fetus to pass into the ab- dominal cavity. Rupture of the uterus may also proceed from disease, as from inflamma- tion, softening, or suppuration of a portion of the walls of the organ ; or it may be produced by accidents, blows, falls, &c. It may even occur without any assignable cause, unless it be then occasioned, as Dr. Burns supposes, by irregular action of the fibres of the uterus. 59. 2d. During parturition, it may also arise from pre-existing disease, and especially from PUERPERAL DISEASES—Rupture of the Uterus and Vagina. 543 any one of the usual consequences of inflam- mation. A portion, also, of the uterus may be atrophied, softened, or thinned by the pressure of the child against it, or by pressure of some part of the abdominal or pelvic parietes, so as to yield during the uterine contractions of par- turition. Duparcque mentions scirrhus of the uterus as one of the causes of rupture ; but this is doubtful. When partial inflammation of the uterus has existed during gestation (9 58), then the laceration has usually corresponded with the situation of the previous pain marking the seat of inflammation. There can be no doubt that a perfectly healthy uterus is rarely or never ruptured. In one case M. MalGaigne attribu- ted the rupture to the administration of ergot of rye. 60. b. The period of labour at which rupture may occur varies ; " it may be at the begin- ning, before the rupture of the membranes ; du- ring the passage of the head through the pel- vis ; or in the moment when the child is deliv- ered." Narrowing of the upper outlet may give rise to it; or any other mechanical obsta- cle opposing the actions of the uterus ; or even oblique positions of the womb. The age of the patient has but little influence in predisposing to rupture. 61. c. The rupture may only be partial, some one of the tissues of the uterus giving way ei- ther previously to or during labour, probably owing to antecedent disease, or to peculiarity of structure. The peritoneal coat alone may be torn, or the muscular coat may be ruptured, the peritoneal covering remaining uninjured. Dr. Collins met with nine cases of this de- scription. Although the extent of lesion is less in such instances, yet Dr. Churchill considers it to be equally fatal. And as in other forms of rupture, it may be caused by external injuries, by excessive movements of the child, by over- distention, &c. 62. Violence in turning the child may cause rupture; " and it. may accompany this opera- tion, in certain states of the cervix uteri, with- out any fault of the operator." Rigidity of the os uteri, or imperforation, may also occasion laceration. Several instances are recorded in which the os uteri was torn completely off du- ring labour. Pressure at the brim of the pelvis, rendering the cervix uteri thinner or softer than natural, and more easily torn, has been assigned for this occurrence. 63. 3d. Al an advanced period of life the struc- ture of the cervix uteri is more or less chang- ed, becoming dense, cartilaginous, and the ca- nal reduced in size, or even obliterated. The outlet for the escape of secretions accumulated in the uterine cavity is thus closed; and if the quantity collected be sufficient to distend the organ, some portion of the walls experiences absorption and thinning, or inflammation and softening. Thus an opening or perforation may be made by absorption, or by rupture, into the peritoneal sac. 64. d. On dissection, the torn edges, and the parts immediately adjoining, usually exhibit marks of disease when the rupture has pro- ceeded from this cause, the laceration in such cases occurring in any part of the organ. " When the rupture is the result of mechanical causes, it generally takes place near the cer- vix, and involves both the uterus and vagina," the part which gives way being usually near the union of the cervix with the vagina. The wound is commonly transverse. Of twenty- three cases, Dr. Collins found one on the right, one on the left side, eleven posteriorly, and ten anteriorly. The structure of4the uterus is hard- ly altered—is firm in texture, and natural in colour, except a few ecchymoses. The edges of the laceration are jagged or Uneven. In very rare instances the bladder has also been ruptured. When the peritoneal surface of the uterus has alone been- torn, several small lace- rations, resembling scarifications, from a quar- ter to half an inch in length, and one or two lines in depth, are found. They are attended by the effusion of blood in the peritoneal cavi- ty, and by the usual appearances and products of peritonitis, which are caused by the effused blood and the injury. When the muscular sub- stance is alone torn, there may or may not be found evidence of pre-existent disease. The peritoneal covering is generally inflamed, and blood is found effused in the cavity of the ute- rus. Laceration of the cervix uteri is-accom- panied with a bruised appearance; its edges are ragged and uneven, and the parts imme- diately adjoining red and swollen. The con- nexion between the cervix and vagina is not compromised. In cases of rupture of the ute- rus in old persons (§ 63), the viscus is rather perforated than ruptured ; the changes caused by the contents, and the softening and thinning of a portion of the parietes, appearing more like perforation than rupture. Peritonitis always follows rupture of the uterus if the patient sur- vive the shock 65. e. Symptoms.—The symptoms vary some- what with the extent of the rupture, according as the peritoneal or the muscular coat is singly torn. The circumstances which may suggest fears of rupture are the occurrence of partial inflammation of the, uterus during gestation, and the existence of violent labour-pains in pa- tients with a narrow or mal-formed pelvis. "Rupture of the uterus and vagina is marked by an acute, sudden, and intolerable pain like cramp; a sense of some part bursting, giving way, or tearing, with an audible noise, accord- ing to the testimony of the patient; the suspen- sion of the labour-pains ; hemorrhage from the vagina; and by a rapidly succeeding state of collapse." (Churchill.) All these symptoms may not be observed in some cases, but the pain and collapse are never absent. When one of the coats alone is torn, the labour may con- tinue if it be the peritoneal coat, and there may be no hemorrhage. In such cases, Dr. Rams- botham remarks that the symptoms of actual rupture of the uterine structure are observed in a diminished degree, excepting the escape of the child. 66. Rupture of the uterus is always attended by continued and extreme pain ; nausea and vomiting supervene—at first of the contents of the stomach, then of a greenish, and lastly of a dark or coffee-ground-like matter; the counte- nance becomes pale, anxious, and ghastly ; the surface and extremities cold and clammy; the pulse rapid, small, and weak, or fluttering and irregular; respiration is hurried, panting, and anxious, with a desire of fresh air ; and hemor- rhage takes place from the vagina, varying much in quantity. The shock or collapse character- nflammation of the Vagina. 544 PUERPERAL DISEASES—] izing tnese cases is owing more to the nature and severity of the injury than to the amount of hemorrhage which may follow, although this is sometimes very considerable ; but both con- ditions contribute to this result. When the rupture is complete, the child passes through the opening into the abdominal cavity, either partially or wholly, where it may be felt through the abdominal parietes, and the efforts at expul- sion cease. If the presentation was within reach before the accident, it cannot now be as- certained. Dr. Churchill refers to instances of a loop of intestine having passed through the rupture when complete, and become strangu- lated. The state of collapse may continue for some time, if it do not prove fatal. But at length reaction takes place to a certain amount, and the usual symptoms of peritonitis appear: exquisite tenderness, pain, and flatulent disten- tion of the abdomen ; pulse small, hard, rapid, and, lastly, weak ; decubitus on the back, with the knees drawn up; hurried respiration, anx- ious and collapsed countenance. 67. /. The terminations of ruptured uterus are, 1st. Death a few hours after the shock, or after delivery; 2d. Death from peritonitis; 3d. Death from consecutive lesions; and, 4th. Recovery. In by far the greater number of instances the accident proves fatal. The aggregate of cases observed by Smellie, J. Clarke, Merriman, M'Keever, Ramsbotham, Collins, and Beatty, amounting to sixty-eight, furnished only six re- coveries. Osiander, Velpeau, and Churchill quote several cases of recovery ; but instances are very rare in which recovery has taken place when the fetus has remained in the peritoneal cavity. (Duparcque.) In cases of interstitial fcetation, also, patients have very rarely survi- ved both shock and consequent inflammation. In all cases, therefore, of ruptured uterus the prognosis is very unfavourable. 68. g. Diagnosis. — The sudden and acute pain, the cessation of labour, the collapse, and the recession of the child, sufficiently indicate the nature of the mischief. When, however, the rupture is partial, the diagnosis is much more difficult. The sudden pain, collapse, and consequent peritonitis are the chief symptoms of rupture of the peritoneal coat; the pain, col- lapse, cessation of uterine action, and vaginal hemorrhage being the principal indications of rupture of the muscular coat. The sudden oc- currence of peritonitis in old women may excite suspicions of perforation or rupture of the ute- rus, but certainty can be arrived at only by a post-mortem inspection. 69. h. Treatment.—When rupture of the ute- rus is recognised, the propriety of immediate delivery cannot be disputed. Common sense and experience, as evinced by the results of re- corded cases, support this practice. When the os uteri is undilated, instant delivery cannot be effected; but the measures to be adopted on this emergency, as well as in others connected with the delivery, especially when the child has passed through the rent into the abdominal cav- ity, come not within the scope of my work. The means which should be administered du- ring the continuance of the vital shock, or col- lapse, are camphor, ammonia, and opium, in such doses as may be just sufficient to support the powers of life without inducing inordinate reaction. If peritonitis supervene, calomel, camphor, and opium ; terebinthinate embroca- tions applied over the abdomen ; opium in large doses, and the other means recommended in cases of inflammation of the Peritoneum (y 138, etseq.), should be prescribed, bearing, however, in recollection that the large loss of blood usu- ally occasioned by the rupture, as well as the shock sustained by the vital powers, prevents either depleting or depressing measures from being too freely employed. 70. D. Inflammation of the Vagina.—In- flammation of the vagina may occur independ- ently of the puerperal state, or it may arise from specific causes, or infection, as shown in the article Vagina.—(a) It is of frequent occur- rence after delivery, in various grades of sever- ity. It may consist merely of slight soreness or excoriation, or irritation, and follow an or- dinary or natural labour, and speedily subside, unless it be prolonged or exasperated by an ac- rid state of the lochia. When, however, the head of the chUd has remained a long time in the pelvis, pressing on the soft parts, or when the narrowness of the passage has created great difficulty, or when the presentation has been unnatural, or when instrumental aid has been required,' the vagina isthen liable to experience most severe inflammation, the consequences of which may be most serious. 71. (b) The symptoms generally commence with a smarting pain, more severe than that usually following delivery, soon passing into a sense of painful heat and scalding, extending from the external parts up the vagina. There is also a feeling of fulness and weight in this situation. On examination, the external parts appear swollen and bruised, with increased heat, and acute pain or tenderness, when touch- ed. On averting the labia, the vagina presents large rugae of a bright red colour. At first the dischage from the inflamed surface is scanty, but it afterward is purulent, or pus may be de- tected, mixed with the red lochial discharge. If the discharge have become more colourless, the puriform secretion from the vagina renders it more opaque. With the local increased ac- tion more or less of symptomatic fever is pres- ent ; and in the more severe cases this fever may assume a very serious aspect. 72. (c) The terminations are sometimes seri- ous. The slighter cases, or those which re- ceive prompt and judicious treatment, usually terminate in resolution. The decrease of pain, and of the local and constitutional symptoms, is the chief indication of this issue. Suppuration and ulceration are not infrequent. When the injury causing the inflammation has been se- vere, or the attack violent from the first, sup- puration advances rapidly, is attended by a co- pious puriform discharge, and, in the course of a very few days, is followed by the appearance of a number of sloughing ulcers, or, rather, of several partially detached portions of sloughing mucous membrane. As. these separate, the parts which they covered appear deprived of membrane. If the sloughing ulceraiion be more severe, the coats beneath the mucous coat may be invaded; and it is then not uncommon to find the posterior part of the neck of the blad- der attacked, and even an opening formed in this situation—a vcsico-vaginal fistula; or to find a similar sloughing ulcer into the rectum—or a recto-vaginal fistula to be formed. When slough- PUERPERAL DISEASES—Inversion of the Uterus. 545 ing ulceration appears, the greatest care may not succeed in preventing these consequences from occurring. 73. Gangrene may rapidly follow when the pressure on the parts has been prolonged or ex- cessive. In these cases the separation of the sloughs is generally followed by vesico-vaginal fistula; more rarely by recto-vaginal fistula. In 1845, a lady who had experienced the most unaccountable neglect while in the care of a surgeon in the East Indies, but who was per- fectly well formed, came to London for the ad- vice of the author and the late Mr. Liston. Most extensive recto-vaginal and vesico-vagi- nal fistulae co-existed in her case. She had been a strong and healthy person previously to her protracted confinement in the East. When she came to London, the urinary bladder, the vagina, and the rectum formed a single cavity. The case was far beyond any measures, except- ing mechanical aids, and strict attention to cleanliness. 74. (d) Treatment.—The usual antiphlogistic means, appropriate in kind and extent to the violence of the inflammation, and the habit of body and constitution of the patient, are requi- red at an early stage. Dr. Churchill has found tartar emetic, conjoined with a saline aperient, of great use. It should be given so as to nau- seate without producing vomiting. " The ex- ternal parts ought to be well fomented two or three times a day; and, during the intervals, a large poultice may be applied over the vulva. Twice or thrice daily, also, the vagina should be syringed with tepid milk and water, or a weak solution of acetate of lead. After the sloughs have separated, a careful examination should be made every second day, to ascertain the progress of healing; and when the surfaces begin to be covered with new membrane, we must take measures for preventing the forma- tion of cicatrices. This can be done only by the repeated introduction of bougies, and the best kind are tallow or wax candles. At first a small-sized one should be oiled and introdu- ced night and morning, and allowed to remain a quarter of an hour. Afterward, as the ten- derness diminishes, the size pAhe candle should be increased ; and it ought to be introduced oftener and retained longer. The warm injec- tions should be continued, and the milk and water may be changed for some slightly astrin- gent fluid." (Churchill, Op. cit., p. 281.) When sloughing ulceration or gangrene exists, a restorative or tonic treatment, and light, nu- tritious diet, ate required. The unfavourable consequence? of these changes—vesico-vdginal or recto-vaginal fistula—are sometimes reme- died, when not very extensive, by surgical treatment. For the measures which may be attempted for these distressing lesions, I must refer the reader either to surgical works, or to the systems of midwifery practice referred to hereafter, and more particularly to Dr. Church- ill's work. (See art. Vagina for other lesions not necessarily proceeding from the puerperal state.) 75. E. Inversion of the Uterus.—The in- side of the uterus may be turned out, and either drawn or pushed down into the vagina. It may take place in different degrees, and form what has been called, 1st. Simple depression; 2d. Incomplete inversion, when the fundus uteri is III. 35 merely engaged in the orifice ; and, 3d. Com- plete inversion, when it protrudes from the va- gina, with the mouth turned upward. The vagina, in this latter case, is also partly rever- sed, so that the tumour is often of considerable length. When the inversion is only partial, the tumour is retained altogether, or chiefly with- in the vagina, the fundus protruding in part through the os uteri. 76. (a) Symptoms.—The patient with inver- sion of the uterus feels severe and obstinate pain, accompanied with bearing down efforts, hy which a partial inversion is sometimes ren- dered complete. She is very weak; her coun- tenance is pale and anxious ; and her pulse is feeble, small, or almost imperceptible. Hemor- rhage is generally present, and is often most profuse. It is frequently scanty, or absent, when the inversion is complete; although a very partial inversion may be attended by a fa- tal discharge. A sense of dragging at the epi- gastrium, or of a dragging downward of the bowels, is usually present; and fainting and convulsions may occur even when the hemor- rhage is trifling. These symptoms cannot fail of exciting suspicions of inversion, which will be readily ascertained on examination ; the womb protruding like a mass of flesh, and no uterine tumour being present in the hypogas- trium. 77. (b) Causes. — Inversion is produced by pulling the cord in endeavours to remove the placenta, which may even .adhere when the uterus is pulled down ; but it is generally sep- arated ; or it is caused by the sudden expulsion of the child, the cord being short or entangled about the child, the fundus receives a jerk, and is thereby inverted. Dr. Burns thinks that great pressure or strong contraction of the abdom- inal muscles on the fundus uteri may cause de- pression of the fundus, in a cup-form, and en- croach on the uterine cavity. This may recti- fy itself, but it may increase and pass on to complete inversion some time after delivery. An incomplete inversion, as well as the com- plete, may become chronic, and occasion incu- rable fluor albus, and even hemorrhage. 78. (c) Inversion terminates in different ways: it may be rapidly fatal by hemorrhage, or by syncope, or by convulsions ; or it may be slow- ly fatal by inducing over-distention of the blad- der, or inflammation, and various consequent changes. After severe pains and expulsive efforts, the patient may survive, or even par- tially recover, from the immediate injury; the uterus may slowly diminish to its natural size, become chronic, and cause little inconvenience; or it may discharge fetid matter, and give rise to frequent debilitating hemorrhages, With co- pious mucous discharge in the intervals; or hectic or pulmonary symptoms may come on, and the patient ultimately sink. 79. (d) The treatment consists in reducing the inversion, if it be discovered sufficiently early. This is to be done by first pressing the uterus, if it have protruded without the vagina, within this passage. The tumour should be grasped cautiously in the hand; and, while it is compressed, the most prominent part of the fundus ought to be pushed up in the direction of the axis of the uterus. If reduction is ac- complished, the hand should be kept within the uterus, so as to excite contractions, which will (TF.RALGIA--NERVOUS AFFECTIONS. 546 PUERPERAL DISEASES—Hy: detach the placenta, if it still adhere. Even after the reduction, when the patient is appa- rently doing well, she may be seized with a fit, and die. But she generally remains long weak if she recover. 80. If inversion have not been early discov- ered, it is always much more difficult, and some- times impossible, to reduce it. The obstacle is the contracted state of the os uteri. It may not admit of reduction, even after a few hours from its occurrence; and if it have become much more chronic, it is not prudent to make the attempt, as violent or dangerous convul- sions may be produced thereby, and the uterus is often so swollen and inflamed as to render reduction impossible. The chronic state of in- version is considered under the head Uterus, as it does not strictly belong to puerperal mal- adies. ii. The spasmodic and nervous Affections of the Puerperal State. Classif.—II. Class, III. Order (Author). 81. The nervous and spasmodic diseases of puerperal females are convulsions, mania or in- sanity, hysteralgia', paralysis, and various irreg- ular spasmodic and nervous affections, Which sel- dom assume any precise or definite form. The first and second of these are considered in sep- arate articles; the others will be briefly no- ticed at this place. 82. A. Hysteralgia.—(a) This painful affec- tion of the uterus occurs soon after delivery; but it is more continued and severe than the usual after-pains (which see). It is character- ized by severe pain in the back and hypogastri- um, by sickness, faintness, and a feeble, or sometimes quick pulse. These sensations may or may not be attended by the expulsion of co- agula, or by a sense of severe bearing down. It not improbably is sometimes occasioned by some, malposition of the uterus consequent upon delivery. It is often connected with ob- struction of the lochial discharge, which ob- struction is probably caused by the painful af- fection of the uterus. Hysteralgia is most apt to occur after a severe or tedious labour. It may notappear until the third or fourth day, or when the patient has got up too early to have the bed made. It seems to be caused by an irregular spasmodic action of the muscular fibres of the organ, the spasmodic action and the altered sensibility sometimes extending also to the bowels. 83. (b) The symptoms of hysteralgia vary with the extension of these morbid states to parts adjoining the womb and its appendages. The suddenness of the attack ; the absence of rigours or chills; the greater severity of the pain than that attending inflammation ; the suddenness of the remission or cessation of the pain, and generally the absence of tender- ness or of increased suffering on pressure, chief- ly serve to distinguish this affection from in- flammation of the uterus. 84. (c) The treatment consists of the admin- istration of a purgative clyster with turpentine, castor oil, and camphor ; and, after the bpwels have been freely evacuated by these, or by a repetition of them, or by a draught containing half an ounce each of castor oil and turpentine, an opiate may be given, or may be administer- ed in an enema. • Terebinthinate fomentations or embrocations should also be applied, suffi- ciently warm, over the hypogastrium; and warm or camphoreted diaphoretics and opium, or henbane, may be given, to equalize the cir- culation and procure a free respiration. Warm cloths soaked with oil of turpentine, and kept applied over the seat of pain, also will seldom fail of procuring relief. The abstraction of blood is rarely required, unless the affection be actually inflammatory, as evinced by increase of pain on slight pressure, by the states of the skin and urine, and by the pulse. 85. B. Various other nervous or spasmod- ic affections sometimes appear in the puerpe- ral state, especially in hysterical, delicate, or nervous females, and are evidently owing to the effects produced by uterine action and the vital shock upon the organic and cerebro-spinal nervous systems.—(a) Palpitations of the heart are not infrequent soon after delivery in the temperaments just mentioned, especially after considerable loss of blood, and upon any alarm. The patient experiences a violent beating not only at the praecordia, but also in the epigastri- um and in the head, sometimes with dyspnoea, or short panting respiration. She is alarmed, apprehensive of dissolution,'and her fears ag- gravate the symptoms. As the attack passes off, languor, depression, or a sense of sinking, or.profuse perspiration, and flatulent distention usually supervene, and after a time the disor- der subsides. 86. (b) Hysteria is not uncommon, in some form or other. It may occur with dyspnoea, or with syncope, with hiccough, or with pains in the side or abdominal muscles, &c, and is gener- ally aggravated, if not excited, by the secretion of air into the alimentary canal. The dyspnoea is seldom attended by cough, and is owing chief- ly to exhausted power of the respiratory mus- cles, and sometimes to either too great or too little tightness of the abdominal bandage, the abdominal muscles and floating ribs being there- by too much compressed and embarrassed in the one ease, or insufficiently supported in the other. When the dyspnaa is owing to an af- fection or spasm of the diaphragm, it is felt most on inspiration, and pain is often complained of in the back or sides, or pit of the stomach, with a feeling of suffocation, sharp pain sometimes darting across the lower part of the thorax, and with a yery rapid weak pulse. This affection of the diaphragm usually occurs a few hours after delivery, and is always sudden in its ac- cession and departure. It may readily be dis- tinguished from pleurisy by these circumstan- ces, and by the slower accession of pleurisy, which is usually accompanied pith shivering or chills, and which very rarely or never ap- pears so soon after delivery. 87. (d) Colic may occur within a few days from delivery. It usually attacks suddenly, and in the evening; but it is not preceded by shivering, although it is sometimes attended by sickness or vomiting. The pulse is at first slow or natural, but it soon becomes frequent. The pain is remittent or intermittent, but com- monly subsides altogether after some hours, when judiciously treated. If the irritating cause be not soon removed it may induce in- flammation. Cramp of the stomach, or spas- modic gastrodynia, may occur during the first fortnight or three weeks after delivery. Its at- tack is always sudden, the suffering extreme 2S—Nervous Affections. 547 PUERPERAL DISEASE and the danger great in delicate or exhausted females. It is often attended and aggravated by flatulence. It requires decided and prompt treatment. 88. (c) Females who have been subject to the more obstinate and complicated forms of hysteria, and especially to spinal irritation, or to affections reflected from the spinal chord or roots of the spinal nerve, often experience va- rious nervous disorders, either immediately af- ter, or at more distant periods from delivery. Soon after the expulsion of the placenta they feel urgent sinking or debility, with a sensation and dread of flooding, although neither internal nor external hemorrhage exists. In the more extreme cases, if stimuli be not administered, the patient may suddenly die, without any oth- er obvious cause than the sinking or exhaustion consequent on the shock of parturition. These severe cases of sinking not only may affect the weak and delicate, or those weakened by flood- ing, or by greater losses of blood than the state of the vascular system can well sustain; but sometimes even fat, plump, and apparently strong females may be placed in jeopardy by these attacks. In other instances, the sinking is followed by violent determinations of blood to the head, threatening phrenitis, or puerperal mania, or even passing into either, or into leth- argy, coma, or apoplexy. Fat, plump, and pale females are even more liable than others to experience these dangerous forms of nervous sinking, owing to their deficiency of vital pow- er and resistance, and the states of the blood and vascular system ; and in them nervous and vascular reaction are more rare. 89. (d) Partial or even complete paraplegia sometimes occurs after delivery, although the labour may have been easy or natural. The head is unaffected, but pain or weight is felt in the back or loins, occasionally with retention of urine. The palsy exists in various degrees, but it generally disappears after a few weeks, when the treatment is judicious. A more se- vere and protraeted form of partial paraplegia occasionally follows severe, protracted, or in- strumental delivery. In these cases severe pain is complained of in the back and loins, with disordered secretion and excretion of urine. In most of these states of paraplegia there is either increased effusion of serum from the membranes of the spinal chord, with con- gestion of these membranes and of the cord it- self; or, what is more probable, extreme con- gestion, also, of the venous sinuses external to the sheath, in the lumbar and dorsal regions of the spine. Hemiplegia is not more frequent in lying-in than in other females. 90. (e) The treatment of these several affections is generally successful if it be prompt and effi- cient.—a. Palpitations of the heart (y 85) require the administration of antispasmodics with an- odynes or narcotics—of Hoffmann's anodyne with small doses of opium or henbane ; of the boracic acid with camphor and opium, or hen- bane ; or with the ammoniated tincture of va- lerian, with either of these narcotics. When the paroxysm has been relieved by these, the antispasmodics should be conjoined with tonics and aperients, and change of air, preferably to the country or to the sea-side, ought to be rec- ommended. 91. 3. The hysterical affections (y 86) are re- lieved by the remedies just now enumerated, more especially by the ethers, valerian, ammo- nia or camphor, and opium ; and if dyspnoea be present, the state of the abdominal bandage should be examined and adjusted. If the symp- toms be aggravated by flatulence, as they often are, ammonia or magnesia may be given with anti-spasmodio stimulants and warm terebin- thinate embrocations, or epithems applied over the epigastrium. When the hysterical affec- tion assumes a colicky form (y 87), from two to four drachms of oil of turpentine may be given with half an ounce of castor oil, and a drachm of tincture of senna, on the surface of an aro- matic water; and the same remedies, in in- creased doses, administered as a clyster, if the bowels are not freely evacuated in six hours. After the evacuation of the bowels a full dose of opium, or of the compound soap pill will be given with benefit. If flatulence still continue, ammonia or magnesia, with gentle tonics, or the fetid spirit of ammonia or the compound galbanum pill, may be prescribed at intervals. If the colicky symptoms assume the form of cramp of the stomach, or severe spasmodic gastro- dynia, the patient is placed in jeopardy, espe- cially if it occur within a fortnight or three weeks from delivery. A draught containing a full or even a very large dose of laudanum, with camphor and ether, or with musk, or the compound spirit of ammonia, ought to be im- mediately given, and the warm terebinthinate embrocation, or a mustard poultice, be applied over the epigastrium. 92. y. For those states of distressing sinking following parturition (y 88), Dr. Burns advises about thirty drops of laudanum, and afterward small doses of wine or brandy, or of compound spirit of ammonia, or ammoniated tincture of valerian, taking care not to give stimuli too freely, lest cerebral affection be thereby excit- ed. Musk or camphor with opium is generally beneficial in these cases; and light nourishment ought not to be overlooked, as not a few of these cases arise from inanition, or the prolonged pri- vation of requisite food and restoratives. If phrenitic or maniacal symptoms supervene, the treatment must depend upon the habit of body and strength of the patient. Vascular deple- tions, general or local, cold applications to the head, active purgatives, and terebinthinate ene- mata, external derivation and irritation, and the other measures advised for cases of Puerperal Mania (see Insanity, Puerperal, y 55, et seq.) should be employed. 93. 6. The occurrence of paraplegia in the puerperal state requires strict attention to the urinary functions and free purging, large doses of purgatives being sometimes necessary. Cup- ping or leeching near the spine may be requi- site. Terebinthinate embrocations may also be applied in the course of the spine, and if these prove not of service, repeated blistering or open blisters may be directed, and the other means advised when treating of paraplegia (see art. Paralysis, y 215, et seq.) may be adopted. Three cases of this disease in the puerperal state have come before me, and have proved both obstinate, and afterward associated with amenorrhcea. In one which had been of long standing, the amendment was slow. As soon as the patient is able to move the lower ex- tremities, she should endeavour to use them as 513 PUERPERAL FEVERS—Ephemeral Fever—Gastro-Intestinal Fever. much as possible, and persist in the use of de- rivatives, both internal and external, of fric- tions, and of rubefacients. III. The Milder Fevers incidental to the Puerperal State. Classif—III. Class, II. Order (Author). i. Ephemeral Fever.—Weed!—Puerperal Ephemera. 94. Defin.—Chills or shiverings during early convalescence from parturition, followed by head- ache, pain in the back and limbs, thirst, rapid pulse, terminating with profuse perspiration and cessa- tion of fever, generally in from twenty-four to forty- eight hours. 95. A. Causes.—The increased sensibility, susceptibility, and irritability of puerperal fe- males give rise to febrile attacks upon exposure to comparatively slight causes, especially when the temperament is nervous or irritable, and the constitution is delicate. These states of pre- disposition are, however, much heightened by the changes in the vascular system, and in the blood itself, consequent upon pregnancy and parturition; and these, moreover, are asso- ciated with the predisposed conditions of the uterus, mammae, and intestines, always present in these cases. The exciting causes are, com- monly, exposure to cold, irregularities of diet, fatigue, exhaustion, want of rest, mental emo- tions, inattention to the state of the bowels and indigestion, getting up, or leaving the bed, or changing the apartment too soon; accumula- tions of morbid secretions and excretions in the biliary organs and bowels, &c. 96. B. Symptoms.—On the approach of the disease the patient is languid, yawns frequent- ly, and experiences a sense of cold in the course of the spine, and extending over the body. The chilliness may increase to shivering, with or followed by headache, pain in the back and limbs ; full, irregular, and rapid pulse, thirst, and slight diminution of the milk and lochia. The bowels are usually costive and flatulent, the stomach disturbed, the tongue coated ; the patient is depressed in spirits ; complains of shifting pains in the abdomen, is anxious or afraid of dying; and, in the more smart attacks, she is slightly delirious at night. The face is flushed, and she has pain in the breasts and in the forehead, with throbbing of the temples, and slight soreness of the abdomen. To these symp- toms a copious perspiration succeeds, and re- moves the fever and its attendant symptoms, the milk and lochia returning to their previous states. The attack is usually terminated in about twenty-four or thirty-six hours; and, if judi- ciously treated, it seldom returns ; but, if it be neglected, it may assume an intermittent, a re- mittent, or a continued form; or it may be com- plicated with some visceral disease, and assume a dangerous aspect. 97. C. Diagnosis.—The suddenness of the attack, the irregularity of the pulse, the absence of local pain, excepting that of the head and of abdominal tenderness, the rapid succession of the different stages, and the cessation of the paroxysm in a few hours, distinguish this state of fever from true puerperal fever, from which, however, it will be distinguished with difficulty during the early stage, if all the phenomena of the latter be not duly considered. (See here- after, y 251, et seq.) 98. D. Treatment. — During the cold stage, warm diluents, warm flannels to the back, gen- tle restoratives, and external warmth are re- quired. The states of the several functions should be carefully examined ; the uterine dis- charge, the mammae, and the abdominal secre- tions and excretions demanding the utmost at- tention. If the tongue be loaded, or if nausea be present, an ipecacuanha emetic should be given, and its operation promoted by warm dilu- ents. If the bowels have been, and still are confined, a full dose of calomel or of calomel and jalap should be taken. In all cases the bowels ought to be freely evacuated by these or other purgatives, as the infusion of senna and salts, &c.; and, having hastened on the hot stage, saline diaphoretics, fewer bed-clothes, and diluents should be directed, in order to pro- cure a free perspiration, which may be kept up for five or six hours. As the perspiration de- clines, or at the end of that period, the patient should have her clothes changed ; and gentle restoratives, especially such as may promote the secretions and excretions, ought to be pre- scribed, with a view of preventing a return of the attack, and of restoring the tone of the sys- tem. From two to three grains of camphor, with as much henbane, taken twice or thrice daily, and such restoratives and diet as the state of the patient will suggest, will prove beneficial. If the patient be exhausted by the attack, wine-whey, or wine and water warm, with sugar, &c, may be allowed ; or the tonic infusions, or the infusion of valerian, or the de- coction or infusion of cinchona may be given, with the solution of the acetate of ammonia, the ammonia being a little in excess, and the spirit of nitric ether may be prescribed. The abdominal excretions ought to be freely pro- moted by a combination of the compound infu- sions of senna and gentian, and any neutral salt, with tincture of cardamoms; and rest pro- cured by a soothing dose of camphor (1 to 3 grs.) with opium or henbane, or with morphia. Change of air, especially to the sea-side, is al- ways beneficial. The diet should be light and nutritious as convalescence advances. The states of the mammae and uterus should receive strict attention, and if either organ present prom- inent disorder, the treatment should be directed accordingly. 99 ii. Intestinal or Gastric Fever—Feb- ris Gastrica vel Intestinalis. — F. Gastrica vel Intestinalis Puerperalis; Puerperal gastro-in- testinal Fever. Classif.— Ut supra. 100. Defin.—After chilliness or shivering, fe- ver, with nausea or vomiting, flatulence, griping, diarrhoea, and various nervous symptoms. 101. A. This state of fever is generally caused by previous torpor of and inattention to the bowels, by accumulations of bile in the biliary organs, and of morbid secretions and faecal mat- ters in the bowels, especially during the ad- vanced period of gestation ; by errors of diet after delivery; by close, low, damp, and cold apartments or situations; and by the use of acid, cold, or unsuitable drink or beverages. It usually appears within ten or twelve days from delivery, and is liable to be confounded with ephemeral fever at its commencement; and, when attended by inflation of the bowels, with the puerperal fevers. 102. B. Symptoms.—After chilliness or rigours PUERPERAL FEVERS—Miliary Fever, etc 649 the patient is oppressed at the stomach, loathes food, and becomes sick. The pulse is frequent and soft; she complains of being cold, although the skin, except that of the feet or legs, feels from the first hot to another person. Afterward she is thirsty, has a slimy or white tongue, sometimes with red edges, and vomits a ropy mucus or bile. She now feels hot, especially in the hands and feet, is distressed with flatu- lence and griping pains in the abdomen, and the bowels are at first either open or costive, the stools dark and very offensive, and subsequently relaxed or even purged. Purgative medicines always act abundantly, and afford relief. The pulse continues quick; the patient does not Bleep, or merely slumbers; and then she talks, or is tormented by visions and dreams. She often complains of short, darting, or nervous pains, or of throbbing or confusion in the head. There is no fixed pain in the abdomen or hypo- gastrium, nor any tumour in the belly, which is generally soft. The local discharge is not neces- sarily obstructed, nor is the secretion of milk affected during several days ; but, when diar- rhoea is considerable, or continues, both one and the other are much diminished or suppress- ed. The countenance is unchanged at first, and continues so for some days, unless nervous symptoms, or pain in the hypogastrium, or some complication supervene. In some cases, when this disorder continues longer than six or seven days, and is neglected, inflation of the bowels, pain and tenderness in the lower part of the belly, pain on making water, or on passing the faeces, and other indications of irritation of the sexual organs supervene ; while, in other cases, various nervous symptoms, as palpitation, ver- tigo, a feeling of sinking, or startings, and shoot- ing pains in the head, are complained of. The duration of this fever, which is manifestly symp- tomatic of gastro-intestinal irritation, or conse- quent upon accumulation of morbid secretions in the biliary organs, and of faecal matters in the bowels, is usually from a few days to a fort- night. 103. C. The Diagnosis.—Intestinal fever may be distinguished from ephemeral fever by not appearing so soon after delivery; by its more gradual accession, and by the manifest disorder of the stomach and bowels attending it; by the character of the evacuations and the griping or shifting pains in the abdomen; by the ready and copious action of purgatives, and the more protracted duration of the disease. It may be mistaken for either puerperal fevers, but the symptoms just enumerated, the relief obtained from purgatives, the softness of the abdomen, and the absence of fixed pain, of tension and of inflation, unless occasionally in very pro- tracted cases, the state of the pulse, and the general condition and appearance of the patient will distinguish this complaint from the more serious fevers of the puerperal state. 104. D. Treatment.—An emetic of ipecacu- anha is always serviceable on the accession of, or early in this complaint. When its operation is over, saline diaphoretics and tepid diluents are then beneficial. A full dose of calomel may be given in a few hours after the emetic, and its operation on the bowels should be pro- moted by the administration of rhubarb and magnesia, or by a single dose of castor oil with spirit of turpentine. If the evacuations still continue offensive, with griping pains, either of these purgatives should be repeated ; but if they be more natural, or if diarrhcea supervene, then the existing irritation ought to be allayed by opiate or anodyne enemata. The bowels should never be allowed to become costive; either of the purgatives just named, or the in- fusion of gentian and senna, being interposed, or given according to the requirements of the case. If griping pains or flatulence, or inflation of the bowels become troublesome, the applica- tion of the warm terebinthinate embrocation over the abdomen, and an enema containing spirit of turpentine, with olive oil and asafoe- tida, will afford complete relief. The diet should depend upon the state of the bowels. If diar- rhoea exist, light farinaceous articles of food, arrow-root, sago, and jelly may be given. If there be no diarrhcea, ripe fruit may be allow- ed; and, as convalescence proceeds, the sev- eral farinaceous articles, various preparations of rice, beef-tea, warm jellies, chicken-broth, etc., may be taken. Ginger-wine with water, Seltzer water with old Madeira or Amontiliado sherry, the milder tonics, as the infusion of co- lumba or of cheyreitta, may also be prescribed as recovery proceeds. 105. iii. Miliary Fever—Febris Miliaris— Febris Miliaris Puerperalis.—The eruption described under the head miliary eruption some- times occurs during the puerperal state as a symptom of puerperal fevers. By several older writers, and by some as recently as the last century—by White and others—it was de- scribed as one of the most formidable epidemics of child-bed ; but it is now rarely met with, un- less occasionally as a symptom of ephemeral fever, of milk fever, and of puerperal fever, when they are attended by profuse perspiration, and is evidently dependent upon a morbid state of the circulating fluids, consequent upon im- perfect secretion and excretion, or upon the absorption of morbid matters, in connexion with excessive secretion from the skin. It occurs most frequently in delicate females, and com- monly from the fourth to the twelfth day from delivery. This eruption affords no crisis to the disease of which it is symptomatic, nor relief to the symptoms. The treatment of this eruption, or, rather, of the disease of which it is a symp- tom, should be directed to the pathological con- ditions of that disease, as stated in the article "Miliary Eruption." IV. Severe Puerperal Fevers.—Synon. Pu- erperal Fevers.— Febris Puerperalis ; Febris Puerperarum; Metritis Puerperarum, Sagar, Sauvages. Hysteritis, Vogel, Cullen. Metri- tis Puerperalis, Boivin, Duges. Peritonitis Puerperalis, Forster, J. Clarke, Hull. Fievre Puirperale, Fr. Kindbetterinn-fieber, Germ. The low fever of child-bed, John Clarke. Child- bed fevers; severe child-bed fevers. Classif. —III. Class, II: Order (Author in Preface). 106. Defin.—i. Nosolog. Great frequency of the pulse, and pain, tenderness, and tumefaction of the abdomen occurring in the puerperal state; the pain often commencing in the pelvic region with rigours, the patient generally lying on her back, with the knees more or less elevated. 107. ii. Patholog.—Fever occurring in the pu- erperal state; commencing, in some cases, in local disease, with rigours or chills; in other cases, from 550 PUERPERAL FEVERS- I—Literary Notices of. infection of the frame and contamination of the fluids, with or without chills or rigours, and fre- quently with, but sometimes without, prominent lo- cal lesion of structure. 108. When treating of Fevers in an early part of this work, I took occasion to point out the several and very different forms or types which the febrile diseases of the puerperal state assume (see Fever, y 44); and Dr. Ferguson, in his classical work on " Puerperal Fever," has adduced the arrangement I then suggested, with others adopted by the more recent writers on puerperal diseases. It is evident, from what this able writer has stated, as well as from the best works which have been published on the subject since the middle of the last century, but still more from an extensive experience of puerperal diseases in different circumstances, seasons, and periods of their prevalence, that puerperal fever is not either a simple or an un- varying malady, and that, thus influenced, it assumes the most diverse types, forms, and complications, and often the most malignant and fatal character of any disease met with in European, or even in other countries. It is hence the more difficult to comprise within the succinct limits of a definition those characters which are applicable to all the states which pu- erperal fever may assume, without omitting what is really important, and at the same time embracing only such features as are essential to its actual and individual existence. 109. i. Literary Notices of Puerperal Fe- vers.—Previously to 1689 and 1733, when Hake and Berger wrote on the " Fevers of Puerpe- ral Females," no satisfactory account of puer- peral fevers existed-, although inflammation of the womb after child-birth had been noticed by Felix Plater and Tulpius ; and the diseases incidental to this period had been viewed as consequences of errors in diet and regimen, and of interruptions or suppressions of the se- cretions and discharges, by Sennertus, Rive- rius, Willis, De la Boe, Mauriceau, Strother, Boerhaave, and others. The earliest accounts of puerperal fever as a distinct malady appeared in inaugural dissertations, published at some of the continental universities. These were probably of some importance at the times of their appearance, as containing much of the experience and views of the professors in these institutions respecting this malady, the earli- est of these having been printed at Leyden in 1689. In 1746, puerperal fever prevailed in Paris, chiefly at the Hotel Dieu, where scarcely any recovered from it, the albuminous exuda- tions found in the peritoneal cavity appearing like to coagulated milk on the surface of the intestines, with a copious effusion of whey or milk-like serum ; and hence the effusion was viewed as a metastasis of the milk, although a slight attention to the history of these cases would have shown that the secretion of milk was not suppressed, or even interrupted. (Fon- taine, Col de Villars, &c, in Hist, de VAcad. Roy. des Sciences, 1746, p. 16.) 110. Pouteau (Melanges de Chirurg.,p. 180) mentioned the appearance of this malady in the Hotel Dieu of Lyons in the spring of 1750, and its great fatality. He noticed sero-puriform ef- fusion into the peritoneal cavity, thickening and contraction of the omentum, a relaxed and soft- ened state of the uterus, and gaseous distention of the intestines as the chief appearances on dissection, and was the first who regarded the disease as an epidemic erysipelatous inflamma- tion of the peritoneum. Dr. Hall wrote an account of this fever in 1755; and Sauvages viewed it as inflammation of the uterus, occur- ring, 1st. In the puerperal state ; 2d. Associa- ted with typhoid fever; and, 3d. With suppres- sion of the milk. Stoerck has stated that pu- erperal fever broke out in the hospital of St. Mark, at Vienna, in 1770, and prevailed through that city during the two following years. It was characterized by pain in the hypogastric region and abdominal swelling, the uterus pre- senting marks of inflammation and gangrene, and the intestines being covered by false mem- brane. Dr. Denman was the first author, after Dr. Hall in Edinburgh, who attempted in this country to give an account of this malady; but he appears not to have examined the body after death from this disease, although he more cor- rectly infers that the milky matter described by the Trench pathologists as existing in the peritoneum is a product of inflammation. Dr. Manning wrote soon after (in 1771), and as- cribed the disease to a putrid tendency in the humours ; and Hulme, Leake, and White, who followed him in quick succession, while they viewed the disease as inflammatory, and as affecting chiefly the pelvic viscera and perito- neum, believed that it could not be ascribed to simple inflammation, but to the inflammatory associated with a putrescent disposition; and Millar subsequently adopted the same view. 111. Next to Pouteau, KirklaNd espoused the most rational doctrine of the nature of this malady, on which he wrote in 1774, and con- sidered it as arising from, and consisting of, sundry pathological changes ; from absorption of putrid or morbid matter from the uterus; from inflammation of the womb ; from the re- tention and absorption of morbid secretions and excretions. He concludes that, while absorp- tion of morbid matter and inflammation orig- inating in the uterus will occasion puerperal fe- ver, the abdominal lesions will also be conse- quent upon the fever when occurring primarily. While Kirkland thus wrote so creditably, this malady appeared in the Hotel Dieu of Paris, and prevailed during 1774 and 1775, but pre- sented nothing of additional importance to what had already been ascertained. During the mid- dle and towards the close of the eighteenth century, the disease was observed by numerous physicians, many of them of great reputation; but little was added to the existing knowledge of its nature and treatment, the fatality caused by it in hospitals being often so great as to harass the feelings of those who were called upon to combat it. More or less detailed ac- counts of the pathology and treatment of the malady appeared during this period in the wri- tings of Stoll, Bang, Burserius, Butter, Hecker, De la Roche, Doublet, Frank, Reil, and others referred to in the Bibliography, but there is nothing furnished by them deserving especial notice. 112. In 1787 Walsh wrote on the disease, and considered it as an infectious fever com- plicated with diffuse inflammation of the peri- toneum. In 1787 and 1788 this malady was prevalent in the General Lying-in Hospital in London, and an account of the appearances ob- PUERPERAL FEVERS—Literary Notices of. 551 served upon dissection was given by Dr. John Clarke in 1788 and 1793. In that manifesta- tion of the disease the peritoneum presented the chief morbid changes, and these he has de- scribed with greater precision than any of his predecessors. He remarked that the uterus and ovaria sometimes partook of the inflamma- tion of the peritoneum, but not more frequent- ly nor more remarkably than other parts, and that the interior surface of the uterus was not inflamed. From this time, and guided by Dr. John Clarke's description of the changes after death, puerperal fever was viewed merely as inflammation of the peritoneum in the puerperal state; and this view was adopted by Dr. Gor- don, of Aberdeen, by Dr. Joseph Clarke, of Dublin, by Dr. Hall, Mr. Hey, Dr. Campbell, Dr. Mackintosh, and by Dr. Armstrong, with but slight modifications, or with no farther mod- ification than the expressing of the same idea in somewhat different words ; for in medical writings different words are too often substi- tuted for different ideas. These writers bring down the literature of puerperal fever in this country to 1822 ; their works deserving notice chiefly as furnishing examples of a particular form or epidemic state of,the disease, without any recognition of other still more important states observed by other authors, and insisted on by Hamilton, Burns, Boer, Douglas, and others referred to in the sequel. 113. In 1823 I became consulting physician to Queen Charlotte's Lying-in Hospital, noto- rious at that time, and indeed for some years before and after that time, for the recurring ap- pearances of this malady in the most malignant forms in its wards ; and for several years sub- sequently to 1823 I had numerous occasions of there observing the several states of puerpe- ral disease. Contemporaneously with my own researches, and still more recently, investiga- tions of a similar nature were made both on the Continent and in this country; and the results proved that inflammation of the peritoneum, in some form or state, although one of the most constant, is not the only, and often not the ear- liest change; and that alterations of the ute- rus, its sinuses, veins, and appendages, are equally common. Pouteau had stated, about a century ago, that the inflammation of the peri- toneum and pelvic viscera, in puerperal fever, is of an erysipelatous kind ; and the same opin- ion was subsequently maintained by Hunter, Gordon, and others, and still more recently by numerous writers. Indeed, the erysipelatous or diffusive character of the inflammation, when once the disease has commenced, could neither be overlooked nor disputed ; for this character is, as I have shown when describing the causes of puerperal maladies (y 35-43, 130, et seq.), a necessary consequence of the operation of these causes, which, by their effects upon the states of organic nervous power and of the blood, preclude the formation, by the inflamed surface, of organizable or coagulable lymph, by aid of which the extension of the disease may be arrested. 114. It has been shown by Kirkland, and still more demonstratively by Bang, of Copen- hagen—a pathologist whose clinical and nec- roscopic researches have not received their merited attention—that not only the uterus, but also the ovaries and the Fallopian tubes were inflamed, softened, or contained purulent collections ; and that the womb often present- ed various changes in its internal surface. Similar lesions were afterward described by John Clarke, Selle, and Osiander, and more recently by numerous, authors in Germany, France, and Great Britain. Inflammation of the uterine sinuses and veins was first dis- tinctly described by Bang and J. Clarke, and subsequently by Dance, Luroth, R. Lee, Du- play, Tonnelle, Cusack, Lngleby, the author, and others, and shown to exist, in many cases of puerperal fever, by several of these writers. Dr. John Clarke, however, in 1793, attempted to prove that the low, or the most malignant form of this malady, is distinct from that which is attended by inflammation of the peritoneum, and of the uterus and its appendages; and al- though doubts have been expressed of the truth of this doctrine, still my experience has shown its accuracy, and has convinced me that a most rapidly fatal and most malignant form of puer- peral fever is occasionally developed in lying- in hospitals which is certainly not character- ized by uterine phlebitis, nor by purulent col- lections in the uterus or its appendages, nor even in some cases by peritonitis, the chief le- sions often being merely a remarkable altera- tion of the blood, general lacerability of the tis- sues or loss of their vital cohesion soon after death, with a dirty, muddy, offensive, and some- times scanty serous effusion into the serous cavities. It is true that the circumstances by which this form of the disease is developed are seldom observed, and still more rarely at the present day than formerly ; but when once de- veloped in these hospitals, under the circum- stances in which I have observed it, not a sin- gle patient, within a week or fortnight from her delivery, will escape this pestilence, which may even be propagated abroad to puerperal females, if the proper precautions be not taken. When I became consulting physician in 1823 to Queen Charlotte's Lying-in Hospital, the wards were small, crowded, and without ventilation, a large number of females being confined in each ward ; and, as might have been anticipa- ted, a priori, a most pestilential form of puerpe- ral fever was always recurring a few months after it was reopened, after each occasion of its having been shut up for the purposes of fu- migation and purification. In the fatal cases— and at first all the cases were fatal—the ap- pearances now stated were those chiefly ob- served, in some instances with more marked disease of the peritoneum, and a relaxed or un- contracted state of the uterus. Subsequently, when the representations of the medical offi- cers procured enlargement and better ventila- tion of the wards, with a diminution of the number of beds in a ward, puerperal fever was of rarer occurrence, and assumed different types and forms, with the progress of these sanitary alterations, inflammatory appearances in the uterus and appendages, in the uterine sinuses and veins, and in the peritoneum, being then most frequently observed in fatal cases. As I believe that in the present and advancing state of medical science and of sanitary im- provement, the circumstances which have pro- duced the more malignant forms of puerperal fever, the local pestilence, which I had to treat many years ago, are not likely to exist and to 552 PUERPERAL FEVERS—Arrangement of their Forms. occasion a similar intensity of the disease, so I infer that the various stages of inflammation of the uterus, of its appendages, of the uterine veins, and of the peritoneum will constitute the chief lesions of puerperal fever ; and that the type or character of the fever will entirely depend upon the state of inflammatory diathe- sis ; upon the states of vital power and of the blood, accompanying the inflammation ; and upon the absence or the presence of contam- ination of the circulating fluids by retained or absorbed morbid matters and excretions. 115. ii. Arrangement of the Forms and States of Puerperal Fever.—Numerous wri- ters have described only one or other of the several forms or states of this fever, very prob- ably from having seen only such form during a limited experience, and in peculiar circumstan- ces, or from having described what they saw on a single occasion, or in a particular epidem- ic. That this has actually been the case is shown by the fact that these authors have not described the same form or variety, but each has adduced the variety he has described as the true and only form of the disease, and has been indignant at those who believed that any other state of the malady can exist excepting that which he has observed. Thus Armstrong, Hey, Mackintosh, Campbell, &c.,who observ- ed chiefly inflammatory forms of the disease, accompanied with a Sthenic diathesis, could not tolerate the idea that any other state of the malady existed, and were most ireful at J. Clarke, Hamilton and others, who believed that a low, typhoid, or malignant form, very different from that which they described, some- times broke out. Thus, from the days of Stoll and Doulcet to almost the present time, some writers have described only a single variety, and have believed it only to be the true malady. But, as will appear more fully hereafter, the symptoms, characteristic features, and still more the post-mortem appearances, display di- verse features and extensive complications, ac- cording to the circumstances occasioning the disease and influencing its course. 116. Several writers, on the other hand, with stronger powers of observation, or with more extensive experience, have viewed puerperal fever as more or less varied in form and com- plicated in its nature, and not from a single position or aspect merely, as those just alluded to, but according as diverse circumstances, sea- sons, or epidemic influences have impressed on it different forms and complications. Thus John Clarke, having observed, 1st. Inflamma- tion of the uterus and ovaria; 2d. Inflamma- tion of the peritoneum; 3d. Inflammation of the uterus, Fallopian tubes, or of the peritone- um, connected with inflammatory fever; and, 4th. Low fever, connected with affection of the abdomen, which is sometimes epidemic, rec- ognized three types or forms of puerperal fe- ver : 1st. That consisting of local inflammation in the puerperal state ; 2d. Primary inflamma- tory or synochal fever developing local inflam- mation; and, 3d. Typhoid fever with inflam- mation. Professor Vigarous next divided the disease into, a. The gastro-bilious ; b. The pu- tro-bilious; c. The pituitous, proceeding chiefly from season, &c.; d. The inflammatory, or as- sociated with inflammation of the uterus, peri- toneum, &c.; c. and the sporadic, arising from mental causes, cold, &c. M. Gardien arrang- ed the forms of puerperal fever into the follow- ing: 1st. The angiostenic, or strictly inflam- matory ; 2d. The adeno-meningic, or slow in- sidious fever ; 3d. Meningo-gastric, with bilious derangement, yellow skin, &c; 4th. The ady- namic ; 5th. The ataxic or nervous ; and, 6th. Fever with local phlegmasiae. 117. Several continental writers on puerpe- ral diseases have confounded those which be- long more essentially to the puerperal state with those which may occur under every con- tingency, which are quite unconnected with this state, and are not more likely to affect pu- erperal females than other persons; and they have thus embarrassed the subject with com- plicated sub-divisions and compound terms. Thus Bisch enumerates the following varieties in the local affection, occurring in the puerperal state: (a) Puerperal fever with inflammation within the abdomen ; (b) With inflammation within the cranium; (c) With inflammation within the thorax ; (d) With inflammation of the extremities ; and he believes that the char- acter of the fever may also be varied as fol- lows: 1st. Gastric fever; 2d. Nervous feverj 3d. Typhus fever; and, 4th. Petechial fever. Ritgen, like Busch, has rendered what is oft- en a very complicated subject still more com- plicated and involved by his mode of discussing it. He views puerperal fever as a disturbance of the economy in its attempts to bring the or- ganism back to the unimpregnated state; and he contends, that any organ in the three cavi- ties of the body may become inflamed during this disturbance. He considers the term " Ma- lacosplanchnitis puerperalis" as the best that can be applied to the malady, since not only may the peritoneum be attacked, but any other vis- cus also, the chief peculiarity being the marked tendency of the local lesion to terminate in large fluid effusion. 118. Dr. Robert Lee, who has directed his attention to the state of the uterine vessels in puerperal fever, has referred the symptoms to four varieties : 1st. To inflammation of the peri- toneal covering of the uterus, and of the peri- toneal sac ; 2d. To inflammation of the uterine appendages, viz., the ovaria, Fallopian tubes, and broad ligaments ; 3d. To inflammation and softening of the proper or muscular tissue of the uterus ; and, 4th. To inflammation and sup- puration of the absorbents and veins of the ute- rus. It is manifest, however, that although cases will sometimes present one or other of these lesions, either singly or chiefly, much more frequently two or more of them will be associated in the same case; and therefore, instead of founding the varieties upon the indi- vidual lesions, it would be preferable to consid- er the local lesions as complications, or prom- inent changes occurring in the course of the malady. 119. The arrangement adopted by some oth- er recent writers have been much more simple, and have possessed this recommendation, al- though it may have been carried too far. Mar- tens acknowledges only the inflammatory, where one organ only is affected; the nervous, com- mencing with delirium ; and the putrid, where the frame is more generally implicated. Doug- las has three forms, the inflammatory, the gas- tro-bilious, and the epidemic, or contagious or ty- PUERPERAL FEVERS—Arrangement of their Forms. 553 phoid. Tonnelle assigns only three varieties, the inflammatory, the adynamic, and the ataxic. Blundell adduces also three, the sporadic, the mild epidemic, and the malignant epidemic. This last physician believes that in this last form, where the epidemical disposition to peritonitis is strong, the diffusion of the inflammation is great and rapid, whence the difficulty of the cure ; that in the milder epidemic the perito- nitic disposition is weaker, and the inflamma- tion of smaller extent; and that in the sporad- ic the epidemic constitution is wanting alto- gether, and the local affection is limited, and the treatment much more successful. 120. Dr. Gooch, Madame Boivin, and M. Duges have reduced the varieties to two: the simple inflammatory form, or metro-peritonitis, and the typhoid. In this last form, M. Duges includes all cases of softening of the uterus and of suppuration of the veins ; but he is certainly not accurate in his description of the symptoms characterizing it. 121. The author, in 1834, adopted an arrange- ment of the forms or states of puerperal fever (see article Fever, y 44), which he had observed in practice, and which will be followed and il- lustrated in the sequel. In that arrangement the local affection or affections were viewed as often being accidents or contingencies in the progress of the fever—as complications super- vening in its course; while inflammations of the uterus and its appendages, and of the peri- toneum, were admitted to be sometimes prima- ry diseases, of which the fever was symptomat- ic. Dr. Moore, in his very excellent treatise, published in 1836, very justly remarks, that the varieties observed in the local lesions in puer- peral fever, arising under the same circumstan- ces, cannot be viewed as forms or varieties of the disease, which may be known by the symp- toms, but should be considered rather as com- plications appearing in its course. 122. Dr. Ferguson, in his very able work on this malady, assigns as the result of his exten- sive experience four forms : 1st. Puerperal fe- ver characterized by abdominal pain; 2d. Fe- ver with gastro-enteric irritation ; 3d. Nervous form of fever ; arid, 4th. Complicated form of puerperal fever. 123. Dr. Churchill, the most recent writer on puerperal fever, divides it, according to the predominant local affection, into five varieties, which he has placed in the order of frequency of occurrence : 1st. Peritonitis ; 2d. Hysteri- tis ; 3d. Inflammation of the uterine appenda- ges ; 4th. Uterine phlebitis ; 5th. Inflammation of the absorbents. This arrangement is open to the following objections: (a) It takes for granted that the lesions of these individual parts are truly and always inflammatory—are, in truth, inflammation seated in one or other of these structures, and the fever the sympto- matic constitutional expression of the inflam- mation of such structure—positions which can- not be supported by enlightened observations. —(b) It leaves without any recognition or men- tion the type or nature of the fever as a conse- quence or effect of the exciting causes : it takes no account of the varying character of the con- stitutional disease, upon which, and upon it only, can rational and successful indications of cure be founded.—(c) It takes for granted that these lesions are primary, although this is only occasionally the case ; and fails of viewing them, as they are presented in practice, in va- rious circumstances, and in different endemic and epidemic states of prevalence. It is based upon a partial or piece-meal consideration of the malady, and instead of being founded on a comprehensive and mature digest of constitu- tional and local changes, it assumes that the nature of the constitutional affection, as well as of the local lesion, is always the same, the only difference being the part originally affect- ed ; and it remarkably fails in this distinction, inasmuch as the local changes are rarely lim- ited to a single organ or tissue, but are gener- ally extended to several, and even to many. When most strictly limited, the appropriation of symptoms, so as to markthe limitation, can- not be effected with either truth or accuracy. 124. The above divisions of the several forms of puerperal fever comprise those which appear most deserving of notice. The classification of these forms, adopted from the results of my experience, and published in 1834, and subse- quently by Dr. Ferguson in 1839, embrace, 1st. The inflammatory states of puerperal fever, or inflammation, (a) of the uterus, (b) of the ovaria and tubes, (c) of the peritoneum, (d) of any two or all of them. 2d. Synochoid puerperal fever, complicated with inflammation—a, of the peri- toneum, 8, of the uterine veins, y, of the ute- rus and appendages. 3d. Adynamic or malig- nant puerperalfever-^a, simple; b, complicated with predominant alteration ; a, of the blood ; 8, of the fluids and peritoneum ; y, of the fluids, serous surfaces, and soft solids generally; 6, of the uterus, or of the uterus and appendages ; e, of the internal surface of the uterine vessels, substance of the.uterus, &c.—(a) The first form comprises the primary or idiopathic inflamma- tions, most liable to occur in the puerperal state, and which, commencing in either of the organs or structures here specified, are attended by symptomatic fever, characterized according to the diathesis, strength, and circumstances of the patient, and are limited, or more or less extended or associated, according to these and other influences and causes.—(b) The second form embraces those cases of frequent occur- rence, especially in lying-in hospitals, in which it is difficult to determine whether the fever or the local affection is primary, or in which the local alterations rapidly follow the consti- tutional or febrile affection. In this form of the disease the symptoms are much more as- thenically inflammatory than in the first, more insidious at the commencement, and often re- ferable to a local contamination or infection. It may prevail in lying-in hospitals, on certain occasions which admit not of precise descrip- tion, and may be propagated by contagion. It is not infrequently connected with the preva- lence of erysipelas. I have seen it in the wards of hospitals which have not been over-crowded or apparently ill-ventilated.—(c) The third form is the most malignant, and in its most intense and pestilential states is seen chiefly in lying- in hospitals, or wards, when over-crowded and ill-ventilated. The whole frame appears infect- ed from the commencement, and whatever lo- cal affections or lesions may exist are develop- ed in the progress of the malady, such lesions merely presenting more prominent forms than those observed in other parts of the body. This 554 PUERPERAL FEV form of puerperal fever is caused by the local or endemic infection of the ward—by respiring an infected atmosphere; the infection origina- ting as stated above. The disease produced by it may terminate rapidly in death, without any tissue or viscus having presented a more prominent lesion than the rest of the body. The blood, however, always is more or less al- tered, and the tissues generally are very defi- cient in vital cohesion immediately after death. When this form of the malady is less rapidly fatal, one or more of the complications, or rath- er of the more prominent alterations enumera- ted above, are generally observed. 125. Between the more primary inflamma- tions, appearing sporadically, and constituting the inflammatory form of puerperal fever, and the malignant form now mentioned, that form which I have named the synochoid holds an in- termediate place, passing insensibly into either of the other forms writh the intensity of the ex- citing causes and the amount of predisposition. This synochoid or intermediate form may arise not only from a less concentration of the causes; from a less impure or contaminated air; from a less concentrated or intense effluvium; but also from an impure or infected state of the bed or bed-clothes, or from the infected hands of the accoucheur, causing a local infection during ex- amination ; or from other circumstances either already or about to be noticed; but according to the nature of the causes, their concentration, the state of the patient and the predisposition, so will it approach either the inflammatory form on the one hand or the malignant on the other; and so will it occur sporadically, or even ex- tend by infection. 126. Another circumstance deserving a brief notice is the fact, which has been presented to me on several occasions, that, although the cases which occurred when ventilation was most deficient were generally of the third or most malignant form I have mentioned, yet oc- casionally a less malignant case, pr one more properly belonging to the second form, present- ed itself, and was to be ascribed to the greater constitutional powers of the patient. But du- ring this state of ventilation and infection not one escaped the disease who was confined in the hospital. Subsequently, when ventilation was improved, and when a fever ward was provided outside the institution, the cases pre- sented generally the second form, and very few of the most malignant or third form were then seen. 127. Besides these three forms of puerperal fever, with their complications or more promi- nent lesions, another may be adduced, namely, infectious, or true typhus fever occurring in the puerperal state ; and of which I have seen a few instances. The infection may have been received before or after delivery ; but typhus fever appearing in this state should no more be viewed as a form of puerperal fever than small- pox, or any other of the exanthematous fevers ought to be so considered, when attacking a woman in child-bed. I shall, therefore, notice it no further than the diagnosis may require. 128. In the several works which have ap- peared upon puerperal fever, the epidemic and the sporadic occurrences of its several forms have been mentioned in a very loose manner. I have no doubt of any of the forms of the mal- ERS—their Causes. ady appearing sporadically, more especially the first and second forms which I have assigned, when circumstances combine to develop them; nor can I deny that any of these forms, more particularly the second and third, may become so prevalent, owing to a combination of causes, as to deserve the epithet epidemic. But most of the instances in which puerperal fever has become so prevalent as to be so called have occurred in lying-in wards; and the disease has been limited to them, unless on soihe oc- casions when the infection has been carried abroad from them. The term epidemic is, therefore, not strictly applicable, the malady being truly endemic as respects such institutions as thus occasion it, the character, the type, in- tensity, and other features of the malady de- pending much upon the endemic sources—upon the concentration of the infectious effluvia and other causes generated in these institutions and wards. It is not improbable, however, that certain atmospheric constitutions, depending upon the states of terrestrial and atmospheric electricity, and of humidity and temperature, and other circumstances affecting the preva- lence of febrile maladies, may so affect also the form and prevalence of puerperal fever as to render.it not only endemic in lying-in hospitals, but also epidemic, or approaching to this state, in various places in which it may break out. For, as I stated above (y 36, 44, 138), causes similar to, or almost identical with, those which generate it in the lying-in wards, actually exist in various houses and localities, in such forms and degrees of concentration as to give rise to sporadic cases, which, when circumstances combine to favour their spread, may propagate the malady. 129. It will be asked, what are these causes which thus exist locally or endemically 1 1st. Beds and blankets contaminated by prolonged use, without any attempts at purification (y 44); 2d. Privies containing immense accumulations of faecal matters, often rising as high as the boards, emitting contaminating vapours, partic- ularly when frequented or disturbed, and some- times occasioning, as I have remarked in sev- eral instances, asthenic or irritative and spread- ing inflammation of the vulva, vagina, and cer- vix uteri of married females, and even also of the rectum. lam convinced that the domestic causes of disease, and even of the most malig- nant maladies, which J have described in the article Pestilences, Protection from (y 10-23), and of which I have even assigned proofs (y 14) at that place, are mainly concerned in produ- cing the more serious forms of puerperal dis- ease, the malignancy of the attack depending chiefly upon the concentration or intensity of the cause. 130. iii. Causes.—The causes of puerperal diseases have been stated above, with reference both to the peculiar condition of the puerperal female, or the predisposition thereby acquired (y 6, et seq.), and to the more efficient and imme- diate agents and influences (y 35, et seq., 129). These are disposing and exciting causes, which with their several concomitants, and especially when present in concentrated or intense forms, commonly occasion puerperal fevers—produce it sporadically and favour its spread. From the days of Hippocrates down to the close of the last century, the suppression of the lochia PUERPERAL FEVERS—their Causes. 555 or of the milk was viewed as the chief cause of puerperal fevers ; and certainly there can be no doubt that the suppression of these will oft- en be followed by very serious disease, partic- ularly of a febrile kind. But in most instances the suppression is merely one of the effects of antecedent causes; and it may not—indeed, most frequently it does not—take place in the most malignant states of the disease. 131. A. The predisposing causes of puerperal diseases have been already enumerated, and the influence of mental emotions has been no- ticed. The depression caused by fear of the disease, especially in lying-in charities, when the death of a patient is known, has a remark- able effect in favouring the extension of the disaster, and the depressing feelings entertained by unmarried puerperal females exert a simi- lar influence. Large losses of blood, by uterine hemorrhage or otherwise, have a manifest in- fluence, not only in predisposing to, but also in aggravating the danger of this disease, more especially,in lying-in hospitals and wards. -Sev- eral instances demonstrating the truth of this statement have been observed in the course of my experience. Hemorrhage appears to in- crease the predisposition, both by augmenting vital depression and shock, and by favouring the absorption of morbid secretions and excre- tions, and the passage of contaminating efflu- via into the circulation. 132. Hydrometric and thermometric states of the atmosphere also favour the occurrence of puerperal fever, both by depressing nervous power and by concentrating animal exhalations. Cold and humid sllates of the air frequently pre- vent due ventilation of wards and apartments, and the requisite dilution of the contaminated atmosphere ; and all methods of warming ly- ing-in apartments which do not promote due ventilation, or currents of fresh air, tend re- markably to generate a pestilential effluvia in lying-in wards or hospitals. Humidity at all seasons, but more especially during winter and spring, favours the generation and propagation of this and its allied diseases, as remarked by writers of all ages, more especially of erysipe- las, fever, dysentery, and rheumatism. 133. Some difference of opinion has existed respecting the seasons and states of the weath- er favouring the development of puerperal fe- ver, especially in lying-in wards. My experi- ence convinces me that cold is influentialchief- ly by preventing that amount of ventilation which is requisite when several women are in child-bed in the same apartment. According to my own observations, during a period of thir- ty years, the disease has been most prevalent during the last three months and the first four of the year. M. Duges's observations, which are limited to 1819 and 1820 merely, show an order of frequency as follows : November, Feb- ruary, January, October, December, September, May, March, April, August, July, June. M. de la Roche, of Geneva, exhibits the following order of prevalence : January, March, Novem- ber, December, April, October, September, Feb- ruary, July, August, May, June. As respects the influence of humidity there is greater un- certainty. But I believe that a moist state of the air, especially when conjoined with a low temperature, is most injurious, especially as respects lying-in wards; and in this opinion I am supported by Chaussier, Duges, Cleit, and others, while M. de la Roche considers that a dry state of the air is most favourable to the prevalence of the malady. Humid states of the atmosphere, conjoined with warmth and stillness, are certainly not infrequently produc- tive of sporadic cases arising from the local sources of contamination and infection already pointed out (y 36, et seq.); and from these cases either contagion or infection may extend, when the media are suitable to the transmission, es- pecially by the midwife or nurse. 134. But neither temperature nor grades of humidity, nor both conjoined, always account for the prevalence or absence of this distemper. There seems to be a disposition to the preva- lence of it at some periods and not at others, independently of the conditions now remarked upon. The states of the electricities, in as far as they affect the human body, may be the cause of this predisposition, or emanations from the soil, of a nature quite incognizable to our senses and means of detection, may favour its development and diffusion. But the epidemic occurrence of the malady seems allied to the prevalence of low, or adynamic, or eruptive fe- vers, more especially of typhus and erysipelas ; and when puerperal fever is found to prevail in lying-in hospitals, independently of crowding or want of due ventilation, it generally partakes of the nature of the prevailing epidemic, or of the general epidemic constitution. 135. Neglected states of the bowels, consti- pation, or diarrhcea; improper or insufficient food ; addiction to the use of spirituous liquors or cordials, and living in low, ill-drained, and ill-ventilated houses, also predispose to puerpe- ral fevers. It is difficult to determine the in- fluence of first or subsequent labours, or of the kind of labour. But very quick labours have been viewed as favouring the occurrence of puerperal disease in those confined for the first time ; and prolonged or difficult labours in sub- sequent confinements. Premature labour seems to dispose to puerperal fever; but it may be mentioned that, when the patient is infected by the disease previously to delivery, or to the full period of gestation, premature labour will be thereby induced. Of this I saw two instan- ces in consultation with medical friends in the winter of 1827 and 1828. 136. Other circumstances often concur with the foregoing in predisposing to puerperal fevers, more especially an age approaching to or above forty years; females who have suffered previous abortions, and who are vitally or mentally de- pressed or exhausted;-severe, prolonged, or in- strumental labours ; those who have been sub- ject to diarrhoea, hemorrhoids, or leucorrhcea ; and those who are cachectic, or have been ill- fed, or kept too low during their confinement. Indeed, insufficient nourishment, or inanition, in the puerperal state, is a more frequent pre- disposing cause than usually believed. These require no remark, especially when they are concomitants of the foregoing causes, and with other states of predisposition noticed above. (See y 6,10, et seq.) 137. B. The exciting causes are chiefly those which tend to contaminate the atmosphere of the lying-in apartment, or which may occasion a local infection.—(a) The sources of contami- nation have been described above (y 35, et seq., 556 PUERPERAL FEVERS—their Infectious Nature, 128,129); and although their nature and effects must have been long ago recognised, their re- moval and prevention have hitherto received very slight attention. But these are not the only sources. Many houses retain within their own walls sufficient causes of contamination and of local infection, as just stated, and as fully demonstrated under the head Pestilences, protection from (y 10-23). These causes are often productive of dysentery and of asthenic inflammation of the vagina and uterus, and they may be inferred not to be less innocuous to fe- males on the eve of delivery, the foul air evolved from these sources infecting the female organs, and thus producing sporadically either some one of the forms of puerperal fever, or uterine diseases incidental to the puerperal state. That these maladies have been thus produced in sev- eral instances I have had sufficient evidence to prove ; and that the more febrile or severe may be propagated to other females in this state, when circumstances combine to favour the prop- agation, I firmly believe. Besides these sources of extrinsic contamination, and the effluvia dis- engaged from foul beds (see y 44), there are other influential causes which should not be overlooked, namely, direct and mediate con- tagion or infection, and the intrinsic contamina- tion caused by morbid matters imbibed, and car- ried into the circulation from the uterus and vagina. [The epidemic puerperal fever which proved so fatal among the lying-in patients of the New York Alms-house at Bellevue in 1840, could be distinctly traced to a vitiated state of the atmo- sphere, both general and local. For twelve or fifteen months preceding, there had been an un- usual tendency to epidemic disease, generally of a typhoid character. An incurable diarrhcea, followed by mortification of either extremity of the alimentary, often with the loss of eyes, de- fied the efforts of medicine. Mortification oft- en succeeded blood-letting. Ophthalmia, when treated in the usual antiphlogistic manner, was followed by rapid ulceration of the cornea. Scarlatina was very malignant and fatal. In short, there was a universal typhoid tendency in all diseases, requiring a tonic and supporting course of treatment.] 138. Not the least important of the exciting causes of sporadic cases, which, however, in circumstances favouring infection, may become more or less prevalent, is confinement in a low, close apartment, near where the exhalations from privies, cess-pools, or drains find an out- let anil contaminate the air. Apartments near the ground floors of houses which are provided with privies and cess-pools that have no com- munication with drains and sewers—and most houses are thus most injuriously constructed— are liable to have the air in them contaminated at all seasons from these sources ; but more especially in winter, when they are kept more closely shut, and when the exhalations arise not much less abundantly, and penetrate wherever hydrogenous exhalations may possibly pass. 139. The unguarded use of improper bever- ages, as beer, ale, wine, spirits, &c. ; all sud- den mental emotions, or shocks, frights, cha- grin, anxieties, &c, and premature excesses of any kind, may concur to induce an attack of certain forms of the disease, especially of the more inflammatory. Coagula in the womb, or retained in the vagina ; portions of the placentt left adhering to the uterus, and death of the foetus in utero, may severally cause uterine phlebitis, or other forms of this disease, espe- cially if the labour has been tedious, or has re- quired the use of instruments. 140. (b) The infectious nature of puerperal fe- ver has been denied by some, proved and be- lieved in by many, and imperfectly elucidated, or stated without precision or due limitation by most recent writers on the disease. Infection, or even contagion, is undoubted—unless by the inexperienced and the skeptical—in certain cir- cumstances and forms of the malady. MM. Tonnelle and Duges, however, do not believe in the contagious nature of puerperal fever, and adduce their experience at the Maternite in Paris in support of their opinion. During the latter part of 1818 and spring of 1819, the dis- ease was extremely prevalent in Paris, where I was then residing, and had an opportunity of seeing some of the cases which were so nu- merous in that institution, where alone about three hundred women died of it in these two years. It was prevalent at that time not only in lying-in wards, but also throughout Paris and its environs. These physicians state that it did not extend itself to the bed nearest that in which a patient was affected by it; and they assert that women newly delivered there had each a separate apartment, and yet were at- tacked. These are the chief facts in proof of their opinion, but they prove nothing beyond what has often been demonstrated (see y 143, et seq.), viz , that the malady is often propagated by the mediate contact of the hands of the mid- wife, and by the effluvium imbibed and conveyed by the clothes. They, however, admit, what was generally observed, both there and in other institutions, that when the fever was prevalent it generally attacked several in the same ward, and was sometimes confined entirely to one ward, a fact sufficiently demonstrative of at least an infectious or contaminated state of the air or of the bedding in that ward.* [* Dr. Vache, of New York, has given a very interesting account of the prevalence of epidemic puerperal fever at the New York Alms-house in 1940. The disease made its ap- pearance in the Alms-house on the 12th of June, 1840, and was quickly followed by two more cases, apparently so ma- lignant that it was immediately determined to vacate the room, with a view to its purification. The inmates were accordingly removed, and the apartment was whitewashed, ventilated, and scrubbed ; the bedsteads were cleansed, new beds and bedding introduced, and at the expiration of about a week it was considered sufficiently disinfected to return to it in safety. But the disease immediately reappeared, equally as violent and irremediable as before, and it was con- cluded most judicious to abandon the building. Another was therefore prepared at some distance from the Alms-house, and appropriated as a nursery, after being put in the most perfect order; the bedsteads were cleansed and painted; new beds and bedding were furnished ; the physician and nurse were changed ; the pregnant women were directed to cleanse their persons by bathing ; new clothes and shoes were given to them immediately previous to transferring them to theii new habitation, and all intercourse arrested with the in- mates of the surrounding premises. Notwithstanding thest precautions, the first woman confined, and subsequently foui others in succession, out of five labours, were attacked with the disease, and in every case it was fatal. The lying-in apartments at Bellevae were then abandoned, and others procured at Blackwell's Island. The same precautions were observed, and for a time the change of air, free ventilation, and a more generous diet seemed to have accomplished the object; several were delivered, convalesced, recovered, and were discharged without an untoward symptom ; but the disease soon broke out with redoubled fury, attacking almost every woman confined, and setting at defiance every effort fo< their recovery. The disease in each locality was almost uui formly fatal. The treatment was diversified, consisting a. PUERPERAL FEVERS—their Infectious Nature. 557 141. A circumstance worth noticing is men- tioned by M. Duges, which is no mean proof of the influence of the infected air of the hospital upon the lower animals. During 1819 several cats, frequenting the wards of the Maternite du- ring the prevalence of fever, were attacked by painful distention of the abdomen, and tumefac- tion of the parts of generation. The most of them died in four or five days; and the dissec- tion of them was made, in the presence of Pro- fessor Chaussier, by M. Duges, who found in the peritoneal and pleural cavities a large quan- tity of a whitish serum mixed with albuminous flocculi, and a thin whitish coating covering the abdominal and thoracic viscera. A similar in- stance of the cat of the hospital becoming in- fected occurred in the hospital to which I was consulting physician during the prevalence of the fever in it. 142. In 1824,1 was requested by a practitioner in the Edgeware Road to see a patient with him in this disease. She was the sixth case which he had had in the course of a few days. She was moribund when I saw her. I learned from him that each case of midwifery which he had attended from the first of these six cases was attacked in succession and had died ; that he had called the most eminent accoucheurs to see these cases ; that they had prescribed large bleedings; and that the present case had been also largely blooded, as was then the general practice, the injurious effects of which were making themselves apparent. I insisted that contagion had caused these cases, advised meas- ures to be taken against his being the medium of its transmission, and no other cases occur- red to him for a considerable time. 143. Dr. Campbell wrote on this disease in 1822, from a short experience; and, because he saw no reason to satisfy himself of the propagation of it by contagion, contended, in opposition to the no mean authority and more extensive experience of Hamilton and Gor- don, that the disease was neither infectious nor contagious, although he has adduced no con- clusive evidence that some, at least, of the nu- merous cases which occurred in 1822 did not arise from contagion. It must be admitted that the sources of sporadic contamination which I have described above (y 137, 138), are so abun- dant in Edinburgh, where Dr. Campbell prac- ticed, that the difficulty of discriminating be- tween the influence of these and of contagion is thereby much increased. With a candour which always characterizes the truly scientific inquirer, this physician states that subsequent experience has shown him his error (Lond. Med. Gaz., Dec, 1831), and, much to his credit, he adduces the following facts: After examining the body of a female who died of the disease after an abortion, and carrying some of the dis- eased parts to the class-room, he attended the delivery of a woman the same evening without having changed his clothes: she died. Next morning he went in the same clothes to assist a difficult case, the subject of which also died of the disease; and of others who were seized, within a few days, three shared the same fate. In June, 1823, he assisted at the dissection of general bleeding, oups, leeches, blisters, and fomentations to the abdomen, Dover's powder, camphor, turpentine, calomel, and opium, mercurial purgatives, Peruvian bark, stimu- lants, Ac] a case, where, from want of accommodation, he was unable to wash his hands with due care. He was soon after called to two patients requir- ing assistance, and went without farther ablu- tion, and without changing his clothes, and both these were seized with the disease and died. 144. Dr. Gordon states, that the malady at- tacked only those women who were attended by a physician or nurse who had previously at- tended those affected with it. He remarks, that he had abundant proofs that any person who had been with a patient in puerperal fever be- came charged with an atmosphere of contagion which infected every pregnant or puerperal woman who came within its sphere. Dr. Ham- ilton affirms that this fever is produced by an infection sui generis, and that he is quite posi- tive that this infection is of so virulent a nature that it may be conveyed by a third person. Dr. Gooch records that a surgeon, after opening the body of a woman who died of this disease, con- tinued to wear the same clothes, and delivered a lady a few days afterward, who was attacked by a similar malady and died. Two more of his patients were seized in rapid succession, and also died. He then suspected the transmission of the infection by his clothes, changed them, and met with no more cases of the distemper. A washerwoman and nurse washed the linen of a female who had died of puerperal fever. The next lying-in patient she nursed died of this disease, and so did a third ; when the cir- cumstance having become known, she was no longer employed. At Sunderland, forty out of fifty of these cases occurred in the practice of one surgeon and his assistant. Many other proofs of infection have been adduced by Drs. Lee, Moore, Waller, Robertson, and by many recent writers. The last-named writer, in a most instructive communication (Lond. Med. Gaz., vol. ix., p. 503), states, that a midwife in extensive practice among the out-patients of a lying-in charity, within one month delivered thirty cases living in an extensive suburb of Manchester, and of this number sixteen were attacked with puerperal fever, and they all died; and that, of about three hundred and eighty de- livered at this time by the midwives of this charity, none had the disease except the patients delivered by this midwife. Other conclusive facts are adduced of contagion by this writer. [Numerous facts of a similar kind have fallen under our observation during a practice of twenty-two years, mostly in this city ; but we conceive it unnecessary to go into detail to prove the contagious nature of this disease, as there are few, if any, American practitioners who do not fully believe in this doctrine. In three instances we have known the disease to follow up the accoucheur so closely that he has found it necessary to relinquish practice for a season, notwithstanding all the precautions he could use to avoid extending the disease through the medium of his clothes, &c. There is some- thing truly remarkable in the extreme tenacity of this animal poison, and the minuteness of dose necessary to infect the lying-in female, as well as the certainty of infection upon exposure to the smallest particle of the infectious mat- ter.] 145. These facts sufficiently show the con- tagious nature of this disease ; that this fever may be propagated both by the hands, and by 558 PUERPERAL FEVERS—their Infectious Nature. the clothes, or by either, of a third person, that third person being generally the midwife or nurse. But not only is it thus contagious—the tangible communication often taking place du- ring an examination per vaginam—but it is also infectious through the medium of the bedclothes or bedding, or the body-clothes of a patient, or of a midwife or nurse, or the contaminated air of a lying-in ward. I have had several occa- sions of observing that a lying-in hospital, or ward, for some time after having been opened or purified, will remain free from puerperal dis- ease ; but that, if too many patients be admit- ted, or if, owing to the season, weather, temper- ature, and humidity, the wards are too closely shut, the emanations from the discharges, &c., will soon contaminate the air, and infect the more recently-delivered women, the effluvium from those first attacked increasing the infec- tious state of the air, which is confined for a time to the wards where the emanations were first accumulated, but which soon becomes dif- fused through all the wards and apartments. 146. It has been very justly remarked by Dr. Holmes, of Boston, United States, that, "sup- pose a few writers of authority can be found to profess a disbelief in contagion—and they are very few compared with those who think dif- ferently—is it quite clear that they formed their opinions on a view of all the facts; or is it ap- parent that they relied mostly on their own solitary experience V Dr. Dewees, in the last edition of his treatise on the diseases of fe- males, has expressly said, " In this country, under no circumstance in which puerperal fe- ver has hitherto appeared, does it afford the slightest ground for the belief that it is con- lagious." The evidence already furnished may be viewed as quite decisive of the infectious and contagious nature of the disease in Europe; but Dr. Dewees is incorrect as to his statement of the matter as respects the United States; for, as Dr. Holmes has remarked, Dr. Francis states that the disease was, in some instances, supposed to be conveyed by the accoucheurs themselves; and Dr. Pierson, of Salem, United States, admits this to have occurred to himself in several consecutive cases. Dr. Condie, al- though not previously a believer in the con- tagious nature of the malady, " has, neverthe- less, become convinced by the facts that have fallen under his notice, that the puerperal fever now prevailing is capable of being conveyed by contagion." (Trans, of Coll. of Phys. of Phila- delphia, July, 1842.) Dr. Warrington stated at the same meeting of the college, that, after as- sisting at an autopsy of puerperal peritonitis, he was called upon to deliver three women in rapid succession. " All these women were at- tacked with different forms of what is com- monly called puerperal fever." At this meet- ing, also, Dr. West stated that seven females delivered by Dr. Jackson in rapid succession were all attacked with puerperal fever, and five of them died. These were the only cases which occurred in that district; for the women be- came alarmed at the existence of what Dr. Dewees and a few with him have denied, and sent for other assistance. " And here I may mention that this very Dr. S. Jackson is one of Dr. Dewee's authorities against contagion !" 147. A physician in Boston, United States, had the following consecutive cases: on the 24th March, 9th, 10th, 11th, 27th, 28th April; and 8th May, seven in all, of which five died. He then left town. Another physician writes to Dr. Holmes as follows : " The first case was in February (1830), during a v6ry cold time. She was confined the 4th and died the 12th. Between the 10th and 28th of this month I at tended six women in labour, all of whom did well except the last, as also two who were con- fined March 1st and 5th. Mrs. E., confined February 28th, sickened and died March 8th. The next day, the 9th, I inspected the body, and the night after attended a lady, Mrs. G., who sickened and died the 16th. The 10th I attended another, Mrs. B., who sickened, but recovered. March 16th, I went from Mrs. B.'s room to attend a Mrs. H., who sickened and died 21st. »The 17th I inspected Mrs. G. On the 19th I went directly from Mrs. H.'s room to attend another lady, Mrs. G., who also sickened and died 22d. While Mrs. B. was sick on the 15th, I went directly from her room, a few rods, and attended another woman who was not sick. Up to the 20th of the month I wore the same clothes. I now refused to attend any labour; and did not till April 21st, when, having thor- oughly cleansed myself, I resumed my prac- tice, and had no more puerperal fever. The cases were not confined tq a narrow space. The two nearest were half a mile from each other, and half that distance from my residence. The others were from two to three miles apart. There were no other cases in their immediate vicinity." (P. 517.) In another communica- tion, the writer considered that he carried the contagion to five cases; and both he and the preceding correspondent state that the disease infected the young and the more aged—the strong and the weak ; and without being influ- enced by the labour or other circumstance. 148. Dr. Ramsbothah remarks, that he has known the disease to spread through a partic- ular district, or to be confined to the practice of a particular person, almost every patient being attacked by it, while other practitioners had not a single case; and he views the dis- temper as being capable of conveyance in not only common modes, but through the dress of the attendants on the patient. (Lond. Medical Gaz., 2d May, 1835.) Dr. Blundell says, that some practitioners have lost ten, twelve, or a greater number of patients in scarcely broken succession ;" that this fever may occur spon- taneously, he admits ; that its infectious nature may be plausibly disputed, he does not deny; but he would considerately add, that he had rather "that those he esteemed the most should be delivered, unaided, in a stable, by the man- ger-side, than that they should receive the best help in the fairest apartment, but exposed to the vapours of this pitiless disease. Gossiping friends, wet-nurses, monthly nurses, the practi- tioner himself, are the channels by which the in- fection is chiefly conveyed." (Led. on Midwifery, p. 395.) My friend, Dr. King, of Eltham, men- tioned at a meeting of the Medical and Chirur- gical Society (Lancet, 2d May, 1840), that some years since a surgeon at Woolwich lost sixteen patients from puerperal fever in the same year. He was compelled to give up practice for one or two years/ his business being divided among the neighbouring practitioners. No case of the disease had occurred in the practice of these PUERPERAL FEVERS—their Infectious Nature. 559 practitioners, or occurred afterward. Mr. Da- vies states, that in the autumn of 1822 he met with twelve cases, while his medical friends in the neighbourhood did not meet with any, or at least with very few. He could attribute this to no other cause than his having been present at the examination of two cases, and his hav- ing conveyed the infection to his patients, not- withstanding every precaution. In December, 18,30, a midwife who had attended two fatal cases of puerperal fever at the British Lying-in Hospital, examined a patient who had just been admitted to ascertain if labour had commenced. This patient remained two days ; but labour not coming on, she returned home, when she was suddenly delivered before she could return to the hospital. On the third day she was seized with the fever, and died in thirty-six hours. A young surgeon, shortly after examin- ing the body of a sporadic case that had, died, delivered three women, who all died of puerpe- ral fever. Mr. Ingleby states, that two gen- tlemen, after the post-mortem examination of a case of this disease, went in the same dress, each respectively, to a case of midwifery. The one case was attacked in thirty hours after- ward, the other in three days. One of the same surgeons attended, in the same clothes, another female, and she was attacked on the evening of the fifth day, and afterward died. These cases belonged to a series of seven, the first of which was believed to have originated in a case of erysipelas. Mr. Ingleby also adduces an- other series of seven cases which occurred to a practitioner in 1836, the first of which was also attributed to his having opened erysipela- tous abscesses shortly before; 149. Dr. Rigby remarks, that the discharges from a patient in puerperal fever are highly con- tagious ; that the puerperal abscesses are also contagious, and may be communicated to healthy lying-in women by using the same sponge, as proved repeatedly in the Vienna Hospital; and that the women engaged in washing the bed- linen of the General Lying-in Hospital have been attacked with abscesses in the hands and diffuse inflammation of the cellular tissue. Dr. Ramsbotham, in a letter to me, mentions a se- ries of seven cases, two of which he saw, which occurred successively to a surgeon in this city ; and he, moreover, notices the connexion of erysipelas with certain of these cases ; but to this I shall revert in the sequel. Now, after the evidence I have adduced—and I could have quadrupled the amount—is it not criminal for any medical man to go from a case of this dis- ease, or even from a case of erysipelas, to a female in the parturient or puerperal state, without using the strictest precautions! I may conclude this part of my subject by stating that the fact of the contagious nature of this mal- ady is completely set at rest by the above evi- dence, especially when it is. undisputed that within the walls of lying-in hospitals a miasm is often generated as palpable to the senses, and even sometimes much more so, than the fumigations used to destroy it, so tenacious as often to withstand the common measures of purification, and, when generated, more deadly than the plague, if not arrested at its com- mencement by the most prompt and efficient means. I may farther add, that lying-in hospi- tals, or even lying-in wards, ought not to be allowed to exist, for the reasons rendered ap- parent by what I have adduced, and because the aid they afford may be more beneficially furnished in other ways; and that boards of health, if such existed, or without them, the medical institutions of a country, should have the power of coercing, or of inflicting some kind of punishment on those who recklessly go from cases of puerperal fevers to parturient or puer- peral females, without using due precaution; and who, having been shown the risk, crim- inally encounter it, and convey pestilence and death to the persons they are employed to aid in the most interesting and suffering period of female existence. 150. The contagious nature of puerperal'fe- ver has been denied by Hulme, Leake, Hull, Beaudelocque, Tonnelle, Duges, Dewees, and others ; but Gordon, J. Clarke, Denman, Burns, Ha'milton, Haighton, Gooch, Blun- dell, Ramsbotham. Locock, Douglas, Lee, Ingleby, Alison, Rigby, Watson, Channing, and others have professed their belief in, or ad- duced proofs of, the existence of this property, as respects this, the most frightful of any of our domestic pestilences; and if any would prefer the weight of authority to the over- whelming evidence now adduced, the names I have enumerated must satisfy him—at least they are quite, nay, more than sufficient to war- rant him in acting with caution, and to render him criminal in the eyes of the considerate part of the community if he should ever be the me- dium of transmitting, contagion and death to those who confide not only in his science, but also in his humanity, and in the incalculable val- ue attached by him to human life. Dr. Holmes has forcibly and eloquently brought this much- neglected subject before the profession ; and he thus concludes : " It is as a lesson, rather than as a reproach, that I call up the memory of those irreparable errors and wrongs. No tongue can tell the heart-breaking calamity they have caused ; they have closed the eyes just opened upori a new world of'love and happiness ; they have cast the helplessness of infancy into the stranger's arms, or bequeathed it with less cruelty the death of its dying parent. There is no tone deep enough for regret, and no voice loud enough for warning. The woman about to become a mother, or with her new-born in- fant upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden or stretches her ach- ing limbs. The very outcast of the streets has pity upon her sister in degradation when the seal of promised maternity is impressed upon her. The remorseless vengeance of the law is arrested in its fall at a word which reveals this transient claim for mercy. The solemn prayer of the Liturgy singles out her sorrows from the multiplied trials of life, to plead for her in the hour of peril. God forbid that any member of the profession to whom she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly, or selfishly !" 151. C. What connexion is there between pu- erperal fevers and erysipelas?—The connexion apparently existing between these diseases has been hinted at above; but it is more remark- able at some seasons and occasions than at others. It was first observed and insisted upon by Pouteau in 1750, who considered the puer- 560 PUERPERAL FEVERS—their Infectious Nature. peral fever as it then prevailed in Paris as an epidemic erysipelas of the peritoneum. Drs. Home and Young, of Edinburgh, and Dr. Low- der, of London, not long afterward, also main- tained this opinion. Dr. Abercrombie, as Dr. Moore has remarked, adopted a similar view, and founded his opinion principally on the cir- cumstance of both diseases giving rise to se- rous effusion. In the various discussions this subject has given rise to, it has been contended by Dr. Whiting, Dr. Waller, and others, that the identity of both these maladies is shown by the similarity of symptoms, and by the ill suc- cess of remedies ; they asserting that, like ery- sipelas, puerperal fever cannot be arrested, and that it is contagious. This last property has been shown to exist, and cannot now reason- ably be doubted. But that puerperal fever may be arrested I have proved on numerous occa- sions ; and I shall have occasion to describe the means by which its arrest may be accom- plished. Phlebitis of the capillary veins not infrequently complicates erysipelas, and ute- rine phlebitis is a frequent complication of the second or more intermediate grades or states of puerperal fever. These phenomena evince a certain amount of alliance, but not identity. Gordon, Hey, Armstrong, and others contend for similarity, if not for identity. Dr. Lee states that in 1829, when the fever broke out in the British Lying-in Hospital, three children died of erysipelas, and on examination after death, the peritoneum in these infants was found extensively inflamed, and covered with a copious sero-purulent effusion. Three other cases are related as having occurred under similar circumstances; but it is admitted that cases of infantile erysipelas repeatedly occur- red when there were no cases of puerperal fe- ver in the hospital. I find it remarked, in my notes of cases of this disease observed by me in Queen Charlotte's Lying-in Hospital, that the relation subsisting between puerperal fe- vers, whether of an inflammatory, or of a ma- lignant, or of an intermediate type, and erysip- elas, especially of an epidemic form, has been evinced on several occasions, and during sev- eral periods, in which the former have prevail- ed. Instances of both diseases occurred in the winter and spring of 1823 and 1830, and of al- most every intermediate year. But cases have also been observed of either malady without the other; and, while infantile erysipelas has occasionally been seen contemporaneously with the appearance of puerperal fevers among the women, the former has not infrequently been met with when the latter did not exist, either sporadically or endemically. 152. Dr. Holmes notices, in his instructive memoir, that Dr. S. Jackson went from a case of gangrenous erysipelas which he had been dressing to the first of the series of cases which took place in his practice; and that a Dr. C, who delivered seven women in succession, who were all seized with puerperal fever, had made, on the 19th of March, the autopsy of a man who died after a very short illness, from cede- ma of the leg and thigh followed by gangrene, and the first of these seven cases was deliver- ed by him on the 20th, the following day. When making the autopsy on the 19th, Dr. 0. wounded his hand, and was confined to his house, after delivering the first case on the 20th, until the 3d of April, and on April the 9th he attended the second case of fever. •' Sev- eral cases of erysipelas occurred very soon af- terward in the house where the autopsy of the man just mentioned took place. There were also many cases of erysipelas in town at the time of the puerperal cases. The nurse who laid out the body of the third puerperal patient was taken on the evening of the same day with sore throat and erysipelas, and died in ten days. The nurse who laid out the body of the fourth case of puerperal fever was seized on the day following with symptoms like those of that case, and died in a week, without any external marks of erysipelas." 153. Another physician, who had a series of five successive cases of puerperal fever, states, in a letter to Dr. Holmes, that for two weeks previously to the first case of puerperal fevei he had been attending a severe case of erysip elas, and the infection may have been convey- ed through him to the patient, as he admits; but, he asks, " Wherefore does not this occur to other physicians, or to himself at other times; for he has since had a still more inveterate case of erysipelas, but he has had no disease in any of bis midwifery cases'!" It would be culpa- ble in him to make the experiment, or to repeat the risk, without due precautions. Inoculation with the matter of smallpox or cowpox does not always communicate the disease; indeed, it often fails of doing so ; but no one now dis- putes the contagious nature of the virus inocu- lated. Dr. Merriman, an able and cautious practitioner, mentioned (Lancet, 2d May, 1840) that he was at the examination of a case of puerperal fever at 2 P.M. He took care not to touch the body. At 9 o'clock the same evening he attended a woman in labour; she was so nearly delivered that he had scarcely any thing to do. The next morning she had rigours, and died in forty-eight hours. Her infant had ery- sipelas, and died in two days. A patient whom I was attending in the hospital, in 1828, was seen by a lady ; and, while listening to her faint voice, her breath was felt by the lady, who was stooping over her. This lady was the following day attacked with erysipelas in fhe face. 154. Dr. Rigby states that, in one epidemic in the General Lying-in Hospital, the child of every woman who died of the disease perished of erysipelas, which ran its course in a few hours. Dr. Ramsbotham remarks, respecting this topic, that the cases recorded by Ceelv and Ingleby are so strongly in point, as to ren- der it almost impossible to withhold the con- viction that there is a form of fever to which puerperal women are liable, not only arising from the contagion of erysipelas, but, in its turn, also occasioning that disease in other per- sons. Whether in this affection, when it arises under such circumstances, the peritoneum is always attacked, is a question which he be- lieves may be answered affirmatively in the great majority of cases. He further states, that on three occasions he has known the wom- en who have nursed patients that died of this fever attacked with erysipelas of the leg; that in 1841, when erysipelas was prevalent in Roth- erhithe, a medical friend of his had six cases, and while attending these he delivered a lady, who was speedily seized with puerperal fever, PUERPERAL FEVERS—their Infectious Nature. 561 and very soon afterward died. Her nurse was attacked with erysipelas of the hand, and was attended by another surgeon. One day, after having made an incision and dressed the wound, this latter surgeon was called to a case of mid- wifery : puerperal fever supervened, and the patient sunk very rapidly. A third fatal case, attended by the same practitioner, Dr. R. also saw, and others that did well. The disease disappeared in that vicinity when these prac- titioners declined to attend.women in labour. Since the appearance of the second edition of his work, Dr. R. has met with additional facts, which he has had the kindness to communicate to me. A surgeon, in Clerkenwell, had five fatal cases of puerperal peritonitis, rapidly fol- lowing each other, and two others, which Dr. R. saw, and both recovered ; but both the chil- dren of these two latter cases died of erysipe- las. One of the nurses in these last cases also took erysipelas. When this surgeon attended the first case of puerperal fever, he was just recovering of an attack of diffuse inflamma- tion of the cellular tissue, with abscess of the fore-arm, consequent on having pricked his fin- ger in opening the body of a woman who died of cancer of the uterus. Dr. R. concludes with believing, that "the connexion between malig- nant puerperal fever—that is, the fever in which the peritoneum is the seat of disease, and which terminates in the rapid effusion of soft lymph and whey-like serum into the cavity—and ery- sipelas is perfectly established." I may add to the above my opinion that the evidence is al- together satisfactory ; that some of the series of cases of the more malignant states of puer- peral fever have been produced by an infection originating in the effluvia proceeding from ery- sipelas, or by ^e contagion of the matter or contaminating material produced by erysipelas. It is quite unnecessary for me to adduce far- ther facts in support of this inference, but they may be found in the writings of Ceely, Acker- ley, Rigby, S. Jackson, Holmes, Ingelby, Pa- ley, Storrs, Nunneley, and numerous others, referred to in the Bibliography to this article. My opportunities of observing this disease since 1812, and what I have seen of it in hospitals and in private practice, have convinced me of the propriety of the following inferences and precautions. 155. a. That lying-in hospitals and wards have been established and supported on mis- taken views as to the benefits they confer on individuals and the community ; that the char- ity would be bestowed more safely to the ob- jects themselves, and to others contingently, if it were so administered as to afford the re- quired aid, to increase the comforts, and to im- prove the sanitary conditions of females in the puerperal states at their own places of residence. 156. b. If these institutions be still continued and supported, as introductions to midwifery practice, or for the doubtful benefit of the re- cipients of a certain kind of charity, the obstetric physicians and surgeons attached to them ought not to attend those cases of puerperal fever or of erysipelas which so frequently break out in the wards of such institutions; for, by doing so, they convey the poison from one patient to another, both within and without the institu- tion. In all such circumstances, the consulting physician or surgeon to the institution, who, as III. 36 in my own case, should not be engaged in the practice of midwifery, ought to take charge of these cases, which should, immediately upon their attack, be removed, with due care and precaution, into a separate ward, provided for the reception of such cases, and situated with- out the walls of the hospital, but apart from other houses. 157. c. A physician or surgeon engaged in obstetric practice, upon the occurrence of pu- erperal fever in any of his cases, should either explain the matter to her friends, and call in a physician not engaged in this practice, to whose care she ought to be committed ; or he should relinquish the care of puerperal females during his attendance on cases of this fever, and even of erysipelas; or he should change all his clothes, and carefully wash his hands, after seeing cases of either of these maladies, before proceeding to a puerperal female. 158. d. An obstetric practitioner should not make an autopsy of a case of puerperal fever, or of erysipelas, or of peritonitis, or of diffu- sive inflammation of the cellular tissue, or of the disease occasioned by the necroscopic poi- son (see art. Poisons, y 487, et seq.), nor even attend, or dress, or visit any of such cases, without immediately afterward observing the precautions just stated, and allowing two or three days to elapse between such attendance and midwifery engagements, or visits to puer- peral females, [and even where these precau- tions have been strictly observed, we have known the disease to be communicated by the physician to his lying-in patients.] 159. e. It is the duty of obstetric practition- ers attached to public institutions to prevent, as far as possible, the spread of this pestilence by midwives, nurses, or other assistants ; and, as soon as two or three cases occur in succes- sion, or other causes of suspicion present them- selves, to take the most decided measures against the extension of contagion. Whatev- er indulgence may have heretofore been ex- tended to those who have been the ignorant causes of the misery disclosed by the above statements—which convey but a small part of what has occurred in recent times—cannot now be expected, and ought not to be granted; for the practitioner is now too well informed, or, at least, the sources of information as to this matter are too open for him to be longer igno- rant, that this most deadly of our domestic pes- tilences is conveyed from the infected to the healthy chiefly and most frequently by the ac- coucheur, when it occurs without the walls of a lying-in hospital, and that ignorance of, or inattention to, this fact, already not unknown to the well-informed part of the community__ this flagrant neglect of what we owe to those who confide in us, and to society in general, to whom we must look for consideration and es- teem—will be no longer viewed as a misfortune, j but will be more justly considered a crime of no small magnitude. 160. D. What connexion is there between puer- peral fever and other maladies, especially such as are epidemic or endemic ? and may atmospheric vi- cissitudes or conditions be viewed as concerned in I this connexion, and in their prevalence severally or | collectively?—The infectious nature of puerpe- , ral fever has been demonstrated above (y 140, ! et seq.), and it has been shown, as in Dr. Mis- 562 PUERPERAL FEVERS—Description. riman's case, that the disease may be commu- nicated without contact, although there is also reason to believe that the contact of a materia morbi will also convey it. The connexion be- tween this fever and erysipelas, also a conta- gious disease, has next been shown (y 151, et seq.); and it has been proved that the effluvium from a case of puerperal fever will produce ery- sipelas in a person predisposed to this latter malady, while that evolved from a case of ery- sipelas will occasion puerperal fever in newly- delivered females. Moreover, it has been shown by several cases in the course of my practice (to two of which I was called by one practitioner in the winter of 1827-28), that the infection of either this fever or erysipelas may be transmitted to females who are pregnant, more especially at a far-advanced period of ges- tation, and may rapidly produce premature de- livery, followed by all the characteristic phe- nomena of malignant puerperal fever; while, on the other hand, abortion or premature de- livery, particularly when either is accompanied with great hemorrhage or flooding, predisposes remarkably to the infection of puerperal fever, as well as to that of erysipelas. 161. The prevalence of typhoid or adynamic fevers have been considered by some writers as more or less connected with the occurrence of puerperal fever, and, indeed, that this lat- ter is merely typhoid fever modified or aggra- vated by the puerperal state. We find that smallpox and scarlet fever, or measles, are re- markably aggravated, and the danger from them greatly increased, when they attack a puerpe- ral female. But these diseases always pre- serve their identity and their specific forms, and the power of perpetuating or extending themselves. Their characters are not lost in those of puerperal fever; and if, during their course, the phenomena or the internal lesions and complications usually observed in malig- nant puerperal fever appear also in them, they are merely superadded, and become the causes of the greater malignancy and more rapid prog- ress of the malady to a fatal issue. Now this has been the case also with the true or exanthe- malic typhus, when it affects a puerperal fe- male, as far as my observation enables me to judge ; for the characteristic eruption and the low, muttering delirium — the typhomania— marking this fever have also appeared in the puerperal manifestation or complication of it, the features of the puerperal malady being also present; the puerperal state imparting to this specific fever, as it does to the exanthemata, dangerous complications, more malignant char- acters, and a much more rapid and unfavoura- ble issue. 162. I have had reason, however, to believe that puerperal fever may arise sporadically from the same causes as that form of fever which I have denominated putro-adynamic—the putrid fever of the older writers (see art. Fever, y 484)—that fever, varying in its subordinate features, and in the lesions supervening in its course, may be produced in the puerperal state by the same causes as those which occasion that form of continued fever; that animal ex- halations, the foul vapours from putrid animal matter and burying-grounds, the effluvia from privies and sewers, and the infectious emana- tions yielded by those affected by this fever, will produce puerperal fever, in all respects the same as when it prevails in lying-in hospitals; and that the puerperal fever thus originating maybe spread in the manner above demonstra- ted; that, in short, malignant puerperal fever may arise sporadically from those sources of infection I have described when treating of this property (see Infection, y 11, et seq.) and of the causes of putro-adynamic fever (sec Fever, y 449, et seq., 484), and be transmitted from one puerperal female to another, when the circum- stances favouring this transmission are present. 163. Dr. Collins states, that puerperaPfever has become epidemic in the Dublin Lying-in Hospital on several occasions when typhus fe- ver prevailed in that city, and at other periods when erysipelas was frequent. A patient was admitted at a late hour labouring under fever with petechial spots over the body. She was removed to a separate apartment, and died soon afterward. The two females who occu- pied the beds adjoining hers were attacked with puerperal fever and died. A patient in fever was admitted at night into one of the la- bour wards, where she remained for some hours. This ward contained four beds. The three women occupying the other beds were attack- ed with puerperal fever, and two died. Dr. Collins adds, that the recovery of the patient attacked with typhus fever at the full period of pregnancy is an interesting fact, as he believes that no complication proves more generally fa- tal than the premature expulsion of the child under such circumstances. 164. The prevalence, also, of the low types of the exanthemata, of rheumatism, and even of other diseases, which are favoured more or less by humid, stagnant, and cold states of the at- mosphere, may exist contemporaneously with that of puerperal fever; but in such circumstan- ces the only connexion subsisting between them is to be ascribed to the atmospheric conditions, especially those just stated, probably also as- sociated with certain electrical conditions of the earth's surface and of the air, and with em- anations from the various sources of impurity and of infection with which all crowded local- ities, towns, cities, factories, &c, abound more or less, particularly when these emanations are not swept away by high winds and due ventila- tion. 165! iv. Description.—Puerperal fevers pre- sent certain types or forms, depending chiefly upon the following circumstances: 1st. Upon the intensity or concentration of the exciting causes, relatively to the predisposition of those exposed to their operation ; 2d. Upon the de- gree of depression of organic nervous energy or powers of life produced by those causes ; 3d. Upon the extent of contamination of the circulating fluids consequent either on the res- piration of a foul or infected atmosphere, or on the absorption of morbid matters from the sex- ual organs, or from other parts ; 4th. Upon the continued operations of these, or of various concurrent causes and influences, during the progress of the malady; 5th. Upon the states of season, weather, and epidemic constitution at the time cases of this malady occur; and, 6th. Upon the manner in which the infection is produced, and the media or channels by which it is conveyed, when the disease is propagated by infection or contagion, as shown above PUERPERAL FEVERS—Description. 563 (y 140, et seq). These circumstances, aided by constitutional peculiarities, the previous con- ditions of organs and functions, and the mor- bid tendencies of the patient, are also the chief causes of the complications, ultimate changes, and"results observed in the advanced course and at the termination of the malady. 166. The various arrangements of the forms of puerperal fever adopted by medical writers have involved the following important ques- tions, namely : (a) Are the several forms or types of puerperal fever the consequences of local chan- ges—of those lesions observed after death; or, in other words, are they merely symptomatic disturb- ances of the constitution produced by these lesions ? —(b) Are the structural lesions or prominent chan- ges found on dissection produced in the course of the malady, and are they the ultimate results of that malady ?—(c) And are these forms or types different from their commencement, and the effects of different grades of intensity of the exciting cau- ses, and of the different avenues or channels by which these causes invade and poison the frame ? Now the solution of these important questions has been eschewed by all writers, and even by the obstetrical writers on this malady, many of whom have mystified, rather than enlighten- ed the subject. The answers which may be given to these questions will appear more il- lustratively in the sequel, for the importance of the topics to which they refer is great, not merely as respects an accurate description of the different resulting forms and states, but also as regards the adoption of appropriate prophylactic measures and rational indications of cure. The discussion of this topic cannot, therefore, be neglected with propriety. It is necessary first to advert to the modes and av- enues by which the poison or infection may contaminate the frame, as above demonstrated (y 143, et seq.). 1st. The atmosphere of a ward may be infected by animal effluvia—by exhala- tion from decomposed discharges, &c„ as there shown ; or a puerperal female may inspire the poisonous effluvium absorbed, retained, and af- terward given out by the clothes of the medi- cal attendant or nurse. In these cases the frame is infected through the respiratory ave- nue ; organic nervous power and the circula- ting fluids being thereby morbidly impressed or affected. Whatever local changes or promi- nent lesions are observed after death, whether implicating the peritoneum, or the sexual or- gans, or other parts, are, in such cases, consec- utive of the operation of the exciting cause upon the nervous and vascular systems, and upon the blood. In these there can be no doubt as to the local lesions being consecutive of the in- fection thus produced ; although the mode in which the consecutive lesions or complications are developed may admit of discussion, as no- ticed hereafter (y 245, et seq.). 167. 2d. It has been shown above (v 137, et seq.) that the poison may be conveyed to the uterus or vagina by contact—by the hands of the accoucheur; or the poisonous miasms or vapours exhaled from foul privies frequented just before delivery—a gust of foul air on those occasions—may infect the vagina andos uteri; or the decomposition of coagula in the vagina or uterus, or of a portion of a retained placen- ta may so contaminate these parts, the imbibi- tion and absorption of the decomposed matters, or of ichorous or puriform secretions in these situations, affecting not only the state of vital power and resistance, but also changing the constitution of the circulating fluids in such a manner as to give rise to all the phenomena and complications of this malady. In this lat- ter mode of infection—and through the chan- nel or avenue now stated—the local changes in the sexual organs are, as respects their earlier grades, the first to be developed ; although they subsequently increase in extent and intensity with the depression or exhaustion of vital pow- er, and with the contamination of the circula- ting fluids; and progressively extend to the peritoneum, digestive organs, heart, and other remote parts, as hereafter described. In the first of these modes of infection (y 166) the lo- cal alterations are generally consecutive of the constitutional affection ; in the second they are primary, but of such a nature as rapidly to con- taminate the whole frame, and as to" become themselves quickly aggravated and extended by the consequent constitutional infection. The former of these modes is produced by an ex- trinsic cause or poisonous emanation generally conveyed through the medium of the respired air ; the latter by the contact of a material poi- son either directly applied to the prominently diseased parts, or affecting them in the manner already stated (v 129). 168. It may, however, be admitted that, when the frame of a puerperal female is infected by a foul air, generated either in a lying-in ward, or in an apartment by privies and sewers, &o, and when vital power is thereby depressed and the circulating fluids contaminated, the secre- tions or discharges from the uterus will then also become altered, more or less acrid or oth- erwise morbid, and thus infect the parts with which they are in contact. Nor will the local alteration, thus originating, be limited to these parts, but it will extend to adjoining parts and surfaces, and even to remote situations, as shown in the second of the above categories; the complications or local lesions thus super- vening upon the constitutional infection, and in their turn augmenting that infection. Such being the two modes of procession of the mor- bid changes, it becomes the more important to recognise the phenomena by which each is dis- tinguished ; and to inquire, as I shall endeav- our to do in the sequel—as I have many years since inquired and acted, and not unsuccess- fully—respecting the means which may be ra- tionally employed to arrest the onward tenden- cy of these changes to disorganization, to dis- solution of the vital cohesion of the tissues, and to death. 169. 3d. Besides the two classes of cases now specified, and arranged according to the manner in which their efficient causes invade the economy and develop the malady, there is a third; and to this class may he referred those cases which evince a more strictly local character, which are more individualized in their manifestations and more limited in their tendencies and structural changes. These gen- erally are primary, or commence with local chan- ges of an inflammatory character, the constitu- tional disturbance being symptomatic of such changes, and varying with the state of the pa- tient, and with the influences to which she is subjected. In this class the local affection is 564 PUERPERAL FEVERS—Inflammatory. more decidedly inflammatory; and if the di- athesis be not altogether sthenic, it is at least much less asthenic than in any of the former classes. The cases in this third class may oc- cur independently of any infection taking place in either of the modes, or by either of the ave- nues, indicated above ; or, if they be produced at all, as there stated, the causes are so weak, or operate in such a manner as not materially to reduce vital power or resistance, or remark- ably to lower the tone of vascular reaction. Some of these cases may be referred to causes productive of irritation or of determinations of blood to the affected parts ; or to the suppres- sion of the secretions and excretions; or to the nature of the ingesta, or to various other causes of visceral inflammation. If in any case either of the modes of infection above specified be concerned in producing this form of the disease, the infectious agent fails in oc- casioning the same amount of vital depression, of structural changes, and of general contam- ination characterizing the other forms, owing either to the relative weakness of this cause, or to the constitutional power and strong vital resistance of the patient. Keeping, therefore, in view the different or varying forms of the malady—the progressively malignant states of puerperal fever, with the nature, intensity, or concentration of the existing causes, and with their continued operation, I proceed to con- sider, first, the more local and sthenic, or in- flammatory form or type of the malady, and af- terward the more asthenic and malignant. 170. A. Inflammatory Puerperal Fever.— This form of the disease has been viewed by many writers as an idiopathic or primary inflam- mation, occurring in the puerperal state—as a puerperal peritonitis, or as puerperal hysteritis or metritis, or as puerperal ovaritis, according as the peritoneum, or the uterus, or the ovaria and ligaments are the chief seats of inflammatory action and of local change. That this form of the disease may thus occur primarily, being de- veloped by causes which tend to localize dis- ease, owing to their nature and channels of op- eration, must be admitted. Cold, humidity, neglect of various comforts and requisites, im- proper food or beverages, mental emotions, &c, may primarily excite either of these local dis- eases, and symptomatic fever, varying in the character or type of vascular action, with the state of constitutional power, and with numer- ous other concurrent influences and circum- stances. But in other cases, as shown above (y 169), the primary character of the local dis- ease is lost in the intensity or severity of the constitutional disturbance ; and the more prom- inent lesion of one or more of the parts just particularized, either is an attendant of the vas- cular reaction following the operation of the exciting causes and the shock produced by par- turition, or is consequent upon the reaction, and is favoured by those conditions and circum- stances insisted upon above as being influen- tial in determining and localizing puerperal mal- adies ($ 10, 11, 41). When the common cau- ses of inflammation occasion disease of one or more of these parts, the constitutional disturb- ance is modified more or less by the puerperal state, and by the constitutional powers and oth- er circumstances of the patient. But as the infectious and contaminating effluvium in poi- | son, so influential in causing the malignant forms of the malady, has little or no share in I the production of the sporadic or inflammatory cases constituting this form, they generally pre- sent more or less of a sthenic diathesis, and pursue a more favourable and less rapid course than the others. 171. (a) Puerperal Peritonitis.—Peritoni lis Puerperalis—Inflammation of the peritoneum may occur in the puerperal state sporadically from causes already noticed, or even without any very obvious exciting or external cause. It may either be primary, or the consequence of the extension of irritation or inflammatory action from some one of the organs or parts seated in the pelvic cavity to that portion of the peritoneum enveloping the part thus prima- rily affected. This latter mode is probably the most frequent; for the uterus, the tubes or ovaria, owing to injury, to excoriation, or to the irritation of the lochia, or to other causes, may be so affected as not to betray the nature or amount of the affection, in consequence of the peculiar condition of the patient, until the disease extends to the peritoneum, and thus the parts primarily disordered are either over- looked or unrecognised, and the more promi- nent and secondary alteration attracts the chief attention, and is considered the only seat of the malady. This form of the disease is most fre- quently caused by violence during delivery, by exposure to cold, or damp or wet linen or bed- clothes, or by the use of improper food or stim- ulants. It may not appear for a fortnight or three weeks after delivery ; but when it is the primary lesion it may occur on the second or third day, or earlier than inflammation of the uterus. Uterine hemorrhage predisposes to it as well as to the other forms of puerperal fever. 172. a. The symptoms of puerperal peritoni- tis vary with the constitution, habit of body, and other circumstances of the patient and the mode of attack. The pulse often continues to rise in frequency from the appearance of the reaction consequent on the shock of delivery, and pain is felt in different parts of the belly, which are soon followed by chills, rigours, or shiverings. With these great increase of pain in the abdomen, with tenderness and tension, sickness or vomiting, is complained of. The pain is occasionally universal, but it is some- times limited to one part, and the belly soon becomes swollen and tense. The pulse is fre- quent, hard or sharp, and small. The skin is hot; the pain and tenderness increase, and ex- tend over the belly. The patient lies on her back with the knees raised. The tongue is white and dry ; sometimes clean, or loaded only towards the root. There are more or less ' thirst, occasional vomitings, and an irregular I state of the bowels, which are generally at first I costive, but afterward often relaxed or bilious. The lochia and milk are much diminished soon after the rigours, and are subsequently entirely suppressed. 173. These symptoms often appear rapidly and acutely, especially when the peritoneum is primarily attacked. But they sometimes come on less severely and more insidiously, especial- ly when they are consequent upon irritation or inflammatory states of the uterus or its ap- pendages. In these cases, the disease may at first be mistaken for after-pains; but the fr©- PUERPERAL FEVERS—Inflammatory. 565 qucncy of the pulse, tenderness above the pubes, the shiverings, and the swelling and tension ex- tending upward from the hypogastrium, indi- cate the nature of the disease. When the mal- ady thus commences the symptoms are milder and more protracted at first; arid the pain for some time is not severe until it rises above the hypogastrium, when it is rapidly aggrava- ted and extended, and all the other symptoms increased. Whether the early symptoms are rapid or slow in their accession, or whether they are limited or extended, they soon augment; the belly becomes nearly as large as before de- livery, and so tender as not to tolerate the weight of the bed-clothes; and the patient is deterred from turning, or lying even for a few moments upon either side, by the increase of pain thereby caused. With the extension of the inflammation over the peritoneum, the res- piration becomes more strictly thoracic, and the movements of the abdomen less apparent; and when it reaches the diaphragm the breath- ing is difficult, anxious, short, and performed entirely by the intercostal muscles. Cough then sometimes occurs, which is short, sup- pressed, and painful. Painful eructations, or belehings of flatus, take place at intervals, at- tended sometimes by discharges of fluid from the stomach. The bowels, which were gen- erally confined, become more relaxed, and dark, bilious, or variously coloured evacuations, or even purging supervene. 174. 8- If a favourable termination is likely to occur, the abdominal swelling does not greatly increase. The pain either is arrested in its extension, or it gradually abates. The vomit- ings cease, the pulse becomes slower and full- er, the urine more abundant, and occasionally the lochia reappears, or is more copious. The breathing is easier and more abdominal, pres- sure is less painful, and the patient can turn more easily in bed. In rare and less favour- able cases, the disease terminates in suppura- tion, and the abscess points and bursts exter- nally at periods more or less distant from the attack, the matter in some such instances pass- ing out at the umbilicus in about one or two months. 175. y. If the disease proceeds unfavourably, the swelling and tension of the abdomen in- crease ; the belly is round and prominent; the vomiting continues or becomes peculiar, con- sisting of a pumping or belching up of the con- tents with much flatus. The countenance be- comes sharp, anxious, or pinched ; the pulse still more rapid and irregular; and her slum- bers short, unrefreshing, and sometimes attend- ed by a wild or wandering delirium; but she often continues sensible to the last. The pain frequently ceases suddenly, although the ab- dominal swelling increases; the countenance sinks; the extremities become cold, and the tongue aphthous. A fatal issue usually takes place within five or six days; but the disease may be protracted much longer. According to the constitution and other circumstances of the patient, and the period that has elapsed from delivery, puerperal peritonitis may vary between the forms described as sthenic and asthenic per- itonitis, when treating of inflammations of the Peritoneum (see y 19-28), the symptoms and progress of the malady being altogether the game as there described. The appearances on dissection are also the same as there stated, (v 80, et seq.), or as exhibited hereafter (y 221, et seq.). 176. (b) Puerperal Metritis.—Hysteritis Pu- erperalis. — Inflammatory puerperal fever often commences in the uterus, the substance of the organ being affected about the third or fourth day after delivery, but often much later. It may arise from prolonged, difficult, or instru- mental labour; from cold or damp ; from stim- ulants or heating food ; and from other predis- posing and exciting causes already noticed.— a. The symptoms vary much with the severity of the attack, and with the extension of the in- flammatory action to the uterine peritoneum on the one hand, and to the ovaria and liga- ments on the other. It thus assumes mild or severe forms, the progress of which is modi- fied by the rapidity of the extension just men- tioned. The milder states of hysteritis usually commence from the fourth to the ninth day, and much resemble the ephemeral fever. The pa- tient is chilly or shivers, is sick, and sometimes vomits. The pulse is frequent an'd soft; and with the establishment of reaction, pains, which were occasionally felt in the hypogastrium, and which were, perhaps, only considered to be af- ter-pains, become more constant, but are not severe. They are usually felt behind the pu- bis ; but they may extend a little to either side, or towards the groin. Pain is also sometimes felt in the back, especially if the patient at- tempts to sit up. It may not be complained of even in the hypogastrium, when she lies still; but it is usually felt when turning to either side, or when pressure is made above the pelvis. There is no fulness, hardness, or tenderness of the abdomen. The lochial discharge gradually diminishes; but it does not necessarily stop; and the milk sometimes continues plentiful. The skin is hot; there are more or less thirst, no appetite, sickness at stomach, and disturbed sleep. The pulse varies from 90 to 110; the head is confused rather than painful; the urine is hjgh-coloured; the bowels confined, and wandering pains are felt in the belly and sides. The bowels afterward become loose or irregu- lar, the stools being dark, offensive, or mor- bid. Strangury, frequent calls to pass the urine, pains in the hips, and bearings down on micturation are often complained of. In the course of a few days, sometimes not until ten, twelve, or fourteen days have elapsed, the pulse becomes slower, the appetite returns, the painful symptoms referred to the uterine region subside, occasionally a slight discharge takes place from the womb, and the disease entirely disappears. Sometimes, however, the patient continues to experience more or less disorder referable to the uterus, with or without slight alterations of the position of the organ, until the menstrual discharge is fully established, when it subsides. 177. b. The more severe form of hysteritis ia often caused by difficult parturition, by rude management, or by other more intense causes. It usually commences between the second and fifth day, but it may appear at a later period. It is ushered in by chills or rigours, which are often present, although the skin is hot, and which are generally preceded by pain in the lower part of the abdomen. With the appear- ance of reaction and of the febrile symptoms, 566 PUERPERAL FEVERS—Inflammatory. the pain becomes more constant and severe, out is usually characterized by exacerbations. The uterine region is very painful on pressure just above the pubis, and in this situation there is generally some swelling, which, however, does not extend farther until the peritoneum is affected. The abdominal parietes is slack or soft, so as to admit of the state of the fundus of the uterus being ascertained. The uterus is larger, harder, and much more sensible than usual. The pain extends to the back, shoots to the groins and hips, is attended by a sense of weight, and by difficulty of passing the urine. Occasionally there is distressing strangury, or complete suppression of urine. The lochial discharge is early suppressed, and the secretion of milk diminished or arrested. The tempera- ture of the vagina is increased, and the sexual and urinary organs feel generally hot, inflamed, painful, and tender, the situation of the pain at the commencement varying with the part in which the inflammation originates. With the development of the local malady the sympto- matic phenomena become prominent and se- vere. The pulse is very frequent, somewhat hard, or sharp; the skin is hot; thirst is in- creased ; the tongue is white or dry ; the urine high-coloured and scanty, or turbid ; the bow- els are at first confined, but afterward lax or irregular ; headache is present; the counte- nance expresses suffering, but it is not collaps- ed or constricted as in peritonitis ; and nausea and vomiting are urgent. Sometimes the in- ternal surface or part of the womb is chiefly or only affected ; and in this case a puriform discharge follows the diminution or suppression of the lochia. 178. c. If the inflammation do not extend over the peritoneum, a favourable issue is more likely to take place than in any other form of puerperal fever. This termination often is pre- ceded by a copious perspiration, by diarrhoea, or by uterine hemorrhage, which is the most complete crisis. The abatement of pain and of the febrile symptoms; diminished frequency of the pulse; the reappearance of the lochia and of the milk; a free and general perspira- tion ; a more natural state and excretion of urine ; cessation of nausea and vomiting, and a more natural state of the bowels, are the surest signs of a favourable result. 179. d. An unfavourable termination of this form of the disease is to be feared when the inflammation extends either to the peritoneum or to the uterine appendages, or when it goes on to suppuration, either of the substance or sinuses of the organ.—a. If it extend to the peritoneum, the local symptoms, especially the pain and tenderness in the hypogastrium, ad- vance upward, and gradually invade all the ab- domen, or sometimes only the lower regions ; and swelling, tension, and tenderness of the belly, with all the symptoms of peritonitis (y 172, 173), supervene and complicate the metritis.— 6. If this latter go on to suppuration, the pulse becomes still more frequent, fuller, softer, and afterward weaker, or more compressible, and smaller. The tongue is red or dry; the pain does not materially abate, but it becomes throb- bing; chills or shiverings are sometimes ex- perienced ; and in the absence, or consecutive of these, copious sweats break out at intervals. The face is paler, or is more sharp than be- fore, and occasionally a circumscribed hectic flush appears in the cheeks. The urine now deposites a pink sediment. The nights are sleepless, and, if the patient slumbers towards morning, she awakens in a profuse sweat. This suppurative form of hysteritis may prove early fatal; the pulse increasing in frequency, the tongue being red and raw, and the strength sinking; or the hectic symptoms may continue for weeks, and at last be fatal. Occasionally matter is discharged from the vagina, or by the bladder or rectum — oftener by the rectum. When it passes by the vagina the patient may recover; but when it passes by the other chan- nels recovery more rarely occurs. It may break into the peritoneal cavity and produce fatal peritonitis.—y. When metritis becomes associated with inflammation of the ovaria, lig- aments, and tubes, the symptoms about to bo mentioned supervene at an earlier or later pe- riod ($ 182). 180. e. The appearances on dissection depend upon the direction the disease takes towards the fatal issue. If it has terminated by fatal peritonitis, the usual alterations produced by that malady are found, sometimes with more or less softening of the uterus, or with sero-puriform infiltrations or purulent collections in the walls or in the sinuses of the organ, occasionally also in the veins and absorbents in the vicinity. If the disease has not extended to the peritoneum, but has terminated by suppuration, these latter changes are the more remarkable; and no far- ther disease of this membrane may exist be- yond some alterations of the portion covering the uterus and appendages, consisting chiefly of exudation of lymph, with little or no serous effusion, but often with puriform infiltrations or collections underneath the peritoneum, and soft- ening of the tissue. Gangrene or sphacelation is rarely observed, unless the autopsy has been delayed longer than twenty-four hours. 181. (c) Puerperal Inflammation of the Uterine Appendages.—It is comparatively rare to find, either during life or on examination after death, the ovaria, broad ligaments, and tubes inflamed independently of peritonitis, or of peritonitis associated with hysteritis, in the more inflammatory form of puerperal fever. In the more synochoid and malignant states of this fever, the uterine appendages are very fre- quently the seat of lesions hereafter to be de- scribed ; but they are, perhaps, never found in these latter states affected alone; the peri- toneum or the uterus, or both, and often sev- eral other structures, being also more or less altered. It is only in the inflammatory or more sthenic form of puerperal fever that these ap- pendages are affected alone, or chiefly, and then only in rare instances. Even when the disease appears to originate in these, which is not unusual, it soon extends to the peritoneum; and, if it preserve its sthenic character, it does not spread much farther than to the portion of the membrane adjoining; but if the asthenic condition exist, or if vital power become de- pressed, or the blood contaminated by the ab- sorption of matters from the uterus or vagina, the disease soon spreads from the uterine ap- pendages over the peritoneum, if it be not ar- rested in its progress by treatment. 182. a. The symptoms of inflammation of the uterine appendages, whether the affection ori- PUERPERAL FEV ginates in or extends to these parts, are gener- ally ushered in with rigours, and with pains, ten- derness, and fulness in one or both sides of the hypogastrium, extending to the groins, the pains generally shooting down the thighs. As vascu- lar reaction is established, the pulse becomes rapid, the skin hot, the urine scanty, high- coloured, &c.; and headache, thirst, diminished or suppressed lochia, suppression of the milk, and other symptomatic phenomena appear. An examination per vaginam evinces increased heat and tenderness at the upper part of the carfal, and in some cases even a tumour may be felt laterally. When the disease extends to the peritoneum, pain, tension, fulness, and exqui- site tenderness advance upward ; and all the symptoms of peritonitis supervene, sometimes with others more strictly appertaining to hyste- ritis (y 176), with which the inflammation of the uterine appendages may be associated, as either the primary or consecutive affection. 183. b. The terminations of the inflammation of the uterine appendages are, 1st. In resolution, which may take place, as in cases of metritis, without any permanent injury being sustained. 2d. In adhesions, by the medium of coagulable lymph to adjoining parts, which, by their situa- tion or extent, may be injurious at some future period. 3d. In obliteration of the Fallopian tubes, and the consequent loss of function, or sterility, which ensues. 4th. In suppuration, the matter forming either in the oviary, or in the broad ligament, or in the veins. The purulent collec- tions or deposites may exist in these situations in various forms, the patient dying of the at- tendant softening and disorganization of the adjoining parts and of the purulent absorption, but most frequently of the consequent or asso- ciated peritonitis, and more rarely of the com- plication with metritis. A large collection of matter in these parts may burst into the peri- toneal cavity, or may open into the vagina, or into the rectum, or through the abdominal parie- tes, near Poupart's ligament. The appearances on dissection are described in the article Ovaria, and in the sequel (y 229). 184. B. Synochoid Puerperal Fever.—Con- gestive Puerperal Fever.—This form of the mal- ady is that most frequently observed both in private practice and in lying-in wards, unless the causes be intense or concentrated, and then the disease assumes a more malignant charac- ter. This form may be sporadic, or endemic, or even epidemic, especially in lying-in hos- pitals ; and in these, as well as elsewhere, it assumes modified states of vascular action and local affection, according to the constitution and other circumstances of the patient, to the rela- tive intensity of the exciting cause, and to the avenues through which this cause affects the frame. Hence it presents, in different cases, every modification, from the inflammatory to the malignant. The same causes, or combina- tions of causes, as infectious miasms, transmit- ted by the medium of the surrounding air, or contagious fluids or secretions conveyed by the hands of the accoucheur, aided by concurrent influences, may, in the same ward, or in other places, produce this form of the malady in one female, and the malignant form in another; the state of the female, the period that has elapsed from delivery, the predisposition resulting from uterine hemorrhage, &c, remarkably favouring FERS—Synochoid. 567 the intensity and character of the attack. Thus I have seen in the same lying-in ward, and even in contiguous beds, cases not only of this form, but also of the most malignant form of the malady, each presenting different prominent af- fections : one peritoneal disease chiefly, another very remarkable uterine affection, a third prom- inent alteration of the uterine appendages and peritoneum, and in a fourth inflammation of the veins or lymphatics of the uterus and its ap- pendages, or of both these vessels. This occur- rence, and the circumstances connected with it, indicate two things, namely, the spread of the disease owing to the operation of a cause infectious or contaminating in its nature; and the production of different local alterations, in different cases, in connexion with the infection and contamination of the constitution ; of the nervous and vascular systems, and consecu- tively of all the living structures. 185. a. The symptoms of this form of puerpe- ral fever vary with the circumstances already noticed, and with the mode of its accession. In many cases the uterus is the first to be attack- ed ; in some the uterine appendages are the first to manifest pain, tenderness, && ; in oth- ers the peritoneum appears to be primarily seiz- ed ; and in a large proportion alterations ex- ist chiefly in the uterine veins, with more or less lesion of other parts. The mode of accession of the disease is no less varied than the local lesions discovered after death ; and neither it, nor the progress of the symptoms subsequently, can always be strictly attached to the several states of the malady so as to indicate them truly during life. The accession of pain is oft- en sudden, and as often insidious, appearing as after-pains, or as an aggravation of these, or merely as the increased sensibility of the ute- rine organs usually consequent upon parturi- tion. It is frequently attended by chills or rig- ours, or by a recurrence of these ; or the chills may be so slight as to escape observation. In the more robust, and when the powers of life are not remarkably depressed by the exciting cause, the shiverihgs are often severe ; and in these reaction is usually more fully developed, and the disease more nearly approaches the inflammatory or sthenic form. As the chills disappear, the pulse, which was already fre- quent and small, becomes more frequent and fuller; but still soft, open, and compressible. The skin is hot; thirst, nausea, and vomiting are complained of, sometimes with cough, ver- tigo, or pain across the forehead. Soon after, or almost instantaneously with these symp- toms, pains in the abdomen are experienced, in various degrees of severity; and the patient lies on her back, with the knees drawn up. 186. b. If the local disease commence in the ute- rus, the pain and tenderness on pressure are first felt in the region of the uterus, and the ab- domen, above this region, is soft and flaccid. The body of the uterus is enlarged; and the pain, frequently at first recurring in paroxysms, or presenting exacerbations, is often mistaken for after-pains, until pressure indicates great tenderness, and discloses the nature of the at- tack. With the aggravation of the fever, the countenance becomes suffused and the respi- ration hurried. With the extension of disease from the uterine peritoneum to the rest of the membrane, the pain and tenderness extend up- 568 PUERPERAL FEVERS—Synochoid. ward over the abdomen, which becomes swol- len, tympanitic, acutely painful, and tender. Vomiting of dark-coloured or greenish fluids ensue, often attended by diarrhcea, the stools being dark, offensive, and watery. The pulse soon becomes remarkably rapid and feeble, sometimes irregular ; the tongue brown or dry, the teeth covered by dark sordes; the counte- nance sunk and pallid ; the breathing short, la- boured, and intercostal, with a short, suppressed cough, singultus, and eructations of flatus, with which more or less dark fluid is thrown up, without retchings. Coldness of the extremi- ties, remarkable smallness and frequency of pulse, and a cold and clammy surface, with a short, gasping respiration, usher in dissolution, the mental faculties being often but little dis- turbed. 187. c. If the local alterations commence in the uterine appendages the symptoms generally are but little different from those just stated. Pain, tenderness, and fulness are first felt in either or both sides of the hypogastrium, instead of behind or immediately above the pubis, as when the disease begins in the uterus. The primary affection, however, may be seated in the ute- rus, without being detected, and extend to the appendages, or both to the uterine peritoneum and to the appendages, and thence, more or less, over the peritoneal cavity. In the early period of these cases, the abdomen may re- main for a short time flaccid, and tolerant of pressure; but it soon presents all the symp- toms just mentioned, with the severe constitu- tional infection, which rapidly increases and aggravates the local changes by sinking the powers of life and contaminating the circula- tion. When the peritoneum becomes implica- ted to a great extent, the symptoms above de- scribed are always present; and, if the disease be not arrested at an early stage, the fatal is- sue advances as there stated—the lesions ob- served after death being most remarkable in the uterine appendages, as will be shown in the sequel. 188. d. That the prominent alterations so fre- quently seen in the peritoneum actually originate in it cannot be doubted, in respect of some cases of this form of the disease ; for the seat of the early symptoms and the appearances on dissection are not sufficiently demonstrative of a primary affection of the uterus or of its ap- pendages. Nevertheless, it may be admitted that a local poison or a contagious fluid may affect the internal surface of the uterus, and that the change which takes place primarily in this part may be extended along the tubes to their fimbriated extremities, and thence over the peritoneum, the symptoms of the early le- sions not being fully developed, or escaping ob- servation, until the peritoneum is extensively implicated. When this membrane is thus pri- marily attacked, the pain generally commences at the epigastrium or about the umbilicus, is sudden and acute, and is attended by extreme intolerance of pressure, tympanitic distention of the abdomen, a rapid pulse, and vomiting; these symptoms being generally ushered in with chills or rigours, which may either precede or accompany the pain and tenderness of the belly. In some cases the chills or rigours are either slight or of very short duration, and may thus escape notice; but they are seldom ab- sent altogether in this state of the disease The pulse is always quick from the commence ment, and even before either pain or rigours are experienced. The lochia and milk, in this as well as in the other states of this form of puerpe- ral fever, are either diminished or suppressed from the appearance of the rigors. The urine is always high-coloured and very scanty, or even suppressed ; the bowels irregular, the stools at first lumpy, afterward relaxed, watery, dark, and offensive ; and the tongue white or parch- ed, subsequently dark or brown. The counte- nance is anxious and collapsed, the respiration short, quick, gasping, and thoracic ; and, du- ring the advanced progress of the malady, the acute pain and tenderness of the abdomen snb- side with the supervention of fluid effusion into the peritoneal cavity; and the tension subse- quently also subsides, the abdomen often being very tumid, but soft and swaggy. All or most of the symptoms accompanying an unfavoura- ble termination of the other states of the dis- ease, now supervene with a rapidity varying with the severity of the attack and with the degree of vital power attending it, or of vital resist- ance opposing the occurrence of dissolution. 189. e. Inflammations of the veins of the ute- rus and its appendages, sometimes of the lymphat- ics, and, in rare instances, of both orders of ves- sels, are frequently the primary and essential alterations in the form of puerperal fever now under consideration ; but they are not the only changes, especially in fatal cases ; for, in these especially, various consecutive lesions, of an extensive and disorganizing kind, are also found on dissection, or even become very manifest before death. Uterine phlebitis is most com- monly observed in the puerperal state; but it may occur, independently of this state, in con- sequence of ulceration of the os or cervix ute- ri,, or of ulceration consequent upon the pres- ence or removal of polypus. It is caused in child-bed by the usual circumstances and influ- ences which occasion other inflammatory dis- eases in persons weakened or exhausted by prolonged suffering or by losses of blood, these conditions, especially flooding and difficult or instrumental labours, the depressing emotions, and a varicose state of the veins, favouring the occurrence of phlebitis. The chief or essential cause is undoubtedly the circumstance of the vessels of the uterus being placed, by the sep- aration of the placenta, in an analogous state to the. wounded surface of a limb after amputa- tion. The irritation occasioned by an adherent portion of placenta, or by the decomposition of it, or of coagula which have not been thrown off, owing to the imperfect contractions of the uterus after delivery, is often a cause of this state of the disease. Injury, also, sustained during delivery, and alterations or decomposi- tion of portions of the retained lochia, may ei- ther inflame the sinuses or veins, or may con- taminate the blood in them, the portion thus contaminated farther changing the circulating fluid, and even affecting the vessels through which it passes. The disease of these vessels may, however, be produced by the contact of an infectious fluid, or by the changes occasion- ed in the lochia by the foul air to which this discharge may be exposed, as shown above (v 137, et seq.). 190. a. Uterine phlebiti* generally commences PUERPERAL FEVERS—Synochoid. 569 in the vessels which have become in some re- Bpects exposed by the removal of the placenta, as shown by the frequent limitation of it to the vessels of that part or side of the uterus to which the placenta was attached. It often ex- tends to the veins and sinuses of the greater part of the uterus, and to the veins also of the ovaria and tubes, but chiefly to those of one side, that side being the seat of attachment of the placenta, or principally its seat. Uterine phlebitis is often a simple or uncomplicated dis- ease of the Uterine organs, but it seldom con- tinues any time without giving rise to various consecutive lesions, both of adjoining and of remote parts. When it is associated with in- flammation of the internal surface of the ute- rus the phlebitis may be consequent upon this latter lesion; but when the substance of the uterus or the uterine appendages are abo in- flamed, it is difficult to determine which is pri- marily diseased. When thus complicated, the veins in some cases are most affected, and the substance of the uterus in others. In many in- stances, however, uterine phlebitis is associa- ted with peritonitis, without the substance of the uterus being materially changed, or merely with slight softening ; while in some there are not only phlebitis and peritonitis, but also ex- tensive softening of the uterus and of the ova- ria and ligaments. It is possible that the al- terations of the sinuses, veins, and substance of the uterus may be nearly coeval; for if we admit the influence of injury, or of retained pu- trescent matters upon that portion of the ute- rus to which the placenta was attached, and upon the exposed openings of its vessels, the effects may be produced upon both the vessels and substance of the organ. But it cannot be disproved that inflammation may commence in either and be limited to it, or extended to the other, as circumstances may favour the exten- sion. 191. Inflammation of the Uterine veins gen- erally extends to the veins of the tubes and ovaria/but those of the uterus maybe inflamed Dn both sides, and yet the disease may extend only to the veins of one tube or ovarium. M. Dance states that, the veins of the right tube arid ovarium are more frequently altered than those of the left. However extensively the veins of the uterus and appendages may be inflamed, the disease may be limited to these organs ; but as frequently it is extended to their trunks, even as far as the hypogastric vein, or nearly to the vena cava. It may be asked, however, what are the changes which may be viewed as consequences of uterine phlebitis 1 and, should the presence of pus, merely in the uterine veins, be viewed as indicative of inflammation of them 1 The existence only of pus in the veins of the uterus is not sufficient proof that the pus is a product of inflammation of these veins, for the pus may have been imbibed by the veins from the cavity or internal surface of the ute- rus, where it had been produced by inflamma- tion of that surface; and therefore, unless its existence be associated with changes in the coats of these veins, it cannot be viewed as a satisfactory proof of uterine phlebitis. 192. 8- The symptoms of this form of puerpe- ral fever—of uterine phlebitis—cannot be sta- ted with the desired precision. Indeed, the ac- complishment of the attempt is nearly impossi- ble ; for the change is so frequently and so early associated in puerperal females with al- terations of the substance of the uterus and ap- pendages, and not only with these, but also with changes in the peritoneum and in remote parts, that it is most difficult to separate the phenom- ena which belong to the phlebitis from those which are attached to the other lesions. The symptoms, therefore, of this form of the dis- ease should be viewed as not strictly those of uterine phlebitis, but of that state of puerperal fever in which this particular lesion constitutes a more or less important part of the organic changes found after death. That this lesion is an important one in puerperal fevers is shown by the fact that pus and other changes in the veins have been found by M. Tonnelle in nine- ty-three cases out of two hundred and twenty- two, and in twenty-four cases out of forty-five by Dr. R. Lee. But in most of those cases in which it has been seen it was associated with other changes, as just stated. 193. Uterine phlebitis usually commences in from twenty-four to forty-eight hours from de- livery, with pain in the uterus accompanying, preceding, or following rigours. The uterine region is tender on pressure, and upon the ces- sation of the shiverings and chills the lochia and milk are generally found much diminished, and if not altogether suppressed, they soon are. The pulse is frequent from the first, and gen- eral uneasiness, with physical depression, nau- sea, or vomitings, and headache are experien- ced. As the rigours cease, the skin becomes hot, the pulse more accelerated, but soft, often full, broad, and open, and the Vomiting more frequent, a greenish fluid being usually thrown up. With the headache some degree of inco- herence may be remarked in some cases, or delirium and agitation in others, which often pass into extreme exhaustion or a state of drowsiness or partial insensibility. Tremours of the muscles of the face and extremities, dy- suria, or scanty or entirely suppressed urine, an irregular state of the bowels, or diarrhcea and offensive stools ; extreme thirst, parched mouth, dry and brown tongue ; a sallow, lurid, and dirty hue, occasionally with miliary or pe- techial eruption, and more rarely a dirty yel- lowish appearance of the whole surface of the body, generally supervene as the disease ad- vances. 194. The pain in the hypogastrium varies in severity, but it may not increase with the prog- ress of the malady, but the tenderness in this region is generally aggravated, and the abdo- men is commonly swollen or tympanitic. If the phlebitis be associated with peritonitis, ex- treme pain and tenderness of the abdomen, great tension and tympanitic distention of the abdomen are experienced with all the symptoms attending the peritoneal state of the malady (y 172, 173). 195. If the uterine phlebitis proceeds with- out being associated with inflammation of the pelvic or abdominal peritoneum, little or no pain in the hypogastrium may be complained of; or merely a dull pain, with a sense of weight. But this region will generally be found tender, or painful on pressure. The uterus, too, may return to its reduced volume, or nearly so if its substance be not implicated ; but, if its sub- stance be diseased, it commonly remains above 570 PUERPERAL FEVERS—Malignant. the brim of the pelvis, and is large, hard, and very painful on pressure. In many instances these local symptoms may be so slight as to escape attention, the constitutional symptoms caused by the passage of morbid matters into the blood, especially prostration of strength, feeble and rapid pulse, vomitings, and diar- rhcea, low wandering delirium, brown parched tongue, diminished, suppressed, or puriform or offensive lochia, &c, at last exciting alarm, and indicating the existence of a most danger- ous malady. A large proportion of cases ter- minate fatally in this more acute stage, or with- in eight or ten days ; but a larger number live longer, some secondary affection supervening. 196. y. The consecutive affections generally ap- pear in remote organs, especially the lungs, pleura, brain, liver, spleen, the joints or mus- cles, the cellular tissue, the eyes, and digestive canal. One or other of these organs and parts, in the course of a few days, experiences a rap- idly-disorganizing form of congestion or as- thenic inflammatory action ; softening, puri- form, or sanious infiltrations, purulent depos- ites, and even gangrenous softening or liques- cence of the tissues, and effusions into serous cavities quickly following the secondary local affection, which is undoubtedly occasioned by the passage of the sanious and purulent mat- ters into the circulation, and by the action of the contaminated blood on the capillaries of predisposed or susceptible parts. Many of these secondary affections advance insidiously, and without being attended with much pain or local distress until tbey reach the last stage of disor- ganization ; while others betray much earlier, and by more evident symptoms, the nature of the consecutive mischief. Their progress, gen- erally to a fatal issue, is often rapid ; but not infrequently it is much slower, the duration of the malady depending on the seat and extent of the consecutive disorganization. 197. In this form of puerperal fever the in- flammation may be limited to the veins of the uterus, but more frequently the muscular tis- sue adjoining the veins participates in it, and becomes of a dark-red or brown colour, and re- markably soft consistence ; the peritoneal cov- ering of the uterus may also be implicated, and the changes hereafter described be found in the appendages and peritoneum. The veins which return the blood from the uterus and appenda- ges may be either wholly or in part inflamed ; commonly, however, the spermatic are chiefly affected, and generally the one on that side of the uterus to which the placenta was attached ; and it may be confined to a small portion of the vessel, or extend throughout it. Injection, in- filtration, or condensation of the cellular tissue in which the veins are imbedded ; thickening induration and constriction of the coats of these vessels; and the exudation of lymph, mixed with pus and coagula of blood within their ca- nals, are the changes chiefly observed in fatal cases of uterine phlebitis. The hypogastric veins are more rarely affected than the sper- matic. Dr. R. Lee ascribes this to the latter vessels being invariably connected with the placenta; but as in respect of the spermatic, so it is observed as regards the hypogastric, that only one is affected. Marks of disease of tne uterine veins may extend by the iliac or the spermatic veins to the vena cava itself. "This occurrence seldom takes place to a great ex- tent through the medium of the spermatic ; tho inflammation usually terminates abruptly at the opening of the spermatic into it on the right side, or of the renal on the left. If it pursue, as it sometimes does, the direction of the kid- neys, the substance of these organs, as well as their veins, may be involved in the disease." 198. C. Malignant Puerperal Fever.—Pu- tro-Adynamic Puerperal Fever.—This most fatal form of the malady—most fatal if not very early, very decidedly, and most appropriately treated—occurs chiefly in lying-in wards, and in circumstances described above (y 36-40, 140). It was the almost only form of the dis- temper observed in Queen Charlotte's Lying-in Hospital in 1823 and 1824, and until the im- provements were made in the house. It is the most certainly infectious and contagious form of puerperal fever, being often conveyed by the clothes of the accoucheur or nurse. When this disease is produced sporadically by the foul or contaminating air of a close or crowded ly- ing-in ward, or of a low apartment, liable to gushes of foul air from privies, sewers, or cess- pools, it is not infrequently conveyed to other puerperal females, as already shown (y 137, 138); and it produces a similar, or but slight- ly-modified state of disease to that which trans- mitted the infection. In all its essential char- acters—as respects its exciting causes, the gen- eral depression of vital power, the rapid con- tamination of the circulating fluids and loss of the vital cohesion of the soft solids, &c, this disease very closely resembles Putro-adynamic fever (described at y 472, et seq., of art. Fever). The chief differences between them arise from the peculiar circumstances of the female at the time of infection ; and to these are entirely to be imputed the rapid progress of the puerperal disease, the greater malignancy, if not early .-arrested by judicious means, and the local com- plications which frequently either appear du- ring the course of the malady or are detected on examination after death. 199. a. The symptoms of malignant or putro- adynamic puerperal fever vary in the mode of their accession with the period of the puerperal state at which the infection appears to be pro- duced. In three sporadic cases, to which I was called in consultation, the disease commenced in the last week or fortnight of pregnancy; and in two instances it either followed or caused abortion, for I was unable to determine the se- quence ; but as I traced, as I conceived, the dis- ease in two out of the three sporadic cases just mentioned to the frequenting of privies having no communication with drains, and containing the accumulated exuviae of many years, it is not improbable that the abortion was the result of a local infection. When, therefore, the infec- tion, poison, or contamination, however, or by whatever channel it may be communicated, at- tacks a female before delivery, or immediately afterward, of not until several days have elapsed from delivery, the accession of the early symp- toms may be expected to vary accordingly. 200. (a) In a case of a female attacked before delivery, to which I was called by Mr. Barnwell, the symptoms were the same as those observed by me in other cases. This patient was seized early on the 12th of:February with acute pain throughout the abdomen, with enormous disten- PUERPERAL FE\ tion and exquisite tenderness ; with very rapid, full, and soft pulse, varying from 130 to 136, and with frequent vomiting. I saw her in the afternoon of the same day. The vomiting and state of the pulse were as now stated. She complained of headache and of thirst, and was very despondent. Her tongue was broad, flab- by, slimy, and tremulous; her countenance pale, anxious, and covered by perspiration, and her general surface moist, warm, and clammy. Labour-pains came on that evening, but were soon inefficient, the action of the uterus having ceased. Mr. Barnwell administered secale cornutum, which ultimately induced uterine ac- tion, and she was delivered after a labour of about twenty hours. On the following day (the 16th) the distention and tenderness of the ab- domen were diminished ; and the sickness and vomitings, with borborygmi and flatulent eruc- tations, continued. A pathetic depression of spirits, anxious expression of countenance, flab- by and slimy state of tongue, a very rapid, flu-' ent, and weak pulse, clammy state of skin, scanty and almost suppressed urine, quick and oppressed breathing, a feeling of pressure on the diaphragm, requiring the head and shoulders to be elevated, were soon followed by the symp- toms ushering in dissolution. 201. (b) When the disease follows almost im- mediately upon delivery, or soon after this event, the earliest indication of the impending mis- chief is the great rapidity, softness, and weak- ness of the pulse, often attended by pain and tenderness at the epigastrium, by sickness and vomiting, followed by general distention of, and pains darting through the abdomen ; but in the majority of cases there are neither chills nor rigours; in a few, a feeling of coldness only; and in still fewer, slight rigours. In this state of the disease the patient soon becomes de- spondent, predicts her dissolution, is afterward apathetic, and makes little or no inquiry for her infant. The milk and lochia are either little or not at all diminished, or are more than usually abundant. The abdominal pain and distention are sudden or quick in their accession, but the pain often soon ceases, the distention remain- ing, and afterward changing its character, if the disease continues above two or three days. The tongue, from the commencement, is flab- by, broad, and slimy, or covered by a mucous or creamy coating; the pulse is usually from 120 to 140, or even upward, fluent, soft, or broad ; and the general surface presents a lurid, or dusky or dirty hue, and is covered by a clam- my and offensive perspiration. The counte- nance is pale and inexpressive, unless when the pain is acute, when it becomes anxious and covered by perspiration. The mind is but little disturbed beyond a state of complete apathy. As the disease proceeds, respiration is short, suspirious, or difficult; the pulse small and soft, or irregular; the bowels frequently relaxed,and the stools offensive and passed without control. Distressing feelings of sinking, leipothymia, or restlessness supervene, and are soon followed by the symptoms of impending dissolution. 202. (c) When the disease does not appear until two, three, or more days have elapsed from delivery, the abdominal pain, distention, vomit- ing, vital depression, and rapidity of pulse are very often sudden in their accession, and unat- tended by either chills or rigours; much more ERS—Malignant. 571 rarely they are more gradual, and attended by chilliness or slight rigours. But physical and mental depression, absence of hope of recov- ery, of all affection or care for the infant, and of regard for any object whatever, and perfect indifference, characterize this form of the mal- ady at whatever period of the puerperal state it makes it appearance. In one case, which oc- curred in the hospital in 1824, the attack took place above a fortnight after the patient was delivered, and while I was in the board-room. When I was visiting some other patients about an hour before her attack, she was sitting in a chair by the fire-place making no complaint; and after this short period I found her complain- ing of agonizing pain over the whole abdomen, with enormous tympanitic distention, extreme tenderness, and a pulse so rapid as'hardly to be counted. Vomiting with eructations of flatus, leipothymia, cold, clammy, offensive perspira- tions, quick, short, and laborious respiration; failure of the pulse at the wrist; cold, clam- my extremities; moist, flabby, and tremulous tongue ; singultus, eructations or belchings of the-contents of the stomach, and loss of power of the sphincters successively supervened, and terminated in death within twenty hours from the accession of the seizure.* * The following case, recorded at the time, will illustrate this form of the malady. I adduce it, not as being charac- terized by extreme malignancy, nor by any marked peculi- arity, but as a specimen of the disease as it was then prev- alent, and as the, treatmen-t which had been adopted was such as could not have influenced the rapid tendency of the (,'isease to dissolution. Mrs. Turner, married, aged about twenty, was delivered on the 2d of February, after a natural labour. She was seized on the 11th, without any chill or rigour, with Severe pain in the epigastrium, distention and tenderness of the abdomen, rapid, soft, and weak pulse, sick- ness, and vomiting. The matters thrown off consisted chief- ly of greenish fluids, and the pain extended to the hypogas- trium and both groins. I was not called to her until the even- ing of the 13th, about fifty-four hours after the accession of the disease. She then presented the following- symptoms: The pulse was so rapid and weak as hardly to be counted or felt,at the wrist; the hands and feet were cold and clam- my ; the breathing remarkably quick, difficult, and labour- ed ; the countenance sunk, and of a pale, livid hue ; the con- junctiva pearly, and the pupil contracted ; the abdomen was tumid, but not tense nor very painful; the milk was abun- dant, and the lochia scanty, but not much more so than usu- al at that period after delivery. The tongue was clean, broad, and slimy; the skin was-covered with a clammy, of- fensive perspiration, and the heat of the trunk was below the natural standard. The urine had been scanty, bat pass- ed without difficulty; the bowels duly evacuated. The odour exhaled from the body was peculiar and very marked. Her mind was collected, but indifferent to everything. She died a few hours afterward—about sixty hours after the first feeling of disease. Inspection twenty-four hours after death, present Drs. Copland and DENNisoN.and Mr. Oholmondeley. The thoracic viscera presented no farther disease than congestion of the posterior parts of the lungs, and loss of vital cohesion. The peritoneum was very slightly adherent in parts by means of a film of puriform lymph which covered the mem- brane throughout the whole surface. This film was thick- est on the right side, and over the diaphragm, stomach, liv- er, and spleen. These viscera, as well as the kidneys, were healthy, excepting that they were more friable and softer than usual, especially the spleen. The omentum was re- markably softened, and was drawn together like a cord in the middle of the abdomen between the convolutions of the intestines. There was not much fluid effused, but it had a livid and whey-like appearance, especially between the con- volutions of the bowels, and between the right ovarium and Officum. The peritoneum, when, the film of puriform lymph was wiped off, was congested, with dark blood in points or streaks, and much softened, so that it could be torn in parts like to wetted paper. The uterus was of the usual size, for the period which had elapsed from delivery ; and iti structure, when divided, appeared natural. The internal surface 0/the uterus seemed, also, sound in consistence and colour. The veins of the organ were quite healthy. The spermatic and hypogastric veins on both sides were natural, and contained little blood. The right ovarium was of a 572 PUERPERAL FEVERS—Malignant 203. (d) Whatever may be the period or mode of its accession, this variety of the disease al- ways pursues a rapid course ; and, unless early arrested by energetic means, it almost always tends to general contamination of the fluids and structures, and to death. At its commencement the nervous system of organic life and the blood appear to be suddenly and seriously affected, as shown by the general loss of vascular tone and of sthenic action ; by the disturbance of all the vital functions, and relaxation of contractile parts. The earliest symptom is often the re- markable rapidity of the pulse, which is. also broad, open, soft, or fluent, or small, thready, or irregular, but always very quick and compressi- ble. Rigours and chills are generally absent; or if they have been present, they are either slight or of sTiort duration. In the most rapidly fatal cases, or such as occur in crowded or close lying-in wards, they rarely occur ; and in these the disease may be uncomplicated, or present no prominent lesion or affection, the whole frame participating in the malady, through the medium of the organic nervous and vascular systems ; or, if any prominent lesion appear, the peri- toneum and other shut eavities most frequently experience it, and present the appearances here- after to be noticed. 204. a. These more simple states of this form of the malady may run their fatal course in from twenty hours to two or three days, the earliest symptoms being remarkable frequency and softness of pulse ; pain in the epigastrium or extending over the abdomen, with tympanitic or flatulent distention, and tenderness; frequent vomitings, and sometimes purging ; a scanty or suppressed state of the urine ; a lurid or dusky appearance of the surface, which is covered by a clammy perspiration, and exhales a peculiar and disagreeable odour ; a pallid, apathetic, and sometimes slightly livid or sallow eountenance, the eyes being sunk, or surrounded by a dark circle; a broad, flabby, tremulous tongue, which is covered by a slimy or cream-like, mucus; little or no thirst; an abundant secretion of milk, and a copious discharge of the lochia, which often becomes offensive or otherwise changed, and great apathy and disregard of the infant and of all relatives. These symptoms may exist in the most marked degree; the res- piration becoming short, suspirious, and gasp- ing, the vomitings being more frequent, and at- tended by belchings of flatus, or passing into a pumping up, or eructations of the contents of the stomach, and alternating with singultus or brownish colour, and slightly enlarged. When divided, a little colourless fluid escaped from the interstices of its struc- ture. The right Fallopian tube appeared slightly inflamed, especially at its fimbriated extremity. No purulent or other matter wag found in the sinuses or veins of the uterus. The site of the placenta was somewhat darker than usual at the biufaces, and covered with a dark, semifluid lymph; but the vessels proceeding from the part were empty, and of natural appearauce. The veins of the heart were much engorged with black blood. The left ventricle was empty and flaccid, the right was filled with black blood. The body was but little rigid, and the external surface slightly discoloured, of a yellowish livid hue. The whole intestinal canal was gTeatly distended by gas. This and other casrs which I have examined have suggested the belief that in some in- stances at least the disease extends from the internal sur- face of the uterus along the Fallopian tubes to their fimbri- ated extremities, and thence to the peritoneum. I have fre- quently observed that the structural changes, both iii the ovaria and peritoneum, have been greater in the same side as that in which the.fimbriated extremities of the tubes were must altered. with leipothymia, and the abdomen still con- tinuing remarkably distended by flatus, until, after a period varying in duration, as just stated, dissolution takes place, preceded either by ex- treme restlessness, difficulty of breathing, and lividity of countenance, or by sudden or gradual sinking of all the vital functions, and a feeling of impending death. In these cases the mind may evince no farther disturbance than the state of indifference just mentioned, or a low wandering delirium at times, the patient an- swering correctly when roused, and expressing a conviction of dying, and indifference as to the issue. 205. 8. When this most malignant form of the disease is complicated, or accompanied with any of the prominent lesions to which frequent allusion has been made, the symptoms are some- whaf modified either early or in the course of the malady. The most frequent complication is that with effusion into and other lesions of the peritoneum- When this surface is promi- nently affected, the pain and tympanitic disten- tion and tenderness of the abdomen are most severe, and is either general, or is felt most severely near the epigastrium, or in one or both sides of the hypogastrium, indicating in this latter case the origin of the mischief in the tubes or ligaments. In rare and most severe cases, especially if the malady has followed floodings, dissolution may take place before the peritoneum experiences farther change than is presented by other parts; but more generally, or if the case continues two or three days, the abdominal pain subsides more or less, and with it the tympanitic distention and tenderness par- tially diminish. The abdomen now furnishes indications of more or less effusion into the peritoneal cavity, which generally increases, and which, by its acridity, increases the loss of co- hesion which this membrane evinces after death. In other respects the symptoms of this state of the disease pursue the same course as that just described (y 204), varying only slightly with the severity of attack, and the extent of contamina- tion or change of the circulating fluids and the degree of vital resistance opposed to these and other alterations. 206. y. There can be no doubt of the uterus and its appendages undergoing, in some cases and on some occasions in which this form of the malady appears, more or less prominent changes ; but it is very difficult to determine the period of the disease in which they occur, or the exact procession of the morbid phenome- na. Although the peritoneum may present the chief lesions, as shown above in some cases, it is seldom that the uterus, and its appendages especially, are much disorganized without this membrane being also implicated very exten- sively or throughout. It is very probable that disease may have extended from the internal surface of the uterus and Fallopian tubes to the fimbriated extremities, and thence over the peritoneum, at least in some cases; and that the uterus may have been so early softened and otherwise affected as to implicate the per- itoneum, the change thus induced in this mem- brane rapidly extending, owing to the infected and contaminated state of the frame. It may not unreasonably be assumed that the general infection produced by the exciting cause will render the lochia more acrid or septic than in PUERPERAL FEVERS—Symptoms. 573 more favourable circumstances, and that this state of the discharge, especially when retained in the sexual passages, may contaminate these parts, and give rise to the changes observed, in some cases not only in them, but also in the peritoneum and adjoining cellular tissue. I have usually observed that in these instances the milk has been undiminished, and the lochia more or less offensive, usually abundant, some- times remarkably putrid or fetid. In this com- plication of the malignant state of the disease, pain, tenderness, and fulness have commenced either in the hypogastrium, or in one or both sides of this region, and extended to the sa- crum and loins, shooting irregularly through the abdomen, which has also presented con- siderable flatulent distention, with borborygmi. The pain has also often extended to the groins and tops of the thighs. In all other respects the symptoms are the same as are observed in the simple and peritoneal states of the malady; but their progress to a fatal issue, although not the less certain, when they are not judiciously interfered with, is generally less rapid, and is often accompanied, as in the former states of the malignant form, with frequent recurrences of faintness or sinking, with dysuria or sup- pression of urine. 207. 6. In the most malignant states of pu- erperal fever, the veins and lymphatics rarely present inflammatory changes. It is chiefly in the synochoid form, or when the disease dis- plays a less degree of malignancy and pursues a less rapid course (y 189, et seq.), that puru- lent matter and other changes are found in these vessels. It does not, however, follow that morbid matters are not imbibed by either the veins or lymphatics, or even by both, and carried into the circulation because they do not evince any lesion of their parietes; on the con- trary, it is not improbable that sanious or pu- trid matters may be imbibed by the veins in this form of the malady, and contaminate the blood, without producing sthenically inflamma- tory lesions, or any very evident changes, in these vessels; the irritation produced by such matters on their internal surface giving rise, in the existing state of the frame, to an ichor- ous exudation, which is carried into the blood and mixes with it, and not to that form of lymph which coagulates and arrests the progress of the mischief, nor even to a puriform matter, such as often is met with in the synochoid orless ma- lignant forms of the malady, not only in the veins, but also sometimes iii the lymphatics. 208. The lymphatics of the uterus and its ap- pendages, and their vicinity, present changes in a few cases which have been viewed as, and which probably are, inflammatory. These chan- ges, however, consist chiefly of the presence of pus in the lymphatics, and of congestion of the glands in the vicinity, and are found chiefly connected with inflammatory changes, or with the presence of pus in the veins, or with puru- lent deposites, or with ulcerations in the pelvic viscera and parietes. The symptoms of chan- ges in the lymphatics of the pelvis are hardly to be recognised during life, owing to their as- sociations with the alterations of other parts just mentioned. I have observed these changes chiefly in cases which have commenced with as- thenic inflammatory symptoms referable to the uterus and other pelvic viscera, and even also to the pelvic parietes, which have been of sev- eral days' duration, from eight or nine to four- teen or more, and which have terminated in one or other of the consecutive lesions already noticed (y 196). I have, however, remarked that these cases generally are attended by acute pain in one or both sides of the hypo- gastrium, extending to the groins, with tender- ness, and sometimes with enlargement of the deeper-seated glands in the groins; but the for- mer of these symptoms also accompany prom- inent affection of the ovaria and ligaments.* 209. D. Of certain Symptoms marking the Form and Terminations of the Disease.—Rigours and chills have been stated by most writers as ush- ering in the disease. This is the case certainly in the more inflammatory states, whether of a sthenic or asthenic diathesis, but they seldom occur in the most malignant forms. When they do occur, then generally are the milk and lochia diminished or suppressed, if, indeed, the secretion of milk has commenced before the ac- cession of the malady. But in some cases rig- ours are experienced without the suppression either of the secretion or of the discharge ; but this is rather the exception than the rule. In the malignant states of the malady, even when effusion into the peritoneal cavity is very great, neither is the milk, nor is the lochia sup- pressed or even diminished, but, on the con- trary, they are more than usually abundant, while the latter is often very offensive and contaminating. In the more strictly inflam- matory, and in the synochoid or intermediate forms of puerperal fever, suppression or dimi- nution of the milk and lochia generally obtains —suppression in the more inflammatory, and diminution in the synochoid. In the malignant states of the disease observed by me in 1823, 1824. and 1825, the lochia was rarely remark- ed ; but in 1827 and 1828, after better ventila- tion was established, diminution and occasion- ally, suppression of the lochia were observed ; the disease having then assumed the synochoid or intermediate grade of impaired vital power. M. Duges states (Journ. Hebdom. de Mid., t. i., p. 348), that in eighty-nine cases observed by him at the Maternite, there were twenty-five instances of suppression or diminution of the lochia during the rigour, twenty-seven of sup- pression or diminution in the progress of the disease, and thirty-seven instances in which there was no diminution, but were sometimes an augmentation of the discharge. [* Professor Austin Flint, of Buffalo, maintains (New York Journal of Medicine) the following two prominent propositions in relation to the epidemic puerperal fever which prevailed in that city in 1844: 1. That the disease is an essential fever, and not a merely modified form of perito- nitis or metritis; and, 2. That it is a fever having a close analogy with that of erysipelas. In corroboration of the latter, the author narrates the following case : Two ladies were in constant attendance upon a friend who died of pu- erperal fever. In the course of three days they were both taken ill, one with severe erysipelas, the other with pre- monitory symptoms of the same disease, and which were fortunately dissipated by the action of an emetic. A labour- ing woman who was employed to wash the clothes of the same patient, having received a slight scratch on the hand while so doing, was attacked with erysipelatous inflamma- tion of the absorbents, and died after a short illness. M. ColomSat d' Isere speaks of puerperal fever under two forms, that of puerperal peritonitis and uterine phlebi- tis ; and in the treatment of both forms, both he and his translator, Professor Meigs, lay great stress upon the in- flammatory origin, and consequently strongly recommend both general and local blood-letting.] 574 PUERPERAL FEVERS—Symptoms—State of Blood in. 210. In some cases in which the lochia is di- minished, an increase of it takes place after a judicious treatment. But a return of the lo- chia is not always followed by amendment; and when this result ensues, the return of the lochia is evidently the consequence of the amendment, and not the cause of it. In esti- mating the value of this indication, the time which has elapsed from delivery, and the state of this discharge from the period of delivery, should be considered. It may be stated, as a corollary, that the state of the lochia varies in different epidemics and forms of the malady, and in different individuals even in the same epidemic or endemic prevalence of it, accord- ing to its more or less inflammatory character, and to the kind of complication which marks its commencement or progress. 211. (b) The secretion of milk, if established before the attack of the most malignant states of the disease, is generally not influenced there- by; and if the accession of the malady precede the appearance of the milk, the accession of this secretion may occur in the course of the malady. I have seen the breasts full of milk at the period of dissolution, although they appear- ed more or less flaccid. In all respects, this secretion generally presents the same relations to the forms and states of the fever as have been just stated in respect of the lochia. 212. (e) A correct interpretation of the pulse is of the utmost importance in the estimation of the nature, forms, and states of this malady; and is not less so as regards the diagnosis and prognosis. A very frequent' pulse — a pulse above 110 after parturition, should always be viewed with suspicion, if the acceleration can- not be accounted for, or referred to mental emotion or physical excitement, although no other symptom be complained of; and inqui- ries, as well as a more particular examination, should be directed to the secretions and excre- tions, to the condition of the uterus, and to the sensations excited by an examination of the abdomen and hypogastrium. If, in connexion with great acceleration, the pulse is open, ex- pansive, and soft, the inquiries now suggested are the more necessary, especially if pain, full- ness, tenderness, or distention in any part of the abdomen be also present. If the pulse rise above 120. the probability of the accession of puerperal fever is much greater, the type or character of the fever being indicated by the tone or resistance furnished by the vessel, and by the various existing symptoms. In the more malignant states of the malady the pulse be-- comes remarkably frequent, often so as hardly to be counted, and at the same time open, ex- pansive, soft, or fluent, as if insufficiently filled with blood. There are also observed, in con- nexion with this pulse, a free and offensive perspiration, copious discharges from the bow- els and from the stomach, while both the milk and lochia are abundant. These evacuations must necessarily soon leave the vascular sys- tem more or less deficient in its contents ; and this deficiency must be the more serious, the greater the loss of blood during parturition, and the lower the patient is kept during the first days after delivery, as too frequently di- rected by accoucheurs, who are more capable of adopting a fashion or mode than of think- ing rationally, uninfluenced by hypothesis, and conformably with the dictates of sound com- mon sense. If we duly consider the effect which the abundant evacuations observed in the course of the more malignant form of pu- erperal fever must have in reducing the quan- tity of blood circulating in the vessels, and view this reduction in connexion with the impaired tone or contractile power of the vascular sys- tem generally, the want of due relation between the quantity of the blood and the capacity of the vessels containing it must necessarily appear as no mean cause of the leipothymia, faintings, or sinkings so generally observed, and of the rapid progress of the disease to dissolution, especially when a lowering or depletory treat- ment is adopted. 213. (d.) In the more malignant states of pu- erperal fever vomiting is almost a constant symptom. It is generally present from the commencement, and frequently consists at first of a greenish-yellow ropy fluid, afterward be- coming greenish-brown, and lastly nearly black, watery, and turbid. A dark greenish fluid is often ejected from the beginning. At first the vomitings are attended by considerable retch- ings ; but as the disease advances to a fatal issue, the matters are belched up with little or no effort. Vomiting sometimes occurs at the commencement of the disease, then subsides, and is followed by diarrhcea, and afterward re- curs in its worst form, the diarrhoea frequently continuing also. 214. (e) The states of the bowels and of the evacuations vary considerably in the different forms of puerperal fever. The intestinal irri- tation, or gastro-enteric disorder, which has been viewed by some writers as a form of the disease, is merely a symptom which is often more or less prominent in all the varieties, but more especially in the most malignant and rap- idly fatal, in which depression of vital power, alteration of the blood,'and loss of vital cohe- sion of the tissues are the most manifest phe- nomena. In the more inflammatory, and in the intermediate or synochoid forms, the stools are at first bilious, feculent, or frothy, some- times costive, or not relaxed, or irregular; but they are often relaxed and irregular, or offen- sive as the disease advances. In the more malignant states the evacuations are generally dark-green, greenish-brown; in a few cases almost approaching to black. They are com- monly, also, fluid, very copious, occasionally slimy, and usually containing numerous small pieces of soft albuminous flakes mixed with them. They are always extremely offensive. Toward the fatal qlose of the more malignant cases they are often passed involuntarily. 215. b. The state and appearances of the blood vary most remarkably in the different varieties of puerperal fever. In the more inflammatory, particularly when the sthenic diathesis obtains, and the disease presents the characters of peri- tonitis or hysteritis, the blood does not differ materially from the states of this fluid usually seen in other inflammations of serous or fibrous structures. It is chiefly in the inflammatory form that an opportunity of examining the blood, while the patient is living, is afforded the phy- sician. But I have been called to cases of the malignant form, produced by infection, in which venesection has been practiced, and opportuni- ties have thus been furnished, fatally to the pa- PUERPERAL FEVERS—. -Appearances after Death. 575 tients, of observing the appearances of this fluid in that form during their lives. 216. (a) In the case of a patient who exhibited the first symptoms of puerperal peritonitis on the evening of the second day after delivery, the pulse being very quick, hard, and full, the res- piration rapid, with heat of skin and thirst, Dr. Simon found that the blood formed a tolerably firm clot, and was covered by a buffy coat of a line and a half thick, the chemical analysis furnishing very nearly similar results to those about to be adduced from Andral and Gavar- ret. These physicians made eight analyses of the blood in four cases, one of perilioneal fe- ver, the others of metro-peritoneal. Two of the cases terminated fatally, and in these a large quantity of purulent matter was found in the abdominal cavity. The following are the re- sults : Venesections. Water. il E 'o 3 5! ,1" ill 1st case 1 p 2d case < 2 f3 3d case 1 o 4th case < 2 (3 Healthy ) blood J 787-2 822-9 831-6 8510 7864 7894 802-7 8135 7900. 212 8 1771 168 4 1490 2136 210 6 197-3 1862 2100 5-5 5-4 5-3 36 7-2 3-8 4-7 61 30 1228 88 3 736 60 5 1170 1200 1095 100-3 1270 84-5 83-4 89-5 849 89-4 86-8 83-1 80 1 800 217. The second case, which proved fatal, re- vealed puriform effusion into the peritoneal cav- ity. The fourth case did not manifest symp- toms of metro-peritonitis until the second bleed- ing was ordered, this disease having been fully developed on the occasion of the third bleeding, when the quantity of fibrin in the blood was greatest. In cases of metro-peritonitis quoted by Dr. Day, from the analysis of Scherer, Hal- ler, Becquerel, and Rodier, the blood pre- sented a similar increase of fibrin, and a much greater diminution of blood-corpuscles. 218. (b) In cases.of metro-phlebitis puerperalis, the clot of the blood drawn from a vein was, according to Ebert, large, and more or less concave. It was covered either with a thin, true buffy coat, or more frequently with a thick and often discoloured stratum of gelatinous sub- stance, forming a false buffy coat. Gelatin- ous coagula of a similar nature were also fre- quently seen floating in the serum. The micro- scope often detects pus in the blood in the course of the disease. In two instances, in which the blood was analyzed by Simon, in this form of puerperal fever, a nearly similar in- crease of fibrin and diminution of blood-cor- puscles to the above were found. The quan- tity of albumen and of fat in the blood was much augmented, the former amounting to 103 35 and 112 77, the latter to 3 12 and 4-32. 219. (c) I am not acquainted with any analysis of the blood in tbe most malignant form of puer- peral fever, unless that which Dr. Day adduces from Heller, who states that the blood was of a very dark brown colour. The clot was dark, of a loose consistence, and covered by a buffy coat, Over which was a delicate mem- brane, which presented tinder the microscope a finely granular appearance, and fat vesicles. The serum was turbid, but after standing for some time became clear; its reaction was al- kaline ; its specific gravity 1025. The fibrin was 5-16; the blood-corpuscles 77 52. Accord- ing to Becquerel and Rodier, the cholesterine and phosphates are increased. 220. The appearances of the^blood in puer- peral fever will necessarily vary not only with the form and state of the disease, but also with the period or stage at which it has been taken away. During 1821,1822,1823,1824, and 1825, and even in some following years, when the mischievous writings of Armstrong, and other insufficiently experienced authors-, had misled those who trusted to ephemeral and unworthy authority, blood-letting had been resorted to in all cases of this disease to which I was called, some of them having been actually moribund, or even dead before I reached them, in conse- quence partly of the practice ; and on every oc- casion I was struck by the peculiar faint odour and very dark hue of the blood; by the very soft state of the clot when the blood did separ- ate into crassamentum and serum ; by the ap- pearance, which occasionally presented itself, of a mass exactly resembling, in colour and con- sistence, a common jelly, the colouring matter covering the bottom of the vessel in the form of a precipitate ; and by, in some instances, a slight separation only of serum, the large, loose, or gelatinous crassamentum consisting chiefly of this jelly-like matter, the lowest stratum of which contained the black, or dark brown pre- cipitate of colouring matter. These appear- ances of the blood were presented in several casps in the hospital in 1823, and three or four subsequent years, in which cases blood had been taken before I saw the patients. It may be here, remarked, that I have seen many cases of this form of the disease in which leeches had been applied to the abdomen ; but in nearly all, and especially in those which occurred in the hospital, the blood which flowed from the bites did not coagulate ; and great difficulty, amount- ing almost to an impossibility, of arresting the bleeding from them, was generally observed, owing both to the state of this fluid and to the impaired "vital cohesion of the tissues charac- terizing the advanced stage of the malignant form of this domestic pestilence. 221. V. Appearances after Death.—The lesions observed after death from puerperal fe- vers vary remarkably, according to the type, and form, and complication ofthe malady; the mode and nature of the infection ; and the manner in which the infection appears to have invaded the frame. In the more inflammatory type, or in those cases which present much of a sthenic diathesis, in which vascular reaction are more developed, and the pulse'less frequent and at- tended with more tone and resistance, the al- terations of structure, whether limited to the uterus or appendages, or to the peritoneum, or to all these parts, approach more or less closely to those which are consequent upon primary and uncomplicated inflammations of these struc- tures, and are not materially, if at all different from those described when treating of inflam- mations of the uterus, ovaria, and peritoneum (y 80-98). 222. A. In the asthenic ox more malignant va- rieties of this distemper, the alterations of struc- ture present different characters from those ob- 84-5 83-4 89-5 849 89-4 86-8 83-1 80 1 576 PUERPERAL FEVERS—Appbarances after Death. served in the more sthenic states, or in those cases which are characterized by greater vas- cular reaction and vital resistance. In the most malignant of these (y 198, et seq.), the changes consist chiefly of impaired cohesion of the tis- sues generally, often with more or less of a tur- bid serous effusion into the serous cavities, more especially into the peritoneal cavity. I examined several bodies after death from this state of the disease in the years between 1822 and 1830, and during that period, as well as subsequently many others, in which the fever manifested an intermediate grade of intensity between that state and the more sthenic or in- flammatory, I made notes at the time of the ap- pearances ; and the description of them are derived from these sources. 223. a. It was but rarely that death took place previously to the effusion of fluid into the peri- toneal cavity. Such an occurrence, however, was sometimes observed in the most malignant form of the malady, especially when the powers of life rapidly sunk, and the patient expired within thirty-six or forty-eight hours. In these cases the peritoneum was finely ingested or congested throughout, especially its venous cap- illaries ; but the injection was not generally diffused; it was usually in the form of spots, patches, or streaks. Those parts of this mem- brane which were closely in contact, as if press- ed upon, were less vascular. The congested patches were generally of a reddish-brown, or livid hue; and the peritoneum throughout of a dirtier and more unhealthy colour than usual. The membrane was soft, easily torn ; and with this loss of cohesion ft appeared somewhat thickened. These changes were not limited to a single or to several situations, but were gen- eral. In some cases, however, they were most remarkable in the peritoneal coat of the intes- tines, in others in the omentum, which was often contracted, or pushed upward, very much soft- ened, of a reddish-brown colour, and sometimes so readily torn as to be incapable of sustaining much more than its own weight. This diminu- tion of the usual cohesion of the peritoneum was occasionally attended by little or no effu- sion in the most rapidly fatal cases, or merely by a delicate film of exudation most remarkable in the open interstices between the convolu- tions of the intestines and viscera. This film of exudation may be unobserved until the finger is passed over the surface, when it will be col- lected in a sensible semifluid mass. In several of these cases the inspection was made while the body was still warm. 224. In these cases there was but little fluid effusion, not above two or three spoonfuls, and that was of a dirty, light-bTown, or reddish- brown hue, or of a whey colour; more rarely it resembled a sanguineous ichor; but it always possessed an offensive odour. In some in- stances, at least, it may have been the result of postmortem transudation. In cases in which life continued longer to resist the fatal tendency of the malady, or where attempts at reaction had partially taken place, with a nearly similar state of the peritoneum to that now described, there was a greater or less quantity of fluid ef- fused. This fluid, in the more rapidly-fatal in stances, and where depression of the powers of life, with flaccidity of the muscles generally, was most remarkable, had a dirty or muddy, or sero-sanguineous appearance and fetid odour in some cases ; and was more abundant in others, and was then either whey-like or of a dirty yellowish tinge. When death had not occurred until about the end of three or four days, the effused fluid was often very abundant, consist- ing of a curdled substance, of which the more consistent part nearly resembled recently cur- dled milk, the curd being soft, gelatinous, and friable, of a cream colour, or approaching it; and the serous portion closely resembling a pale whey. This effusion was generally most abun- dant in the pelvis, in the more depending situa- tions and opener spaces between the viscera, and convolutions of the bowels. It is obviously this state of the effusion which induced several French physicians to ascribe the malady to me- tastasis of the milk. In other cases the effusion was equally great, but it presented the appear- ance of an emulsion of a more or less deep yel- low, yellowish-green, or grayish-yellow hue. In some instances it consisted of a dirty serum, with semifluid, albuminous, or puriform matter mixed with the serum. Occasionally the ef- fused liquid was almost puriform, or sero-puri- form. 225. B. In those cases in which the disease, owing either to the robust constitution of the patient, or to the less intense action or concen- tration of its exciting cause, has not rapidly sunk the frame into dissolution without some degree of sthenic vascular reaction, the peri- toneum, in addition to a large effusion of a se- rous or whey-like fluid, containing flakes or masses of lymph, or of a puriform or albumino- puriform matter of various sizes floating in it, was very generally covered by a thick coating of lymph, or of a substance of a yellowish or greenish-yellow colour, of a soft consistence, in some places slightly agglutinating the opposing surfaces, in others occasioning no adhesion, however slight, and containing in the opener spaces the fluid just described. These exuda- tions were most abundant in the pelvic portion of the cavity, and lower abdomen, and some- times also in the vicinity of the liver, spleen, and diaphragm, and around the omentum, which seldom presented the same appearances in two cases. The odour of this effusion was peculiar and disagreeable, and it, as well as the fluid previously described, was often so acrid as to irritate the backs of the hands of the examiners of the body. 226. a. Even in cases of the greatest effu- sion, the peritoneum was often the most devoid of redness ; the congested state of its capilla- ries, particularly of the venous capillaries, no- ticed in those cases which terminated most speedily and without effusion, was observed only in parts, streaks, dots, or spots, its sur- face being of a dirty grayish colour. This membrane itself was opaque, thickened, and somewhat softened, and readily torn, more es- pecially in those parts reflected over the vis- cera of the pelvis and lower abdomen, but sometimes, also, in the iliac fossae, even more remarkably in the omentum, and occasionally in the mesentery, and in that reflected over the abdominal parietes. In a few instances only were slight ecchymoses under the peritoneum remarked.- In rare cases only has gangrene of the peritoneum been observed, and only in those portions reflected over the fundus of the PUERPERAL FEVERS—Appearances after Death. 577 womb and the appendages, and over the iliac fossae ; and in still rarer instances has it exist- ed in the peritoneal covering of the bowels. In some cases, probably, this change had ta- ken place, or become more marked, after dis- solution. The external or adhering surface of the peritoneum, or, rather, the connecting cellu- lar tissue, in the most rapidly fatal cases, was sometimes slightly oedematous, or infiltrated by a serous or sanguineo-serous fluid, and this was most frequently seen in the omentum, when it was remarkably softened, and in the Fallopian tubes ; but it was associated with no farther change in the uterus, appendages, or veins than slight softening of the former, from participation in the loss of vital cohesion so remarkable throughout the frame. In cases which had continued three or four days, and in which vascular reaction had partially ap- peared, slight infiltrations of a serous or a se- ro-sanguineous, or a sero-puriform, or even of a pus-like matter under this membrane were found, occasionally so minute as hardly to be detected, until it was squeezed out upon divi- ding the parts. When thus slight the perito- neum was opaque* and had a dirty, macerated appearance. These infiltrations were most re- markable under the reflections of the peritone- um over the pelvic viscera and iliac fossae, and in the omentum and folds of the mesentery. 227. ft..The viscera enveloped by the perito- neum were frequently sound, excepting their impaired vital cohesion, and old or pre-existent lesions, and the changes observed in the sexu- al organs and their vessels, which were the next in importance to those found in the peritone- um. These organs in the most malignant and most rapidly fatal cases, as in those which oc- curred in the hospital during 1823, 1824, and 1825, generally presented no farther change than remarkable relaxation, flabbiness, or soft- ening, without any purulent matter having been found in the vessels or sinuses of the uterus, this organ being but little or not at all contract- ed, although several days had elapsed from de- livery. The peritoneal covering presented the changes just described, in some cases in a great degree, and in those latter the uterine appenda- ges participated very remarkably. 228. These were often the principal changes in the most malignant states, or when the dis- ease at its commencement was not localized in any particular region of the pelvis or abdo- men, as in those cases which occurred in the most unfavourable circumstances of deficient ventilation and contamination of the air. But in the less rapidly fatal or intermediate states of the malady, where the duration of the mor- bid action admitted of the development of va- rious complications, or when the disease ap- peared to originate in the absorption of mor- bid matter from the uterus and vagina, or from contamination in these situations, not only were those organs more or less altered, but serious lesions were observed also in remote parts. The uterus was generally flabby and relaxed ; its substance softened throughout, but most re- markably toward the inner surface, or infiltra- ted by an ichorous, sero-puriform, or purulent matter; its sinuses and veins containing also puriform matter, or a substance resembling that found in the uterus, a similar matter irregularly filling or distending the veins and lymphatics III 37 not only of the viscus, but also of all its appen- dages. None of the cases which I examined during 1823 and 1824 presented these changes in the vessels ; the first case in which I found the vessels of the uterus and its appendages inflamed or containing purulent matter, occur- red in the spring of 1825, Mr. Mullins having assisted me in the autopsy. 229. The inner surface of the womb was oft- en covered with a gelatinous layer coloured by partially decomposed blood, or by a dark green, or greenish brown exudation of soft lymph, sometimes by a thick purulent coating of a greenish yellow or yellowish brown matter; these matters were generally offensive, or even had become putrid at the earliest period of in- spection. The changes in the uterus were al- ways most remarkable in the part where the placenta was attached, whether those seated in the substance of the organ or in the veins and sinuses. The Fallopian tubes, broad ligaments, and ovaria were swollen, injected with blood, infiltrated with an ichorous serum, or with pus; their vessels charged with similar matter, and their substance more or less softened, and read- ily broken down. 230. c. The veins and sinuses of the uterus are frequently changed, and the lymphatics some- times also implicated, the changes occasionally extending to the whole sexual apparatus and along the spermatic and renal vessels to their trunks. The coats of the vessels, in a few eases, were thickened, the canals partially ob- literated, or their parietes contracted in parts and dilated at intervals. The internal surface of the veins was sometimes covered with a false membrane, although it was pale when ex- amined. The adjacent cellular tissue was oft- en infiltrated, or contained purulent or sero-pu- riform deposites, especially in the iliac fossae. These changes in the coats and contents of the vessels were in some instances limited to the uterus, in others extended to the appenda- ges ; and they occasionally did not exist in the Uterus, but were found in the latter parts ; and in a few cases they were observed only or chiefly in the spermatic or renal veins. Puri- form or other morbid matters were, in a few instances, most abundant in the lymphatics,. forming in them small pouches, and more rare- ly they were found in both the veins and lym- phatics. The veins often contained not only ichorous or puriform matter or pus, or these more or less mixed with small, grayish, or light-brown coagula, or with blood variously altered, but generally fluid or grumous, with- out any marks of inflammation of their parietes. 231. d. The heart was usually flabby, soft- ened, or friable. In the more malignant ca- ses these changes were often remarkable ; and the endocardium was often deeply stained, this change of colour generally extending to the ar- terial trunks. The cavities of the heart some- times contained fluid dark blood. A small quantity of a dirty serum, or of a sero-sanguin- eous fluid, was occasionally effused in the per- icardium, especially in the most rapidly fatal states of the malady. 232. e. The diaphragm, especially at its per- itoneal aspect, partook of the changes observed in the peritoneum. Slight infiltrations of se- ro-puriform or sero-sanguinolent matter were seen in a few instances in the connecting ce!*> 578 PUERPERAL FEVERS—Appearances after Death. lular tissue, but they rarely extended into the muscular structure. The mediastinum was sometimes infiltrated with a similar matter. The pleura, in some of the most malignant cases, presented nearly the same alterations as were found in the peritoneum, more espe- cially the diaphragmatic and pulmonary pleura. This membrane was more easily torn than usu- al, or was softer, or appeared in places oedema- tous and discoloured, owing to infiltrations of a dirty serum or of a sero-sanguineous fluid in the connecting cellular tissue. The pleural cavities contained, in some cases, a turbid or whey-like serum—more rarely a scanty sero- sanguineous effusion. In some of the most rapidly fatal cases little or no effusion was found, while in some of the more prolonged malignant cases the effusion in, and the state of, the pleura were similar to those of the peri- toneal cavity (y 223, et seq.), excepting that the quantity of the fluid was much less. In those cases in which the changes were seated chiefly in the uterus and appendages, and in the more prolonged and sthenic form of the disease, the pleura presented either slight or no material alteration. 233. /. The lungs were generally more or less congested with dark fluid blood, especial- ly at their posterior or more depending parts. Their substance was soft and friable in the most malignant states of the malady. In the more prolonged cases, and when uterine phle- bitis existed, they sometimes contained small puriform deposites or infiltrations, or larger col- lections or abscesses, with grayish hepatization or other changes consequent upon congestive pneumonia. 234. g. The digestive canal presented few changes in its mucous surface. Sometimes, however, inflamed patches were observed; and more or less softening of the mucous mem- brane, especially of the stomach, was not infre- quent. Occasionally the softening of this or- gan was attended by erosions and perforations; and more frequently a brownish, transparent, and gelatinous substance was found between the mucous and muscular coats. Softening and perforation of the stomach has been more frequently observed by Duges and others than I have seen them. This physician thinks that the brownish viscid matter exuded from the perforated portion of the stomach acts upon the adjoining parts as a caustic, softening, dis- solving, and perforating them. But these chan- ges, as they respect the stomach and adjoining viscera, are, in my opinion, in a great measure post mortem, and are much more rarely observ- ed when the inspection has been made a few hours only after death. The intestinal parietes seldom presented other changes than deficient physical cohesion, especially in the most rap- idly fatal cases. In a few of longer duration, the glands of Pfyer and Brunner were enlarg- ed or otherwise changed ; but I rarely observ- ed ulceration of them, or in their vicinity. The whole digestive canal was remarkably distend- ed with air, and contained much brownish or brownish-green fluid matter; that which was found in the stomach and oesophagus being similar to the matters thrown up shortly be- fore death. 236. h. The liver was covered by the matter described above as being found in the perito- neum ; and a layer of soft lymph, or of a sub- stance similar to that covering the fundus of the uterus, was often interposed between it and the diaphragm, or between it and the stomach, even, in some instances, where the abdominal portions of the peritoneum were comparatively but little altered. The substance of the organ was often softened, more friable than natural, in some cases congested ; in others, pale, soft, as if it were parboiled, and deficient of blood. In rare instances it contained purulent depos- ites. The gall-bladder often contained much greenish bile, which was occasionally thick and ropy. The spleen was softened, somewhat en- larged, and in the more malignant cases it was so friable and soft as hardly to admit of being handled, even when the examination was made while the body was still warm ; and the blood contained in it resembled treacle. 236. t*. The peritoneal coat of the kidneys generally participated in the changes existing in other portions of this membrane. The veins of the kidneys in some instances contained pu- riform matter mixed with grumous blood; and deposites of pus were found in the substance of the kidney generally on the same side as that in which the ovarium and ligaments were most altered or their veins inflamed. The brain and membranes were rarely diseased, even in cases attended by delirium. Slight soften- ing was met with in a few instances of the more malignant form of the malady. 237. k. Effusions of sero-puriform, or puru- lent matter in the'joints, especially the hip, el- bow, and knee-joints, and more rarely into the shoulder, ankle, or wrist-joints, were met with in the states of the disease complicated with uterine phlebitis ; and when the case was pro- tracted beyond five or six days, infiltration of a sero-puriform or sero-sanguinolent fluid into the cellular and muscular tissues were some- times observed. These fluids were hardly ever encysted; they always infiltrated, softened, and, as it were, decomposed the texture which they infiltrated, the parts around the softened pla- ces gradually passing to a healthy appearance. The muscular structure presented a pale-brown hue where it was thus softened and infiltrated; the skin was lurid or dusky, and the part swol- len or boggy, occasionally to the extent of some inches. The soft solids passed rapidly to de- composition) the internal viscera, especially the abdominal, being the first to evince the change. In the more malignant form of the malady this change commenced before the an- imal warmth had altogether departed. Nearly all my examinations were made before twenty- four hours from dissolution had elapsed, most of them from eight to twelve hours after death. I believe that several of the changes which have been described by some writers have ta- ken place after death, or at least have become more remarkable during the period between this event and inspection of the body, for de- composition follows death more rapidly in this disease than any ether. 238. ii. Results of Post-mortem Examination* made by some other Physicians.—A. M. Duges ad- duces the results of 341 deaths. In these peri- tonitis was observed 266 times. Of these 266 peritonitic cases the uterus was affected in three cases out of each four. But M. Duges re- marks, that if the cases in which pus was found PUERPERAL FEVERS—Pathological Inquiries respecting. 579 in the veins, and which he believes, with con- siderable probability, not to have been cases of uterine phlebitis, be abstracted, the ratio of me- tritis would be very remarkably lowered, and reduced to 29 in 266, or 1 in 9. He states that the ovaria axe affected in the proportion of one to seven cases; and that in the 266 cases the stomach was perforated in 10 ; the stomach and intestines were inflamed in 4; there was single or double pleurisy in 40; pericarditis in 6; arach- nitis in 1; purulent deposites in muscles in 8. It is not improbable, however, as stated above, that the perforation of the stomach in some of the cases, at least, was either a post-mortem change, or was increased after death. 239. B. The researches of M. Tonnelle are more precise.-^(a) Of 222 dissections he found peritonitis in 193; alterations of the uterus and appendages in 197; lesions of both the uterus and peritoneum in 165; the peritoneum alone af- fected in 28; uterus alone in 29.—(6) The altera- tions of the uterus and appendages were, simple metritis, 79; superficial softening, 29; deep softening, 20 ; inflammation of the ovaries, 58 ; inflammation of the ovaries with abscess, 4= 190.—(c) The alterations of the vessels were, pus in the veins in 90; pus in the lymphatics in 32 ; pus in the thoracic duct in 3; suppura- tion of the lumbar and inguinal glands in 9= 134.—(d) The combinations of these lesions were, suppuration of veins and uterus in 32; suppuration of veins and putrescence of uterus in 11 ; suppuration of veins with metritis and softening in 5; suppuration of veins with peri- tonitis alone in 34 ; suppuration of veins alone in 8=90. Suppuration of lymphatics and veins in 20; suppuration of lymphatics and uterus in 13 ; suppuration of lymphatics and softening of uterus, 6 ; suppuration of lymphatics and sim- ple peritonitis, 3; suppuration of lymphatics alone, 2=44. Inflammation of ovaries with peri- tonitis alone, 29 ; with various uterine lesions, 27; with metritis alone, 8; with softening of uterus, 7; with-suppuration of vessels; 12; with all the preceding lesions, 6=89.—(e) The sec- ondary affections were, in the pleura, pleurisies, 29 ; effusion of blood, 6 ; of serum, 8=43. In the lungs, pneumonia, 10 ; tubercles, 4; ab- scess, 8 ; gangrene, 3 ; pulmonary apoplexy, 2=27. In the heart, dilatation, 4; hypertrophy, 3; pericarditis, 1 ; hydro-pericarditis, 6=14. In the digestive canal, softening of the stomach, 8; perforation of stomach, 5; ulceration of stomach, 5 ; gastro-enteritis, 5 ; entero-colitis, 1=24. In other parts, abscess of the liver, 3 ; of pancreas, 2 ; abscess in muscles, 14; infil- tration of blood in muscles, 3; abscess in pubes, 2; in the elbow, 2; in knee, 6; alteration in cellular tissue of pelvis, 6 ; sanguineous infiltra- tion, 2=40. 240. C. Of forty-five dissections made by Dr. R. Lee, the peritoneum and its appendages were inflamed in 32; the uterine veins in 24; softening of the uterus in 10 ; pus in the absorbents in 4. The peritoneum was not altered in thirteen cases of the forty-five ; and there was no phlebitis in seventeen. Dr. Collins found, in thirty-seven disseotions, the peritoneum more or less af- fected in all; and in seven fluid was effused in the thoracic cavities similar to that found in the abdomen. The effusion into the peritoneal cav- ity was of a straw-colour in twelve, and sero- purulent, or of the consistence of thick cream, in eighteen. It consisted of a sanguinolent se- rum in seven, and had a glutinous feel when rubbed between the finger and thumb. AH these last cases were rapidly fatal, and no co- agulated lymph was found in them. In the other cases lymph was deposited in large quan- tities, aud generally, but more especially in the vicinity of the uterus. "The uterus in the great majority was quite natural in appearance; in some it was soft and flabby, and in a few un- healthy matter was found in the sinuses. The ovaries in many instances had suffered much from the effects of inflammation ; being gener- ally enlarged, and so softened as to be broken down by the least pressure." (P. 398.)* 241. Vi. Pathological Inquiries respecting Puerperal Fevers.—i. Is inflammation or al- teration of the blood-vessels, or absorbents of tht uterus, a necessary consequence of the passage or imbibition of morbid matters, or of other infecting agents from the sexual passages into, the circula- tion ?—Although uterine phlebitis exists chiefly in cases which originate in an extrinsic or in- trinsic local infection—which are caused by an internal or external contaminating or infect- ing agent—and occurs less frequently or more equivocally when the malady is produced by the general infection of the frame received through the medium of the respiratory organs, I never- theless believe that, in the latter class of cases, more especially if the patient has experienced flooding, or is vitally depressed, or continues under the influence of an impure or infected air, morbid matters or fluids may be imbibed by the uterine vessels, or absorbed from the sexual passages and carried into the circulation to such an extent as to contaminate the circular tion and infect the whole frame without pro- ducing any inflammatory alterations of the ves- sels. I was so impressed by the symptoms and course of the disease, and by the examination of the bodies after death, in 1823 and the fol- lowing years, as to infer at that time, and sub- sequent experience has confirmed my belief, that morbid matters, or altered or putrid fluids are imbibed, in the circumstances just men- tioned, and passed into the circulation, pro- ducing the effects now specified without in- flaming the vessels, or producing such a change in their internal surface or in their parietes as may be recognised by the unaided senses ; and that the passage of these matters from the uterus into the circulation may take place so rapidly and so efficiently as to produce their effects in so malignant a manner, and in so short a time, as not to admit of the production of the usual alterations consequent upon irrita- tion of the vessels along which these matters have passed. From this it may be inferred that the absence of change in the uterine vessels is not a conclusive proof, in rapidly fatal cases of puerperal fever, that morbid matters, or altered fluids, or other infecting agents have not been imbibed from the uterus and carried into the circulation. When the imbibition of such mat- ters or agents takes place without causing, in the first instance, irritation, inflammation, and its consequences in the vessels, there is every reason to believe that the effect upon the frame t* It i» unnecessary to quote American authorities rela- tive to the pathological appearances found in puerperal fe- ver, ai they closely correspond with those described by ooi author.] 680 TUERPERAL FEVERS—Pathological Inquiries respecting. will be the more immediate and intense, owing to the absence of these changes, and to the free passage thus afforded to the morbid agents about to enter into the current of the circula- tion. Whereas there are equally cogent rea- sons for concluding that, when the morbid mat- ter excites inflammation of the vessels which imbibe it, the passage of it into the circulation will be either altogether prevented, or retarded, or diminished by the inflammation thereby pro- duced. 242. ii. Are the uterine vessels actually inflamed in all, or even in the majority of instances, in which they contain pus, puriform, or other morbid mat- ters ?—When the disease is not arrested by the prompt adoption of rational and decided means, ux when such means have not been employed early, or not at all, then the altered fluids, an offensive or putrid lochia, or the secretion pro- duced upon the internal surface of the uterus may be imbibed by the vessels, and either in- flame them, or contaminate the blood without inflaming them, as inferred above (y 241), or may both inflame the vessels and contaminate the blood. That the vessels are inflamed, and present the changes consequent upon inflam- mation, are among the most frequent changes observed in this disease; and that matters sim- ilar to those covering the internal surface of the uterus, or in its cavity, are also found in the veins, and that even puriform matter is seen in these vessels, sometimes without any marks of inflammation of the containing ves- sels, are undisputed facts, and serve to confirm the view, already stated, that these matters may pass into the circulation and change the blood without leaving any signs of phlebitis. It is not improbable that, when the passage of morbid matters from the cavity of the uterus into the veins takes place towards the close of life, or when it has been increased at this period of the malady, the change of the blood remain- ing in these vessels will then be more mani- fest ; and the contents of the vessels will more closely resemble the morbid matters existing in the uterus, or will be more or less altered, owing to admixture of these matters with the blood ; and that, while the matters found in the vessels will thus be much altered, the state of vital power and vascular action at this period of the malady will preclude the occurrence of inflammatory changes in the vessels by which these matters were imbibed. Itmay, therefore, be concluded, 1st. That the morbid matters found in the uterine vessels may be the prod- ucts of inflammation of these vessels, and in this case inflammatory appearances or changes are also found in the coats of the vessels. 2d. That they may have been imbibed from the uterus, and their presence may have caused irritation and inflammatory alterations in the vessels ; and, 3d. That they may be imbibed by the vessels, pass through them, or be retained in them, especially at an advanced period of the disease, or near the close of life, and yet fail of producing any marks of phlebitis, although con- taminating the blood and all the frame. I 243. iii. Are the softening and other changes often found in the substance of the uterus and of its appendages the results of inflammatory action, and to what other pathological conditions may they be imputed ?—(a) Certain of these changes are the undoubted consequences of inflammation, others are the results of a very different state of vital and vascular action. Even the most ob- viously inflammatory lesions are not referable to pure sthenic action, but rather to an asthenic or diffusive state, unattended by the exudation of a healthy lymph, and characterized by its tendency to spread, to soften, dissolve, or dis- organize the parts which it affects ; and to in- filtrate them with a sero-puriform or sero-san- guinolent matter. The flabbiness of the parts, their swollen, softened, and infiltrated states, their friable and almost putrescent conditions in some instances, and the deposites of puriform matter, without any cyst or exudation of firm lymph in others, evince the asthenic character of the vascular action, of which these changes are the results. In some cases, especially when vital power is less depressed and the disease is more prolonged, the matter found in the sub- stance of these organs is more consistent, in larger collections, and more nearly approaches that produced by sthenic action. 244. (4) The depression of vital power and contamination of the circulation caused by the exciting or infecting agents, when they operate energetically, occasion changes in the lochia, or so affect the fluids exuded from the internal surface of the uterus and sexual passages as not merely to irritate the parts with which they come or remain in contact, but also to contami- nate them locally, so as to partially dissolve their vital cohesion, to soften and almost liquefy or putrify them, even before life has taken its departure. This local contamination thus su- pervenes upon the general infection produced by the poisonous agent, and in proportion to the intensity of its operation, relatively to the re- maining power of vital resistance, will be the extent of change ; of softening or disorganiza- tion that will result in the uterus, in the ovaria, and in the ligaments, the mischief extending, moreover, to the peritoneum, and spreading throughout its surface with a rapidity propor- tionate to the reduction of vital power and to the contamination of the circulating fluids. In many of these cases the softening and disor- ganization of the uterus and appendages, espe- cially of the ovaria, are carried to the utmost extent. If, however, the examination of the body be delayed beyond eighteen hours after death, these changes may be viewed as partly post mortem. 245. iv. (a) Is the peritonitis existing in the majority of cases of puerperal fever a primary mor- bid condition ? (b) or is it consecutive of the infec- tion and febrile action ? (c) or is it the result of an extension of the morbid action from the uterus and appendages to this membrane ?—These are ques- tions by no means easy to solve, for they ad- mit of being answered both affirmatively and negatively, inasmuch as there is reason to be- lieve that the procession of changes is different, or even opposite in different cases or forms of the malady, and according to the channels through which the causes invade the frame.— (a) Instances have occurred in which I have believed the disease to originate in inflamma- tion of the peritoneum, of greater or less ex- tent, the accompanying fever preventing vary- ing grades of action between the sthenic diath- esis on the one hand, and the asthenic on the other. The peritoneal affection may be pri- mary, and yet appear as a complication, or as a VERS—Diagnosis. 681 PUERPERAL FE consecutive lesion, especially when it occurs very soon after labour, or is developed with the reaction following the shock produced by par- turition. Indeed, both the fever and the peri- toneal affection may be coetaneously produced -, the latter, commencing as reaction, follows the depression caused by delivery, or by the excit- ing causes of the malady. This latter mode is probably that which actually obtains most fre- quently, whether the disease is characterized by sthenic or inflammatory action, or by asthenic action, or marked deficiency of vital power. But, as reaction is adynamic and imperfect in the latter cases, the prominent affection of the peritoneum in these is modified accordingly, and presents alterations varying in extent and character, especially as regards the fluid ef- fused, with the intensity or concentration of the cause, with the state of vascular action and vital power, with the constitutional peculiari- ties of the patient, and with the several cir- cumstances of the case. 246. (b) That the peritoneal affection may, however, be consecutive of the constitutional infection and febrile action, at least in some instances, is shown by the fact that death' has taken place, although in comparatively rare cases, before the peritoneum has presented a more remarkable change than other parts—be- fore exudations of lymph or fluid in its cavity had supervened ; such cases having occurred in the same ward, and in similar circumstan- ces, with those in which the peritoneal symp- toms and effusion into the cavity were most prominent; in some of these cases effusions of fluid have also taken place into the pleural cavities, and even into the pericardium. 247. (c) That the changes in the peritoneum are often an extension of those which had pre- viously taken place in the substance or vessels of the uterus and its appendages cannot be disputed. The phenomena characterizing the progress of the malady ; the occasional limita- tion of these changes to the peritoneum reflect- ed over the pelvic viscera, the uterus and ap- pendages, in some one or more of their con- stituent structures, being more or less altered; and the frequent extension of the peritoneal changes, as distinctly marked by the symptoms, from the pelvic peritoneum to the reflections of this membrane over the abdominal viscera and diaphragm, demonstrate that the abdomin- al alterations often commence and advance as now stated. In those cases which originate in a local infection, and even in those where the general infection is followed by a local con- tamination, it may be reasonably inferred that the morbid irritation and its consequences, thus produced in' the internal surface of the uterus, extend along the sexual passages—along the Fallopian tubes to their fimbriated extremities, and thence to the peritoneum, over which it spreads with a rapidity great in proportion to the intensity of the infection, and to the pros- tration of vital power and resistance. 248. v. In what manner are the consecutive changes in the joints, cellular and muscular tis- sues in the eyes and in the viscera, to be explained? —These consist chiefly of the deposite of puri- form matter, in smaller or larger collections, and of infiltrations of this matter in the soften- ed, disorganized, or otherwise altered struc- ture ; and are only sometimes observed. That they are to be referred to the imbibition or absorption of puriform, or ichorous, or putrid matters from the uterus into the circulation, or to the passage of a purulent or ichorous fluid into the blood from irritation or inflammation extending from the sinuses and capillary veins of the uterus and appendages, is generally ad- mitted ; either modes of contamination, or both, occurring according to the early states and pe- culiarities of the case. The morbid matter, having thus passed into the blood, excites and develops a diffusive form of inflammation, with puriform deposites, softening and disorganiza- tion of those parts which are most predisposed by previous disorders, by depressing influence, or by impaired vital resistance. These con- secutive or secondary purulent collections and destruction of parts have been viewed by some as resulting from the mere deposite of the morbid matter circulating in the blood; while others more correctly consider it as the termi- nation of an asthenic, gangrenous, or destruc- tive form of inflammation produced by the pres- ence of the imbibed contaminating matter in the circulation. This matter, by acting upon the interior surface of the capillaries, produces. effects much more disorganizing and diffusive than those resulting from the usual states of inflammation consequent upon external irrita- tion. Although these secondary lesions are most frequently seen after puerperal fevers, and uterine phlebitis occurring in the puerperal state, they supervene in various other circum- stances ; and as I shall show in the article Ute- rus, sometimes upon ulceration of the os uteri, and of other parts. This subject is more fully discussed in the articles Abscess (y 24, et seq.), Absorption (y 15, et seq.), Cellular Tissuk (y 10, et seq.). 249. VII. Diagnosis.—After what has been remarked respecting the forms and states of puerperal fever, and the descriptions of these forms and of the appearances after death, it is unnecessary to do more than briefly to notice this topic. The diagnosis of fevers in the pu- erperal state has, however, been very loosely stated by some writers, and most inaccurately by others ; while by nearly all those who have written, with a.dogmatism and self-sufficiency which would be ridiculous if they were not most mischievous, and actually destructive of life in the most interesting epoch of female existence,' the inflammatory form has been assumed as the type of all the others. Most writers, even the most recent, have described and attempted the diagnosis of puerperal fevers with refer- ence only to the local or prominent affections presented at their commencement or their course, and with entire neglect of the differ- ent states of vital power and resistance which characterize their several forms, more espe- cially the synochoid and malignant. The vital depression, the poisonous contamination, the mental apathy, or, rather, the despondency conjoined with indifference, characterizing the worst cases from their commencement, and the origin of such cases in infectious causes—in foul air, poisonous effluvia, contagious emana- tions, &.c, even of a domestic nature, and which I have fully described at another place (see Pestilence, preservation from, y 10, ct seq.)—heightened, favoured, or predisposed to, by the exhaustion consequent upon parturition, 582 PUERPERAL FEVERS—Diagnosis. and the state of almost inanition, or of depri- vation of requisite nourishment and even of ac- customed stimuli in which puerperal females are often kept too strictly or for too long a pe- riod—-are pathological conditions and etiologi- cal circumstances of the greatest importance not only as respects the diagnosis, but even more as regards the indications and the means of cure. 250. A. The inflammatory form of the disease, occurring either as peritoneal, or metro-perito- neal, puerperal fever, are indicated by the mode of accession, by the seat of pain and tender- ness, by the vascular reaction consequent upon shivering, by the state of the pulse, especially its hardness in the former and its fulness and firmness in the latter; by marked diminution or suppression of the milk and of the lochia; by thirst and dryness of the mouth and tongue; by the often costive state of the bowels at the commencement, and by irregularity afterward, the evacuations being offensive ; and by scanty urine, the excretion of it being more or less disordered. Peritonitis, occurring in the puer- peral state, presents most of the symptoms de- scribed when treating of inflammations of the Peritoneum, the disease assuming more or less of a sthenic form on the one hand, or of an as- thenic on the other, according as the disease is inflammatory, synochoid, or malignant, the symptoms and lesions found after death very closely approaching, or being identical with, those described under that head, the chief dif- ferences arising from the constitutional influ- ence exerted by the puerperal state, by the constitutional infection, or by the exhaustion, or inanition, or other circumstances of the pa- tient.—(a) Peritoneal puerperal fever cannot be confounded with gastroenteric irritation (y 103, et seq.), if the abdomen be carefully examined ; for in this latter the abdomen is not tympa- nitic, nor tense, nor very tender on pressure ; nor does it usually appear so soon after deliv- ery, nor cause so marked constitutional dis- turbance as the peritoneal or metro-peritoneal disease.—(b) Ephemeral fever cannot be mista- ken for any state of inflammatory or synochoid puerperal fever, inasmuch as the former is un- attended by the severe abdominal pain, tympa- nitic distention and tenderness characterizing the latter; and is, moreover, a much less severe disease, of much shorter duration, soon termi- nating in a copious perspiration, the lochia be- ing uninterrupted, and the breasts continuing distended. 251. B. Puerperal fever, commencing either as hysteritis or as ovaritis, or affecting chiefly the ligaments, and either limited to these, or extending thence, to a greater or less extent, over the peritoneum, whether it assumes an inflammatory or sthenic type, or a synochoid or asthenic, will generally be recognised by the severity of the constitutional symptoms ; by the persistence of the local signs, especially the pain, tenderness, fulness, and tension in the hypogastric and iliac regions, shooting through the abdomen to the loins and tops of the thighs; by the rapidity of the pulse, prostration of strength; by the dysuria and irregularity of the bowels; and by the diminution, irregular- ity, and offensive state of the lochia. If the peritoneum continue unaffected, the abdomen Will be neither tympanitic, nor tense, nor ten- der ; excepting towards the pelvic regions, where the pain, tenderness, and fulness will be considerable, and the uterus will generally be felt hard and enlarged. The persistence and duration of these symptoms, the grave character of the attendant fever, the disorder- ed states of the secretions and discharges, will distinguish these states of puerperal/ever from after-pains, from ephemeral fever, and from gas- tro-intestinal irritation. 252. C. The malignant form of puerperal fe- ver often arises from similar infectious and contaminating sources to those which produce putro-adynamic fever; and it may be consid- ered in every respect a putro-adynamic fever in the puerperal state, presenting all the char- acters of this fever in an aggravated form. It is distinguished chiefly by the absence of chills or rigours at its accession, by a remarkably rap- id, soft, broad, open, and compressible pulse, which soon becomes small, weak, fluent, and ir- regular ; by abroad, flabby, or tremulous tongue, covered by a slimy or cream-like mucus; by the little, or almost entire absence of thirst; by the character of the discharges from the stomach and bowels, as above described ($214); by the persistence of the milk and lochia, or the greater abundance and more putrid state of the latter; by the dusky, lurid, or sallow ap- pearance of the general surface and counte- nance ; by the free, clammy, and peculiarly of- fensive perspiration; by the frequent recur- rence of faintness or of a sense of sinking, with moral apathy and vital depression; by the man- ifest contamination of the circulating fluids and impaired vital cohesion of the tissues; by the quick and peculiar state of perspiration; by the extremely tympanitic distention of the abdo- men, and the almost constantly rapid progress of the malady to dissolution, if not early arrest- ed by judicious means ; singultus, eructations of flatus, and dark fluids from the stomach, a dirty livid hue of the face and general surface, and loss of the power of and control over the sphincters, ushering in death. After death, the rapid accession of putridity, especially of inter- nal organs, the pelvic particularly, and the lit- tle or no diminution of bulk—the, almost entire absence of emaciation* notwithstanding the free discharges from the stomach, bowels, and skin during the disease, remarkably attract at- tention. 253. The malignant form of puerperal fever has been considered by many, especially when the peritoneum is prominently affected, as an erysipelas of internal surfaces and organs in the puerperal state; and by others as typhus or typhoid fever, modified by this state.—(a) The evidence adduced above (v 151, ef seq.), and the facts which have fallen under my own observa- tion as early as 1826 and 1827, have convinced me of a connexion between erysipelatous and puerperal fevers, arising chiefly out of a similar- ity, if not identity, of their respective predispo- sing and exciting causes, and of the constitu- tional—nervous and vascular—conditions ex- isting in their progress, and characterizing their terminations ; the connexion being remarkable chiefly as respects the synochoid or interme- diate states of puerperal fever, more especially that with prominent affection of the peritone- um. It cannot be said that both maladies are identical, for their respective seats are altogeth- PUERPERAL FE er different. The connexion or similarity I now point out certainly obtains in a remarkable man- ner, and is of great importance as respects both the origin and treatment of puerperal fevers. A similar connexion may, however, be traced between several other malignant maladies, ari- sing out of their exciting causes, and their prom- inent pathological conditions, tendencies, and terminations. A septic or contaminating ani- mal poison, varying in kind, administration, ap- plication, and avenue of invasion, is the exci- ting cause of them all; and, while this cause depresses organic nervous power, contaminates the circulating fluids, loosens the vital cohesion of the tissues, weakens constitutional or vital resistance, and disposes the whole frame to dis- solution, it thereby generates miasms, exhala- tions, and secretions, equally poisonous "vvith itself, and produces effects altogether similar to, if not identical with, those which itself had produced. In this category of effects may be arranged the severer forms of erysipelas, diffu- sive inflammations of the cellular tissue, poi- soned wounds in dissection—the necroscopic poison—puerperal fevers, especially the syno- choid and malignant, putro-adynamic fever, and other- fevers of a malignant form, which are generally produced by animal emanations ^or poisons. 254. (b) The opinion as to puerperal fevers being prevailing typhoid or other fevers, occur- ring in the puerperal state, may be thus dis- posed of: 1st.. The most malignant form of puerperal fever does not produce typhus or typhoid fevers in other persons, however sus- ceptible they may be, by age and otherwise, of the infection of these fevers, as shown on sev- eral occasions both in lying-in institutions and in private practice. 2d. When other fevers, both typhous and exanthematous, occur in the puerperal state, whether the invasion of such fevers have taken place immediately before or very soon after parturition, these diseases re- tain their distinctive characters, although they are generally much more severe in the puer- peral state, as I have observed on various oc- casions. As respects the exanthemata, the diagnosis requires no remark; but in respect of typhus fever appearing after delivery, a few observations may be here offered. 255. (c) Typhus or typhoid fever may appear after delivery, from infection either shortly be- fore or soon after this event. And it is not im- probable that an adynamic or typhoid fever may occur in the puerperal state, owing to great anxiety of mind, or other moral emotions, or to exposure to various morbific exhalations. When, however, typhoid or adynamic fever oc- curs during child-bed, it generally assumes a more than usually severe and almost malignant form. The patient complains, after chills or rigours, of severe pain of the head, back, and lower extremities; rapid pulse; dry, hot, and acrid skin ; wandering or low delirium, occur- ring first at night, and becoming permanent, the ideas running upon one subject; deafness, and suffusion of the conjunctivae; grinding of the teeth, thirst, and dryness of the mouth, the tongue being loaded, brown, or furred, dark, and dry. The position of the patient is on the back, with the knees but little or not at all drawn up. During the delirium the patient gives short ut rational answers when roused. The coun- fERS—Prognosis. 583 tenance is sunk, livid, or sallow; the features are afterward sharpened; and the delirium pass- es into coma, with subsultus tendinum. The pulse varies from 100 to 120 or 130, and is gen- erally soft and quick; respiration is quick, and accompanied with frequent sighing; the ab- domen is not remarkably, or but slightly, tumid or tender; the bowels at first are slow or cos- tive, subsequently irregular or relaxed, the stools being offensive; the urine is scanty and turbid, sometimes suppressed; and the milk and lochia are early diminished, and soon afterward en- tirely suppressed. At last the patient sinks down in bed; the tongue is dry and dark; the evacuations are involuntary, and without con- sciousness ; and eschars form on the parts most pressed upon. The duration of the fever is generally longer than that of any of the forms of puerperal fever, and is seldom shorter than fourteen days, and is sometimes above twenty- one days. The history of typhoid fever in the puerperal state shows several points of differ- ence from puerperal fevers; indeed, the phe- nomena just described are distinctions between these fevers, most of them not existing in the latter; and, in addition to these, petechia? are observed in typhoid, and the measly eruption in true typhus, these never appearing in any of the forms of puerperal fever. 256. VIII. Prognosis.—An opinion of the re- sult of a case of puerperal fever should depend chiefly on the form and state of the disease, in respect both of the character of the eonstitu- tionaldisturbance and the prominent local af- fection, and on the period of its progress, and the effect produced by treatment.—a. In the in- flammatory form of the malady, a favourable is- sue may be anticipated from a gradual abate- ment of the acute, symptoms ; from a return, or an increase, or a more natural state of the se- cretions and excretions ; from a diminution of the pain, distention, tenderness, and tension of the abdomen ; and from a less frequent and more natural state of the pulse. An unfavour- able result is indicated by the appearance of de- lirium ; of increased distention of the abdomen, which becomes round and very prominent; by an aphthous eruption in the throat; by in- creased frequency and irregularity of the pulse; by a sudden cessation of pain; or by evidence, by percussion, of copious effusion into the peri- toneal cavity ; by sinking and sharpening of the features; by continued eructations of flatus with dark fluid matters from, the stomach, and sin- gultus ; by rapid or gasping respiration ; by cold, clammy perspiration, or a similar state of the extremities; by involuntary evacuations and restlessness ; these latter phenomena indi- cating speedy dissolution. 257. b. The synochoid or intermediate grades of puerperal fever furnish nearly similar phe- nomena to the above, by which their termina- tions may be anticipated; for, although the sthenic diathesis obtains at the commence- ment, or during the early progress of the in- flammatory form, still it more and more nearly approaches the synochoid or asthenic, as re- spects both the constitutional disturbance and the local changes, as the disease continues, es- pecially as it proceeds towards an unfavourable issue, so that an advanced stage of the inflam- mation differs but little from the same period, of the synochoid form, as respects the indica- 584 PUERPERAL FEVERS—Pathological Inferences. tions of the ultimate result. In this latter form of the malady treatment is seldom availing, unless it be early and decidedly prescribed ; and unless symptoms of amendment, or, at least, of alleviation, soon follow the remedies employed. If the secretions and discharges have been sup- pressed, the.return of these ; an improvement in the states of the pulse and of the abdomen, as ascertained by a careful examination ; and the capability of turning or of lying for a time on either side, are the chief indications of a favourable issue; and these may not continue long, an exacerbation of all the symptoms some- times occurring, and soon carrying off the pa- tient ; or an alleviation of the more painful symptoms may take place, the pulse still con- tinuing rapid, and after a very few days be fol- lowed by secondary affections, as described when treating of the metro-phlebitic state of the malady, which ultimately destroy the pa- tient. 258. An unfavourable issue is indicated by the symptoms already mentioned (y 256), and espe- cially by the character of the vomitings and of the matters thrown up; by singultus and the' state of the respiration ; by faintness or lei- pothymia ; by failure or irregularity of the pulse; by the amount of effusion in the abdomen, as indicated on percussion, and by the toleration of percussion in connexion with effusion ; by the suppression of urine ; by the indifference of the patient to her child, and to all other ob- jects ; and by an early entertained idea or an- ticipation of an unfavourable result by the pa- tient herself. Sinking of the animal heat and of the features, and a lurid hue or lividity of the face, extremities, or surface generally, indicate approaching dissolution. 259. c. The malignant form of the malady often manifests the result from the accession of the attack, especially in the suddenness and severity of the appearance of the abdominal symptoms. This form of the disease is seldom recovered from, if it continue but a few hours, without the administration of appropriate and energetic means; and, unless these soon pro- cure an alleviation of the symptoms, especially of the vomitings, and of the pain and distention of the abdomen, and an improvement in the pulse, particularly in diminishing its frequency and in improving its tone, hopes of recovery should not be entertained. The symptoms just enumerated usually precede a fatal issue ; and that issue may be expected if the lurid, dark, or nearly livid hue of the countenance and sur- face; the clammy and peculiarly offensive state of the perspiration ; the putrid odour of the lochia; the moral apathy, and mental and phys- ical depression appear soon after the attack; inasmuch as these symptoms indicate a con- tamination of the circulating fluids, and a de- pression of organic nervous energy which is rarely removed. A soft or flabby state of the tissues in conjunction with the gastric symp- toms described above; a pulse too fast to be accurately counted ; loss of power over the sphincters ; absence of abdominal pain, the ab- domen continuing tumid, with a swagging or tremulous motion when struck or examined, loss of pulse and coldness of the extremities are rapidly followed by death.* * Dr. Collins, formerly the resident physician of the Dublin Lying-in Hospital, states that of eighty-eight cases 260. IX. Pathological Inferences. — (a) Puerperal fevers axe varied in the character or type of the constitutional disturbance, and in the seat or seats of the prominent local changes. —(b) They present the most inflammatory and the most malignant forms—the most sthenic, or the most asthenic or ataxic, with all inter- mediate grades, according to the nature of the exciting causes, and the mode of operation or avenue of invasion of these causes—as the lo- cal affection is primary or consecutive, and aa the constitutional disturbance, with its second- ary changes, are the effects of infection by an animal miasm or poison.—(c) Owing to these varied constitutional conditions; to these dif- ferent grades of vital power and resistance, and one was attacked before delivery ; one in six hours after de- livery ; one in nine hours ; one in ten ; three in twelve ; one in thirteen ; one in fifteen ; two in seventeen ; one in eight- teen ; one in twenty ; one in twenty-one hours ; and two in thirty hours. Thirty-two were attacked on the first day; twenty-nine on the second day ; eight on the third ; two on the fourth ; and one on the eighth day. The attacks were earlier than those observed by me in Queen Charlotte's Ly- ing-in Hospital in 1823, and the seven following years. Du- ring that period the majority of the cases were of the most malignant type, and the largest proportion of the attacks were on the second, third, and fourth days. In one most rapidly fatal case the attack was on the fifteenth day from delivery. The statement of Dr. Collins, that in only thir- ty-three cases out of eighty-eight was the accession of the malady attended by shivering, very nearly agrees with my own experience, which also is in accordance with the fol- lowing : In fifty-six deaths this termination took place at these periods from the attack, viz.: T"u>o in twenty-four hours; one in twenty-sevei>; one in thirty-six hours; nine on the second day ; fifteen on the third day ; thirteen on the fourth ; four on the fifth ; four on the sixth j three on the seventh ; two on the eighth ; and one on the eleventh day. " Forty-four of the eighty-eight cases occurred in women who had given birth to first children ; sixteen with second children; nine with third; six with fourth; seven with fifth; two with seventh; and four with eighth children. Thirty of the forty-four women delivered of first children died. Fifty-four of the eighty-eight gave birth to mole chil- dren." Dr. Collins adds, that "when he was assistant physician in 1823, puerperal fever raged to an alarming ex- tent. The master (physician) of the hospital was a strong advocate for the free removal of blood generally al the com- mencement of the attack. With'his approbation it was re- sorted to with great frequency, and in the promptest man- ner. The effect ou the patient and the mortality was such as to satisfy him fully of the inexpediency of adopting (his line of treatment." It may be remarked in palliation of such adoption, that just before this outbreak of the fever several works had appeared filled with the results of an experience of a few months' duration of this malady, most of them writ- ten before the authors were of legal—certainly not of med- ical age, although distinguished by the title of doctor; which results were dogmatically, and, to my own knowledge of one of these productions, falsely adduced in favour of blood-let- ting. In the case of this malady, as in that of a somewhat similar pestilence, blood-letting was once extolled as the " sheet anchor" of treatment, especially by the navy wield- ers of the lancet, who, like Dover of old, rendered this mi- nute instrumeht of mighty mischief one of the greatest im- portance with those Who credulously received assertions as facts, and believed all assertions according to the confidence with which they were made. Early in the present century a work appeared on the diseases of intertropical countries, in which blood-letting was the first " sheet anchor," and calomel was the second. In it all preceding writers were ridiculed, and told they knew nothing of what they had written upon, and these remedies were considered so good that patients could hardly have Joo much of them. This work was the guide of all the inexperienced in tropical dis- eases, and the results may be inferred from the statement made to me by an inspector of hospitals when I was travel- ling within the tropics, in answer to my request to know hit opinion of the treatment of the fevers of the country, that, for the first niue cases of fever he treated he prescribed blood-letting, relying on the confidently-expressed results of the experience of the author of the work alluded to, and they all died ; that he next tried large doses of calomel, but was not more successful; and that he lastly had recourse to cinchona (quinia was not then discovered), but he could not gel it to remain on the stomach. I suggested to him that he would succeed better if he conjoined the bark with cap- sicum. He some time afterward was himself a victim to this fever. PUERPERAL YE\ diverse complications, the arrangement of the forms of these fevers must necessarily be ar- bitrary and conventional, inasmuch as each form is not defined by any precise limit or line of de- marcation, but passes insensibly into that near- est it in grade or character.—(d) The contami- nating or poisonous influences of the causes upon the circulating fluids, and their depressing effects upon organic, nervous, and vital power, affect the states of all the secretions and excre- tions, and ultimately impair the vital cohesion of the tissues and the tone of the vascular sys- tem and of the capillary vessels, thereby occa- sioning effusions into serous cavities, and in- creased discharges from exhaling and secreting surfaces, and all the phenomena characterizing the progress of the more malignant forms of this malady.—(e) The most important parts of the pathological conditions of puerperal fever are the states of vital power and of vascular tone characterizing the disease, inasmuch as these states, more than the seat and amount of local lesion, mark the kind and tendency of the malady, and either resist or remarkably fa- vour the extension of the local changes.—(/) According to the mode of operation of the ex- citing causes, or to the avenue by which these causes invade the frame, either the constitu- tional infection or the local affection may be primary ; but, whichever may be secondary, an aggravation of the primary disorder will be pro- duced by it, the one reacting upon and increas- ing the other until disorganization and death result, if the procession of morbid actions be not arrested by agents capable of changing the states of vital power and vascular action, and of enabling them to resist farther alterations, as well as to restore those which have already taken place.—(g) A due recognition and esti- mation of the states of vital power and of vas- cular action are the basis on which a rational treatment of puerperal fevers should be placed, inasmuch as it is by means of agents affecting these especially that we are enabled to arrest the progress of the malady, and to resist the extension, and even to remove the effects of the local disease. 261. X. Treatment.—It is obvious that, in order to be successful, the treatment of puer- peral fevers should be appropriately assigned to each of its forms ; and that, as these forms are characterized not only by different, or even op- posite states of vital power and of vascular ac- tion—by very different pathological conditions —so the treatment should be assigned accord- ingly. Has there appeared in the numerous works on puerperal fevers, or in the still more numerous productions on the diseases of fe- males, either a due estimation of the different forms of these fevers, or a satisfactory exposi- tion of the treatment suited to each form, sup- posing that the forms and states of these fe- vers are there dnly set forth 1 Let the reader, who may be supposed to be excited by a desire to know as much as possible of the opinions of those who profess themselves to be experienced by attempting to instruct others—of opinions of the greatest importance to the community respecting, moreover, the most fatal disease known in this country, and that disease attack- ing only females in the most interesting and most important period of their existence—refer to tho works enumerated at the end of this ar- ERS—Treatment. 585 tide, and then let him answer not only the above question, but also the following two ques- tions : Have these numerous productions, which have appeared since the latter part of the last century, advanced our knowledge of the pathol- ogy and treatment of these fevers in any im- portant particular, or in any way- excepting as respects a few subordinate details 1 Have certain remedial measures, confidently recom- mended many years ago by physicians possess- ed of experience, and capable, by ability and education, of observing and of reasoning with, at least, an average degree of accuracy, been satisfactorily tested, or adopted, or at all ap- propriately employed in those institutions which are most notorious for the generation of these maladies 1 Leaving these questions to be an- swered by those whom they may concern, and suppressing those painful and humiliating reflec- tions which the subject suggests to the minds of those even partially informed as to its ethical as well as therapeutical relations, I proceed, firit, to consider the treatment which my ex- perience has shown me to be most appropriate to the different forms and states of puerperal fever ; and, next, to notice the several methods and means advised by other writers, and the value which I believe to be attached to them. 262. A. The Inflammatory Form of Puer- peral Fever, in its more sthenic manifesta- tions, whether commencing as puerperal peri- tonitis, or hysteritis, or as metro-peritonitis, re- quires the prompt and decided antiphlogistic treatment recommended for inflammations of the Peritoneum (y 137, et seq.) and of the Ute- rus, with a due consideration of previous san- guineous losses or exhaustion of the patient, of the state of her constitution, and of the sev- eral circumstances and symptoms connected with the case. It should not be overlooked that all cases of these inflammatory states of the disease are not possessed of an equal amount of sthenic diathesis ; but that, owing to the nature of the causes, and to the consti- tution or previous state of the patient, the feb- rile disturbance as well as the local affection may approach nearer the asthenic than the sthenic condition, and thus the synochoid or intermediate grade of the malady be nearly ap- proached, if not altogether reached. In these states it may be a matter of doubt as to the ex- tent to which vascular depletions, either gen- eral or local, ought to be carried; or, if they have been already employed, as to the propriety of repeating them. In these circumstances, and especially in large towns, or in a vitiated atmo- sphere, less risk will accrue from the rational adoption of other measures; from a due re- course to calomel and opium, conjoined, in the more asthenic cases, with camphor, to terebin- thinate embrocations or fomentations, and to the other means recommended for peritonitis (see Peritoneum, y 138-143), than from large or frequent bleedings. When the disease com- mences in the uterus, in the form either of[ hysteritis, or of metro-peritonitis, or in the ute- rine appendages, as ovaritis, too large deple- tions may only favour the extension of the in- flammatory action, unless the sthenic diathesis exist, Or the patient be not remarkably ex- hausted by previous losses or inanition. When the local affection assumes an asthenic charac- ter, the most appropriate treatment is that 586 PUERPERAL FEVERS—Treatment. which I have advised for the asthenic form of peritonitis {see art. Peritoneum, y 150), and which is equally suited to the other prominent affections appearing in this and in the syno- choid forms of the malady. 263. B. The Synochoid or Intermediate Forms of Puerperal Fever, however com- mencing—in whatever organ or structure, as fully set forth (y 185, et seq.)—require a treat- ment which should have strict reference to the states of vital power and vascular action ; to the predominance of either the sthenic or as- thenic diathesis ; for, however obvious may be the local seat of mischief, the treatment is not materially or at all different as respects the local affection, especially at an early stage, or until the disease is far advanced. In this form of the disease, especially when commencing with rigours, the early reaction associating the local disease assumes more or less of a sthenic or inflammatory character, which, however, soon passes into the asthenic, especially when the patient breathes a close or impure air, or is morally or physically depressed, or when the veins are more especially affected. In many cases of this form vascular action is often at- tended by great irritation or excitement, and by an expansive or open state of the pulse, indi- cating an alteration in the state of the blood both in quality and in quantity—in quantity es- pecially as relates to the capacity of the vascu- lar system, and to the power of adjusting itself to the quantity of blood contained—and in these vascular depletions are often injurious, whether general or local; and although, in some in- stances, a small or a local bleeding may be of service, yet, if it at all pass a very moderate amount, the most irreparable mischief may en- sue. In this form of the malady, the inflam- matory states of the parts so generally compli- cating it, if not altogether asthenic at the com- mencement, «oon passes into this condition, especially when the treatment is calculated to lower the powers of vital resistance ; and, as vascular depletions not merely possess this property, especially with females confined in lying-in wards, or in the close and impure air of large towns, &.C., but also remarkably favour the imbibition and absorption of the discharge retained in the uterus and sexual passages, the occurrence of uterine phlebitis or lymphangei- tie, and contamination of the circulating fluids, they are most liable to be injurious, and,they ought to be most cautiously and moderately prescribed. 264. a. A large proportion of the cases of this form of puerperal fever originates in imperfect contraction of the uterus, owing to deficiency of vital power, or to the vital depression more immediately following the impression of the infectious or poisonous cause; the imperfect contractions favouring the retention of an un- usually large quantity of lochia within the cav- ity of the organ and in the vagina, followed by changes in this discharge of a septic and con- taminating nature. Thus altered, the lochia not merely affects the surfaces with which it is in contact, but is also imbibed by the vessels, inflaming or irritating them, and altering the blood. With the view of enabling the uterus to throw off the coagula and fluid which may be retained in it, I have advised, in cases where the contraction of the organ after delivery ap- pears to be weak or imperfect, those remediea which are most calculated to produce or to promote a tonic or contractile action of the womb. With this intention, I have directed the early application of the infant to the breast; and, if the uterus fails to contract sufficiently, an occasional dose of the biborate of soda, oi of ergot of rye, or an enema containing spirits of turpentine with asafoetida. When, there- fore, the disease commences thus locally, the cause is, owing to the circumstances just sta- ted, more or less septic or contaminating, al- though the vascular reaction may be consider- able, when the strength and habit of body of tho patient are capable of developing it; and the lo- cal effect produced by this cause is generally of a diffusive kind. Admitting that the effect produced locally by this cause, or by any other calculated to occasion it, is of an inflammatory nature, the question still remains, Is the inflam- mation of a sthenic or asthenic nature, or to what amount may it be supposed possessed pf either of these characters 1 That it is not purely sthenic inflammation of the parts, is shown by the state of the pulse and other con- stitutional symptoms, and-especially by the rapid extension and consequences of the local mischief; and that it is either wholly asthenic, or largely possessed of this property, is proved by the constitutional disturbance, by the rapid diffusion of the local affection, and by the prod- ucts of such affection. As it has been demon- strated by John Hunter, and confirmed by all subsequent observers, that asthenic or diffusive inflammations, and inflammations of circulating vessels, are not arrested or even mitigated by general vascular depletions, and hardly even by local depletions, but that they are aggravated in their most distinctive characters and conse- quences by this treatment, more especially by venesection, it is a matter of the utmost im- portance that some other than this most abused means should be resorted to. Cases, however, may occur where a nearer approach to sthenic inflammatory action, and a more robust and plethoric state of the patient may warrant a re- course'to a moderate depletion ; locally in pref- erence, and early in the attack, especially when it is followed by the remedies about to be men- tioned ; but cautious observation and experi- ence should direct this measure, too often reck- lessly prescribed by the insufficiently informed, or by the followers of worthless authorities, not a few of which have appeared in recent times. 265. Whether this form of the disease origi- nate in the uterus or uterine vessels, or in the uterine appendages, or in the peritoneum, aa shown, both here and in other places, to be probably the case in many instances; or wheth- er it proceed from a cbnstitutional infection re- ceived through the avenue of the respiratory organs, the local affection or affections being secondary or contingent, as contended for in respect of other instances (y 245, et seq.), there is certainly no remedy so efficacious as a de- cided and judicious use of spirit of turpentine, This medicine was first employed for this dis- ease by Dr. Brenan, of Dublin ; and although it has been " damned by faint praise" by sub- sequent writers, who either have not had re- course to it, or have employed it insufficiently or injudiciously, I can assert that it is the roost efficacious remedy that can be employed in this PUERPERAL FEVERS—Treatment. 587 form of puerperal fever. I state this from a lengthened and diversified experience of this substance in disease; and yet in England I know not of any other physician than myself who has given it a satisfactory trial in puer- peral fever, even up to the present day. I state this, in order that the remark may be disproved as regards the knowledge of others, and that I may be enabled to record the fact. The chief hinderances to the employment of this sub- stance are, 1st. A mistaken view of the nature and consequences of its operation ; 2d. Its nau- seous or unpleasant effects ; and, 3d. The opin- ion that it cannot be retained by the stomach when nausea and vomiting are complained of. As to the first of these, I can assert that it is, according to the mode of its exhibition, anti- phlogistic in acute inflammations, and more ef- ficacious in arresting the progress and conse- quences of asthenic or diffusive inflammations than any other substance; while it possesses the property of accommodating, by its tonic and astringent operation, the vascular and capillary system to the state and amount of its contents, Of lowering the frequency of the pulse, and of restraining effusion from serous and mucous surfaces. That it is unpleasant, and that it is sometimes thrown off the stomach, tadmit; but in many such cases it is beneficial never- theless, its emetic action, independently of the impression produced by it on a vital organ, oc- casionally being of service, and even actually required. In those cases where the irritability of the stomach is even the greatest, it not only is the most easily retained, but is actually the most efficient remedy for the removal of the irritability, which, in the opinion of many, is the chief reason against a recourse to it. But the exhibition of it by the mouth is often not the only, and sometimes not the most beneficial way of prescribing it; for it may also be ad- ministered in enemata, or applied externally and occasionally, according to the nature of the case, even more efficaciously than in any other mode. 266. Although the spirit of turpentine may be more efficaciously employed in this form of puerperal fever than in the more sthenically in- flammatory or in the malignant, still it is a val- uable remedy, also, in both these extreme forms; in the inflammatory after sufficient vascular de- pletions, aided by other means, as described When treating of inflammation of the Peritone- um (y 141, et seq.); and in the malignant, as will be shown hereafter. In this, the interme- diate state of the malady, whether commencing locally or with a constitutional infection, this remedy is most beneficial when employed early, or before effusion into serous cavities, or soft- ening or disorganization of the tissues has made much progress. In this, as well as in other forms of the malady, success depends upon a prompt recourse to treatment. If even a few hours elapse from the invasion, changes beyond the reach of remedies may hare already super- vened. If the symptoms and circumstances of the case, and especially the state of the pulse, indicate the propriety of a small or moderate venesection, or of local depletion, this should be immediately adopted ; if the latter mode of depletion be preferred, a number of leeches, varying with the peculiarities of the case, may be applied near the seat of tenderness and pain ; and when they come away, flannels wrung out of hot water, and freely sprinkled with spirits of turpentine, should be applied over the abdo- men, and Covered by oiled silk or by a napkin ; or the spongio-piline may be employed instead of these; and contemporaneously with the ap- plication of leeches, a full dose of Calomel, cam- phor, and opium (calomel, gr. v.-viij.; cam- phor, gr. iii.-vj.; and opium, gr. ij.) ought to be given. A few hours after this medicine has been taken, about half an ounce of spirit of tur- pentine, and, if the bowels are not freely open, an equal quantity of castor oil should be taken on the surface of an aromatic water, er on spearmint water, or on milk, or in a cup of cold coffee. In most instances the intention is not so much to evacuate the bowels, for they are often sufficiently open, as it is to exhibit a rem- edy which is calculated, by its passage into the circulation, at least partially to resist the chan- ges taking place in the blood and vascular sys- tem generally; and, at the same time, to pro- cure the discharge, both from the bowels and from the uterus, of such morbid matters as would be inevitably most injurious if retained even for a short period. In prosecution of this intention, therefore, an enema containing spir- its of turpentine should also be administered some hours afterward; the quantity of this sub- stance, the medicines conjoined with it, and the time of having recourse to it, depending upon the peculiarities of the case. If the bowels are too frequently acted upon, castor oil should not be conjoined with it, either when taken by the mouth, or administered in a clyster; but olive oil may be substituted. Indeed, the lat- ter may be very advantageously given with the spirit of turpentine in almost every state of the disease ; for if the bowels should be too relax- ed, the compound tincture of camphor or laud- anum, or sirup of poppies, may be added ; and emollients or demulcents may be made the ve- hicles for its administration, with olive oil, in enemata. The repetition of these medicines, of the turpentine more especially, the quantity of each,.and their combinations, must necessa- rily depend upon the acumen and experience of the physician, upon the appropriate use of them, and upon the effects produced. But, with their internal employment—by the mouth or in clysters—a recourse to the turpentine em- brocations or stupes should be persisted in as Jong as tenderness^pain, or distention in any part of the abdomen is complained of; and the above dose of turpentine should not be given by the mouth oftener than twice or thrice at the most. 267. If the urinary organs should become af- fected, either by the quantity of turpentine pre- scribed, or by its retention by the alimentary canal, the effects will soon disappear if demul- cents are freely exhibited; and, if much de- pression be experienced, either from the opera- tion of this medicine or the state and period of the malady, restoratives, such as quinine with camphor and capsicum, or wine taken in Selt- zer water, or opium conjoined with aromatic stimulants, &c, may be administered, accord- ing to the state or urgency of the case. 268. b. Metro-phlebitis is one of the most fre- quent complications of this form of puerperal fever, although it is rarely recognised at an early stage. But, if recognised, should the 588 PUERPERAL FEVERS—Treatment. treatment be different from that now recom- mended for the arrest of this serious state of the malady? I believe that no other plan of cure will be found more beneficial for it than that now advised; that no other than power- fully restorative, tonic, and soothing means will be found beneficial in this form of phlebi- tis, or, indeed, in any other form. Dr. R. Lee, who has attached so much importance to me- tro-phlebitis as a pathological condition of pu- erperal fever, adds nothing to the treatment of this condition, and is even unaware of the means recommended, with great propriety, and often with great success, by John Hunter in cases of phlebitis. Dr. Lee gives us no farther information on this topic than to profess his want of confidence in the use of mercury for this state of the malady. Hunter's treatment of phlebitis was powerfully tonic, stimulant, and restorative, and he directed it with the view— correct both in pathology and in therapeutics— cf enabling the vessels of the diseased part to throw out lymph capable of coagulation, and of assisting the powers of life, by these or oth- er means, to resist the progress and to retrieve the consequences of the disease. Of the use of oil of turpentine in this malady, Dr. R. Lee entertains a most unjust opinion. I question much the fact of his having given it a satisfac- tory trial. He distrusts the evidence furnished by Dr. Brenan's cases, is not convinced that the lives of those to whom it was administered were saved by it, and says that he has seen many recover without turpentine, in whom the Bymptoms were more unfavourable than in the cases described by Dr. Brenan; and that he has seen other patients in whom the disease appeared to be aggravated by its use. Now it would have been most desirable if Dr. Lee had favoured his readers with an exposition of the treatment which was so fortunate as to restore many cases in which the symptoms were more unfavourable than in those described by Dr. Brenan, seeing that in those turpentine had not been used; " sed de non apparentibus et non existentibus eadem est ratio." Having my- self since 1815 prescribed this substance in nu- merous diseases, malignant, febrile, and inflam- matory, and having for manyyears—since about the above period—employed it in puerperal dis- eases, I have been induced to make inquiries t respecting its use by other physicians; and yet, notwithstanding the notoriety of the practice, and its undoubted success if duly and appro- priately prescribed, I have not heard of its hav- ing been employed by any other physician in this metropolis besides myself. This is some- what singular, when the general fatality of the disease, and the highly favourable reports of the practice which have been made by Dr. Bre- nan, Dr. Douglas, and myself, are considered. What are the obstetric practitioners, who ap- propriate the treatment of puerperal diseases, about? Should the obstetrician cease to be physician, in respect of liberality and candour of sentiment, and of a due appreciation and adoption of remedies recommended by others? 269. Let the opinion given by Dr. Douglas, in an excellent memoir on puerperal fever, be the answer to this question as regards the rem- edy in question. He states that, in the epidem- ical and contagious puerperal fever, 3iij. of the turpentine should be given, with an equal quan- tity of sirup, and 3vj. of water, three or four hours after the first dose of calomel; and that after an hour this should be followed by an ounce of castor oil, or some other purgative; or the turpentine and castor oil may be given together; and he restricts the internal use of turpentine to twice only. I have, however, given it even in a larger dose—in half an ounce —thrice in the same case, besides administer- ing it in enemata and externally, with complete success; although I have found one or two doses more generally sufficient. "The exter- nal application of turpentine," he adds, "with- out either its internal use or the aid of blood- letting, I have frequently experienced to be en- tirely efficacious in curing puerperal attacks; and although I have hitherto omitted to speak of turpentine for the cure of the other varieties of this disease, yet I should not feel as if I were doing justice to the community if I did not decidedly state that I consider it, when ju- diciously administered, more generally suitable, and more effectually remedial, than any other medicine yet proposed. I can safely aver, I have seen women recover, apparently by its influence, from an almost hopeless condition, certainly after every hope of recovery under or- dinary treatment had been relinquished." (Dub- lin Hosp. Rep., vol. iii, p. 157.) 270. Now, without referring to my own ex- perience and authority in the matter, and to the statements of that experience which have ap- peared in various quarters, I may remark that Dr. Buenan's publication was in 1814, and Dr. Douglas's statement, now quoted, was made in 1822; and yet, unless in those cases for which I prescribed this remedy in Queen Char- lotte's Lying-in Hospital, I am not acquainted with any sufficient trial which has been made of turpentine in any of the lying-in wards of this city. The eminent senior physician to the General Lying-in Hospital, writing in 1839, re- marks as follows:- "I have no experience of the use of this remedy (turpentine) introduced by Dr. Brenan in 1814, and praised by Dr. Doug- las of Dublin, and Kinneir of Edinburgh, in pu- erperal fever." 271. C. The Malignant or Putro-adynamic Form of Puerperal Fever (y 198, et seq.), if not recognised at its commencement, and promptly treated, is always fatal. If even a few hours elapse from its seizure, the changes which have already taken place in the fluids, and even in the vital cohesion of the structures, are rarely arrested in their onward course by any treatment. The means of cure should therefore be early, promptly, and decidedly em- ployed. When thus prescribed they are gen- erally efficacious; at least they proved so in several outbreaks of this form of the malady in Queen Charlotte's Lying-in Hospital, espe- cially when I had the advantage of the assist- ance of an intelligent resident pupil. In one of the most severe of these epidemics I had the aid of Dr. Voweles, an intelligent and well-ed- ucated young physician, who was constant in his attendance, and who, immediately upon an attack, had recourse to the treatment about to be recommended, varying it according to my directions with the peculiarities of the case and the effects produced by the early part of it. On this occasion almost every case recovered. When I was first called upon to prescribe for PUERPERAL FEVERS—Treatment. 589 this disease in the hospital, the most malignant form prevailed, and every case that had occur- red had terminated fatally. I first had recourse to Doulcet's plan of giving emetics, but it fail- ed, probably owing to my being called at an ad- vanced period.of the disease. Having frequent- ly employed the spirit of turpentine in the more malignant states of fever, and being aware of Dr. Brenan's recommendation of it for this malady, I next prescribed this substance, both by the mouth and in enemata, trusting to it principally; but without obtaining from it all the advantage's which I had expected. It should, however, be stated, that frequently I was not called to a case until it was far advanced. I was next induced, by my experience of the ef- fects of large doses of calomel and opium in some acute diseases, to try the effects of these; but they still more signally failed. I afterward had recourse to both modes of treatment, and prescribed every four, five', or six hours a large dose of calomel and opium, and the spirit of turpentine with castor oil, the turpentine be- ing employed both internally and externally. From this practice more success accrued than from either of the plans adopted singly. Yet as the success did not equal my wishes, and reflecting upon the phenomena, pathological conditions, and structural changes of the dis- ease, I resolved upon trying the effects of cam- phor in large doses, in conjunction with calo- mel and opium, and sometimes with opium alone, or with quinine-and capsicum, omitting the calomel, aided by the turpentine, in the manner about to be stated, and upon preceding these by an emetic when ifs use was indicated by the symptoms. 272. Immediately upon the accession of the disease, or as soon afterward as possible, from ten to twenty grains of calomel, from eight to sixteen grains of camphor, and from one to three grains of opium were administered in the form of bolus, with conserve of roses, the quantities of these medicines thus varying with the appa- rent severity of the case and the state of the pulse. In some instances, when vital depres- sion was extreme, or the disease farther ad- vanced, the camphor was conjoined with capsi- cum and opium, and occasionally either with ammonia or with sulphate.of quinine, the calo- mel being omitted. The above were the ex- treme doses of the camphor, calomel, and opi- um ; and when the largest quantities were given, five or six hours were allowed to elapse before they were repeated. If smaller doses were given, three or four hours only were some- times allowed to pass. Soon after the second exhibition of these medicines, about half an ounce of spirit of turpentine, with or without castor oil, according to the state of the bowels, was taken as above directed ; and a few hours afterward a larger quantity was administered in an enema, with castor oil or with asafoetida, and demulcents or emollients, as circumstances euggested. The intention was to make a strong impression on the constitution by means calcu- lated to arrest the morbid action, and to coun- teract the changes taking place in the blood. Very soon after the development of the abdom- inal symptoms, especially the pain, distention, and tenderness, several folds of flannel, suffi- cient to cover the whole abdomen, were di- rected to be wrung as dry as possible out of hot water, sprinkled very freely with turpentine, and applied as already described. This application was renewed at intervals, if the progress and symptoms of the case required a recourse to it. 273. In two or three hours after the treat- ment had advanced thus far—or after one or two of the boluses had been taken, and one dose of the turpentine and an enema adminis- tered—the symptoms had generally much aba- ted, if these means had been early employed. Jn this case the doses of the camphor, calomel, and opium, or of the other combinations of which the bolus was composed, were diminish- ed, and wine also given at the longest intervals above mentioned. The turpentine draught was seldom prescribed oftener than twice, and one only was taken in the twenty-four hours. It sometimes also contained an aromatic spice, as capsicum, &c. If the enema was soon thrown off, another was sometimes administered a few hours afterward, and the fomentation was re- newed. If the malady resisted the first or sec- ond doses of these substances, the bolus was repeated a third, and sometimes a fourth time after the longer intervals, and in a few in- stances a third dose of the: turpentine was or- dered ; or the enema containing it was repeated and conjoined with other medicines, according to the state of the bowels. If vital depression was extreme, the turpentine was given in small doses or withdrawn, and capsicum, or carbonate of ammonia,- was taken in the bolus instead of the calomel; and a dose of decoction of cin- chona, with chlorate of potash, carbonate of soda, and the compound tincture of cinchona or tincture of serpentaria was ordered in the in- tervals. If the lochia were very offensive, in- jections containing the solution of chlorinated soda were employed; and the same solution, or a solution of chloride of lime, was used in the wards. 274. If the symptoms evinced marked biliary disturbance or congestion, and the other indi- cations, for the exhibition of an emetic were present (y 278), fifteen grains of ipecacuanha were given immediately and previously to the first dose of calomel, camphor, and opium ; and the free operation of the emetic was promoted by the repetition of the same dose in an hour, and by the infusion of chamomile flowers. The emetic generally procured the early evacuation of much altered bile, both by the stomach and by the bowels, and also caused a copious sweat, which the camphor and Opium farther promo- ted, and the terebinthinate embrocations on the abdomen tended to encourage and to perpetu- ate. But of the use of emetics in these cases I shall take farther notice in the sequel ($278). 275. When the above treatment was era- ployed early, or before either effusion into the peritoneal cavity or other structural change had supervened or made any considerable progress, it was generally successful both in preventing or arresting these changes, and in resisting far- ther alterations of the blood, as well as in re- moving such as may have already taken place, by increasing the depurating actions of the sev- eral excreting organs. The successful em- ployment of the above means required the con- stant attendance of an intelligent assistant as well as the frequent visits of the physician. During the prevalence of the disease I visited the cases three or four times in the day, direct- 590 PUERPERAL FEVERS—Treatment. Ing the repetition, succession, or modification of the above remedies, according to their ef- fects or to circumstances. If beneficial results did not follow after a very few doses—after the repetitions of the medicines as now stated—or if they did not appear in from twenty-four to forty-eight hours after their first exhibition, the patient rarely recovered. In some extremely malignant cases, for which I did not consider the calomel to be indicated, as well as in others which I did not see sufficiently early, I pre- scribed camphor in large doses, with capsicum and moderate doses of opium, and sometimes also in conjunction with the sulphate of quinia, which, at the time of the.occurrence of these worst cases, was coining into frequent use. In some of these very hopeless cases these means, aided by an occasional dose of turpentine, given either by the mouth or in an enema, and by the external application of this substance, proved almost unexpectedly successful. In others, however, a temporary check only appeared to be given to the disease, the duration of this im- provement being seldom longer than a few hours ; these cases suggesting the conviction that the changes observed after death had ad- vanced too far to be removed by the agents employed in medical practice. Of the other means which were occasionally tried in this and the preceding varieties of the disease, mention will be made in the sequel. 276. B. Remarks on several Means of Cure, &c.—In many of the works which have appeared on puerperal fevers some particular remedy or method of cure has been recom- mended, empirically rather than conformably with rational views of the pathology of these diseases; and in most of these the treatment, which seemed, in the eyes of those recommend- ing it, successful to an extent which satisfied their expectations, was lauded as altogether applicable to all appearances of these maladies which may hereafter occur. But while each held forth his own method as most worthy of adoption, other methods, which had been equally praised by equally sanguine predecessors, met with little approbation, if, indeed, they escaped a complete condemnation. It would neither be gracious nor profitable to trace the various dif- ferences of opinion as to the treatment of these diseases to their sources; for some of them may be referred to those imperfections of our nature, which medical practice is calculated to develop and to foster when not directed and elevated, in its ethical relations, by the higher and more generous sentiments; while others may appertain to the very different forms of these maladies in different occasions, circum- stances, and epidemic constitutions. With no marked disposition to jb skeptical on the one hand, or to be credulous on the other; not dis- posed, with saintly faith, to place much confi- dence in that which I cannot explain, or to be- lieve in what appears impossible, still I cannot al4em.pt to set limits to the operations of na- ture, or to the influence of mind and its numer- ous manifestations on the vital actions. What may appear now as at least improbable may hereafter be found to be entirely in agreement with some principle hitherto concealed from our superficial knowledge. The unknown may seem difficult, complex, unfathomable, and even unattainable, but, once known, it may be easy, simple, obvious, and within the reach of everj intellect. The malady which Is found to-day fatal, malignant, and pestilential may be proved to-morrow to be possessed of these properties only in virtue of our ignorance, and of our en- deavours to encounter a formidable calamity by complex and ill-understood means ; simpler agents, promptly and efficiently applied, accom- plishing the ends, with a direct and beautiful simplicity, which were attempted, under the de- lusions of "false science," by multiplied and inappropriate measures and jarring influences. 277. a. Vascular depletions and other antiphUh gislic measures were advised for these fevers at an early stage by Hulme, Kirkland, Gordon, Horn, Armstrong, Campbell, Macintosh, and others; and, while some carried these deple- tions to a great extent, others recommended greater circumspection ; while a still greater number of writers prescribed very different or opposite measures. All were equally sincere, and all equally erred ; all applied, as true of the genus, what was true only of the species; for, as I have shown above, there are sthenic inflam- matory, asthenic inflammatory, and malignant or putrid states or forms of the malady, this last state having no inflammatory attribute what- ever, and to each of these different or opposite means are requisite. In the first of these, vene- section, carried to an amount which can be truly assigned only by the closely observing physician to the peculiar circumstances of each case, is absolutely necessary ; in the second of these forms, local depletions, by a number of leeches, are only contingently required, and often then with a caution which should never be laid aside ; and in the third, vascular deple- tions of any kind are certain agents of destruc- tion. Thus the different forms of the malady, depending upon very different states of vital power, of vascular action, and of constitutional disturbance—upon different pathological condi- tions—occurring at different periods and in pe- culiar circumstances, required very dissimilar methods of cure, the method which is quite ap- propriate to the one form being inappropriate to the others ; the great error of writers being their recommendations of what they found most beneficial in their limited sphere of observa- tion, and in the short period of their experience, for all other outbreaks or manifestations of these fevers, without reference to form, charac- ter, or epidemical constitution. There is one circumstance connected with the employment of leeches in the more asthenic states of this malady which should always be kept in recollec- tion, namely, the difficulty of arresting the hem- orrhage from them, owing to the states of the blood and the itnpaired tone of the capillaries and tissues. Many years ago, when all cases of this disease, under the delusions created by those who, in the fulness of their ignorance, rushed into reckless print, were treated by bleed- ing of some kind or other, a large number of leeches were applied over the abdomen of a patient, and, upon these falling off, were fol- lowed by a warm fomentation. When this fomentation was looked to after a time, she was found lying dead in a pool of blood. In another case, which occurred in the hospital, leeches were prescribed by one of my colleagues, and the night-nurse who was left to attend to them fell asleep ; and although no long pcrioJ could PUERPERAL FEVERS—Treatment. 591 have elapsed, the patient was found dead when she awoke. These facts prove not only the risk of copious hemorrhage from leech-bites in certain states of the disease, but also the im- propriety of having recourse to them in these states, when even a small loss of blood may oc- casion fatal sinking. 278. b. Emetics had at one time a great reputa- tion in the disease, and have received the com- mendations of Willis, White, Doulcet, Bang, Lentin, Walsh, Le Roy, Hufeland, Osiander, and Desormeaux ; while Kirkland, Horn, R. Lee, and many others are opposed to the exhibi- tion of them. Ipecacuanha has generally been preferred as the emetic substance, and is cer- tainly most deserving of adoption whenever a trial of this practice may be determined upon, although it may be conjoined with other sub- stances. Among the experienced writers fa- vourable to ipecacuanha emetics, Doulcet is most distinguished. Observing, in 1782, that the disease often commenced with vomiting, he viewed this as an indication of nature, and he assisted her efforts by giving fifteen grains of ipecacuanha, which were repeated the next day. " The patient recovered. This unexpected suc- cess led him to try it on all the rest, apd two hundred were saved, while six, who refused to take the emetic, died. This treatment, when methodized, consisted in giving fifteen grains of ipecacuanha, repeated in an hour. The last dose acted generally on the bowels, an action which he sustained by a potion, consisting of olei amygdal., 3ij.; sirupi malvae, ?j..; kermes mineral, gr. j. M.; a table-spoonful of which was taken every two or three Jiours. He re- peated the emetic the next morning if the symp- toms were alleviated, and the father if they were not. If the belly remained meteorized and painful for several days, he looked upon it as a reason for persevering. The previous devasta- tion of the malady, and the consequent despond- ency in the practitioners of France, caused the news of Doulcet's success to be hailed with enthusiasm throughout the kingdom. Trie gov- ernment compensated the discoverer largely. TheFaculty of Medicine drew up minute instruc- tions for this mode.of treatment, and distribu- ted them gratuitously over the whole of France. On the following year the malady was once more epidemic, ahd the remedy of Doulcet re- sorted to in full and earnest faith, but this time it was quite unsuccessful." Dr. Ferguson-, from whose work I have now quoted, justly remarks, that the failure arose from want of discrimina- tion between the varieties of this malady, and from applying in all cases that which is useful only in some. The evidence in favour of emet- ics is quite as great as that for bleeding or mer- cury ; and it is not supported merely by Doul- cet's remarkable success, but by the experi- ence, also, 0fRlCHTER,CRUVEILHIER,T0NNELLE, and Desormeaux. The question is, however, What are the cases to which this remedy is appli- cable? When there are nausea and vomiting on the accession of the disease ; when there is bilious vomiting or diarrhcea, with bilious or dusky suffusion of the skin, or signs of con- gestion of the liver; when the upper regions of the abdomen are the earliest or ehief regions affected ; when the invasion of the attack is unattended by rigours; and when the disease presents more of the malignant than of the in- flammatory or synochoid characters, then the early exhibition of an ipecacuanha emetic has proved most serviceable. On the other hand, when the painful symptoms appeared in the hypogastrium, or when the pain and distress of the abdomen were aggravated by vomiting; when the disease had advanced; and when signs of effusion into the peritoneal cavity had appeared, emetics were manifestly contraindi- cated, and were not prescribed. In a few of the most malignant cases which I treated, I pre- scribed, previously to other means, when the patient was seen at the commencement of the seizure, a full dose of sulphate of zinc with powdered capsicum, in order to procure a more immediate operation, and to prevent any con- tingent depression, which I dreaded from the use of ipecacuanha. This last substance I sometimes gave also thus combined. I re- marked, however, that when the ipecacuanha was thus combined, the emetic effect was liable to be prevented by the capsicum, while the operation on the bowels and skin was evidently increased by it. 279. Dr. Ferguson, in his very instructive work, remarks as follows upon this important part of the treatment of this most dangerous malady: " Besides the examples of the utility of emetics afforded by Tonnelle, I have been informed by my friend Dr. R. Maunoir, that his father, the celebrated Maunoir of Geneva, looks on ipecacuanha as the remedy most to be relied upon in the treatment of puerperal fever —a faith founded on repeated experience in an extensive practice. Among the older authors, Willis, White, and A. Petit were advocates for its employment. In our own times, Osian- der and Hufeland in Germany; Recamier, Cliet, Tonnelle, and Desormeaux in France, have all borne their testimony to the signal benefits to be derived from the use of ipecacu- anha as an emetic. It would appear that some seasons, or some portions of the year, are more favourable for its exhibition than others. De- sormeaux first tried emetics in the end of 1828, with great success. During the greater part of the following year they failed ; but their use did not aggravate the.symptoms. In Sep- tember, 1829, being cold and humid, they, were again given with great benefit. Towards the end of October they lost their power, and in No- vember were totally useless. When it is con- sidered that puerperal fevers are often cured, or alleviated, by copious spontaneous perspira- tion, or by purging and vomiting, we ought not to wonder at the success of an agent like ipe- cacuanha, which is capable of producing, and usually does produce, all these effects at once." (Op. cit.,p. 210.) 280. c. Purgatives have been recommended by Hulme, Selle, White^Denman, Stoll, Aas- kow, Leake, Butler, Hey, Chaussier, and oth- ers. Dr. Ferguson states that Cederskiol, a Swedish physician, tried them extensively, and concluded that the more drastic purgatives are prejudicial. This is also the opinion of Bagli- vi and John Clarke. The treatment which I have advised above almost precludes the neces- sity of having recourse to any other purgative medicines than those comprised in the t^ove plan ; for the large doses of calomel, some- times preceded by an emetic, and the subse- quent recourse to turpentine and olive or cas- 592 PUERPERAL FEVERS—Treatment. tor oil, and to enemata containing the same Bubstances, as circumstances may require, are sufficient to answer all intentions as to biliary and faecal evacuations, and to produce at the same time an impression on the economy cal- culated to arrest the progress of the malady, and to augment the functions of the several emunctories. Dr. Ferguson justly remarks, that in the wielding of this remedy, as of every other useful one, the disputants have each ta- citly assumed the universal similarityof all puer- peral fevers—an assumption, I may add, which has been fatal to thousands. His own experi- ence with regard to purgatives is, that when- ever they create tormina, there is the greatest risk of an attack of metro'-peritonitis succeed- ing. In order to avoid this, he invariably mix- es some anodyne—usually Dover's powder, or hyoscyamus, or hop—with the purgative. 281. d. Mercurials in various states of com- bination and modes of administration have been advised for puerperal fevers. Calomel, how- ever, is the preparation generally preferred, and is usually conjoined with opium, as recom- mended by Hamilton, and subsequently by Wolff, Hufeland, and many others. The in- unction of strong mercurial ointment over the abdomen has been suggested by Gebel and J. Davies, who have likewise advised the weaker ointment to be applied over the blistered sur- face of the belly. But the larger doses of cal- omel, as I have employed them above, appear to me most deserving of adoption ; for it is not so much from the specific action of this medi- cine that benefit is to be expected, in many cases, as from the operation of it on the biliary organs, and secretions and excretions generally —by its depurating action on the blood, through the medium of the liver and of the other excre- ting organs. It should not, however, be infer- red that calomel or other mercurials are equal- ly beneficial in all the forms of this malady. They, especially calomel, are most serviceable in the inflammatory varieties—in the sthenic after blood-letting, in the asthenic after local depletions, or after an emetic. In the malig- nant form of the, malady, calomel was most ser- viceable at an early stage, conjoined with stim- ulants and opium, and was employed chiefly with the view of increasing the actions of the liver and other emunctories. It was often fol- lowed by powerful tonics and restoratives. If the large doses of calomel failed early in the disease, they were seldom of any advantage at an advanced stage, although this substance was given subsequently in smaller quantities. When the bowels are irritable, Dr. Ferguson recommends the abdomen to be kept constant- ly covered with the linimentum hydrargyri com- positum. He agrees with Sir B. Brodie in con- sidering the bi-chloride of mercury to be pref- erable when the disease is presumed to be con- nected with uterine phlebitis ; and in this com- plication the bi-chloride may be conjoined with camphor and opium, or taken in a decoction of cinchona, as I have given it in several analo- gous pathological conditions. 282. e. Opium has long possessed considera- ble reputation in the treatment of puerperal fe- vers and peritoneal inflammations. (See art. Peritoneum, y 150-153.) For the former, it has been much confided in by Gebel, Holst, Horn, Michaelis, Bates, &c.; for the latter, by Hamilton, Armstrong, Graves, Stokes, Bates, and others. It has been variously com- bined with other medicines for these states of disease—with calomel, or with antimonials, or James's powder, or with ipecacuanha, or with musk, or with camphor, or with valerian, or with capsicum, &c, according to the views of the physician and circumstances of the case. The influence of opium in these maladies has been very justly estimated by Dr Watson, who truly remarks : " Of the great value of this rem- edy in certain cases, and after sufficient blood- letting (in the treatment of inflammation), I have long been satisfied. I presume its bene- ficial operation is to be explained by its known power of tranquillizing disturbed and uneasy nerves. Mere nervous irritation appears some- times to keep alive or to rekindle inflammation, which depletion of the blood-vessels had almost or for a time extinguished; and opium, given in a full dose, will often prevent this renewal of disturbance in the vascular system, by quiet- ing the nervous irritability. I am, indeed, per- suaded that opium is, of itself, equal to the cure of some forms of inflammatory disease in which bleeding would be improper, the disor- der of the capillary vessels subsiding spontane- ously as soon as the teased and teasing con- dition of the nervous system is allayed. Ac- cordingly, the opiate treatment has been found the most effectual in persons who possess by nature, or who have acquired through disease or intemperance, undue irritability of frame. It is especially useful, also, whenever local in- flammation is attended by, much bodily pain, which in all persons is a source of irritation." It is most satisfactory to me to find my views, as to the pathology and treatment of Inflam- mation (y 7-9 and 206), in accordance with those of so able and discriminating a physician as Dr. Watson. 283. Mr. Bates, of Sudbury, confides chiefly in opium for the treatment of puerperal inflam- mations and fevers. According to one plan, which appears to be directed against the more inflammatory states of disease, he directs bleed- ing from the arm to about a pint, except there be great exhaustion; and an opiate enema, consisting of 3J. to 31'j. of tinctura opii in fxij. decocti amyli calefacti, to be repeated in twelve hours if there be no return of pain, and when- ever there is a renewalof the symptoms. The patient is allowed only barley water or thin gruel, cold, and in small quantity. When the bowels are confined, and after the pain and sickness are removed, and the abdominal ten- derness somewhat abated by the foregoing means, he prescribes the following clyster: R. Vini aloes, 311J. ; magnesiae sulphatis, ?j. ad Iij.; olei olivae, 5J.; aquae calida?, sxij. Miscc. He farther directs bottles of warm water to the feet; fomentations and linimentum sapo- nis cum opio to the abdomen ; and leeches when great tenderness is present. According to another plan, the following bolus is to be ta- ken as soon as possible, and repeated in an hour, and then to be continued every two hours until the pain has ceased. Ease ensues, he says, from the administration of the fifth to that of the tenth bolus; if not, he resorts to the enemata. R. Pulveris opii, pulveris aca- ciae, pulveris antimonialis, aa, gr. j.; confectio- nis rosae caninae, q. s. Misce. Fiat Bolus. PUERPERAL FEV 284. /. Stimulant, restorative, and even tonic remedies have been recommended by several writers, and are more or less serviceable in the more malignant states and far-advanced stages of the disease. I have very often had recourse to them, and almost always in conjunction with opium. The substances belonging to this category which I have most frequently prescri- bed are camphor, as directed above, capsicum, ammonia, and sulphate of quinine. Musk and valerian have likewise been advised, biit com- monly conjoined with opium, by Horn, Mi- chaelis, and others. The ammoniated tincture of valerian I have found of service in some in- stances, variously conjoined with tincture of opium and other medicines, according to the peculiarities of the case. These stimulants and tonics are efficacious in the more malig- nant states of the disease only when given early, in full, large, or frequent doses of opium, in large doses, and aided by the turpentine, as prescribed above (y 266); and after the second or third dose I have not found any benefit de- rived from calomel in these states of the dis- ease, when repeated more frequently. 285\ g. Of other internal remedies recommend- ed for this malady but little notice is required. Calumba has beeh preferred by -some writers when a tonic is required; and alkalies have been employed by Barker and Allan. Borax has been given by Brefeld, Bang, and myself; and it is certainly of use under certain circum- stances, especially in promoting the contrac- tions of the uterus, and the discharge of coag- ula or retained matters from this organ; and thereby removing a cause of the disease, or an obvious source of aggravation and contamina- tion. Boer attributed his success in the treat- ment of an epidemic- appearance of this malady to his use of an antimonial preparation, which was without doubt the well-known James's pow- der, which, when conjoined with opium, or with camphor and opium, is certainly extremely ben- eficial, and when prescribed after vascular de- pletions, in the inflammatory states of the mal- ady, or when given from the commencement in the synochoid or intermediate form, so as to produce copious diaphoresis. 286. h. Of clysters, or enemata, it is unneces- sary to add any thing to what I have already stated. The medicines which are most benefi- cial, when thus administered, are the spirit of turpentine, olive oil, castor oil, opium, camphor, asafoetida, &c, according to the form and stage of the disease. 287. i. Injections into the vagina, and even into thecavity of the uterus, have been recommend- ed by several physicians, and by the author when the lochia is acrid, excoriating, and of- fensive. Collingwo.od, Schmidtmann, Dance, and Tonnelle have advised frequent injections of warm water only, or chiefly. I have seen benefit derived from the addition of a small quantity Of one of the chlorides, or of creasote, to the fluid when the discharge was manifestly offensive. Michaelis directed vaginal injec- tions, consisting of an infusion of valerian and linseed, and they were probably of service in washing away the morbid discharge, and in soothing the irritation of the sexual passages produced by it, the chief intentions which these means are calculated to accomplish. 288. k. It is hardly necessary to notice any III. 38 ERS—Treatment. 593 other external means of cure besides those al- ready mentioned. General warm baths and hip- baths have been directed by several writers ; but there are several difficulties placed in the way of them; and in many of the most severe cases they are either of doubtful or of no ad- vantage. Still they ought not to be entirely overlooked in the more inflammatory states of the malady after depletions, and occasionally in other circumstances, which will suggest a re- course to them, but which hardly admit of de- scription. The application of a large blister to the abdomen has received the approbation ot Goodwin, Michaelis, Hufeland, and J. Da vies, and is certainly deserving of adoption iu sev- eral states of the disease ; although a more im- mediate and decided advantage is derived from the turpentine stupes mentioned above (y 266), especially when early and perseveringly em- ployed. If these cease to be of service, or are insufficient, or inappropriate to certain ad- vanced states of the more prolonged cases, a blister will occasionally be of use. [There are some striking cases on record, where cold water applied to the abdomen has been remarkably efficacious in the treatment of the disease. Al- though no friend to the indiscriminate use of water as a remedial agent, we believe, never- theless, that it is, when judiciously applied, a most powerful remedy, and well worthy of trial in this affection.] 289. C. Prophylactic Measures.—I have al- ready noticed certain topics connected with the prevention of puerperal diseases generally (y 43, et seq.); but there are others more especially relating to the prevention of puerperal fevers that require a very brief notice. Prophylactic measures relate, 1st. To the management of the female during and subsequently to parturi- tion ; and, 2d. To the prevention of foul and contaminated air in the ward or apartment in which she is confined, and to the destruction and counteraction of these and all other infec- tious and contagious agents. — (a) As to the former of these, it is unnecessary to state more than that an officious interference with the par- turient process, violent measures used to hasten it, or the neglect of means to promote it, whsn the efforts of nature are either insufficient or exhausted, the admission of a foul and contami- nated air to the generative organs after parturi- tion, or the retention of such an air or of foul exhalations in the vicinity of these organs, and neglect of due measures of cleanliness and of the frequent removal of the discharge, are cal- culated to cause or to favour an attack of this malady, and, consequently, that a careful avoid- ance of these causes should always be observed. 290. I quite agree with Dr. R. Lee that the administration of acrid cathartics soon after delivery should be avoided, and that the great- est care ought to be taken in performing the requisite operations of midwifery. The hand ought not to be passed into the cavity of the womb unless with the greatest gentleness, when the introduction of it is quite indispensable; and portions of the placenta should be prevent- ed from remaining to become decomposed with- in the uterus. " It is impossible to condemn too strongly the practice recommended by Dr. Gooch, in cases of flooding after the expulsion of the placenta, of passing the hand into the uterus for the purpose of compressing the part 594 PUERPERAL FEVERS—Bibliography and References. where the placenta was attached, and from which the blood is flowing." {Op. cit., p. 113.) 291. (i) The prevention of infection or con- tagion in respect of puerperal fevers can be ac- complished only by the adoption of those meas- ures which I described when treating of Infec- tion (see y 55, et seq.), and by the avoidance of those causes (y 41, et seq.) which are productive of these fevers, as well as of those sources of contamination described when treating of the prevention of Pestilence. The measures rec- ommended in that article are especially appli- cable to the prevention of and protection from outbreaks of puerperal fevers in lying-in wards; and for the purification of these and other chambers, and of the bed-clothes and bedding on the occasions of these outbreaks. To that article I must, therefore, refer the reader, and more particularly to what I have stated at y 77, and when treating of the " Domestic Sources of Pestilence." Bibliog. and Refer.—Willis, De Febribus, cap. 16.— Hake, Dissert, de Febre Puerperarum. Leyd., 1659.—C. Strother, Criticon Febrium, or a Critical Essay on Fevers, 8vo. Lond., 1718, c"h. ix., p. 212.—A. Berger, Dissert, de Febribus Puerperarum. Fran.,-1733.—Hall, Dissert, de Febre Acuta Puerpens superveniente. Edin., 17*5.—Thi- lenius, Med. und Chirurg. Bemerkungen, p. 140. (Insists on the diverse forms of Puer. Fee.).—T. Denman, Essays on Puerperal Fever and on Puerperal Convulsions, Svo. Lond., 1768.—H. Manning, A Treatise on Female Diseases, Svo. Lond., 1771, ch. 20.— N. Hulme, A Treatise on the Puerp, Fever, wherein the Nature and Cause of this Dis- ease are represented in a new Point of View, &c, 8vo. Lond., 1772.—C. White, A Treatise on the Management of Pregnant and Lying-in Women, &c, 8vo. Lond., 1772,— Bang, in Acta Reg. Soc. Med. Hafn., t. i., p. 266, et t. ii., p. 75.—Burserius, Instit. Med. Pract., t. i., p. 519.—T. Leake, Practical Observat. on Child-bed Fever; also, On the Nature and Treatment, &c, 3d ed. 1775.—T. Kirk- land, A Treatise on Child-bed Fevers, and on the Method of preventing them, &c, 8vo. Lond., 1774.—W. Butter, Account of Puerperal Fevers, vy/xdg. Pouls,Fx. Puis, Germ. Classif. — General Pathology. — Semei- . t ology. 1. The arterial pulse is produced by the blood thrown into the aorta by each contraction of the left ventricle. There are three elements which contribute to the production of this phenome- non : 1st. The arterial tubes or vessels which manifest it to the touch; 2d.x The blood, or contents of these tubes, which, upon receiving the impulse from the heart, affect the condi- tion of the arteries ; and, 3d. The heart it- self, which originates the impulse transmitted through the blood to the vessel, and by the ves- sel to the touch. According to the conditions of these three elements or constituents of the pujse—the arteries, the blood, and the heart— and to the various combinations which they may severally produce, will the pulse vary in disease, and even in health, although within a much more confined range. These three con- stituents of the pulse require an individual and particular consideration in estimating the states of the pulse, or, rather, as the causes of these states, and in connecting these states with functional and organic changes—with the manifestations of vital power and action. 2. I. Historical Notices as Tr> the Pulse. —Little mention is made of the pulse by Hip- pocrates ; and Celsus notices it chiefly to re- cord his opinion as to its fallacies. Galen may be justly viewed as the first who attempted to investigate -the pathological relations of the pulse, and he did this at great length. An abridgment of his treatises on this subject has. been made and published by Andrea Lacuna. As far back, probably, as the days of Galen, if not even farther, the Chinese had published treatises on the pulse ; and by means of their acquaintance with it, and by it chiefly, they pre- tended to a knowledge of all diseases. The im- portance attached to the pulse by Galen, and by all the writers on medicine in Eastern coun- tries, in ancient times, appears to have been such as to have given rise to the greatest char- latanry and pretence in the practice of medi- cine. It was supposed in those times, and down to the present day in these countries, that the pulse furnished all the information which the physician required, both as to the seat and as to the nature of a disease; and it was not until past the middle of the seventeenth century that attempts were made by Bellini to 596 PULSE—Physiologic; investigate the subject with some reference to scientific principles; the researches and dis- coveries of Hahvey having opened paths by which the ruins of ancient opinion might be removed, and laid foundations for permanent structures. The publication of Sir J. Floyer's "pulse watch," in 1707, first imparted precis- ion to our estimation of the pulse ; and various conditions of it, possessing much importance in practice, especially as being sources of prog- nosis, were pointed out by Solano in 1731, and more clearly illustrated by Nihell in 1745, in his " New and extraordinary Observations con- cerning the Prediction of Crisis by the Pulse." The subject was farther, pursued by Fouquet. and Bordeu about the middle of the last centu- ry in France, and towards the close of that cen- tury by Heberden and Falconer in this coun- try ; these latter divesting the subject of much of the inanities and puerilities which had be- come connected with it since the days of Ga- len. Although these writers had thrown aside much of the encumbrances under which sound observation was more or less concealed, still correct views as to the states of the pulse were very far from being entertained. Nor could such views be exhibited while the morbid con- ditions—functional and organic—of the heart itself, the prime factor of the pulse, remained hardly or very imperfectly known. 3. II. Physiological Pathology of the Pulse.—Before the various states of the pulse can be duly considered, some notice must be taken of the conditions of each of the three con- stituents of the arterial pulse—of the arteries, of the blood, and of the heart.—A. The Arter- ies, as I have shown in other places (see arti- cles Irritability and Sympathy), are not inert tubes, but living vessels endowed with certain vital as well as physical properties.—a. Their physical properties are chiefly expansibility, ex- tensibility, and elasticity: expansibility in the expansion of their diameters or enlargement of their calibres; extensibility in their elongation to a certain extent during muscular movements, and other causes; and elasticity, or the recovery of their natural states immediately upon the re- moval of the expanding and elongating causes. These properties are possessed by arteries in a very eminent degree, and in virtue of their conformation—of their fibrous coats, and of their serous and dense cellular and connecting tunics. They are evinced to a great extent af- ter death ; but they exist to a greater extent during life, vitality not only endowing these vessels with peculiar properties, but also in- creasing their physical qualities. 4. b. The vital properties of arteries, and which contribute very remarkably to form the charac- ter of the pulse, depend especially upon the or- ganic or ganglial nerves, which not only accom- pany all the arterial trunks and ramifications, but form reticula around them, and are lost in their fibrous and serous coats ; the states of organic nervous energy affecting the vital conditions of these vessels. These conditions or properties are referable to different states of one vital en- dowment, viz., tone or tonicity. According to the state of vital tone will the arteries manifest a greater or less degree of expansion or of con- striction, both when subjected to the sense of sight and when examined by the sense of touch. The expansion and the constriction are al Pathology of thk. states of vital tone, or different states of vital- ity manifested by the arterial system, through the medium or influence of the organic or gan- glial nervous system supplying it, and are ea- sily made apparent by means of various agents; as, by plunging the hand in warm water, a cer- tain increase of the vital expansion of the ar- terial vessels will follow, and the vessel will become full and broad; and by plunging the hand in cold water, the artery will become small and more constricted. In an excellent lecture by Dr. C. J. B. Williams (Lond. Med. Gazette, vol. xxi., p. 594), he observes, that he repeatedly observed the aorta of an ass recently killed contract very remarkably when plunged in cold water; while the pulmonary artery did not contract so much. The vital conditions of the arterial system vary remarkably: 1st. "With the states of vital energy of the whole frame— with the states of constitutional power; 2d. With the influence of agents acting externally or internally on the vessels, the operation of agents varying according as they are thus ex- ternal or internal; 3d. With the conditions of the capillary and venous circulations, and with the freedom from obstacle to the onward trans- mission of blood circulating through the ar- teries. 5. (a) When constitutional or vital power is unimpaired, the arterial pulse then presents a state of healthy or natural tone, modified some- what with the peculiarity of constitution or the amount of vital energy. In these cases the pulse evinces neither broadness, nor expansion, nor softness, nor weakness, on the one hand, nor un- due constriction, hardness, or smallness on the other. It is then possessed only of moderate firmness and fulness, its frequency or number in a given period depending upon the action of the heart. When vital power is reduced, and in proportion to the reduction, is the tone of the artery weaker and rendered soft, compressible, and otherwise changed according to the states of the blood and heart's action (see $ 6, et seq.). When, on the other hand, the vital energy is excited, the state of the vessel is then firm, round, or hard, and otherwise altered with the action of the heart, and the quantity and qual- ity of the blood. Marked modifications in the state of the arteries result from agents influen- cing the conditions of the organic nervous sys- tem ; but these agents frequently also co-ordi- nately affect the heart—both the arteries and the heart; whether these agents affect this part of the nervous system primarily and externally to the arteries and heart, or secondarily and in- ternally to the vascular system, by imbibition and absorption, or through the medium of the blood; the state of the arterial vessels being, in either case, thereby more or less changed, according to the nature of, and the influence exerted by, these agents. The natural confor- mation of the arterial system is sometimes dif- ferent in different individuals, some persons possessing a more pbwerfully constituted state of this system than others, especially in respect of the fibrous coat, the vessels thereby acquiring increased tone, and often a greater degree of hardness or firmness, both in health and in states of excited action. 6. B. The Blood is another necessary con- stituent of the pulse; the uninterrupted column of blood, extending from the commencement PULSE—Physiological Pathology of the. 597 of the aorta to the part of the artery to which the finger is applied when feeling the pulse, be- ing essential to the sensation communicated by the artery to the organ of touch. It is pre- sumed, in our examinations of the pulse, that the states of this column of blood ar^,the same throughout the arterial system, the difference being only as respects the diameter and length of the column, according to the artery which is felt. This, however, is not always the case, as slight modifications will occasionally follow from local determinations, influenced by the state of nervous power, and from local impedi- ments or obstructions to the venous or capilla- ry circulation of a part. But without reference to these modifications, we shall firx! sufficient sources of alterations of the pulse in the condi- tions of the blood circulating through the arterial system. The conditions of the blood which af- fect the pulse are, 1st. Quantity; 2d. Quality, or alterations in its physical and sensible condi- tions, and probably also in its vital states. 7. a. Adverting first to quantity, it is obvious that any deviation from that quantity which is adapted to the capacity of the vascular system generally will affect, in a very sensible manner, the arterial pulse, as respects both the states of the arteries and the contractions of the heart. When there is a due correspondence be- tween the capacity of the vascular system and the quantity of blood circulating in this system, the coats of the arteries will be kept in that state of healthy tension, or tone, favourable to a regular, firm, free, natural, or healthy pulse, varying chiefly in frequency with the state of the heart's action, which will depend upon ei- ther exciting or depressing causes.—(a) When the quantity of blood in the system is excessive, more or less of oppression may be evinced in the state of the artery, as well as either of in- creased or of diminished frequency, much of these changes arising from existing states of vital excitement or depression. Excessive ful- ness of blood, however, may exist, and, being attended by congestion of one of the minor cir- culations—of the lungs, of the liver, or of the sinuses of the cerebro-spinal axis — may not materially affect the pulse. But as this state will not long continue without evincing its con- nexion with either depression or reaction of vi- tal power, so will the pulse, through the medi- um of the heart's action, be slow or frequent, as well as oppressed ; the degree of frequency depending on the heart's contractions, and these contractions depending upon the state of the organic nervous or vital influence, and other causes, to be noticed hereafter. The sensa- tion produced by an artery in cases of.exces- sive vascular fulness I have designated that of oppression, the vessel feeling as if it were kept in a state of tension, or of distention, in the in- tervals between the beats ; and, if the pulse be at the same time much accelerated, an idea suggests itself that the-heart is excited by the load, and, by its more frequent contractions, is endeavouring to disembarrass itself and the vascular system generally; while if, with this state of the artery, the pulse is slow, the notion presents itself that the organic nervous energy actuating the heart is insufficient for the amount of blood circulating through the frame. Under these circumstances, it is found that the ab- straction of blood renders the pulse more free, less tense or oppressed, and more natural, while it diminishes the acceleration in the former cir- cumstances, and increases it in the latter. 8. (b) Deficiency of blood is attended by a very different state of the arterial pulse; the fre- quency of it depending, as in all other cases, upon the cardiac action, and the tone of the vessel very much upon the state of vital power. When the blood is very deficient in quantity, the state of the pulse will depend much upon the power of the vessel, and of the vascular system generally, to accommodate themselves to that deficiency. If the vital or the organic nervous power is not depressed to a very low state, the vessels will evince merely less ful- ness,.or become more constricted or smaller, yet, at the same time, soft or compressible. If vital power is excited or irritated, notwith- standing the, loss of blood, the vessel imparts, with great frequency, much quickness, or sud- denness of impulse against the finger, and great- er constriction. If it be extremely depressed, the pulse may be either rapid or slow, accord- ing to the irritability of the heart, but the ves- sel feels very soft or compressible, the slightest pressure obstructing its canal, while the impulse communicated to the eolumn of blood in the ar- tery is quick or rapid when the heart's action is excited, the vessel feeling as if it were nearly empty between each impulse, and is slow, un- dulating, and weak when the contractions of the left ventricle are much weakened, and ir- ritability exhausted. Much, however, of the changes in the states; of the pulse, with altera- tions in the quantity of blood in the body, is ow- ing not only to the associated state of cardiac action, but also to the quality; to the constitu- tion and states of the blood, physically, sensibly, and vitally. 9. b. The quality of the blood, as well as the quantity, has been shown in various parts of this work (see art. Blood, Disease, Fever, Pes- tilence, &.c.) to be remarkably changed in its sensible appearances, and in its vital states. I have in several places attempted to show that the blood, in addition either to excess or defi- ciency in its quantity, may have either an ex- cess or deficiency of its red globules, or of its fibrin, or of any other of its constituents ; and that it may, moreover, abound in morbid or in foreign matters, owing either to imbibition and absorption, or to imperfect depuration and ex- cretion. Still there are manifestly additional morbid states of this fluid which also affect the pulse, although these cannot be accurately esti- mated in grade or kind : these are the vital con- ditions of the blood, derived from the vessels and body generally, through which this fluid cir- culates. That there is a very intimate rela- tion and even connexion between the vital con- ditions of the vascular system and the consti- tution of the blood, especially of its globules and liquor sanguinis, cannot be doubted; and although the vital slates of the blood are de- rived from or dependant upon those of the vas- cular system, still they react upon this system, especially if they continue for any time, or are not removed by the efforts of the constitution, or by the aids of medicine. 10. During the progress or continuance of changes in the sensible qualities and vital states of the blood, especially as evinced in the course of rheumatic, inflammatory, or of adynamic, 598 PULSE—Physiological Pathology of the. malignant, and pestilential maladies, the pulse can only imperfectly manifest such changes, which usually commence in the nervous and vascular systems, although most apparent in the blood. In cases of vascular excitement, in inflammations, in acute rheumatism, &c., the fibrin of the blood is abundant, and the vital crasis of the coagulum is firm or even increased, and these states may continue after repeated blood-lettings, showing that these changes of the blood proceed from vascular excitement or reaction rather than that the changes in the blood cause the vascular reaction; the condi- tion of the blood being the effect, not the cause of the state of the pulse, which is always more or less quick, sharp, and rapid, owing to the in- creased irritability and irritation of the heart. When, with this state of vascular excitement, there is also vascular fulness, then the pulse will feel full and hard, as well as sharp, quick, or rapid; but if the vascular excitement con- tinues, or is fed by irritation or pain, or by tbe state of organic nervous sensibility and energy, after the vascular system is depleted, or after large losses of blood, then the pulse will be- come sharp, constricted, rapid, and of various grades of tone or strength, according to the nature and seat of the disease, as observed in acute rheumatism, &c. 11. In cases of depressed vital power, or when the organic nervous energy and vascular action are more Or less weakened, as well as other- wise altered, as in the course of malignant, pestilential, or specific maladies, the fibrin of the blood is diminished, the constitution of the haemato-globuline is altered, and the crasis of the blood remarkably impaired. In these cir- cumstances the pulse is affected, and the ex- perienced and close observer may even predi- cate from the state of the pulse the character of the changes proceeding in the blood, although he may not infer their exact amount; but ac- cording to their nature and extent—in propor- tion to the loss of vital power and of the crasis of the blood—will the pulse become open, broad, soft, weak, and compressible, the artery sug- gesting to the mind of the examiner ideas of defective or lost tone, of impaired elasticity, and of relaxation. But With these changes in the vessel others are associated, depending upon the amount of blood and thestate of the heart's action. If the blood be abundant in quantity, in proportion to that abundance will the pulse be full as well as broad and soft. The artery will furnish a sensation of largeness, and feel full and broad, but still soft between each im- pulse communicated by the contraction of the ventricle, the parietes of the vessel feeling as if they yielded to the impulse, especially if the heart's action be excited. If, on the other hand, the amount of blood be deficient, the pulse is not only soft, weak, relaxed, or open, and very compressible, but the vessel feels to the examiner as if it were nearly empty between each wave of fluid undulating through it, the impulse of each wave bejng quick or sudden while the heart's action continues excited, but weak, or languid, or slow as the irritability of the heart becomes exhausted. The action of, the heart will be noticed hereafter; but it may now be stated that, in these as well as in many other circumstances, to it belong those changes in,the number of the pulse in a given time with the qualities of quickness, sharpness, or sudden- ness of the impulse of the column of blood against the parietes of the vessel where it is pressed upon by the finger, or with the opposite qualities of languor, weakness, smallness, &c, according to the excited, or weakened, or near- ly exhausted irritability of this organ. 12. C. The Heart furnishes, besides/regency, several other qualities, as already noticed, to the pulse. The influence of the heart on the pulse is, 1st. Functional, or dependant upon the strength or weakness of the contractions of the organ, and upon the grades of irritability pos- sessed by it; and, 2d. Structural, or owing to lesions in the parietes of the cavities, or in the valves or orifices of the heart.—a. The func- tional influence of the heart.on the pulse varies with different diseases, as these diseases are characterized by excited or' increased organic nervous energy and vital power, and increased irritability of muscular and contractile parts on the one hand, or by impaired or exhausted power and irritability on the other. The heart being, by nervous supply from the ganglial and cerebro-spinal nervous systems, and by mus- cular structure and Vascular connexions, inti- mately associated with all the vital functions, is not only influenced by these functions, but also influences them. But whatever may be the state of the heart's action, thus influenced and influencing, the frequency and the character of the impulse communicated to the column of blood in the artery is produced by the contrac- tions of the left ventricle. When the actions of the heart are unimpaired in tone or in strength, if the irritability of its structure is un- exhausted, the frequency of the pulse is seldom very great, although the excitement may be very considerable. In strongly constituted per- sons the pulse seldom rises above 100 in a minute, even during inflammations; and it is only as the excitement.or irritation becomes associated with diminution of vital power—this latter always gradually supervening upon, and increasing with the continuance of excitement or irritation—that the pulse becomes very fre- quent, or much above 100. In delicate, sus- ceptible, or nervous females especially, the pulse is often very rapid during nervous excite- ment ; or in various febrile or inflammatory diseases, or in state's of irritation ; but in them power is deficient, and although the irritability of the heart is readily excited, it is the more rapidly exhausted. 13. But frequency of pulse may be occasioned not only by nervous excitement, by increased irritability, or by febrile or inflammatory action, but also by losses of blood, and by the want of due correspondence between the quantity of blood and the capacity of the vascular system in general. It is difficult, however, to deter- mine whether or not,the increased frequency be caused by this want of correspondence, and the efforts made to compensate for deficient quan- tity by accelerated motion, or by augmented excitability consequent upon the loss of blood. Most probably this latter effect is that which is immediately caused by this loss; the former effect, or the compensating influence of accel- erated motion, being the result of exalted ex- citability. But the acceleration of the heart's contractions caused by losses of blood has al- ways a more or less obvious relation to the PULSE—Semeiologi amount of such loss, and to the conditions of the blood which remains. If the quantity lost be very great, the irritability of the heart soon becomes exhausted, even although the morbid state of the remaining blood, or other sources of irritation, may tend to excite and to prolong the irritability of this organ. This is evinced by various diseases for which large vascular depletions are. ordered, and by acute or active hemorrhages, &c. At the commencement of the former of these, while the vascular system is full, vital energy excited, and the blood un- contaminated, or at least not very materially altered, the pulse is full, firm, or strong, and not remarkably frequent, the contractions of the heart being energetic, without abruptness or quickness. After a considerable loss of blood the pulse becbmes soft, the impulse of the col- umn of blood against the wall of the artery pressed on by the finger much more frequent and more abrupt, and the vessel is felt more empty in the interval between each impulse. The contractions of the ventricles are more frequent and sudden, because the excitability of the organ is at first increased, probably, not only in consequence of the loss of" power, but, also, owing to the state of the blood supplied to the structure of the heart itself. If still more blood be lost, the constitution of the re- maining blood is more or less altered, the pulse becomes more accelerated, more abrupt and quick, softer,, smaller, or more compressible ; the contractions of the heart more numerous and abrupt, but much less energetic; and if the patient be not aided,.or if still more blood is abstracted, the action of the heart becomes weaker and.weaker; in some cases so frequent as not to be counted ; in Others as remarkably slow, according to the states of the remaining blood, and of the organic and cerebro-spinal systems, by which the vital properties of mus- cular structures, irritability, and excitability are developed and influenced. 14. A somewhat similar procession of changes in the pulse follows acute hemorrhages. Du- ring the vascular excitement often preceding the loss of blood the pulse is very full, more or less frequent, and often bounding, the impulse of the column of blood against the walls of the vessel apparently exciting a reaction, or de- veloping the elastic property of the artery. In- this case the contraction of the ventricle, and the consequent momentum transmitted to the column of blood, is so great or energetic as par- tially to overcome the vital tonicity of the ar- tery, and to manifest the resiliency of its walls; hence the bounding or hemorrhagic pulse. But as soon as blood is lost, particularly if the quan- tity be large, the pulse becomes still more, fre- quent, quicker, or more abrupt, much softer and opener, the vessel feeling more empty, or, at least, much more compressible in the intervals between the abrupt or sudden pulsation. If the hemorrhage be still progressive, and excessive or fatal, the pulse will present changes similar to those just mentioned, modified, however, by constitution, by the seat of hemorrhage, and by the diversified circumstances affecting the pa- tient externally and internally. In many cases, however, commencing in the acute manner de- scribed, a moderate loss of blood, by relieving the vascular system of a load too great for the tonicity of the vessels, and by lowering the in- :cal Notices of the. 599 creased action of the heart, restores this sys- tem and the pulse to their natural states, and, with such restoration, a cessation of the hem- orrhage results. 15. b. The influence of lesions of the heart upon the pulse is necessarily remarkable. But the changes in the pulse which these produce be- long to the diseases of the membranes, the valves, the orifices, and the structure of this organ. (See art. Heart.) These changes con- sist of intermissions, irregularities, smallness, weakness, remarkable slowness, and numerous other states of the pulse, which, however, can never be duly estimated without a close exami- nation of the sounds and impulses of the heart simultaneously with a similar examination of the pulse, and a comparison of the phenomena furnished both by the heart and by the artery. Many of the states of the pulse caused by struc- tural lesions of the heart may also proceed from nervous and functional disorder ; impaired ner- vous power of the organ, with or witbout other functional changes affecting the^ state of the heart or large vessels, so disordering the ac- tions of the ventricles as to produce intermis- sions, irregularity, inequality, remarkable fre- quency or slowness, or smallness, &c, which soon disappear as nervous power is restored, or the functional disorder is removed. A pulse may present intermissions, although the heart contracts during the intermission, the contrac- tion being only too weak to communicate a momentum to the column of blood sufficient to be felt by the examiner, ox the quantity of blood thrown out by the ventricle being too small to produce any manifest change in the column of blood in the artery. 16. III. Semeiological Notices of the Pulse. —Having considered the principles on which our knowledge of the pulse is based, and with due reference to the principal conditions of the three constituents, or elements of the pulse, it may be useful to take ^a brief view of those states of the pulse which attend, and hence in- dicate certain morbid actions, and their several seats. In the view which has just been taken of the elementary principles of the pulse, it has been shown that changes in the vital manifesta- tions of the frame—in the organic nervous en- ergy, in the irritability or excitability of living fibres, and in the quantity and quality of the blood—remarkably and co-ordinately affect the tone of the vessels and the contractions of the ventricle; andV that, while an alteration may originate in any one of the three constituents of the pulse, and affect it chiefly for a time, it will not long exist thus limited, but will impli- cate more or less the others. Changes com- mencing in the blood will affect both the tonicity of the. vessels and the actions of the heart, and generally co-ordinately in grade and in kind. Changes, moreover, originating in the organic nervous system will necessarily extend them- selves not only to the heart, buj; also to the ar- teries, as it is this system which supplies and actuates both heart and arteries, and ultimately to the blood and structures generally ; and the alterations thus superinduced in the blood will react upon both the heart and arteries. Hence, in the course of disease, the pulse becomes a more or less accurate index of the vital condi- tions of the heart, of the vascular system gen- erally, and even of the blood; the indications 600 PULSE—Semeiological Notices of the. furnished by it being accurate, according to the powers of the physician to interpret them cor- rectly, the want of accuracy depending more upon the observer than the object of observa- tion. The pulse varies in diseases, and even slightly in health, as to its development and rhythm. 17.' i. The Development of the pulse differs in different cases, and in different stages of the same case, in force, consistence or tone, and in volume; and according to these differences, and to the various combinations of these, the fol- lowing states of the pulse occur, without refer- ence to frequency or rhythm : 1st. Hard, re- sistent, tense, firm, or sthenic. 2d. Contracted, constricted, or concentrated, and small. 3d. Full, large, broad, ample, or open, and bound- ing, rebounding, &c. 4th. Soft, compressible, empty, weak, feeble, unequal, small, &c. 5th. Precipitate, quick, rapid, sudden, vibratory, &c. 6th. Languid, undulatory, &c. Several of these terms are, however, nearly synonymous, and convey the same, or very nearly the same idea. —ii. The Rhythm of the pulse, in its various grades, is superadded to any of the above, and differs remarkably in frequency, regularity, and inequality, or intermittence. 18. A. A hard, resistent, tense, firm, or sthenic pulse are terms applied by writers to convey nearly the same notion, and are met with, at- tended by more or less acceleration of the pulse, in young, robust persons of the sthenic diathesis and muscular habit, and irritable temperament, during the early stage of reaction in inflamma- tory fevers, in inflammations of serous mem- branes, in acute rheumatism, in inflammations of the membranes of the brain, in the hot. stage of intermittents, and in eccentric hypertrophy of the heart, and when the arterial system is strongly developed. They always indicate the sthenic diathesis, and excited power and ac- tion, and admit of large vascular depletions. 19. B. A contracted, constricted, toncentrated, and small and hard pulse are various terms ap- plied to the same state, and are intended to convey an idea of that pulse which is met with in some cases of the diseases just mentioned, especially when there is less fulness of blood, and which is usually attended with greater ac- celeration of the heart's contractions, and indi- cates a more violent and less favourable dis- ease. This state of the pulse, as well as the foregoing, seldom continues long without pass- ing into some one of those about to be noticed; and it more especially indicates the superven- tion of structural lesion, and a dangerous issue if not promptly or actively treated, especially by moderate and early depletion, diaphoretics, re- laxants, and derivatives. 20. C. A full, large, ample, broad, open, bound- ing, or rebounding pulse are states not altogether identical, but very nearly approaching each other. They are met with in various diseases. —a. In inflammatory fevers, especially at an advancing stage or after a moderate depletion. —b. During inflammations of mucous, cellular, and parenchymatous structures.—c. In inflam- mations of serous membranes after the pre- ceding states of the pulse have been removed by large blood-lettings— d. Preceding and ac- companying hemorrhages, the pulse being also much accelerated when the hemorrhage is abun- dant, and when inflammations have been treat- ed by copious blood-lettings. The pulse is fre- quently then open and compressible, rather than full, and often passes into the two next states to be noticed. A full, large, or broad pulse is often observed in inflammations of the structure of the lungs, and of the substance of the liver, with various grades of acceleration. It is gen- erally met with in young, plethoric persons, and in the sanguine temperament,, also in the scrofulous and hemorrhagic diathesis. It indi- cates a less degree of tolerance of blood-letting than the preceding states ; and if it assumes an open, bounding, and, at the same time, a com- pressible quality, blood-letting should be pre- scribed with great circumspection. 21. D. A small, soft, compressible, feeble, empty, and unequal pulse are modified conditions, which j severally indicate important states both of the I vital power and of the blood. Smallness is | generally dependant upon diminished quantity of blood, or an afflux of the fluid to a quarter remote, from that where the pulse is felt. Soft- ness and compressibility indicate defective tone and vital power. Feebleness, is merely an ad- vanced state of the same qualities, showing still greater depression of power, especially of the heart; and a feeling of emptiness in the vessel suggests the same condition, and a deficiency of blood in addition. Inequality of the tone, or strength, or fulness of the pulse usually at- tends, as well as the other qualities just in- stanced, diseases characterized by debility, or a far-advanced stage of acute maladies ; and in these several circumstances it presents certain modifications. The strength, tone, and fulness of the pulse may differ in different parts of the body ; and this is not uncommon in the course of various nervous diseases. It generally oc- curs also in connexion with local congestions and determinations, and in various states of ex- haustion and of the blood. The inequality may exist as regards the character of the pulse in the same vessel, and it may then present a modified form in different diseases. It may be unequal, inasmuch as it varies in strength and fulness for three, or four, or five beats in an ascending scale, or in a descending scale re- turning for two, or three, or more pulsations to a natural standard, or to a more constant rate or grade. This state of the pulse is often met with in the advanced course of diseases of the abdominal viscera, when inflammations of se- rous surfaces terminate in effusion, after hem- orrhages or during convalescence from them; and it is generally attended by a varying rhythm, or by different degrees of acceleration. 22. E. A precipitate, rapid, quick, iharp, sud- den, vibrating pulse should not be viewed as in- dicative of increased frequency. These terms, which are expressive of the same, or nearly the I same quality, have reference merely to the char- I acter of the impulse of the column of blood in the vessel against the finger, and, as the im- pulses are thus brief, the intervals between them are more distinct, or even prolonged, when the pulse is not accelerated, which, how- ever, it generally is more or less when it pre- sents this character. These states of the pulse are caused by the rapid or precipitate contrac- tions of the ventricle, and are indicative of mor- bidly excited irritability in connexion with defi- cient power, and often also with more or less anaemia. It is met with in chlorosis, in anaemia, in diseases of debility characterized by increased PULSE—Semeiological Notices of the. 601 susceptibility and excitability, in the advanced stages of acute diseases, especially after copi- ous hemorrhages and blood-lettings, and in the advanced progress of fever, and when the blood is either contaminated or deficient. When there is no deficiency of blood the pulse may, at the same time, be full, large, or open, or even bound- ing ($ 20), but it usually is also soft or com- pressible, indicating the defective vital power which attends it. More or less frequency is also present, especially in the advanced stages of acute diseases, when the acceleration is gen- erally very great, and great in proportion to the exhaustion of vital power. This combination of quickness or precipitancy with extreme fre- quency is characteristic of the operation of con- taminating poisons, of poisoned wounds, of ma- lignant puerperal and other fevers, and of that state of morbid action which surgeons have called irrjtative fever, and which is owing to excessive irritation in connexion with depres- sed vital power, and often also with a poisoned or contaminated state of the blood. It'guggests active means of a powerfully;restorative nature, and diametrically opposite to vascular deple- tions ; and yet I have seen these latter insisted upon, and even employed to the rapid destruc- tion of the patient, the quickness and great ac- celeration of the pulse having been misunder- stood from a culpable ignorance of the states of the pulse, and of the indications furnished by a true interpretation of them. 23. F. A languid and undulating pulse occurs in the course of diseases characterized by ex- hausted vital power, especially in melancholic temperaments and leucophlegmatic habits of the body. When the pulse is merely languid, a weak and protracted contraction of the ven- tricle may be inferred, owing either to ex- hausted or to weakened excitability, or to vis- ceral congestion. If the pulse be also small; deficiency of blood generally also exists, and this is still more likely to be the case if the pulse assumes an undulating character. Lan- guid and undulating slates may coexist with various grades of frequency, but the latter is most manifest when the pulse ranges below, or but little above 100 or 110 in a minute. 24. ii. The Rhythm, or frequency of the pulse, differs both in health and in disease.—A. In health it varies with the age, sex, and the tem- perament and diathesis of the individual —a. As to age, the pulse usually ranges from 120 to 130 soon after birth ; and it is generally somewhat more frequent, or from 130 to 150, during the early coiirse of dentition, or from three to six or seven months. , After six or seven months, the pulse becomes less frequent with the ad- vance of age, so that at about two years of age and up to four it varies from 115 to 110, and from four to ten it ranges from 110 to 90 or 80. After puberty, and during middle age, the pulse varies in different persons from 60 to 80 in a minute; and, as old age advances, the pulse generally falls to 50 or 60, or ranges be- tween these numbers ; numerous exceptions, however, occurring, and even instances of an increased frequency sometimes being met with. 25. b. Sex has some influence on the frequency of the pulse. In males the pulse in health va- ries from 60 to 75, with the position of the body, &c, from 65 to 70 or 72 being the most com- mon grade of acceleration. In females the pulse usually ranges from 70 to 80 or 85, and it is also more excitable, particularly upon mental emo- tions, especially in early age, a similar excita- bility being also often observed in males about the age of puberty or soon after. The most common range in females in good health is from 72 to 80 ; but the pulse is usually more frequent and more developed during pregnancy. 26. c. The temperament and diathesis affect the pulse in a slight degree even in health and in repose, as the pulsations are somewhat more frequent in the nervous, the irritable, and san- guine than in the melancholic, bilious, or leu- cophlegmatic or lymphatic temperaments, and the action of the heart is more excitable in the former than in the latter, and in the scrofu- lous than in the rheumatic diathesis. Habit of body also affects the pulse more or less; but much depends upon the actual fulness of the vascular system ; for if plethora exist, the pulse may be a little slower than the usual rate, especially in a state of repose ; and if the blood be somewhat deficient in quantity the pulse may be much accelerated, and very excitable. In all our investigations of the pulse, not only the above causes of variation in frequency should be recollected, but others, also of not less influence, as ,the position of the body, and the states of sleeping and waking. 27. d. The position of the body varies the fre- quency of the pulse more or less ; but, accord- ing to my own observation, in no definite grade, the effect in health, and still more manifestly in acute and febrile diseases, differing in amount with different individuals, in some cases in a very remarkable degree, and in others very slightly. The recumbent position generally re- duces the pulse somewhat below the standard of health, as observed in the sitting posture; while the standing posture raises the pulse above this standard even more than the recum- bent depresses it. As to any scale of depres- sion in the one posture and of exaltation in the other, it is impossible to determine with satis- factory accuracy, as the variation, which is wide in different cases, and even in the same case at different times, depends most probably upon several causes besides those already ad- verted to, and it is not more easy to assign the causes than to determine the exact amount of variation. The complete repose of the body and absence of muscular exertion during the recumbent position may be supposed likely to leave the heart also in a state of quietude; but probably other circumstances favour this state of the circulation. The slight retardation or embarrassment of the respiratory movements, when a person lies on either side, the position of the heart with reference to itself and its large vessels, and to that of the trunk and the con- tained viscera, the disposition to congestion of the lung of the side on which the person lies, and the state of the circulation within the cranium, seem to me severally to combine to slightly retard the circulation in the recumbent position. In the sitting posture these causes are removed, and with them the retardation of the pulse, while the heart is in a position the most favourable for its action. That the stand- ing posture should accelerate the pulse may be inferred, although to a less amount than is oft- en observed, from the circumstances of this posture admitting not only of a free circulation, 602 PULSE—Semeiological Notices of the. but also favouring it by the slight degree of 1 degree of acceleration of the pulse which should muscular action required to sustain this posi- be viewed as morbid ; for nervous, weak, sus- tion It also favours the full exercise of the i ceptible females, and the irritable and sanguine respiratory functions, which will also influence temperaments in this sex, sometimes present, the circulation more or less. > ■ in states of very flight mental excitement, or 28. e. Sleeping and waking favour different even soon after a full meal, a very considera- states of frequency of the pulse. During sleep | ble acceleration of pulse, and yet preserve their the pulse becomes slower than in the sitting ; usual good health; and these temperaments, posture, and even sinks beloW what the recum- j in this sex particularly, are often attended by bent posture generally manifests, and it is at the same time softer. The influence of sleep in reducing the frequency and tone of the pulse is most remarkable in nervous and irritable per- sons, in females, and in early age, in whom the pulse often then becomes unequal. Dreaming, however, often excites the pulse much above the healthy standard; so that the individual may awaken up remarkably excited with palpi- tations, flushings, or with pallor, and a rapid, small, or weak pulse, according to the nature of the dream—as the dream occasions fear, anx- iety, depression, or anger, &c. 29. During the waking hours, the pulse is lia- ble to be remarkably affected, not only by the emotions of mind, but also by the impressions made on the senses, according to the various states of excitability of the heart. The influ- ence produced on the pulse in the course of the day is not very remarkable, as so many causes of deviation are apt to occur, and affect the in- dividual more or less—the external or physical influences to which he is exposed, the emotions of mind, the ingesta and egesta, and the states and stages of digestion and assimilation. It was stated by Dr. Knox that the pulse is more frequent soon after waking in the morning; but Dr. Christison has shown that the heart is only more excitable in the morning, the pulse con- tinuing nearly the same throughout the day, all things being equal; but much depends upon the nature of the food, even in the absence of all stimuli. 30. B. Disease furnishes the widest range in the rhythm of the pulse, and the greatest deviations from the healthy condition. The morbid pulse may range from twenty or thirty to two hundred, or even more, beats during the minute ; but neither of these extremes can be looked upon as being compatible with a proba- ble, or even with a possible recovery, or with the continuance of life for any time.—a. Re- markable slowness of the pulse may be caused by pressure on the brain, especially near its base and the medulla oblongata, or by intense vital shock; but the more extreme states of slowness most frequently depend upon structu- ral or vital lesions of the heart itself. A more than usually slow pulse may, however, be con- stitutional, or be met with in health. I have thus found the pulse range from 50 to 60 in a minute; and a pulse from 55 to 60 is not in- frequent in bilious, melancholic, and leucophleg- matic temperaments and diatheses; and it is sometimes hereditary. Great slowness of the pulse occasionally is observed on the invasion of acute diseases, particularly periodic and con- tinued fevers, and shortly before death from malignant fevers, from some acute maladies, and from diseases of the brain, or of the heart itself, especially when vital power is either sud- denly or violently depressed, or remarkably ex- hausted by previous inordinate excitement. 31. b. It is often difficult to determine the the greatest frequency of pulse during acute diseases, more especially when these diseases occur during the puerperal state. A pulse rang- ing above 110, in a person older than twenty- five years, of the male sex, and not of the ner- vous or irritable temperament, is not without risk, the amount of which will depend on con- comitant circumstances. If it rise to 120, or above this, the danger is great, unless in ner- vous and susceptible temperaments, and in fe- males. In this sex, especially the nervous, the hysterical, irritable, or delicate, the pulse may range as high as 130 without any risk; but this will depend much upon the nature of the dis- order, upon its seat, and upon other circum- stances. 32. The frequency of the pulse is seldom very great in the early stage of acute diseases, while vital power is unimpaired, as of inflam- mations, fevers, &c, unless in the class of pa- tients just mentioned. It is chiefly when these diseases have gone on to the exhaustion of vi- tal power, or to the contamination of the blood, and in this class of females, and in the puerpe- ral state, that the pulse rises above 120 ; and at that amount or frequency, and more espe- cially if the number is increased, it behooves the physician to be cautious as to his prognosis, and as to the treatment he may adopt; for, un- less the pulse be also firm, or full, or hard, or at least not deficient in tone, venesection, par- ticularly if it be large, may aggravate the dis- ease, remarkably increase the frequency of the pulse, and even endanger the patient. Great acceleration of the pulse, as above 110, should be viewed as militating against, rather than in favour of, vascular depletions, unless in small quantity, or locally. If, however, this frequen- cy be attended by fulness, hardness, or firm- ness, vascular depletions, to an amount which concomitant states and symptoms will regu- late, may be prescribed, especially when serous surfaces are affected. When the acceleration amounts to 110 or 120 and upward, and when it is attended by a very soft or compressible, precipitate, small, feeble, or languid state of the pulse (see $ 8, et seq.), then restorative measures, rather than depletory or depressant, are required, and required with an urgency proportionate to the greatness of the accelera- tion and the want of power or of tone in the vessel, and other concomitant symptoms. 33. c. Inequality or irregularity of frequency of pulse, as well as of fulness and power, is oft- en observed, especially in persons far advanced in life. It is sometimes met with in children when asleep, even when in health. It occurs in diseases of the heart, in affections of the liv- er, in those of the brain, and not infrequently in the maladies of the puerperal state. When, with this inequality, the pulse is small, weak, or precipitate also, or when the inequality is very great, then a serious or even dangerous state may be inferred. Leroy says (Du Prog- PULSE—Bibliography and References. C03 noslic dans les Maladies Aigues, v I., ch. i.), that when this state of the pulse is accompanied with hemorrhage, or with bilious vomiting or purging, a favourable crisis may take place. 34. Irregularity, or marked inequality, of the pulse is not infrequent in the puerperal states, especially at the accession and in the advanced progress of puerperal fevers, and should be viewed as indicative of great danger, especially if the pulse is at the same time very rapid, broad, precipitate, or undulating. In these ca- ses, as well as in the advanced stage of malig- nant fevers, this state of the pulse is generally connected with failure of vital power and an altered condition of the blood. 35. The pulse is necessarily always of the same frequency in different parts of the body; but it varies often in strength, fulness, and tone in opposite or remote parts. In hemiplegia the pulse is often weaker, smaller, and softer in the paralyzed side, and in paraplegia in the lower extremities. In cases of local determi- nations of blood, and in susceptible and nervous persons, the pulse varies in fulness, volume, and strength in different parts, according as the local irritation and vital power may determ- ine an increased flow of blood, and thereby dis- turb the natural equability of the circulation and distribution of the blood. 36. d. An intermitting pulse is not uncommon in every period of life, and in different diseases. It is rarely observed in children, unless when they are the subjects of rheumatic endocardi- tis or pericarditis, or of the more dangerous states of disease of the brain. It is in rare in- stances also observed in children when they are asleep, but not so often as inequality and slowness' of pulse. An intermittent pulse is much more common in aged persons, and com- mon in proportion to advanced age. At this period of life it is often caused by organic change; but it is sometimes, although not so frequently, the result of impaired organic ner- vous energy, and is connected with dyspepsia, or with flatulence or torpor of the liver. In these latter circumstances, however, the inter- missions are not so frequent nor so complete as in cases of organic lesion, and the pulsa- tions between the intermissions are more equal. At all periods of life, functional intermissions of the pulse may occur, although most frequent- ly in advanced age, in the dyspeptic, the flatu- lent, and the sedentary ; anfl in these it is gen- erally irregular, or after various numbers of regular pulsations, and.is caused by impaired organic nervous power, and by flatulence ei- ther pressing on the diaphragm, or rising in the oesophagus, and embarrassing the dilata- tions of the auricles and ventrieles. In many instances, however, of these intermissions the ventricle does not altogether fail to contract; it only contracts too weakly, or throws out an insufficient quantity of blood to occasion the usual impulse of the column of blood in the vessel on the finger (y 8, et seq.). In these cases, therefore, the heart should always be ex- amined by percussion and by the ear, in order to ascertain the state of contraction of the left ventricle, and to ascertain the cause of the in- termission, and its dependance upon functional disorder, or upon organic lesion, as well as the nature of that lesion as far as this may be inferred. When the intermission is complete, is frequent, and depends upon organic lesions, the danger is greater and more imminent than when the intermission is merely incomplete, and caused by impaired vital power, unless, indeed, at a far-advanced stage of low or ma- lignant fevers, or in acute diseases attended with effusion into shut cavities. Our opinions, however, as to the indications furnished by in- termissions of the pulse, should depend much upon the nature and history of the diseases in which they are observed, and upon the charac- ter of the pulse and of the sounds of the heart's contractions between the intermissions. An intermittent pulse, in connexion with great fre- quency or even with remarkable slowness, with a small, weak, languid, or undulating state of the vessel, occurring in hemorrhagic diseases, or at an advanced period of fevers, especially when they are attended by hemorrhages, is generally a fatal indication. 371 It is unnecessary in this place to consider at greater length the several irregularities of the pulse, as they are noticed more appropri- ately when treating of those diseases in which they are most apt to occur. Nor will my lim- its admit of any notice of the influence of di- verse stimuli, or of various depressants on the pulse. I may, however, simply mention, that the remarkable influence of the exciting emo- tions of the mind on the one hand, and of the depressing emotions on the other, upon the fre- quency and character or development of the pulse, should never be overlooked ; that the na- ture of the usual food and beverages of the pa- tient is also important, especially when either has been partaken of shortly, or even for some time before the pulse is examined ; and that great frequency of pulse, especially when caused by exhaustion and vital depression, will often be reduced most remarkably by suitable stimuli and restoratives, even although the skin may be hot, if other symptoms do not decidedly contra- indicate them. The effects of various ener- getic agents on the pulse will be seen by refer- ring to the symptoms produced by poisons. (See art. Poisons.) Bibliog. and Refer.—Galen, De Usu Pulsuum. De Pulsibus Libellus. De Pulsuum Differentiis, libri iv. De Dignoscendis Pulsibus, libri iv. De Causis Pulsuum, libri iv. De Praesagitione ex Pulsi bus, libri iv,. Synopsis Libro- rum Suorum sexjecim de Pulsibus. A good account of these is contained in Epitome Galeni Pergameni Operum in quatuor partes digesta, &C, per A. Lacunam. Accesserunt Annotationes, et de Ponderibus et Mensuris Medici nalibus utilis Commentarius, folio. Argentor., 1604.—Philaretus, Libellus de Pulsibus. Venice, 1483.— G. Valla, De Differ- entiis Pulsuum, — Anon., Journ. Complement des Sc. Med., t. xxxvi., p. 425.—Journ. des Progres des Sciences Medicales, t. xvii., p. 264.—Grateloup, In Archives Gener. de Med., t. v., p. 311.—A. Macleod, in Lond. Med. Gazette, Feb. 4, 1837, p. 697. (Apoplexy during.)—R. Bright, ibid., Sept. 30, 1837, p. 775. Lancet, Aug. 19,1837, p. 775, 777. (Large bleedings—Citric Acid.)—M. Stoltz, Archives Ge- ner. de Med., t. xv., p. 92.—Rogerson, Lond. Med. and Phys. Journ , vol. xlii.—Latour; Hist. Philos. et Med. des Hsm- orrhagies, 8vo. Paris, t. ii., p. 172, pluries.—Olhvier D'An- gers, in Archives Gener. de Med., t. xv., p. 296.—Brachet, in Revue Medicale, t. vii., p. 83. Paris, 1822.—Fourneaux, Obs. sur quelques Hemorrhagies Cutanees et sous Cuta- nees, 4to. Paris, 1826.—P. Rayer, A Theor. and Pract. Treatise on the Diseases of the Skin, 2d ed. Trans, by R. Willis, 8vo. Lond., 1835, p. 888.—G. Goldie, Cyclop, of Pract. Med., vol. ui., p. 571.—E. Wilson, Pract. and Theor. Treatise on the Diseases of the Skin, 8vo. Lond., 1842, p. 266. [Amer. Bibliog. and Refer.—S. W. Avery, Remarks on the Nature and Treatment of Purpura H contami- nation of the blood und viscera, advances with frightful rapidity, death sometimes taking place in eighteen or twenty-four hours from its in- vasion. The local alteration in the integu- ments is occasionally of no great amount; the formidable symptoms and the fatal termina- tions are explicable Only on the supposition that chariges in the blood, or in the internal organs, or in both, have taken place to an extent in- compatible with the continuance of life. M. Rayer has adduced two cases of this form of the malady which were treated by him and ex- amined after death. 12. D. Certain local modifications of the mal- ady have been observed. When anthracion at- tacks the face, it is attended by a phlegmonous erysipelas of the features, often extending to the neck and anterior of the chest. When the eye- lids are the seat, it occasions an enormous and very painful tumefaction of the face, with in- tense headache and delirium, often with the loss of the eye, always with eversion of the eye- lids, which are then formed by the orbicularis muscle and the conjunctiva alone. Wherever muscular fibres are contiguous to the skin, there the gangrene extends less deeply. Neverthe- less, when the lower lip is attacked with an- thracion, it is apt to be destroyed through a considerable extent either by the disease or by the caustics employed to arrest its progress. When the neck is the seat of the malady, the deep extension of the inflammation impedes respiration and deglutition ; and ptyalism, epis- taxis, swelling of the face, &c, generally take place. If the parietes of the chest axe attacked, the inflammation generally extends to the sub- cutaneous cellular tissue of the thorax and ax- illae. When the back of the hand, or the instep, is the seat of anthracion, every part of the limb is successively attacked with a phlegmonous- erysipelas inflammation. 13. E. Appearances after Death.—In the more severe and general states of the disease, un- equivocal symptoms of an altered condition of the blood, of congestive inflammation of the lungs, or of asthenic gastro-enteritis, or of the absorption of purulent sanies into the blood, are observed before death. M. Littre, in a case of anthracion of the lower lip, found pus within agnosis—Prognosis—Treatment. 614 PUSTULE, MALIGNANT—Dn the veins of the face, and a number of small abscesses in the substances of the lungs. In addition to the destruction of the integuments and adjoining cellular tissue of the affected part, marks of congestive inflammation with ecchy- moses have been observed in the lungs, liver, spleen, and digestive canal. M. Viricel states, that he found malignant pustules in the colon ; and M. Lambert says, that the gelatinous serous deposites always found in the adjoining sub- cutaneous cellular tissue is occasionally also found in the cellular tissue of the mediastinum. A quantity of sanguinolent serum is commonly effused into the serous cavities. The several tissues are more or less softened, and the vis- cera and blood present the same changes as are found in the malignant carbuncle of animals. 14. III. Diagnosis.—On its first appearance the malignant pustule may be mistaken for the bite of an insect; but it wants the minute cen- tral yellowish point of an insect bite, and soon presents the painful indurated base, and the sanious vesicle with which malignant pustule commences, and which, with the diffuse or eri- sypelatous and emphysematous-looking inflam- mation surrounding it, also distinguishes it from furuncle, carbuncle, or anthrax. Malignant pus- tule in some instances, however, can hardly be distinguished from the more gangrenous form of carbuncle (see —Wagner, Med. and Chirurg. Review, vol. xxii., p. 582. PYLORUS. See Stomach, Diseases of. PYROSIS. — Synon. Tlvpuoic (from Uvp, fire, and 7rvpou, fut. oou). — Pyrosis, Sauvages, Sagar, Cullen. Cardialgia sputatoria, Lin- naeus, Good. Ardor ventriculi, Hoffmann. So- da, Gastrorrhcea, Ardor stomachi, Auct. Ar- deur de VEstomac, Cremason, Fr. Das Bren- nen; das Sodbrennen, Germ. Black-water, Water-brash, Heart-burn. Classif.—2d Class, Nervous Diseases. 3d Order, Spasmodic Affections (Cullen). i. Class, Diseases of the Digestive Func- tion, i. Order, Affecting the Alimentary Canal.—I. Class, I. Order (Author). 1. Defin.—Constrictive pain at the pit of the stomach, extending to the back, and bending of the body forward:, followed in a short time by eructa- tions, without nausea or retchings, of a large quan- tity of a thin, watery, and often insipid, fluid that afford relief. 2. The description furnished by Dr. Cullen has generally been considered as most accurate, his experience of the disease in a country where it is prevalent having been considerable. But it is liable to the objections which may be urged against nosological descriptions, namely, that it represents merely a single type or phase of the disease ; a single and distinctly characterized form, without any notice of the modifications and gradations which ally it to other disorders of the digestive organs. I shall first describe this affection nearly in the terms used by Dr. Cullen, and afterward notice such variations as have fallen under my observation. 3. I. Symptoms.—Pyrosis appears most com- monly in persons under middle age, but seldom before the age of puberty. When it has once taken place, it is apt to recur occasionally for a long time after; but it seldom appears in per- sons far advanced in life. It affects both sexes, but more frequently the female. The fits of the disease usually come on in the morning and forenoon, when the stomach is empty. The first symptom is pain at the pit of the stomach, with a sense of constriction, as if the stomach were drawn towards the back. The pain is in- creased by raising the body erect, and is alle- viated by bending forward. It is often severe, and after continuing for some time it is followed by an eructation of a thin, watery, limpid, or nearly clear and often ropy fluid in considerable quantity. This fluid is generally insipid, but it is sometimes more or less acid. The eructa- tion is for some time repeated frequently, and does not immediately give relief to the pain ; but it does so at length, and terminates the at- tack. 4. I may add to the above, that I have seen this affection more than once in males much below puberty, occurring at any hour of the day when the stomach was empty, and affect- ing patients with good appetites and rapid di- gestion. I have seen it also unattended and not preceded by any actual pain at the pit of the stomach, but by slight uneasiness only in that situation; and in more than one case the pa- tient complained of the great coldness of the fluid thus ejected. The pain is quite different from that of cardialgia, or heart-burn, when the fluid brought up is abundant, insipid, ropy, and 61C PYROSIS—Diagnosis—Prognosis—Causes. colourless; but when it closely resembles car- dialgia, the sensation of constriction, with bend- ing forward of the trunk, is not present, and the fluid ejected is often acid, and less abundant than when the pain is of the constrictive char- acter above described. In no case is the dis- ease attended by fever, or by nausea or retch- ings. The fluid is always regurgitated or eruc-. tated by a similar inverted action of the esopha- gus to that producing rumination. It has ap- peared to me, during a careful observation of some cases, that the constrictive pain, as well as the ejection of the fluid, partly may be re- ferred to the diaphragm. 5. Complications.—Pyrosis may be independ- ent of indigestion, or be attended by rapid di- gestion ; it also may be associated with either of the forms of dyspepsia or with flatulence. It is commonly complicated with costiveness, and often with torpid function of the liver, or even with disease of this viscus. That it is often associated either with organic or with func- tional disease of the pancreas seems probable. Indeed, it has been long supposed, and by vari- ous writers, that the fluid thrown off is merely an excessive discharge of the pancreatic fluid regurgitated into the stomach, and thence into the mouth; but, as Dr. Kerr has justly remark- ed, if this were the case, we should expeot the fluid to be mixed with some bile. Besides, it could hardly be expected that so large a quan- tity of fluid could be furnished by the pancreas in so short a time as during a fit of pyrosis. I am not aware of any instance in which organic disease of the pancreas has followed pyrosis, or in which such disease had taken place in a patient who had been at any previous period the subject of this affection. Dr, Seymour ad- duces a case in which organic change in the liver followed pyrosis; but the cases which I have observed have not been associated with any organic change, excepting in one instance, although various functional disorders have often been present. It is not unusual, especially in northern countries, where pyrosis is most prev- alent, to observe it in the course of pregnancy, and in both married and unmarried females, complicated with leucorrhcea. I have seen it in one instance associated with disease of the ovaria, and frequently in these countries with chronic rheumatism. 6. II. Diagnosis.—Pyrosis is readily distin- guished from other affections of the stomach by the absence of the usual symptoms of indi- gestion ; by the appearance of the fluid ejected, its clear, colourless, generally insipid nature,- and abundant quantity; by the absence of fe- ver, of nausea, or retchings ; by the manner in which the fluid is thrown off; by the mere re- gurgitation without nausea ; and frequently by the little inconvenience or general disturbance attending it. The eructations which often ac- company cardialgia, or other forms of indiges- tion, are usually observed during the progress of digestion ; the fluid eructated being generally in small quantity, and acrid, always discolour- ed, and often furnishing indications of the indi- gestible matters. When the fluid of pyrosis is at all acid or acrid, these properties are much less marked than in cardialgia or the allied states of dyspepsia (see art. Indigestion, y 13, 14); it furnishes no indications of undigested matters, and is thrown up from a stomach which has digested its contents, and contains nothing but the fluids which it thus ejects. Pyrosis cannot be confounded with simple gastrodynia, inasmuch as the former is attended by the co- pious discharge of a peculiar fluid, without nau- sea or vomiting, and as this discharge may be abundant although the pain may be very slight, . gastrodynia being only a symptom of several gastric diseases. Dr. West states, without, however, adducing his authority, that the secre- tion of true water-brash is composed of water, albumen, and a trace of sodaic salt, with an ex- cess of soda; and that, when it is acid, this property is owing to the muriatic and acetic acids. A recent analysis of the fluids thrown off the stomach has been published ; but they do not appear to have been the fluids ejected by pyrosis, as they were mixed with undigest- ed food, and contained much acetic acid. (Si- mon's Animal Chemistry, by Day, dec., vol. ii., p. 393) 7. III. Prognosis.—Having once taken place, pyrosis is very apt to recur, and it is often very difficult to cure ; but I have not met with an instance of it having passed into serious or structural disease, or been attended with dan- ger. I am intimately acquainted with a gen- tleman who was long subject to this disorder when he was a boy residing in the north of Scotland, and who was afterward frequently at- tacked by indigestion ; but he is now well and strong at an advanced period of life. Persons who are subject to it generally are able to pur- sue their avocations without much inconveni- ence ; and often continue free from it for a considerable time, without any very obvious cause, and then are attacked, owing either to some error of diet, or exposure to cold and moisture. When the complaint is prolonged, the patient frequently becomes pale, consider- ably emaciated, and debilitated; and when it is protracted in females, scanty, or difficult, or painful menstruation is a common consequence. 8. IV. Causes.—A. Pyrosis is more frequent in females than in males, and in the unmarried than in the married. It may occur at any age, after six or seven years, but it is most com- mon after puberty and until far-advanced aga It is so prevalent in some countries as to be considered endemic in them, especially in Swe- den, Norway, Lapland, Scotland, and the Isles, &c. It has been attributed to the diet used by the natives of these countries—to the use of rye, barley, oats, potatoes, &c, and the want of animal food. It has been supposed that the use of unleavened or unfermented bread may be concerned in producing it. The share that these causes may have in occasioning it can hardly be determined. But it is also prevalent in countries where not only these causes pre- vail, but others which may concur with them, as the use of dried and smoked meats in con- siderable quantity, and of dried fish—both the dried meats and the dried fish being preserved without salt, or with very little. Pyrosis is cer- tainly, also, much more frequent in cold and hu- mid climates than in temperate, dry, or warm countries, and among the poor and ill-clothed than among the wealthier classes; although the latter are not exempt in these climates. Linn^us states that nearly one half of the pop- ulation, men and women, living near the mount- ains in Lapland, were in his time the subject PYROSIS—' of this complaint, and that in some it endured through their entire lives. 9. B. The exciting causes of pyrosis are chief- ly long fasting, errors in diet, tasting savoury articles of food, without partaking of them — cold and humidity, especially when their influ- ence is prolonged, and the warmth of the body is not promoted by exercise; cold applied to the lower extremities; powerful mental emo- tions; a poor and unwholesome diet; the priva- tions often contingent upon a laborious life in a cold and humid climate; and the want of saluta- ry stimuli, or of wholesome beverages, experi- enced by persons who are thus circumstanced. 10. C. The nature of this complaint has been much discussed. Pyrosis has been viewed as a form of indigestion, and it is probably allied to indigestion in many instances as it occurs in this and other temperate countries; but in northern countries I have seen instances of it attended by powerful and rapid digestion. Dr. Pemberton viewed it as a morbidly increased secretion from the stomach, analogous to a di- abetic secretion of urine by the kidneys. Some physicians imputed it to obstruction or conges- tion of the collatitious viscera ; and in this light it appears to be viewed by Dr. Seymour. Others have considered it as actually a disease of the pancreas ; this organ furnishing the fluid which collects by regurgitation into the stom- ach, where it causes pain and irritation, follow- ed by its expulsion. The reasons which mili- tate against this opinion have already been no- ticed (y 5); and the analysis of the fluid is said to demonstrate that it is not pancreatic, al- though this is not a sufficient proof, for the pancreatic fluid may be considered just as like- ly to be altered in quality as in quantity. I once considered it as not improbable that this fluid partly consists of the gastric juice; for, having observed it in persons possessed of pow- erful digestion, and who live on food requiring strong digestive and assimilative powers, I in- ferred an abundant secretion of this juice, which would not infrequently be continued to be, se- creted in exeess, especially in circumstances favouring the determination of blood to the di- gestive viscera, and in the very circumstances by which I have observed a fit of pyrosis to be produced, although there existed no food in the stomach to excite the secretion of the gas- tric juices ; or, in other words, that pyrosis is produced by the continuance of the secretion of the gastric juices after the food taken into the stomach has passed into the duodenum; and that these juices, by irritating or other- wise acting on the stomach, cause the pain at- tending the disorder, the inverted action of the organ, or the regurgitation by which they are thrown off; the complaint ceasing for a time with the rejection of these juices, and return- ing only when the exciting causes (y 8, 9), the nature of the food, or prolonged abstinence from it, oi' other circumstances which may fa- vour the secretion of these juices, without fur- nishing food to the stomach on which they may act, are brought into operation. According to this.view, the frequent discharge of secretions, so instrumental as they are in the assimilative processes, must necessarily be followed, in pro- tracted cases, by pallor, emaciation, anaemia, and the other complications and consequences mentioned above (y 5). reatment of. 617 11. V. Treatment.—The indications of cure should be based upon sound views of the na- ture of a disease ; but if these views are not to be found, we must fall back upon the results of experience as far as they may be trusted. If the above opinion that the disease is gener- ally produced by a diet requiring a copious se- cretion of the gastric juices, but that the at- tack is excited by the want of that supply of food which is usually furnished to the stomach, or which is-required for the quantity of the juices habitually secreted, or secreted in ex- cess under the influence of circumstances, be at all correct, the intentions of cure may be readily devised. Indeed, this view, as well as the treatment, or, rather, the no treatment, founded on it, is not infrequently adopted by persons subject to this complaint; for they gen- erally GideavoUr to prevent long fasting, rather than to cure the attack by eating, when the pain characterizing an attack has commenced; for if food were attempted to be taken at that time, unless in the slighter fits, it either could not readily pass into the stomach, or it would be rejected along with the fluid which has now oc- casioned a retrograde action of the stomach. According to this view, a change to a more di- gestible diet — to food habitually requiring a less abundant secretion of the gastric juices, and avoiding long fasting, will often be sufficient to cure the disease. This, in most places, can- not be even attempted ; although a popular re- course to several articles has been recommend- ed as substitutes for change of diet, and to pre- vent the ill effects of long fasting or of improp- er food. Thus, opium, spirituous liquors, nux vomica, canabis Indica, tobacco-smoking and chewing, die., are severally used in some coun- tries with these intentions, and are more or less efficacious in warding off an attack in per- sons who are subject to this complaint. These substances, by allaying the morbid irritation of the nerves of the organ, diminish or prevent the excessive secretion of the gastric fluids causing the disorder; but, as long as the diet is persisted in that causes the complaint, the continued use of these substances is required to prevent a recurrence of the disorder, and thus the remedy often becomes as great an evil as the disease itself. 12. Many systematic writers, as well as au- thors of works on diseases of the digestive or- gans, appear either to have had no experience of pyrosis, or to have observed it imperfectly, for they have confounded it with cardialgia and other forms of indigestion on the one hand, or with the more common occurrences and states of gastrodynia or gastralgia and of vomiting on the other, and have treated it accordingly. Doubtless there is a more or less close approx- imation of cases of these affections to each oth- er ; still they are distinct. The pain of pyro- sis is different from that of cardialgia, or of the more usual painful affections of the stomach termed gastrodynia, or gastralgia, and it may be so slight as to amount only to uneasiness. The matters brought up from the stomach are either not acid or very slightly so, are unmix- ed with undigested matters, are clear and col- ourless, are so abundant, and are so peculiar, even as respects their low temperature, as to constitute the chief feature of the complaint. The substances ejected either by eructations 618 PYROSIS—Treatment of.—Bibliography, etc. or by retchings, in the ordinary forms of dis- ordered stomach, are generally acrid, acid, or rancid ; consist partly of, or contain, undigest- ed articles ; and proceed from an unloaded, or a partially loaded, as well as irritated stomach. They are often the products of excess, or are consequent upon errors of diet, or are owing to a weakened or an irritated state of the stomach. But pyrosis occurs only when the stomach is empty, after the usual diet, taken in very mod- erate or even in insufficient quantity, and the fluids, by which it is chiefly characterized, are regurgitated without nausea or retchings, and always unmixed with undigested matters, as already stated (y 6). 13. States of disorder quite distinct in them- selves, and different in.their natures and char- acters, have thus been confounded with each other ; and substances which have baM found of service in one or more of these have been recommended as cures for pyrosis, although they are either altogether inappropriate, or only temporarily Beneficial. Indeed, unless the chief causes of the disorder be removed—unless many of those who are the subjects of pyrosis live on more nutritious and digestible food, and are bet- ter protected from cold and wet tlVa-n usually fall to their lots—no permanent advantage can be expected from treatment. Most of the rem- edies which have been prescribed for pyrosis, and have been said to remove it, merely alle- viate the attack, but seldom succeed in prevent- ing a recurrence of it. These medicines are generally appropriate in cardialgia, and in most cases of indigestion which are attended by acid- ity and flatulence, and by the eructation of fluid matters, more or less acid, or acrid, containing undigested, or partially digested substances. But these cases are not cases of pyrosis ; and although these medicines are sometimes useful in thi& latter affection, still they are not per- manently beneficial unless they be aided by change of diet, especially by .an improved diet. Among the remedies thus recommended, those usually prescribed for the severer forms of in- digestion hold prominent places, especially ab- sorhents, as lime-water with milk; soap with small doses of opium ; magnesia with various antispasmodics, and narcotics (Ranoe, dec); the oxyde of bismuth, with aloes er henbane (Odier, Marcet, dtc.); and ammonia in bitter infusions. As pyrosis was thus generally view- ed as a form of indigestion, and not as an af- fection, caused by the nature of the diet and by the influence of cold and humidity upon the sur- face and extremities, and independent of de- fective digestive power, numerous other digest- ive aids were prescribed for its cure; and among these I may mention, as being some- times beneficial, the mineral acids, particularly Haller's or Mynsycht's sulphuric acid—the acidum sulphuricum dromaticum—the prepara- tions of iron, and the balsams, especially the Peruvian balsam. Bitter almonds, with ammo- nia and the preparations of angelica root, were much praised by several German writers ; and inspissated ox-gall,* with asafoetida and soap, * It maybe mentioned that the ox-gall was recommended in several places of the first part of this work, and numer- ous formulae, in which it formed the chief ingredient, were given in the Appendix. These were published in Septem- ber, 1832; but this medicine was employed by me in prac- tice since 1820, and was not viewed as a novelty, as it had been for centuries prescribed on the Continent; yet has it by Niemann and others. Linnaeus recommend- ed nux vomica in powder for the native Lapland- ers subject to pyrosis; and most probably, if it had been long or often used, in the doses (20 grains) to which he allowed it to be carried, the remedy would have been soon found worse than the disease. (See article Poisons, y 371, et seq.) Dr. Baillie prescribed a drachm of the tincture of benzoin suspended by mucilage, and Dr. PEMBERTON,„ten grains of powdered kino with half a grain of opium every fourth hour at the commencement of the attack; or a bolus, consisting of six grains of alum with two or three grains of the soap and opium pill, the bowels being kept in an open state by rhu- barb or other aperients. There can be no doubt of the occasional efficacy of these and of other remedies, especially those prescribed for the more painful forms of dyspepsia (see ar- ticles Indigestion, y 49/et seq.; and Stomach, painful affections of), wheii they are aided by diet ahd warm clothing; but without such aids they will often fail. Change to digestible and wholesome food, due promotion of the cutane- ous functions, and an open state of the bowels by means of stomachic or tonic aperients,-are most deserving confidence, both for the cure and for the prevention of attacks of this com- plaint, which if otherwise'treated will always prove most obstinate.. [Pulverized charcoal, blended with carbonate of magnesia and united with ginger, has been successfully given (since 1812) in various forms of gastralgia and pyrosis, according to Dr. Francis.] Bibliog. and Refer.—S. Alberti, De Morbis Mesenterii, Ardore Stemachi, hich canal it had commenced. It very rarely thus appears to commence simultaneously in he rectum and urinary tfladder in men. M. Cruveilhier thinks that cancer of the rectum s mostly a local disease; but this is the case only at its commencement, or at an early stage, before the cancerous contamination of the blood and frame generally has taken place. 112. B. Symptoms. — Malignant stricture of the rectum is more frequently met with than the simple thickening and induration already noticed (y 96, et seq.). Whatever may be its particular characters—whether scirrhous, sar- comatous, lardaceous, fungoid, or encephaloid —it encroaches upon and narrows the canal of the rectum, so as more or less to obstruct fae- cal evacuation, and occasion great and constant distress. The patient complains of a dull, fixed, or aching pain at the upper part of the sacrum, with severe shootings, or sharp exacerbations, extending down the limbs, with violent tenes- mus, and a sense of weight or bearing down in the part, especially after evacuations, or what- ever may cause irritation of the part. Bloody purulent matter, or a puriform sanies, is passed with the stools, which are thin and frequent. In the fungoid variety, discharges of blood may be large and often. Mr. Syme remarks, that though in the early stage difficulty may he ex- perienced in passing the faeces, owing to the thickening of the coats of the gut, yet there is for the most part ultimately rather an inability of retention, from the action of the sphincter being impeded by the progress of the disease. 113. At an advanced stage, the countenance and general surface display more or less of the appearance of malignant cachexiaror a sallow, leaden, or greenish-yellow hue ; and flesh and strength are lost, the blood also becoming de- ficient. On examination per anum, the bowel is found contracted, thickened, and irregular on the surface. The affected parietes are hard and unyielding, and morbid growths are felt projecting into the cavity, in some places in the form of rounded tubercles, in others with rough or ulcerated depressions. These changes may not feel very different to the touch from those which attend simple stricture, excepting in their greater degree ; and hence more reliance is to be placed upon the symptoms indicative of malignancy, than upon the sensations fur- nished by the examination. The acute, lanci- nating, and paroxysmal pains, extending to the loins, pubis, and thighs ; the sense of weight, aching, and numbness in the sacrum, loins, hips, dtc; the aggravation of these upon stand- ing or walking; the irritability of the bladder, or incontinence or retention of urine ; the more frequent and larger discharges of blood than in simple stricture ; the bearing down sensation, especially in females; and the general cachexia and anaema, as the disease advances, sufficient- ly indicate the malignarit nature of the malady. Ultimately hectic, exhaustion, abdominal ten- derness, hiccough, vomiting, dec, usher in dis- solution. 114. C. Causes.—This disease may occur at almost every age. Mr. Mayo has seen it as early as twelve years of age. It is most fre- quently met with between the ages of thirty and sixty. The encephaloid is the variety which is met with early in life ; the scirrhous and lar- daceous at more advanced periods. Women are certainly more subject to the malady than males, and more especially after the cessation of menstruation. Some local injury, as a blow op or near the part, has sometimes appeared to excite the disease, but generally the particular cause has not been recognised ; and it is not improbable that the tendency to the complaint has arisen out of a constitutional vice or tend- ency. 115. D. The treatment of this malady is very unsatisfactory. But, although it admits not of cure, unless in those rare cases in which the anus only is affected, and even in these most rarely, and at an early stage, much may be done in palliating the symptoms, and even in pro- longing life. The encephaloid or fungoid va- riety generally runs a rapid course, especially when it is attended by frequent discharges of blood ; while the more cartilaginous, scirrhous, or lardaceous form may last for years. Dilu- ent, emollient, and anodyne injections are gen- erally requisite in this state of disease, in con- junction with those means, internal and con- stitutional, which I have advised for cancer in other parts. (See art. Cancer, y 29, et seq.) Sir B. Brodie recommends opiate injections, and injections of linseed oil, either in a pure state or conjoined with lime-water, with the view of allaying irritation; he gives alkalies internally, with balsam of copaiba ; and he very justly considers the preparations of opium to be indispensable, notwithstanding the inconve- niences attending the use of them. Supposito- ries of conium or of henbane, or of both con- joined, or of opium with camphor, Peruvian balsam, or zinc ointment; mucilaginous injec- tions, containing the chloride of zinc or crea- sote, with the solution of opium or sirup of poppies ; and such laxative, emollient, and an- odyne enemata as the state of the case may suggest, especially those with warm olive oil, with small quantities of camphor or balsam, will generally afford considerable relief. Ac- cording to Mr. Calvert, much benefit is de- rived from " carefully introducing a hollow tube of elastic gum, through which the faeces are drawn off by injecting tepid water." 116. Of internal remedies, I can add nothing to those recommended for cancer in another place. (See art. Cancer, y 29, et seq.) The preparations of iron with narcotics, especially the mistura ferri comp., with liquor potassae, tinctura conii, or tinctura opii, or tinctura cam- phorae comp.; or the iodide of iron in sirup of sarza; or the pilula ferri composita with the pilula saponis cum opio, may be prescribed and varied according to circumstances. As to re- sorting to excision of the part when the disease is limited to the anus or lower portion of the RECTUM AND ANUS—Bibi rectum, the determination should depend upon the peculiarities and complications of the case. This subject is well discussed in the surgical works referred to, and in Mr. Cooper's Sur- gical Dictionary.—(For other diseases connected with the r'ectum and anus, see articles Digestive Canal, Intestines, Hemorrhoids, Hemor- rhage from the Bowels, and Dysentery.) liography and References. 663 mens de Pathologie, 1. v., p. 152. Paris, 1833.— L. Lis- franc, Mem. sur l'Excision de la Partie Inferieure du Rec- tum, &c.; in Mem. de l'Acad. Roy. de Med., 1833, t. Hi., p. 291.—A. Costallat, Essai sur un nouveau Mode de Dila- tation applique au Retrecissement de Rectum, 8vo. Paris, 1834.—S. Tanchou, Traite de Retrecissements de l'Urethre et de l'lntestinum Rectum, 8yo: Paris, 1835.—Laugier, art. Rectum, in Diet de Medecine, 2d edit.—A. Lepelletier, Des Hsemorrhoides et de la Chute du Rectum, 4to et 8vo. Paris, 1835—.F. Salmon, Pract. Observat, on Prolapsus of the Rectum, 8vo. Lond., 1831; and Pract. Essay on Stric- ture of the Rectum, &c, 4th ed., 8vo. Lond., 1833.—J". Houston, in Dublin Hospital Reports, vol. v., p. 158.—B. C. •Brodie, Lectures on Diseases of the Rectum, in Lond. Medical Gazette, vol. xvi., 1835, and vol. xviii., 1836.—G. Bushe, A Treatise on the Malformations, Injuries, and Dis- eases of the Rectum and Anus, 8vo; illustrated by Plates in 4to. New York, 1837.—.4. Vidal, Du Cancer du Rec- tum et des Oper. qu'il peut reclamer, 4to. Paris, 1841__ Velpeau, Leeons orales de Clinique Chirurgicale, t iii.— J. M. Chelius, System of Surgery. Translated by J. F. South, 2 vols., vol. ii., 328, p. 128. Paris, 1841.—J. W. Fer- gusson, A System of Practical Surgery, 2d edit, 8vo. Lond., 1846, p. 592. [Amer. Bibliog. and Refer.—E. A. Vanderpool, Stric- ture of the Rectum, New York Jour. Med., vol. vii., p. 405. — W. H. De Leon, Case of scirrhous contracted Rectum, &.O., Amer. Jour. Med. Sciences, vol. ii., p. 330.—S. Park- man, Case of imperforate Rectum, Amer. Journ. of Med. Sciences, vol. xiii., p. 306.—Alexander H. Stevens, On Fis- sure of the Rectum, New York Medical Journal, vol. iv., p. 242.—J. W. Heustis, Case of Prolapsus Recti, success- fully treated by Excision, Amer. Journ. of Med. Sciences, vol. xi., p.i411—B. Atkinson, On Diseases of the Recto- vaginal'Wall, Boston Med. and Surg. Journ., vol. xxiii.; New England Journal, vol. xiii., p. 119.— T. Harris, Lec- tures on Stricture of Rectum, Medical Examiner, vol. i., p. 79.—.4. H. Stevens, Lecture on Diseases of Rectum, in New York Lancet, edited by J. A. Houston, 1842.] RHEUMATISM.—Synon.—'Pevudriouoc, a de- fluxion—from fcvuaTifa, to be affected by a fluxion, from fcv/xa, a fluxion, and that from (>eu, I flow ; Rheumatismus, Pliny, Sydenham, Vogel,- Ju'ncker, Sauvages, Cullen, Pinel; Dolores Rheumatici, Hoffmann ; Myositis, Sa- gar; Myitis, Chrichton ; Arthrodynia, Cullen; Febris Rheumatica, Auctor. Var. ; Arthritis Rheumatica, Swediaur ; A. Rheumatismus, Parr. ; Cauma rheumatismus, Young ; Arthro- sia Acuta et Chronica, M. Good ; Gliederfluss, flusskrankheit, Germ.; Rhumatisme, Fr.; Reu- matismo, Ilal. ; Rheumatism, Rheumatic fever, Rheumatic pains. Classif.—Class 1st. Febrile diseases ; Or- der 2d. Inflammations with fever (Cul- len):— Class 3d. Diseases of the sanguin- eous function ; Order 2d. Inflammations (M. Good).—III. Class, II. Order (Au- thor in Preface).. 1. Defin.—Severe pains preventing, or remark- ably aggravated by, motion of the affected parts; apparently seated in the fibrous structures, chiefly of the large joints, the aponeurotic expansions, and the fibro-serous surfaces ; arising from external or manifest causes, and assuming various forms and complications—being sometimes remarkably acute, febrile, or inflammatory, and shifting their situa- tions, often sub-acute, and oftener still less acute, non-febrile, unattended by heat or swelling, of chronic duration, and accompanied with debility or stiffness of the affected limb. 2. Although rheumatism is, owing to geo- graphical and social circumstances, one of the most prevalent diseases in the British Isles, yet is it one respecting the nature and treatment of which there exist the greatest diversity of opinion and the least amount of undisputed knowledge. The remarkable prevalence of the malady, this diversity of doctrine, and the sev- eral very important pathological relations sug- gested to the thinking physician by every man- Bibliog. and Refer.—Oribasius, Synopsis, 1. ix., c. 17. —Aetius, Tetral., ii., s. ii., cap. 36.—Paulus Mgineta,\. iii., sect. 59.—Ruysch, Observat, No. 95.—Vaughan, in Philo- soph. Transact, No. 281—Payne, in ibid., No. 391—Mad- den, in ibid., No. 442.—Shermann, in ibid., No. 453.—JF. Hoff- mann, Consultationes, cent, ii., No. 23.— Wisemann, Chi- rurgical Treatises, &c, 3d edit. Lond., 1696, p. 234.— Memoires de l'Acad. de Chirurgie, t. i., p. 540; t iii., p. 620. —Morgagni, De Sed. et Caus. Morborum, epist. xxxiii., sect. 7.—L. H. J. Duchadoz, De Proctostenia, seu de mor- bosis Intestini Recti Angustiis, 4to. Montsp., 1771.—San- difort, Museum Anatomicum, t i., p. 255.—De Haen, Rat. Med. Contin., vol. ii., p. 314.—Graham, in Edin. Med. Com- mentaries, vol. i., p. 464. (The first to employ Belladonna in Dis. of Rectum and Anus.)—Petit, Traite des Mai. Chi- rurg., t ii., p. 83.—Monteggia, Fasciculi Pathologici. Tu- rin, 1703, p. 91.—Lettsom, in Mem. of Med. Society of Lon- don, vol. ii., art. 25.—Sherwin, in ibid., vol. ii., art. 2.— Hodges, in ibid., vol. v.— White, in ibid., vol. yi., art. 17.— M. Baillie, Morbid Anatomy, &c, and Series of Engrav- ings, &c., fascic. iv., t. 4.—J. P. Frank, De curandis Horn. Morbis, &c, 1. ii., p. 259.—Reil, Fieberlehre, b. iii., p. 551. —B. Gooch, in Edin. Med. Comment, vol. ii., p. 373.— Oberteuffer, in Stark's N. Archiv., b. ii., p. 679. (Carcino- ma.)—Hey, Practical Observat, chap. ii. (Excision.)—Horn, in Archiv der Pract. Heilk. fur Schlesien, b. iii., st. 4, n. 2. — W. Hey, Practical Observations on Surgery, 2d. ed., 8vo. Lond., 1810.—A. Portal, Cours d'Anatomie Medicale, t. v., p. 250.—Chevalier, in Transac. of Med. and Chirurg. So- ciety, vol. x., p. 401.—E. Home, Observat on Cancer, &c, Svo. Lond., 1805, p. 129.—H. L. Thomas, in Med. and Chirurg. Transact, vol. i., p. 129.—Nasse, Die Schleichende der Entziindung des Mastdarms, in Horn's Archiv fur Med. Erfahr., b. i. 1817.—A. Monro, Morbid Anatomy of the Gullet, 8vo, p. 347.—J. Howship, Practical Observat on the Symptoms, Discrimination, and Treatment of some of the common Diseases of the Liver, Intestines, and Anus, 8vo. Lond., 1820, ch. iv.—Desault, QSuvres Chirurgicales, &c, vol. iii., p. 380.—Boyer, De la Fissure<>u Gercure de l'Anus, accompagnee du Reserrement spasmodique du Sphincter; in Traite des Maladies Chirurgicales* t. x., 8vo. Paris, 1825.—Retard, Revue Medicale, &c, t. i. 1825, p. 309, 479. (Ore the Treatment of Fissure of Anus.)—Dupuytren, in ibid. Mars, 1826; et Journ. des Progres des, Sciences Medicales, &c, t. xv., p. 225. (Recommends Ext. of Bella- donna for Fissure of Anus.)—Detzmann, Dissert de Fistula in Ano, 4to. Jense, 1812.—F. Reisinger, Darstellung eines Verfahrens die Mastdarmfistel zu unterbinden. Augs., 8vo, 1816.—T. Copeland, Observ. on the Principal Dis. of the Rectum and Anus, 8vo. Lond., 1814.— W. White, Ob- servations on the contracted Intestinurri Rectum, 8vo. Bath, 1822; and Observations on Strictures of the Rec- tum, and other Affections which diminish the Capacity of that Intestine, 8vo. Bath, 1820.—Richerand, Nosog. et Therapeutlque Chirurgicales, 4 vols., 8vo. Paris, 1821.— R. Allan, A System of Patholog. and Operative Surgery, vol. iii., p. 488. Edin., 1824.—G.Calvert. Practical Treat- ise on Haemorrhoids, Piles, Strictures, and other Import- ant Diseases of the Urethra and Rectum, 8vo. Lond., 1824.—P. F. Blandin, art. Rectum, in Diet, de Med. et Chi- rurg. Pratiques.—A. Jukes, A Case of Carcinomatous Stric- ture of the Rectum, in which the descending Colon was opened in the Loin, 8vo. Lond., 1822.—Kothe, in Rust's Magazine, b. i., pt. ii., p. 259.—Schrcger, Ueber die Unter- bindung der Mastdarmfisteln, u.s.w. Chirurgische Ver- suchen, b. ii., pt. 1. Niirnb., 1818.—Larrey, Memoires de Chirurg. Militaire, t. iii., p. 415.—J1. Ribes, in Revue Med- icale Histor. et Philos., &c, 1820, livr. i., p. 174.—:Mem. sur la Situation de l'Orifice interne de la Fist, en l'Anus, &c., in Mem. de la Soc. M6d. d'Emulation, t ix.—C. Bell, A Treatise on the Dis. of the Urethra, Vesica urinaria, Prostate, and Rectum, 3d edit, 8vo. Lond., 1822.—Pie- dagnel et Velpeau, in Diet, de Medicine, t. iii., p. 328—7. Syme, On Diseases of the Rectum, 8vo. Edin., 1828.—4. Cooper, Lectures on Surgery, vol. it, p. 333.—Dupuytren, De la Fissure a l'Anus; in Leeons orales, t. iii., p. 282. Paris, 1831.—H. Mayo, Observations on Injuries and Dis- eases of the Rectum, 8vo. Lond,, 1833.— W. Hedenus, Ue- ber die verschiedenen Formen dier Verengerung des Af- terdarms und deren Behandlung., 8vo. Leip., 1828.—A. Collis, on Dis. of the Rectum and Anus; in Dublin Hospi- tal Reports, vol. v., p. 131.—R. Liston, Elements of Sur- gery, 8vo. Lond., 1832, p. 73.—Sanson, Nouveaux Ele- 664 RHEUMATISM—Description of Acute. ifestation of rheumatic affection, are sufficient to direct investigation to the subject with great- er energy than has hitherto been bestowed on it, and with more success than has hitherto sig- nalized it. 3 Rheumatism was not described, or even noticed as a recognised malady, by the ancients, either by this term or by any other, to which the assemblage of symptoms thus denominated can be traced. Yet the word is sometimes found in their writings, although it does not al- together represent the disorder to which the moderns have applied it, this name having been given by the former to affections, to which they attached the idea of a humoral defluxion, con- formably with its derivation, especially to those characterized by mucous or pituitous discharg- es.* One of the earliest writers among the moderns, who employed this term according to its modern acceptation, treated of the subject in connexion with catarrh, an affection to which rheumatism is closely allied, and with which it is often complicated. (See J. Vigier, Tract, de Catarrho Rheumatismo, &c. Geneva, 1620. In Haller's Bibliolh. Mid. Pract., t. ii., p. 376.) Svdenham, however, was the first to treat fully of rheumatism, and to distinguish it from gout, with which it had been frequently, if not gen- erally, confounded by former writers under the name of Arthritis. Subsequently Boerhaave, Hoffmann, and Juncker described the disease with tolerable accuracy; but it was not until the end of the last and the commencement of the present century that the various metasta- ses and pathological relations of rheumatic af- fections received even a partial notice. 4. I. Description.—Various forms of rheu- matism have been described by authors, or, rather, several states of disorder, more or less intimately allied to each other, have been rank- ed as varieties of this disease, although cer- tain of them might have been placed, with greater propriety, under a different category: thus the pains in a limb or limbs caused by or- ganic disease of the nervous centres, and the sympathetic pain produced by hepatic conges- tion, &c, have been often mistaken for rheu- matism, and described and treated as such. Since, or at least soon after, the first notice of rheumatism as a distinct disease, two remark- able forms of it have been admitted—the acute and chronic. Recent observation has recog- nised the varieties of the complaint and the pathological distinction between certain of its states with greater accuracy ; but there has been a greater disposition also among observers to multiply distinctions than to point out alli- ances and pathological relations. The division most generally adopted of the forms of rheu- matism has been that founded upon the severi- ty and duration of the attack. It is almost identical with the foregoing, the term sub-acute * "Si Hippocratem, Galenujt, Aretjeum, Paulum- QUE iEGINBTAM Graecos, sive Celsum, Aurelianumo.uk Scriptores Romanos accurate evolveris, quod hunc mor- bum indubitate designat, nihil dilucide enodateque descrip- tum invenies. Plinius (1. xxii., 47, 68; 1. xxv., 39, 47) quidem Rheumatismum nominavit, morbum eo nomine non omnind attigit Sunt tamen apud eos loci, qui tamen invalitudinem quasi obiter indicant, quippe qui ei wvptrov Komaita et SiaBeotv ptvpuniKriv, et alia hujuscemodi nomi- na indidant. Qusb res quidem, hunce morbum antiqulo- ribus nee prorsils ignotum fuisse, nee dum tam frequen- ter, quam hodie, ob oculos venisse, nobis plane demon- strat."—(J. Copland, De Rheumatismo, 8vo. Edin., 1815.) being employed to mark intermediate states of severity. If the division into acute, sub-acute, and chronic be not arbitrary, it is at least con- ventional ; but it has this recommendation, that it is simple, and involves not theoretical or pathological doctrines, nor necessarily suggests ideas as to the seat and extent of morbid changes, which vary remarkably in their asso- ciations and concomitants, in different cases, and even in the same case at different periods. 5. More recently, a pathological division has been attempted, in which distinctions are based on conditions that are contingent, varying, and uncertain; and qualitative or adjective terms have been applied as distinctive of varieties, derived from the names of the tissues, which are assumed to be the seats of the particular forms of the malady; thus we have had rheu- matism denominated capsular, muscular, perios- teal, neuralgic, &c, the meaning implied being that the capsules of the joints, the muscles, the periosteum, celerated, often weak and compressible. That more or less thickening of the periosteum actu- ally takes place, has been demonstrated on dis- section of some of these cases. Dr. Hawkins remarks, that this form of rheumatism is often allied with deep-seated pains, which sometimes continue fixed in the shoulder, and occasionally affect the hip., They are aggravated by any motion in the joint in any direction ; which ren- ders it probable that the fibrous capsules with which these joints are provided are here the seat of pain, and these capsules are closely in- terlined with the periosteum. 34. It is often very difficult to distinguish rheumatism affecting the periosteum from pains occasioned by syphilis or by the abuse of mercury. The previous bistory of the case, should guide the diagnosis; but it may be inferred that the affection is rheumatic when the pains and the periosteal affection- are decidedly local, or con- fined to a single limb, or to defined portions of one or more limbs. Whereas the pains from the other causes now assigned are more dis- persed or wandering, affect a greater number of places, and are seldom confined to one part until nodes are being, or have already formed. The nocturnal exacerbations are also much more severe when the disease is syphilitic than when it is rheumatic; and they moreover are generally associated with other signs of second- ary syphilis. If the pains have been produced by the abuse of mercury, the swellings or en- largements of the periosteum are more remark- able, more numerous, and more defined than when the disease is rheumatic. 35. D. Rheumatism may affect chiefly the Fi- brous Envelopes of the Nerves.—Neuralgic Rheu- matism—Rheumatism of the Nerves.—This form of the disease is met with in the rheumatic di- athesis, from the same causes as produce rheu- matism, and often in alliance with rheumatism of other fibrous structures. Yet, although pains following the course of certain nerves, and pro- duced by exposure to cold, may be viewed aa being very closely allied to rheumatism, they should not be viewed as being altogether iden- tical with it; but, in many instances, as more intimately connected with neuralgia or with neuritis. Nevertheless, the connections of these pains with either may obtain in different cases, the one affection passing into the other by insensible degrees. Neuralgic rheumatism is observed chiefly in the sciatic nerve and its branches. The attack generally commences in the loins, affecting one side chiefly or solely, extending down the corresponding limb, and Oc- casionally reaching the foot. It occupies the posterior aspect of the limb, and follows the course of the nerve. The suffering is generally very severe, and is commonly increased at night; hut it is seldom so distinctly periodical as neuralgic affections are ; nor is the pain so sudden in its invasion and cessation, nor so transient as that of neuralgia. The symptoms often resemble those of incipient ulceration of the cartilages of the hip. (Sec articles Neural- gia, y 35, and Nerves, Affections of.) , 36. Neuralgic rheumatism is sometimes seat- ed in the nerves of the face, usually in conse- quence of exposure to currents of air ; is often associated with other rheumatic complaints, andsometimes even alternate with rheumatic affection of the sciatic or other nerves. This form of rheumatism is often attended, at its commencement, by a foul or furred tongue, by acceleration of pulse, by disorder of the secre- tions and excretions, and by biliary congestions or accumulations. It may present a sub-acute character; but it is most frequently chronic, and often very prolonged, being of several months' duration. 37. E. Rheumatism affecting chiefly the Apo- neuroses, Muscles, or fibrous Tissues of the Loins and Back—-Lumbago.—This form of the disease may-be either primary, or consecutive, ox simple. or associated. When it is primary it is some- times sub-acute, but it is more frequently chronic, especially when it is consecutive of other forms of the complaint; and in this latter case espe- cially it is often complicated with some other form of rheumatism, as neuralgic or sciatic rheumatism. Lumbago is often - confounded with other complaints ; these complaints, espe- cially congestion of the venous sinuses of the lumbar vertebrae and its consequences, conges- tions of the kidneys, &c., being mistaken for lumbago. This form of rheumatism is some- times but little painful unless the muscles of the loins are called into action, more especially if the action be sudden. Owing to this remark- able increase of pain on motion, the patient either remains at rest in his bed, or on a sofa, or he walks bending forward, and is unable to raise himself quite erect. 38. When the pains in the loins are truly rheumatic, the lower limbs and joints are sel- dom affected; but when they depend upon con- gestion of the venous sinuses of the lumbar vertebrae, or upon congestion of the kidneys, there are, in addition to more marked disorder of the urinary excretion, syrrtptomatic pains, numbness, cramps, or pricking, or lancinating pains in the limbs, usually in both limbs, when the venous sinuses of the spine are congested; and in one limb, if only one kidney is thus af- fected. 672 RHEUMATISM—Gonorrhceal. 39. Rheumatism sometimes affects not only the lumbar region, but also the dorsal portion in some instances, and in others it apparently ex- tends to, or has advanced from, the ischial or the gluteal aponeurosis to the lumbar or dorso- lumbar aponeurosis. It is doubtful, in these ca- ses, whether the muscles or the aponeuroses are the seat of pain. I believe that the latter are chiefly affected, the contractions of the mus- cles inducing pain by stretching the affected aponeurosis. 40. F. There are various other parts of the body in which rheumatism sometimes appears, independently of those more internal parts which it sometimes attacks either contemporaneous- ly with, or consecutively upon, an affection of the external structures. (See y 47, et seq.) Of the manifestations of rheumatism in these ex- ternal parts, little notice is required at this place, as the more important topics connected with them are discussed under other heads. It is necessary only to mention what these local- ities are, and the usual forms in which the dis- ease affects them.—(a) Rheumatism of the head —Cephalagia rheumatica—Epicranial rheuma- tism.—The rheumatic affection may appear ei- ther primarily or consecutively in the head, in a chronic or sub-acute, very rarely in an acute form. It may affect either side of, but very seldom the whole head ; and it may be seated in the frontal and temporal regions, or in the occiput. It appears to be seated in the epicra- nial aponeuroses of these situations, and not in the periosteum. (See art. Headache—Rheu- matic and Arthritic, y 29, et seq.) 41. (b) Rheumatism of the Neck—Cervical Rheumatism—Torticollis—Crick in the Neck.— This, as well as the preceding local form of the complaint, generally follows the action of currents of cold air, or other kinds of exposure to cold, or to cold and moisture. The pain af- fects chiefly either the back or one* side of the neck ; and in this latter case the head is held to one side, or held awry, and is always in- clined so as to relieve the suffering part. The neck is sore, stiff, and incapable of motion, un- less with great increase of pain. This form of the complaint is often complicated with the preceding, and is apparently seated in the cer- vical aponeuroses. 42. (c) Rheumatism of the Face—Facial Rheu- matism — Facio- temporal Rheumatism. — This form may be associated with either of the fore- going, and especially with rheumatism of the head (y 40). The pains may commence in ei- ther the temples or in the face, on one side, or in both at the same time. It is liable to be con- founded with tic douloureux, or neuralgia fa- cialis, or with toothache, with which latter it not infrequently alternates, or even is asso- ciated, the same exciting causes producing ei- ther or both. It is sometimes, also, compli- cated with severe attacks of catarrh, or with catarrhal fever, and, in rarer instances, it ei- ther is seated chiefly in, or extends to, the scle- rotic coat of the eye, forming rheumatic ophthal- mia. (See Eye, Diseases of, y 96, et seq.) 43. (d) Rheumatism may likewise be seated in, or extend to, the aponeurotic investments of the intercostal muscles, or these muscles them- selves, according to the opinion of some writ- ers. It has, in this situation, been usually de- nominated pleurodynia, or spurious pleurisy, under which head it has been considered. It may also affect the aponeurotic expansions, o fibrous tissues of any part of the abdominal pa- rietes, although the disease is seldom observed in these parts. Its affection of, and metasta- sis to, internal organs or structures axe consid- ered in the sequel. 44. II. Gonorrhceal Rheumatism—Specific Rheumatism. — Rheumatism affecting chiefly the capsules of joints and the synovial mem- branes not infrequently occurs in the course of other constitutional and cachectic diseases, es- pecially gonorrhoea, the venereal or mercurial cachexy, or other states of general taint. It is, however, only in connexion with gonor- rhoea that I have to view the complaint at this place.—a. The rheumatic affection generally supervenes upon gonorrhoea about ten days, or a fortnight, or three weeks from the first ap- pearance of the urethral discharge, which usu- ally is very much diminished, or has entirely disappeared, when the former is developed; and the one affection may alternate with the other, and become remarkably obstinate, espe- cially when neglected at first, or injudiciously treated. The cause of rheumatism thus super- vening upon, and more or less superseding, the gonorrhceal discharge, is not very manifest. The operation of the usual causes of rheuma- tism upon a constitution affected by gonor- rhoea, and previously exhausted by seminal dis- charges, seems the chief source of the malady; but in some instances the exciting causes are not evident, the gonorrhceal infection both pre- disposing to and determining the rheumatic dis- ease. Probably diathesis is much concerned in producing the attack, the gonorrhoea im- parting the peculiar conditions by which this form of the complaint is characterized. 45. b. The symptoms of gonorrhceal rheuma- tism generally appear before the urethral dis- charge has altogether ceased. A severe ach- ing is complained of in one or more joints. Of four cases which were under my care, three had the knees affected ; the other the ankles, and bursae of the adjoining tendons; but the affection was severer on one side than on the other. The pain soon becomes acute and burn- ing, and affusion rapidly appears within the cap- sules and bursae, which become much distend- ed. The external surface is rarely or never reddened or inflamed. Motion aggravates the pain, which is much exasperated during the night, causing watchfulness. The affected limb is usually kept in a semi-flexed position, and either stretching or bending it greatly aggra- vates the pain. This form of the disease as- sumes either an acute, sub-acute, or chronic char- acter, the last generally following the first or second. The acute is always attended by fe- ver. In a case which I lately attended, the pulse rose above 120; but more commonly the febrile symptoms are less severe than in the usual form of the complaint, and assume more of a sub-acute character, and a truly remittent form- The tongue is loaded, the bowels con- fined, but not so obstinately as in other states of rheumatism ; and the urine is loaded with lithates. The perspiration is copious, and some- what offensive. Dr. Macleod states that the skin presents a pulverulent deposite, which may be scraped off in sufficient quantity to bo tested, and which consists of the lithate of RHEUMATISM—Complications soda. I have not observed this. In no in- stance which I have seen has the urethral discharge entirely disappeared, a very scanty gleety fluid still exuding from the urethra. Several surgigal writers have noticed the al- ternation, or the succession of gonorrhceal oph- thalmia and gonorrhceal rheumatism. I have seen it only in one instance. I have not met with a case in which this form of rheumatism was complicated with, or succeeded by, cardiac or any other internal affection. In one instance there appeared a slight delirium during the acute stage. 46. The course of this complaint is very pro- longed, according to the usual mode of treat- ing it. M. Ricord states that it generally con- tinues many months; Although the more acute symptoms may soon subside, the sub-acute and chronic stages are most obstinate. Even when it has apparently disappeared the complaint is apt to recur, generally in a chronic form, the urethral discharge returning during the inter- vals. In this way it may continue a long time, and even induce serious organic changes in the affected joint 47. III. Of the Complications, Extensions, or Metastasis of Rheumatism.—Rheumatism, especially in its acute and sub-acute forms, is a more or less external manifestation of a consti-^ tutional malady, during the existence of which. internal determinations, also, of morbid action may appear in similar tissues and structures ; or, in other words, the constitution, being, af- fected in an acute or sub-acute form, will throw the morbid action on the periphery of the frame, without any internal complication in persons of strong vital resistance or unimpaired power; but in those of diminished energy or vital re- sistance, a somewhat similar state of morbid action is apt to appear in internal fibrous and serous tissues and surfaces,'either contempo- raneously with, or consecutively upon, the ex- ternal affection. In these latter, the vital en- ergy is insufficient either to throw off the mor- bid action on distant or peripheral parts, or to protect more central structures from the inva- sion of this aetion. 48. A- Of the several associations, complica- tions, and metastases of rheumatism, there are none of greater importance* and of more fre- quent occurrence, than those in which the heart and pericardium are concerned. The en- docardium, in certain of its reflections espe- cially, and the pericardium, axe particularly lia- ble to be affected, either contemporaneously with, or consecutively upon, acute and sub- acute attacks of rheumatism—the acute more especially. Of this complication or metasta- sis I have fully treated when considering the diseases of the Heart and Pericardium (y 129, 132, 133), and to that article I must now refer the reader. That many cases of-this complica- tion present the heart as the primary seat of the disease is by no means improbable, especially in young subjects, inasmuch as I have often observed a fully developed state of cardiac af- fection at an early period. Dr. Todd takes a similar view of this association of the internal and external disease, and believes that it is less frequently a metastasis than is usually sup- posed ; and states that the occurrence of the cardiac affection " is inexplicable by the doc- trine of metastasis, which supposes that the III. 43 i, Extensions, or Metastasis of. 673 cardiac inflammation has been transferred from the limbs to the heart. The truth is, that the cardiac inflammation may be primary: it, fre- quently exists at the same time with the artic- ular affection, and dates its origin from the same period, as it derives it from the same cause." (P. 116.) This remark is confirmatory of what I have stated at another plape (see art. Heart, v 129), and agrees with what I shall have to no- tice in the sequel. 49. Dr. Graves even believes that the rheu- matic disease may exist without its external manifestation, and that the cardiac affection may precede the articular swellings, or may exist without any disease of the joints being manifest, especially in persons who have been formerly the subjects of acute rheumatism. Such cases as these are comparatively rare; but I have met with two cases, both in fish- mongers, in which the symptoms were identic- al with acute rheumatism, with many of the symptoms of endocarditis, but without the ex- ternal rheumatic affection. These cases were viewed and treated as internal rheumatism of the heart, and terminated favourably. 50. B. The head is variously affected in rheu- matic cases. It may, as stated, above (y 40), .be the primary seat of sub-acute or chronic rheu- matism in either of the parts there designated; or it may be implicated consecutively, or in the course of either of the forms of the disease. The usual states of rheumatism of the head have been considered in the article on Head- aches (y 29, et seq., 50). But the head may be differently affected from either of the modes there mentioned. First, head affection, deliri- um, or mental disorder, in some form or other, may occur in the course of acute rheumatism, without any abatement, or with slight abate- ment, either of the fever or of the local dis- ease. In these cases the head affection is chiefly nervous, and contingent upon the fe- brile condition, in connexion with depression of nervous or vital power. The affection of the nervous system may, however, be produced by too large or repeated bleedings, by a rapidly- induced anaemia, or by colchicum, or by anti- mony, or by narcotics, and other depressing and perturbating agents. In all these cases the head affection is independent of any in- flammatory action within the cranium. 51. -Secondly, the symptoms referred to the head may appear at an advanced stage of acute or sub-acute rheumatism, most frequently of sub-acute and capsular rheumatism, attended by effusion into the cavity of the joint, and is gen- erally followed by the subsidence of the dis- ease of the joint. In this class of cases, al- ways the most unfavourable, and generally oc- curring in persons of exhausted or depressed vital powers, or of a cachectic habit of body, the head symptoms are more or less indicative of inflammatory irritation of the brain or its membranes, often passing into effusion of se- rum into the ventricles or between the mem- branes. Although the affection of the head is attended by the partial or entire subsidence of the disease of the joint, yet it cannot be con- ceded that the subsidence has produced the disease within the cranium. It should rather be considered that, during the course of the rheumatic disease, owing to the existing states of the nervous and vascular systems, influen- RHEUMATISM—Complications, Extensions, or Metastasis op. ces acting on the brain or its membranes de- velop a morbid action in these parts which su- persedes, or partially or entirely removes, that which previously existed in the joints; and that this form of bead affection is superinduced most frequently by causes acting on the mind, or on the brain and membranes, through the media of the senses, or still more directly and locally during states of vital depression, conse- quent either upon the duration or intensity of the disease, or upon an injudicious mode of treatment. 52. C. Disease of the membranes of the spinal chord, probably commencing in, or at least im- plicating the theca of the chord, is occasionally observed either complicated with, or immedi- ately consecutive of, an attack of acute or sub- acute rheumatism. A case occurred to me in 1820, in which acute rheumatism of the joints, complicated with pericarditis, was followed by chorea and inflammation of the membranes of the spinal chord, soon passing into effusion of lymph, and terminating in complete general pal- sy. This case was not only demonstrative of this complication and succession of local affec- tions, and of the appearances after death (see London Med. Repos., vol. xv.), but it also evinced tHe connection subsisting between rheumatism and inflammation of internal fibro-serous sur- faces on the one hand, and between atonic spas- modic affections, chorea, and paralysis on the other. 53. When treating of the forms of paraplegia and general paralysis (see art. Paralysis, y 70, et seq.), I described certain states of that dis- ease which depended upon inflammation of, fol- lowed by the effusion of lymph upon or between, the membranes of the spine, and which often commence in a very slight form or degree of palsy, the movements of the limbs being at first uncertain, tremulous, irregular, or spasmodic, in many respects resembling chorea, and grad- ually becoming still more imperfect, until they are altogether lost, sensation still remaining un- impaired. This affection, in rare cases, is con- sequent upon acute or sub-acute rheumatism, appearing as a transference of the morbid ac- tion from the more external parts to the theca and membranes of the spinal chord. I have met with five cases of this description, two of them in children under twelye years of age; and in three of the cases I had an opportunity of examining tne spine after death. In all three, coagulable lymph was effused within the theca, and pressed upon the chord and origins of the nerves; and the venous sinuses of the verte- brae were remarkably congested. It ought not, however, to be overlooked that inflammation of the membranes of the chord, occasioning ef- fusion of lymph and palsy, is generally attend- ed by severe pain in the limbs, and a girding sensation around the abdomen, which may be mistaken for rheumatism, but which is owing to the irritation at the origins of the nerves sup- plying the pained muscles, and may be quite in- dependent of pre-existent rheumatism, or of the rheumatic diathesis. (See art. Spine, its Chord and Membranes.) [Occasionally rheumatic inflammation attacks the intervertebral sub- stance, ossific matter is effused, and complete anchylosis follows. Such a case recently fell under our observation in a gentleman who had long laboured under chronic rheumatism, and who resorted to a water-cure establishment for treatment. The vertebrae of the spinal column all became firmly soldered together, so that flex- ion of the back became impossible, and even any motion of the head coukl not be executed without movement of the whole body.} 54. D. The pleura may be affected either in the course or consecutively of an attack of acute or sub-acute rheumatism ; but not so frequently as may be expected. In one case the pleura was implicated very soon after the complication of the rheumatism with pericarditis was ascer- tained, pleuritis with effusion rapidly superven- ing. The earliest writer who noticed the in- ternal or visceral complications of rheumatism was probably Boerhaave {Aphorisms, y 1491). He mentions the viscera in general terms, but particularizes only the brain and lungs; Van Swieten, in his excellent and practical com- mentaries, is more explicit; although even he fails in duly recognising the frequent complica- tions of cardiac disease with rheumatism, if, in- deed, this complication was as frequent in those days as in the present, which admits of some doubt,* although certain symptoms of this com- plication are not entirely overlooked by him; yet, in noticing these, we are surprised that more particular attention had not been direct- ed to the state of the heart and pericardium. It is not improbable, although such cases are not frequently detected, or are often overlook- ed or mistaken, that rheumatism, affecting the intercostal muscles, or the fibrous tissues in the vicinity, may extend to the pleura, and be there followed by inflammation or effusion, in • * " Verum quandoque pontingit, ut materies rheumatica admodum vaga sit, et, mox externas, mox internas, partes occupet; unde tales aegri in majori versantur periculo. Aliquando enlm dolor in membris disparet, oritur pecto- ris anxietas, cordis palpitatio, pulsus intermittens, et, re- deunte ad membra dolore, haec symptomata rhsparent, pulsusque, paulo ante tremulus et intermittens, denuo aequalis et liberrimus est. Alibi describuntur plures simi- les morbi, qui mense Novembri, 17591, m Nosocomio Pat- manniano aderant quorum initium fuit horror per totum corpus, dein languor; postea dolor rheumaticus, partim vagus, partim fi'xus, qui omnia membra obsedit, et subinde post unam alteramve, horam cessavit, tuncque pectus op- pressum fuit, et aegri inceperunt tussitarc. Caput etiam dolnit vario modo. Quandoque post plures horas dolor rheumaticus jde novo per omnia membra diffusus est; et tunc illico desiit dolor capitis, pectoris oppressio, et tussia evanuerunt Illae autem piutationes in eodem aegro as- pius contigerunt. " Haec materies rheumatica, quandoque adeo mobilis et vaga, nisi bona curatione, dissipari possit de corpore, vel expelli, in unum locum conduit aliquando, et ingentes tu- mores lymphaticos producit; de quibus eadem hac para- grapho dictum fuit, quomodo in externa corporis superfr cie appareant, et illis pertusis, exiverit semper serum fla- vum visGidum, quod leni calore potuit inspissari. Cum ergo pateat, eandem hanc materiam ex artubus derivari posse ad caput, ad pectus, si nee hide salutari metastari redeat ad artus, nee curatione expellatur de corpore, po- terunt tales tumores in inte,rtoribus colligi, et pessima mala producere, imo mortem, uti cadaverum hoc morbo defunctorum sectio docuit. "Tres aegri, in quibus serum, per universum corporu superttciem antea dispersum, subito interiora occupavit, rheumatismo perierunt In binis cadaveribus reperieba tur copiosjssima flava gelatinosa materia inter membra- nam pulmones ambientem et ipsos pulmones; totaquo pulmonum substantia in admodum parvam molem com pressa erat. Talis materies valde copiosa quoque inter piam matrem et cerebrum atque cerebellum haeflit; ante- riores cerebri ventriculi simili gelatina pleni erant. In tertio aegro disparuit tumor artuum, secuta fuit difficihs respiratio, et tussis convulsive, quae nullis remediis obedi- vit; unde miser intra quatuordecim dies; omnibus viri- bus exhaustus, periit. In medio pulmonis dextri detege- batur saccus, qui quinque libras seri flavi subacris recluait Caetera fueraut sana."—(Van Swieten, Commentaria w H. Boerhaave Aphorismos,t v., p. 654.) RHEUMATISM—States of the Blood and Excretions in. 675 more numerous instances than generally sup- posed. 55. E. The diaphragm and the peritoneum are, as far as my experience permits the remark, more frequently affected in connexion with, or consequent upon, rheumatism than the pleura. When rheumatic diaphragmitis is observed, ei- ther the pleural or the peritoneal surface pre- sents the most evident indications of change, al- though the crura, or the tendinous parts of the diaphragm, may be the chief seat of disease. When this viscus is implicated, the symptoms vary not materially from those mentioned in the article on its diseases, where, also, the con- nection sometimes existing between rheuma- tism and inflammation of the diaphragm is point- ed out, conformably with-the results of my ob- servations, and with my subsequent experience. {See art. Diaphragm, y 9, et seq.) 56. Although rheumatism may affect the dia- phragm either alone, or in conjunction with one or other of its serous surfaces, or both, as a complication, extension, or metastasis of the disease, yet the peritoneum may be chiefly or even solely affected; the external disease ei- ther subsiding or entirely disappearing upon the development of the peritoneal affection. Rheu- matic peritonitis is probably most apt to occur either during the puerperal states, or when rheu- matism affects the aponeurotic expansions and fibrous structures of the abdominal muscles and parietes ; but it is of comparatively rare occur- rence. (See art. Peritoneum, y, 128.) 57. F. Rheumatism or rheumatic inflamma- tion may attack the ovaria or the uterus gener- ally upon the subsidence or disappearance of the disease from more external parts. Cases of this kind are rare. An instance of metasta- sis of rheumatism to the ovaria has been ad- duced by me at another place. (See Ovaria, y 7, note.) The testes, either one or both, may be also similarly affected ; the pain being very severe, and the swelling considerable. Three instances of well-marked metastasis of rheuma- tism to the testes, of which I have preserved notes, have come under my care. [We are inclined to believe that rheumatic affections of the uterus are not as rare as our author supposes, having not unfrequently met with cases of this description. Indeed, what is often considered and called neuralgia of the uterus, is nothing but rheumatic inflammation transferred to this organ. There is scarcely an organ of the body which may not occasion- ally be the seat of the same morbid action, call- ed rheumatic] 58. G. Of the more pure complications of rheu- matism, there are none so frequent as those with catarrhal fever, or simple catarrh. I shall have to show hereafter that exposures to cold and humidity are more likely to produce attacks of rheumatism when malaria, even in slight grades, is superadded to these states of atmos- phere, the catarrhal affection resulting equally with the rheumatism, which may assume either of its forms, but most commonly the sub-acute, slight, and chronic, from the combination of malaria with cold and humidity. Many writers, from Boerhaave to Stoerck, Van Swieten, and others, have noticed the frequent association of rheumatism with ague, during some seasons, with scurvy in other seasons, and even with dysentery—complications manifestly depending upon the combination of atmospherio condi- tions, upon weather, season, &c.; and more es- pecially upon exposure to cold, in conjunction with an impure or malarious atmosphere, or with exhalations of decayed vegetable and ani- mal matter, and often with unwholesome or improper food. 59. H. Rheumatism is not infrequently com- plicated with disorder of the catamenia, or of the catamenial discharge. This subject has been recently noticed by Dr. Todd, who remarks that he " has been strongly impressed with the idea that the secretions of the uterus, if of an un- healthy character, and not duly thrown off, may be absorbed into the circulation, and contami- nate the blood, producing symptoms of greater or less urgency;" and he adds, that he " can- not do more than propose as a query whether, under certain circumstances, the uterus may not be regarded as a source of rheumatic or arthritic matter." (Op. (it., p. 148.) I believe that in no circumstances is the uterus pro- ductive of such matter; but that it is, as I have contended ia various parts of this work, a most influential agent in depurating the blood when it fully discharges its functions; and that it thus may prove, in the full exercise of these functions, the means of preventing attacks of both rheumatism and gout; while the imper- fect discharge of the catamenial function, and of the depurating process thereby produced, may favour the development of either rheuma- tism or gout, the former especially before the forty-eighth or fiftieth year, especially in the rheumatic diathesis, or where the hereditary predisposition to either of these diseases ex- ists. , Hence interrupted, scanty, imperfect, or otherwise disordered states of the catamenia may be an efficient or a concurrent cause of rheumatism; and thus catamenial disorder may be complicated with either of the forms of this disease. Hence, moreover, arises the frequen- cy of cbronic arthritic affections in females when the catamenia-become difficult, scanty, and altogether cease. 60. IV. Of the States of the Blood and Excretions in Rheumatism.—i. Of the Blood. —It becomes a matter of some interest to con- sider the states of the blood in rheumatism, see- ing that the disease is considered by several re- cent writers, as it was by Boerhaave, Baynard, Van Swieten, and many others, during the com- mencement and middle of the last century, to depend upon a materies morbi existing in the blood. I shall, therefore, give the results of observations and examinations of the blood ; and when I come to consider the nature of the disease, I shall then notice in how far the changes observed in the blood are the patho- logical conditions constituting the malady, or are merely the results of the influence of the disordered organic nervous system on the blood —whether the alteration of the blood is the proximate cause, or ia the result, of the disease. 61. Baynard had long since asserted that the saline and acid ingredients found in the blood and urine are present in the former in excess, owing to the non-elimination of them by the kidneys and skin; and that the excessive ac- cumulation of them in the blood caused the rheumatic disease. It is obvious to common observation, even if not shown by Nasse, Si- mon, and Andral, that the blood contains more 676 RHEUMATISM—States of the Blood and Excretions in. fibrine in acute rheumatism than in the normal state, and that the corpuscles decrease in pro- portion to the excess of fibrine. The fat is also increased. In proportion to the increase Of the fibrine and fat, and the decrease of the corpus- cles, the whole solid residue is diminished— this state constituting what Simon has termed hyperinosis, for a principal part of the science of German pathologists consists in the coining of terms. In rheumatism, especially in the fe- brile states of the disease, the physical condi- tions of the blood, rather than its chemical con- stitution or its microscopic appearances, are most important to the practitioner, who cannot carry a chemical laboratory, nor even a modern microscope in his pocket, and who cannot shape his treatment according to the reports furnish- ed by these sources, however they may aid him in forming an hypothesis. In the acute states of the disease the clot is rather small, consist- ent, cupped, and covered by a strong buffy coat; the cupping and thickness of the buffy coat de- pending much on the deepness and shape of the vessel in which the blood is received, and upon the rapidity and size of the stream. Nasse states that the coagulum is firm, but that when the buffy coat is very strong the consistence of the lower part of the clot is much less. Jen- nings, according to Ancell, maintains that the clot under tbe buffy coat is so loose as to fall to pieces on the slightest touch. Both are right in different cases and in different stages of the disease; at least such is the result of my ob- servations. The serum is always clear, and of a deep yellow hue. With the frequency of blood-letting the size of the clot diminishes in proportion to the amount of serum, and the cup- ping and buff either continue, or even increase, however far depletion may be carried.* * Many years ago a remarkable illustration of this fact occurred in a case, which was attended by a Burgeon in Walworth, to which Dr. W. and I were called at ad- vanced stages of this disease. A man, aged about fifty, of a leucophlegmatic appearance and corpulent, had a se- vere attack of rheumatism of the lower extremities, for which he took, of his own accord, a large dose of croton oil. Violent hypocatharsip was the consequence, and the pain in the limbs suddenly ceased; but he was as sud- denly seized with excruciating pain in the region of the Heart, with extreme anxiety and palpitatiqn. The sur- geon instantly saw him^ and bled him largely about the middle of the day. When he was seen again at night, he was found in no way relieved; the blood which was taken was very much cupped and buffed; and this appearance, in connexion with the continuance of the distress, induced the surgeon to bleed him again the night of the same day —twice largely on the day of the occurrence of metasta- sis. The following morning he was no better. The sec- ond qnantity-of blood taken was more buffed than the first. Dr. W. was sent for, and he was bled a third time largely on the second day. The coagulum was now small, but still remarkably cupped and buffed. On the third day he was no better, and constant jactitation had supervened. He was bled the fourth time. I was requested to see him on the evening of that day: I saw the third and fourth quantities of blood taken away, the clots of which were very small, but remarkably cupped and buffed; the first and second quantities were described in consultation. The anxiety, action of the heart, and jactitation were ex- treme. The lipg, gums, and surface were remarkably anremied, and he presented all the appearances I have de- scribed, as indicating extreme losses of blood. (See art. Blood, § 63, er seq.) Having heard the history of the case, and observed bis existing state, I expressed my be- lief that he could not live twelve hours. He died within that period. The surgeon and I opened the body about twenty hours after death. Adipose matter was very abnndant in the usual situations; and all the tissues pre- sented the most remarkable pallor, very much resembling the appearance of veal. There was no fluid effused in any of the cavities, and the large vessels and cavities of 62. According to Simon, Andral, and Ga- varret, the quantity of fibrine and of fat is al- ways much increased during the acute form of the disease, and that of heemato-globulin much diminished ; the proportion of blood corpuscles diminishing, and that of serum increasing with the quantity or frequency of depletion. The first part of the following table exhibits the maxima, minima, and mean of forty-three anal- yses of the blood of fourteen persons in this disease; the second part, the analyses of the blood in four peculiar cases. Water. 3i •o-S s a li Maxima. . Minima . Mean . . . Healthy ) blood J 839-6 771-6 805-4 7900 228-4 160-4 194-6 2100 10-2 2-8 6-7 30 1300 701 1010 1270 1048 76 9 860 80 0 Case 1st . Case 2d . . Case 3d. . Case 4th . 8268 818-3 815-4 7411 173-2 181-7 184-6 2599 4-8 46 40 2-6 79 0 891 82-6 1543 89-4 880 980 1020 63. The blood in the first of the cases (the second part of the table) was taken from a col- our-mixer under the influence of lead, to which M. Andral attributes the deficiency of the cor- puscles. The blood was taken in the second from a person who had been bled six times, and had had 200 leeches applied. The third was the blood from a person with incipient chlorosis; and in the fourth, the blood was taken from a vigorous person, twenty years of age. 64. The blood of ten persons suffering chron- ic and sub-acute articular rheumatism, furnished, according to the analysis of Andral and Gavar- ret, no striking results. The proportion of fibrine in no instance exceeded 50, and in two cases was as low as 2-9 and 2-6. The blood corpuscles in one amounted as high as 154-3, and the solid constituents to 259-1. In the oth- • er cases the corpuscles were below the healthy average. As rheumatism loses its acute, fe- brile, and severely painful character, so the fibrine diminishes and the blood approaches, or altogether returns to the healthy state. As these forms of rheumatism are more frequently aggravated than relieved by blood-letting, I have very rarely had an opportunity of observing the state of the blood in connexion with them; but in two cases, the chief change from the healthy state, observed in sub-acute rheumatism of the head, was an increase of the fat in both; the serum having been of a very white or milky hue in one case. 65. ii. The Urine, in rheumatism, requires constant observation, as upon its varying states modifications of treatment are often indicated. —A. In acute rheumatism the colour of the urine is generally high, sometimes of a purple- red, or thin claret. Its acid reaction is very decidedly marked; and very bulky fawn-colour- ed, or lateritious sediments, consisting of urate of ammonia, and occasionally of crystallized the heart contained very little blood, which was coagula- ted into fibrinous, stringy clots, which contained a very small proportion of red globules. The internal cavities, and the valves, and columnse carneae appeared deeply red. The pericardium was natural, but pale, and contained no fluid. The appearances generally were similar to those of an animal blooded to death. (See art. Blood, § 50-64.) RHEUMATISM—Diagnosis of. 677 uric acid, are deposited. Acetic and phosphor- ic acids have also been found in the urine in this form of the disease by Henry and Vau- qdelin. In eighteen cases, in which the urine was examined- by Becquerel, it always pre- sented the characters usually observed in in- flammation, as long as the fever continued. The deep colour and the acid reaction were al- ways observed. The mean specific gravity was 1022-6. In cases which threw down a spontaneous sediment it was 1025-2 to 10270. He found that after large bleedings the urine assumed the characters of that in cases of anae- mia. Albumen was detected in seven of the eighteen cases. Oxalate of lime is of frequent occurrence. The other constituents vary some- what ; but as the urine of persons in sound health varies in different individuals, and in the same person at different times, no precise in- ference can be drawn respecting them. 66. B. In chronic rheumatism, and when the pains are not very acute, the urine often retains its normal characters. Of thirty-seven cases, Becquerel found the urine unaffected in twen- ty ; in seventeen it assumed the inflammatory character, and in nine of these it threw down a spontaneous sediment. If the complaint be very long continued, and much debility exist, the urine may, without being red or high-col- oured, present a turbid, thick, or even foetid ap- pearance. I have generally found the urine to have an acid reaction in the chronic as well as in the subacute states of the disease. In some cases, and especially when the membranes and sheath of the spinal chord are implicated, the urine has contained the phosphates ; and it has never been alkaline unless much debility or vi- tal exhaustion exists. 67. iii. The perspiration has not received due attention in the different forms of the dis- ease, as respects either its chemical constitu- tion or its quantity- and sensible characters. When the perspiration is profuse in acute rheu- matism, minute vesicles, or sudamina, are oft- en observed on different parts of the surface, especially the breast or trunk. The perspira- tion has generally an acid or peculiar offensive odour, which is less remarkable, or becomes so, when any internal complication or metastasis supervenes. Lactic acid, the ordinary free acid in sweat, is usually increased ; and Simon states that, when there is an acid odour, acetic acid is present. Persons subject to chronic rheuma- tism have these pains removed by a free or co- pious perspiration ; and those thus subject, who do not take sufficient exercise, are generally liable to have a return of the complaint, if a sufficiently perspirable state of the skin be not preserved, the cessation or sudden suppression of this discharge often sufficing to reproduce the disorder, without any exposure or other ex- citing cause. 68. V. Diagnosis.—Rheumatism may be con- founded with gout, with scurvy, and, in the form of lumbago, with nephritic affections, or with inflammation of the membranes or sub- stance of the spinal chqrd. Various affections of the joints, of the periosteum, and of the nerves, especially neuralgic affections, may also be mistaken for rheumatism.—A. Rheumatism is often not easily distinguished from Gout* * " In rheumatismo discernendo a podagra chiragrave, •spills falluntur medici. Sunt tamen, quae distinguant In general, however, the large joints are first attacked by rheumatism, and the small joints by gout, the former disease appearing, after chills or rigours, in the acute form, and at an earlier age than the latter; and, unless at a very early period of life, gout is more disposed to affect internal organs than rheumatism, and it is generally preceded by, and sometimes as- sociated with, more marked disorder of the stomach, liver, and kidneys. It should not, however, be overlooked, that both diseases are so nearly allied, especially in certain of their forms, as not to admit of diagnosis, the arthrit- ic form of rheumatism, especially when affect- ing the small joints, and occasioning nodosities (y 25), nearly resembling chronic gout, and just- ifying the popular appellation of "rheumatic gout." 69. B. From simple or scrofulous inflamma- tions of the joints rheumatism is often distin- guished with difficulty. Rheumatic inflamma- tion of the joints may, however, affect scrofu- lous persons, or inflammation of these parts may attack either the rheumatic or the scrofu- lous diathesis; and, although closely allied to rheumatism, as affects the former diathesis, it cannot be viewed as an instance of rheumatism of the part. In acute or sub-acute rheumatism not one joint only is commonly affected, but several, and the affection moves from one to another, and along the aponeurotic expansions; or if it be permanent in one, or intra-capsular, the distention gives the joint the appearance noticed above ($ 28, et seq.). When inflamma- tion and its consequences supervene upon the rheumatic affection, then the local disease pre- sents the changes usually consecutive of sim- ple inflammation of the joint, while the consti- tutional disturbance still preserves many of the rheumatic characters, and both one and the other often are influenced by atmospheric states and changes. 70. C. Rheumatism may approach the char- acters of neuralgia, or be associated with it. It may even affect, as stated above (y 35), the fibrous sheath of a nervous trunk, as in sciatica, or the ischias nervosa of Cotunnius. When Medicus igitur primum omnium, utrurn aegri corpus ar- thritidi proclivius sit, necne, animo diligenter perpendat. Deinde qua; indicia ante apparuerint, praesertim an ven- triculus affectus sit, quod quidem in rheumatismo sim- plice perquam rard fit: pe'rturbatio autem ventriculi sive dyspepsia, arthritidiB accessionem biduum triduumve an- tevenit Qualis febris et rheumatismnm et arthritidem .comitatur, talis posted animadvertenda est. Hie enim a frigore et horrore incipit, nee remissionem habet; hujus \ verd febris statis temporibus remittit, et interdum omnia j febris symptomata ex toto cessant Turn ex ratione, quS | dolor accedit, et ubi resideat facile dignoscitur: Rheuma- tismus plerumque tarde advenit, et statim ab initio articu- los majores occupat: si quando minores occupet, nun- quam nisi in longinquioribus morbi exemplis fieri vide- mus' Contra ea tamen Arthritis multd frequentius mino- res, quam majores torquet; qui quidem articuli ed magis rubescunt et tumescunt. Podagra denique estate provec- tiores, juniores verd rheumatismus, victimas excruciat. " A deloribue scorbutfcorum facile discriminator. Scor. buticorum arteriae non nisi permodice) inequaliterque mi- cant ; interdum et subsiliunt Scorbutus etiam specie in terdum livida, quam urina prae se fert; specie et putres- cendi, quaB per totum corpus hie Hue conspicitur, sese baud rard prodit " A nephritide satis distinguant' dolor in regione renis, saspe ureteris iter sequens, vomitus, cruris stupor, testi- culi ejusdem lateris retractio aut dolor,' et dolor renum ex statu prona nunquam adaugendus. " Non est, cur hac in re, dolores, qui debilitatem e lue venerea enatain consequantur, nos in rheumatismo distin- guendo fallant Prior syphilis, et rerum inde ortarum i cognilio, satis discriminat"—(J. Copland, Op. cit., p. 30.) 678 RHEUMATISM—Causes or. rheumatism is complicated with that form of neuralgia which depends upon an affection of the sheath of the nerve, they may be both view- ed as almost the same complaint, and differing only as implicating different seats or parts ; and they generally both arise from the same cause. True neuralgia, or tic-douloureux, however, de- pends more upon some change affecting the origin or roots of the nerve than upon any al- teration implicating its trunk or branches, and occurs in very violent paroxysms, between which there is a complete immunity from pain; whereas, when the sheath of a nerve is attack- ed, there is more continued affection, more of the symptoms of neuritis, and often numbness of parts below the seat of pain, with a sense of burning heat in the part affected. 71. D. Although the painsexperienced by per- sons suffering from secondary symptoms of syphilis have been ascribed by some to that mal- ady, and by others to the mercury used for its cure, yet there is reason to believe that these, or either of them, may be only a chief cause, cold and other causes concurring with them to produce the distressing pains experienced dur- ing the night, generally in the periosteum of the more exposed bones. These pains, instead of affecting the joints or extremities of the bones, as in rheumatism, are seated chiefly in the superficies of the bodies or shafts of the bones, and depend on a specific form of inflam- mation of the periosteum with thickening and nodes. The history of the case, the previous treatment, the seat of pain, the elevation and irregularity of the part affected, the absence of fever, and the great severity of the pain during the night, generally indicate the nature of the complaint, especially when the flat surface of the tibia, or the outside of the ulna, or of the radius, or the sternum, or the frontal or parietal bones, are affected; or when eruptions, sore throat, &c, accompany the disease ; or when large quantities, of mercury have been pre- scribed. 72. VI. Prognosis.—Sydenham places the prognosis of rheumatism in a too favourable point of view when he says that it is rarely fatal; and Van Swieten very justly remarks, that this is only the case when it is fixed in the joints; for, when acute rheumatism changes its place, it is apt to seize upon some internal viscus, and place the patient in the most im- minent danger. The justness of this remark will be readily acknowledged at the present day, when the frequency of complicated and metas- tatic rheumatism is considered, and the influ- ence of age, and of various states of predisposi- tion, in favouring the complications and metas- tasis of the disease is recollected. The risk of cardiac complication is especially great; indeed, the existence of it may be inferred in the great majority of cases under the age of puberty; and both this and other complications and metas- tases, already notieed (y 47, et seq.), may occur at all ages. Van Swieten observes that, when an internal affection commences after the sub- sidence of external rheumatism, and terminates fatally at a more or less remote period, the re- sult is too often considered as due to the in- ternal disease, and not to the rheumatism, which is actually the cause. While, therefore, acute rheumatism is attended by fever, if it occur very early in life ; if the pulse be very rapid, open, and compressible; if tne patient have experi- enced a depletory or lowering treatment, and is the subject of mental anxiety; or if the pain continue to change its place, there still exists more or less contingent risk, even although the sounds and impulse of the heart be found natu- ral upon a careful examination, and the func- tions of the brain be undisturbed ; if internal complication is detected, or metastasis occurs, then the patient should be considered in a state of great danger, although recovery may take place in such circumstances, or the changes which have already supervened may only re- motely tend to shorten life. 73. Even the sub-acute and chronic forms of the disease may be followed by prolonged suffering, or, if seated in the joints, may be followed by irremediable or partially remediable changes, as anchylosis, if neglected or improperly treated; and still more frequently by relapses, or by more or less suffering for months, or even years. In all cases of acute, sub-acute, or chronic rheuma- tism, an immunity from the disease, or from a relapse or return of it, should not be relied upon until the tongue becomes clean, the biliary and intestinal secretions are natural, the alvine and urinary excretions are healthy, and until the perspiration is free and equable. 74. Vlt. Remote Causes.—i. Predisposing Causes.—A. Temperament and diathesis have some share in producing a state of predisposi- tion to one or other of the forms of rheumatism. The disease may affect any constitution or tem- perament, but the bilious, melancholic, and bilio- irritable temperaments are apparently most lia- ble to it. That, there is a rheumatic diathesis —a diathesis rheumatica—has been asserted by most medical writers ; this diathesis being he- reditary. I have certainly observed numerous instances which seemed to support this opinion; but I-shall give it a more particular attention in the sequel. 75. B. The most remarkable source of pre- disposition exists in the several digestive, depu- rating, or eliminating organs, especially the stom- ach and the skin, kidneys and liver, and even, also, the intestinal canal. In very few cases are the functions of the stomach, duodenum, and Ziuerduly discharged, either for some time previously to or during the attack. The stomach is weak, or the food unwholesome and insufficient; and the liver is torpid in function, or retentions of the secre- tion in the ducts and gall-bladder have taken place, until primary and secondary assimilation has been impeded or disordered, and excremen- titious materials have accumulated in the blood. While this state of the hepatic functions, espe- cially when accompanied with biliary congestion or accumulation, occasions merely wandering or fixed symptomatic pains in some persons, it is often followed by attacks of either gout or of rheumatism, both in them and in others, when the predisposition to either is more fully devel- oped, and the respective exciting causes come into operation. The functions of the other dep- urating organs, especially of the kidneys, skin, and digestive mucous surface, and even of the uterus, when imperfectly discharged, are also more or less concerned in predisposing to some forin or other of this complaint, and even also in determining the particular states,or compli- cations in which it is often observed. 76. C. Sex has manifestly but little influence RHEUMATISM—Excitins Cattbks op. 679 in predisposing to rheumatism; for so much depends upon exposure to the exciting causes, that those classes, whether males or females, which are thus most exposed will present nu- merically the greatest predisposition. Hoff- mann is certainly not correct in considering fe- males more predisposed than males. Rheuma- tism is, perhaps, more frequent in the former, in a chronic form, after the age of fifty; but be- fore that age it is certainly more frequent in males. Van Swieten justly remarks that men, being more exposed by occupation, by irregu- larities, and by dissipation, and their numerous concomitants, are more liable than females to rheumatic affections. Haygarth states, that he found the disease more frequent in males than in females, in the proportion of 98 of the former to 73 of the latter. 77. D. Age has also no very marked influence after 15, or after puberty, if the proportion of persons living at certain ages be taken into the account. The greatest number of cases ts met with,between the ages of 15 and 30 ; but the proportion of those living at that age is greater than at a more advanced age. M. Chomel found that, in seventy-three, cases, thirty-five were first attacked between the ages of 15 and 30; twenty between 30 and 45 ; seven between 45 aiid 60; and seven after 60. Two only were attacked before 15, one at .8, and the other at 9 years. I have seen several cases between the ages of 5 and 15 ;but hardly one at that early age that Was not complicated with either en- docarditis or pericarditis, or with both, and even also with inflammation of the membranes of the spinal cord. 78. E. Depressed, impaired, or exhausted or- ganic nervous energy is most influential in pre- disposing the frame to the invasion of every form of rheumatism ; and by whatever causes this energy may be weakened" or exhausted, by none is this effect more manifestly induced than by premature of excessive venereal indulgences, and masturbation or self-pollution. By these, more, perhaps, than by other causes, is organic nervous power depressed, and the tone or healthy condition of the fibrous tissues subvert- ed, thereby occasioning imperfect assimilation and excretion, and favouring the morbid influ- ence and operation of causes which alter organic sensibility, and vital tone and contractility.* 79. ii. Exciting Causes.—A. Of these, cold has been viewed as the most influential, in whatever way it may be directed on the frame. In many cases, however, it is not the mere ab- straction of the animal caloric from the whole or part of the frame, but the combinations of this with other influences or agents.—(a) Of these combinations the most common depend upon the modes of warming and ventilating houses and chambers in this country. Although * " Inter hodiernos et nostrates potissimum ad luxuri- ant et incontinentiam nimiam referendus est, et ad artes operaa sedentariee egentes, quae corpus intra parietes re- tentum et occupatum infirmant Eos certd, qui sedenta- rii victum quaaritant, quique sub dio ferd nunquam mo- rantur nee ibi ad sudores medioores exercentur, citd in- firmari; niraium admodum sentire, quique imtentur justd procliviores esse; idcircd e causis extra afficientibus fa- oilius in valetudinem incidere, ex omnium experientia sa- tis constat. Nee igitur latet, quamobrem nautas rheuma- tismo vacare, etiamsi praeter ceteros homines, crebriores cceli mutationes, et causae omnes excitantes,- subeunt Ex hoc quoque liquet fceminas quam mares, imbecillos quam robustos, et antea affectos qu&m immunes, sibi sae- pius mancipare." these modes, viz., by open fire-piaces and coal fires, admit ot a free and healthy ventilation, provided that the air thus supplied be pure, still the body is unequally heated by them; and while the parts opposite the fire are inordinately excited by the radiated heat, the other parts are exposed to, and depressed by, the currents of cold air proceeding from the doors and windows to the fire-place.* To this cause, more espe- cially, may be imputed the prevalence of the several forms of rheumatism in this country. Still more injurious, are insufficient clothing, especially if it be connected with unwholesome or insufficient aliment; exposure to cold con- joined with humidity, and to currents of cold and moist air; riding in open carriages, espe- cially at night and withouj; sufficient protection, and more particularly if the cold and humid air contain malaria, or exhalations from decayed vegetable matter ; and living in tents, or lying and, still worse, sleeping on the ground, or on cold, damp, or wet places. This last cause is more especially injurious, inasmuch as it ab- stracts the animal heat, changes the natural electrical states of the body, find exposes the frame more completely to terrestrial exhala- tions at a time when it is most predisposed to ^e affected by them. In addition to these, wet clothes, the sudden suppression of perspiration, the living in cellars or on the ground-floor, or where the exhalations from the soil or sources of vital depression are given out constantly, and even solicited by fires and ventilation. 80. The causes now enumerated, both predis- posing and exciting, are such as depress the or- ganic nervous energy, and weaken the functions of those organs which are actuated by the or- ganic nervous system—the digestive, the as- similative, the secreting-, and the excreting functions—thereby changing the condition of the blood, as well as more directly affecting the circulating fluids through the heart and vessels themselves, and giving rise to morbid states of the secretions and excretions, more especially of the cutaneous and urinary excretions. [Rheumatism is a disease which, from its fre- quent occurrence in J;he United States, its pain- ful and protracted course, and the many evils that follow in its train, has especial claims upon the attention of the American practitioner. The following table, for which we are indebted to the able work of Dr, Torry, on the " Climate of the United States" (p. 273), exhibits the annual and quarterly ratios of rheumatic cases treated per 1000 of mean strength, on an average often years, among the United States soldiers, in each system of climate: * "Inter causas ejuscemodi, quae patria in nostra rheu- matismum longum excitare soleant, enumerari debet ratio domiciliorum calefaciendorum, qui conclavia et cubilia nostra calore radiante temperantur. Nam aded ineequaU- ter facit ignis, ut una ex parte corpus calefiat, ex altera frigeat Hue forsitan adnumerandae sunt crebrae vestium mutationes, vel potius ratio vestes induendi frequenter mutata. Rheumatismum longum et excitant cceli intern- peries, tempestatumque anni assidua mutabilitas. Ubi vel hiems vel aestas incipiat, et ubi desinenda sit, certissimd distinguere prorsus nequimus. Hiemem in media BBstate et Bsstum interdum haud mediocrem frigoribus in mediis non rard vidimus: quin immo intra diem unicum tempe- ratura agris xxx gradus seepe percurrit. Ccelum nostrum humidum est, quippe qui insulam incolamus, cui Zephy- rus et Caurus, e regione calida exorti, perque oceanum magnum perequitantes, madidis incubat alis; et sudorem, qui corpus leniter perfundat, subitd reprimit: ideoque morbum sopitum resuscitat, aut in iis, qui antea vacabant, prdgignit" 680 RHEUMATISM—Or the Nature of. ratio of rheumatic diseases. System* of Climate. NORTHERN DIVISION. First Class. Coasts of New England ..... Second Class. Posts on north- ern chains of lakes . Third Class. Posts remote from the ocean and inland seas...... MIDDLE DIVISION. First Class. Coastfrom Dela ware Bay to Savannah . Second Class. Southwestern stations...... SOUTHERN DIVISION. First Class. Posts on Lower Mississippi ..... Second Class. Posts in the peninsula of East Florida Average . . Ratio treated per 1000 of Me** Strength. 29 30 36 38 37 34 27 20 24 27 22 23 9026 110 151 166 126 112 90 119 29,29,125 From these results Dr. Tokry concludes that those affections which are generally ascribed to sudden variations of temperature, conjoined with excess of moisture, are less under the influence of atmospheric agency, as exciting causes, than is usually supposed, but that they are in some measure controlled by the same laws which govern pulmonary diseases. He very justly remarks, that if cold, moisture, and sudden alternations of temperature were the chief causes, the highest ratio should be given on the New England coast, and the northern chain of lakes ; but that, on the contrary, it is found that, like pulmonic diseases, rheumatism is most rife on the dry and cold atmosphere of the interior (the Tbird Class of the Northern Division), characterized by the extreme range of the thermometer, and by seasons strongly contrasted. Among 6257 cases registered, only one death is reported. Were these affections, as Dr. Torry observes, very mtich under the influence of meteorological causes, we should find, as in pulmonic lesions, a great contrast in the ratios of the seasons. Taking the mean of the four seasons, as shown above, the first and second quarters give the highest averages ; but, contrary to the law which governs pul- monary diseases, the ratios of the third and fourth are the same. Viewing the whole sub- ject, however, it is found that a similarity ob- tains in the general laws which, on the one hand, govern rheumatic, and, on the other hand, pulmonary, but especially catarrhal dis- eases. The same results are arrived at by the re- cent reports upon the medical statistics of the British troops, as will appear from an in- spection of the table at the head of (he next column. These results show that rheumatic diseases are more prevalent in the Mediterranean than in Canada and Nova Scotia, and that, as the British Reporter observes, " though some of the prov- ■ t •0 .- X J? U J « O 3} Adminsioha from a 1 £ i 1 « "S-s It | Rheumatic Af- c J -3 3 le 4 0. fections annu- = 1 s u 0 5 sd;£ ally per 1000 of Mean Strength. 29,30 33,34 34^38,40,46 49,50 57 inces of the Cape of Good Hope have occasion- ally been without rain for several years, these diseases are more frequent in the dry climate of that command than in the West Indies, where the condition of the atmosphere is as remarka- bly the reverse ; yet have extreme cold and at- mospheric vicissitudes, coupled with excess of moisture, been assigned as satisfactory causes for their prevalence." Dr. Torry notices the fact, that between the ratio of Canada and that of Nova Scotia and New Brunswick, the former being one third higher than the latter, the same law obtains as in the United States; for while " in Canada the cold becomes so intense that the mercury, congealed in the thermometer, serves no longer to indicate the extreme reduc- tion of the temperature, in Nova Scotia, on the contrary, the mercury is seldom lower than 6° or 8° below zero in winter, or above 88° in sum- mer. Notwithstanding the atmosphere, in con- sequence of the same causes which modify its temperature, viz., its insular character and in- tersection by lakes and bays, is exceedingly moist, and fogs are, along the coast, common throughout the year—a circumstance regarded as most favourable for the production of rheu- matism—yet it is seen that the ratio is lower than in the dry and intensely cold climate of Canada." Dr. Torry explains this fact, on the ground of the predisposition induced by the ex- tremes of the opposite seasons, and maintains that rheumatic affections, like those of the lungs, obey in some measure the inflectiftns of the isotheral and isocheimal curves. He also observes, that the term rheumatism is generally so loosely applied that a host of ailments, with no character in common save that of pain, are classed under it; and hence that, were this in- vestigation confined to cases of the acute form, the result would be modified. " Of the fact," he adds, " that the application of cold, more especially when combined with moisture, to the body, when unusually heated, is the chief ex- citing cause of acute rheumatism, there can be little doubt; but when we reflect that, for every instance of rheumatism so induced, numbers continually endure a much greater exposure to the alleged causes with impunity, it follows that still more depends on the predisposition, how this predisposition is said to be given by many circumstances, as age, temperament, cli- mate, and even hereditary liability. As regards the influence of climate, it would appear that acute rheumatie affections, like those of the lungs, are less dependent on mere variations of temperature than upon its extreme range as con- nected with the seasons, the former being an exciting, and the latter a predisposing cause"] 81. VIII. The Nature of Rheumatism has been much discussed during the last and pres- ent centuries. It was formerly imputed, by Baynard, Boerhaave, Van Swieten, and oth- ers, to a materies morbi existing in the circula- tion, which affected particular parts in a promi- RHEUMATISM—" ■Of the Nature of. 681 nent and painful manner, according to their predisposition or morbid tendency. More re- cently, it was viewed by Stoll and Latham as an inflammation of a peculiar form, or affecting a particular series of vessels, namely, those only admitting the colourless parts of the blood, al- though the existence of such vessels had not been demonstrated. Cullen, C. Smith,-and Bichat considered acute rheumatism as an in- flammatory state of the muscular fibres, which assumed a peculiar form, owing to the cause and the nature of the structure affected. Bi- chat, however, considered that this affection implicated more particularly the fibrous tissues of the joints and the aponeurotic expansions. These latter opinions were generally received, when I ventured to suggest the view taken in the subjoined passage.* Since then, Sir C. Scudamore; Hildenbrand, and Todd have ad- vanced different views as to the pathology of this disease. " The first of these writers has re- garded rheumatism as pain of a peculiar char- acter, with or without inflammatory action, af- fecting several tissues at the same time, but chiefly the white fibrous tissues of the joints and muscles. " In acute rheumatism, he con- ceives the morbid action to be seated in the ligaments, the tendons, the aponeurotic mem- branes, and the bursae, but in the ligaments most frequently. In the sub-acute form, though any of these textures, and even the nerves, may be affected, the disease is most frequently con- fined to the bursal, that is, the synovial texture surrounding the tendons. In the chronic form, though the disease may occur in the ligaments and tendinous tissues, he represents it as most common in the sheaths of the tendons and the aponeurotic membranes." 82. Hildenbrand is more elaborate in his consideration of this subject than any recent writer. He views it as a specific form of in- flammation, affecting fibrous, or serous, or fibro- serous membranes, and differing from other * " Quidam e scriptoribus antiquioribus de rheumatis- mo disserentes, quales hypotheses explicaturi sumus, tales fingebant: fluidorum scilicet lentorem esse"j qui partis af- fectse vascula obstruat; quidam verd, materiam morbidam in corpore generatam, et ibi per totum corpus circule'n- tem, donee maturuerit, ut medieatricibus naturae viribus, per vascula emunctpria expellatur; et hujusce materies morbidaa expulsionem. perquam necessariam ad icpioiv vel sanationem proferendam conducere. Huncce mor- bum in vasculis articuli dolentis lymphalicis sedem habu- isse, apud quosdam hodiernos hypothesis tenet Frigus tamen cui corpus, corporisve pars objicitur,' vasculorum subter cutem dispositorum contentionem, h. e. spasmum efficere, indeque partiurrf interiorem et articulorum ct fibrarum musculorum et aponeurosedn tendinosarum in- tlammationem necessarid oriri, opinio jam propd universa est Hae hypotheses jam memoratae, eorum quae in rheu- matismo occurrant partem tan-turn explicant, itaque simul ac editae sunt, obsolescunt " Ab iis tamen, qui nihil nisi musculorum fibrarum et aponeurosedn tendinosarum statum innammatum esse rheumatismum affirmant, qusBri possit: Quard inflamma- tionem gangrsna aut suppuratio consequi nunquam repe- riaturr quae res quidem in reliqui corporis affectionibus, quae ex inflammatione oriuntur, saBpissimd accidit. Et quaeri potest: Cur dolor hujusce morbi a caeterarum in- flammationum cruciatibus tantum differat ? " Nihil quidem, nostra judicio, obstat qud minus rheu- matismum affectionem nervorum, prsBcfpud ad partem affectam pertinentium, singularem, hisque inseparabilem; et ex nihilo alio nisi adauctiore corporis, ut excitetur pro- clivitate (vel ut vulgd dicimus ex irritabilitate, vel Bensili- tate adauctd), nasci existimemus. Quard inflammationem, non rheumatismi causam; sed hujusce affectionis singu- laris nervorum, sive systematis vel ad partem affectam pertinentium, effectum esse arbitremur."—(Op. sup. cit., p. 17.) specific inflammations proceeding from atmos- pheric conditions and changes, from catarrhal inflammations which affect mucous surfaces, from erysipelatous inflammations which attack the skin, and from phlegmonous inflammations which appear in any structure. Pain he con- siders to be the chief characteristic, or eminent nadoc of the complaint, the other characters of inflammation either being absent or contingently present. He considers that the imponderable agents, light, heat, and electricity, are chiefly concerned in the causation of the disease; states of the air, alterations of the temperature, and conditions of the surface of the body, &c, sub- verting the equilibrium, of the circulation, and occasioning efforts to recover the harmony sub- sisting between the different systems. These efforts he believes to be concerned in, or to constitute, the more immediate cause of rheu- matism. I cannot refer to the numerous argu- ments by which he supports his views, but many of them are fallacious, and are founded on "postulata. {See Institut. Medico-Practica, t. iii., p. 360, et seq.) 83. Dr. Todd, one of the most recent writers, has adopted a similar theory to that contended for by early writers in the last century. He observes that, on reviewing the leading phe- nomena of the rheumatic paroxysm, it is im- possible not to perceive a resemblance of the most marked kind to some of those diseases which are confessedly due to the introduction of a morbid material into the blood ; and that, as in those diseases, the fever is not relieved " until the morbid element which gives rise to it has, as it were, spent its fury on the textures to which it is attracted." He next inquires into the nature of the morbid matter, which he considers " to be the cause of the rheumatic di- athesis, as well as of rheumatic fever;" and he proceeds to observe that "the two most re- markable excretions in the rheumatic diathesis, or fever, are the urine and the sweat. Both these are distinguished by the presence of an unusual quantity of free acid. The urine con- tains a large proportion of lithic acid; and those highly coloured deposites take place in it, which Dr. Prout supposes to arise from the formation of purpurates. The lithic acid diathesis, how- ever, is by no means so strongly marked in the rheumatic as in the gouty state, and these ex- cessive deposites of lithates are more to be re- garded as belonging to the paroxysms than as constant concomitants of the diathesis. The high colour of these deposites is more marked in rheumatism than in gout. The sweat of rheumatism is much more copious than that of gout, and is evidently much more acid. In the latter disease, indeed, sweating is generally absent. Lithate of soda is never found in the rheumatic paroxysm, nor in the diathesis ; and those derangements in the biliary system, which so often occur in gout, are not so apparent in rheumatism. If, with these considerations, we take into account the most frequent causes of the rheumatic diathesis and paroxysm, we shall obtain a farther clew to the determination of the problem we have proposed. These causes must be admitted to be imperfect assimilation and vicissitudes of temperature; and hence the ill- clad and badly-fed children of the poor are the most numerous victims of rheumatism. Hard work, exposure to cold and wet, bad food, are 682 RHEUMATISM—' ■Of the Nature of. strongly contrasted as causes of the rheumatic diathesis, with the ease, comfort, and excess which give rise to the analogous one of gout. If now we remember that the skin is the great emunctory of lactic acid, and that bad food, or too little food, may give rise to its undue devel- opment, as well as too much food, it is no won- der that, as lactic acid is imperfectly excreted through its natural channel, in consequence of the influence of cold in checking perspirations, and is too freely developed in the alimentary canal, it should accumulate in the blood and become eliminated at every point. "Moreover, the long continuance of the causes which pro- duce the defective cutaneous secretion, and the deranged gastric one, will give rise to the undue development of the lactic acid, in the secondary destructive assimilating processes ; thus infect- ing the.blood from every source, and tending to perpetuate the diathesis." (P. 142-4.) 84. There is much that is manifestlytrue in the above view taken of this disease ; but the changes described are merely a part of the suc- cessive morbid conditions consequent upon the remote causes. They are, however, important changes, and have been always insisted upon by me in my lectures, and have furnished the basis for one of my chief indications of cure for many years, as shown in a work published some time ago, in which the author states this doc- trine and the treatment founded on it. He there remarks that, " in this species of fever the perspiration, urine, and saliva will be found invariably acid, and the use of alkalies benefi- cial ;" and he adds, that " this employment of alkalies, and the observation upon which it is founded, I derived a long time since from Dr. J. Copland."—(The Simple Treatment of Dis- ease, by J. M. Gully, 8vo ; Lond., 1842, p. 133.) But, as I shall have to state hereafter, these are not the only changes which either consti- tute or prove a materies morbi existing in the blood, and directly causing or perpetuating rheu- matism ; there are other alterations which are both antecedent to, and concomitants of, these changes, and some of which are the causes of those which are more prominently manifested in the blood and in the excretions. There is every reason to infer, from the nature of the predisposing and exciting causes, and from the more immediately resulting phenomena, that the earliest changes which take place in the economy are depression of the organic nerv- ous or vital energy, imperfect assimilation and impaired excretion; and that the resulting re- tention of effete and excrementitious materials (see art. Disease, v 99-102, et pluries) is fol- lowed by morbid excretions, chiefly from the kidneys and skin. But, perhaps, the most im- portant of the consecutive changes—consecu- tive especially of the morbid'condition of the organic nervous system—is the increase of the. fibrine of the blood and diminution of the red globules; states which, under the influence-of this system, are manifestly concerned in pro- ducing the complications and metastases which so frequently occur in acute rheumatism, and especially in those cases in which these changes in the blood are the most remarkable. After the most attentive consideration I have been able to devote to the subject, I believe that the pa- thology of rheumatism may be stated as follows : 85. a. The remote causes or occasions of rheu- matism are principally of that kind which either directly or indirectly depress the organic nerv- ous or vital energy of a part or of the whole body, altering the sensibility and other vital conditions and functions thus partially or more generally ; and these causes, whether intrinsic or extrinsic, as respects the economy, affect, through the medium of the organic nervous sys- tem, the vascular system, and the blood, and ul- timately the secretions and excretions, 86. b. These causes, especially such as im- pair the power of the constitution to generate animal heat, or rapidly transfer this heat from the surface, and are connected with changes in the electrical conditions of the body in relation to those of the atmosphere—more particularly insufficient nourishment and clothing; low, humid, and cold localities ; living in cellars, or upon or near the surface of cold, damp, or clay- ey soils ; the proximity of marshes ahd other sources of malaria; seasons in which the quan- tity of rain has been excessive, and east or north- east winds prevalent, &c.—are such as produce the most remarkable effects upon the organic, nervous, and vascular systems, thereby devel- oping, according to peculiarity of constitution and concurrence of causes, the several forms of rheumatism and their characteristic phe- nomena. 87. c. Owjng to the greater prevalence of these causes in some districts, or countries, than in others, rheumatism is so prevalent in these as to be endemic as respects them; and owing to unusually wet seasons, and the preva- lence of east or northeast winds, or to remark- able vicissitudes of weather and temperature, this disease has been not merely prevalent in a single district, but also so very generally dif- fused as to have been epidemic, endemic and epidemic prevalences of the complaint having been generally overlooked by writers, and hence not referred to their respective causes. 88. d. The nature and operation of the remote causes—the effects produced by them on the or- ganic, nervous, and vascular systems, and con- secutively upon the blood, the secretions, and excretions, and the nature of these effects, espe- cially in acute and sub-acute forms of the dis- ease, serve to explain the frequency of the com- plications and metastases of these forms; the constitution of the blood manifestly favouring the supervention of disease of internal serous or fibro-serous surfaces, and the effusion of fibrinous lymph on the affected surface. 89. «. There is no satisfactory proof of the lactic or acetic acids, found in the perspiration during acute rheumatism, or of the uric acid found in the urine, having existed in the blood previousy to their excretion from it, and there forming a materies morbi. It is, on the contrary, more reasonable to infer that the elements of these acids accumulate in the blood, owing to the operation of the predisposing and exciting causes upon the organic, nervous, and vascular systems, and upon the organs which these sys- tems actuate; and that the accumulation or condition of these elements gives rise to these acids in the excretions as well as to the other changes in them and in the economy ; and that these acids are probably the effect, rather than the cause, of the disease. The excess of fibrine, and diminution of red globules, in the blood, are most probably owing to the same mode of oper- RHEUMATISM—Treatmknt. 683 circulation of these tissues, and to the irritation of the morbid fluid exuded from them, either internally or externally, to the capsules. 94. k. That the disease actually originates, and continues mainly seated, in this part of the nervous system, is shown, 1st. By the nature and operation of the remote causes; 2d. By the transition of the morbid sensibility from one part of the periphery of this system to an- other—from one side or joint to that on the other—from a superior to an inferior extrem- ity, &c. ; and, in cases of exhaustion, from the periphery to more central parts, and not in the course of the cerebro-spinal nerves. The changes in the vascular system, in the blood, and in the secretions and excretions, are the consequences of the morbid condition and ex- cited, sensibility of the ganglial nervous sys- tem. Inflammatory irritation or action, when it supervenes, either internally or externally, is owing to this cause, or to the irritating nature of the fluid effused from the affected tissues, or to a combination of these causes ; and the aug- mented pain, on motion, of an affected joint or limb, is also owing to the exalted sensibility and tenderness of the affected fibrous or fibro- serous tissues, manifested more especially when these tissues are stretched or brought to a state of increased tension. 95. I. The treatment of the several forms of rheumatism, especially the acute and sub-acute, has been conducted by me since the subject first engaged my mind in 1814, upon the patho- logical basis now stated, and always with a successful issue, and without internal compli- cations and metastases, if they were not pres- ent previously to the employment of the means which this view suggested. 96. IX. Treatment.—The indications and means of cure advised for the several forms of rheumatism have been as different, or even op- posite, as the views which have been enter tained of the causes and nature of the malady; and even at the present time very opposite doc- trines respecting the pathology and treatment of the disease are promulgated by able author- ities, each one appealing to facts—too often false facts—as demonstrative of success, with- out giving due consideration to the influence of vital resistance or constitutional power—the vis medicatrix natura—ih withstanding injurious influences and agents, and to the manifest dis- position of the economy to return to a normal condition, where injurious causes no longei continue to operate, and where no organic in- jury calculated to impede or interrupt the vital functions has been produced.* ation of the remote causes. Even granting that these acids are in part formed in the di- gestive canal, and in the blood during the dis- ease, it is not unlikely that they are also partly formed by the excreting organs, especially when their large amount in some cases is considered. 90. /. The great importance of the primary effects produced in the organic nervous and vas- cular systems, and of the consecutive changes in the blood and excretions, should direct a more intimate reference to these effects, when devising the indications and means of cure, than has hitherto been attempted. These effects, primary and consecutive, are such as require the organic nervous energy to be duly support- ed and developed, the exuberance of fibrine to be diminished, the tendency to the exudation of fibrinous lymph on serous surfaces to be counteracted, and the morbid conditions of the secretions and excretions to be removed by means appropriate to the respective conditions. 91. g. The frequency of complications and metastases of rheumatism is owing, 1st. To pre-existing tendency, lesion, or disorder of some organ or part; 2d. To exposure to some energetic cause during the rheumatic disease, as violent mental emotions, causing affections of the heart or brain ; 3d. To depletory, depress- ing, or exhausting means of cure, thereby low- ering the vital resistance, and favouring the ex- tension or metastasis of disease from the pe- riphery to the centre of the frame ; 4th. To the neglect of the morbid states of the blood, espe- cially of the exuberance of fibrine ; 5th. To the neglect of the physical and chemical states of the secretions and excretions, and of the means which these states should suggest; 6th. To measures which act locally, and which, by sup- pressing the local manifestation of a general or constitutional disease, tend to the production of it in other parts, or in internal organs. 92. h. Rheumatism is attended by phenom- ena, which, however nearly allied to gout in many cases, are different as respects, 1st. The seat and character of the pain ; 2d. The state of the blood, particularly in regard of the abund- ance of fibrine, and the diminution of red glob- ules in the former disease ; 3d. The nature of the excreted acids and salts, and the state of the excretions from the skin and kidneys (y 65- 67); 4th. The seat and nature of the consecu- tive local changes, which in arthritic rheuma- tism are chiefly within the capsules and at the ends of the bones, but which in gout are ex- ternal to the capsules, and are often attended, in chronic cases, by the peculiar gouty concre- tions ; 5th. The remote causes, predisposing and exciting ; those of rheumatism chiefly causing a deficiency of red globules and poor- ness of blood ; those of gout, an exuberance of globules and richness of blood. 93. i. The pain in rheumatism, whether af- fecting the fibrous tissues of joints, or of ten- dons and aponeurotic expansions, does not pro- ceed from inflammation of these parts or of the muscular fibre; and the increased pain on motion, or the inability of motion, is not de- pendent on affection of the muscles them- selves, but are chiefly owing to the change in the functions and sensibility of the ganglial or organic nerves supplying these structures. When inflammation supervenes, it is owing to the influence of these nerves upon the capillary * "Apud antiquiores de rheumatismi curatione nihil certi repertum: quippe qui morbum, sicut supra memo- ravimus, pend ignorare, et cum arthritide confundere, vi- derentur. Veruntamen, ut e scriptis Graicorum patet, sanguinem mittere, movere alvum, et tepidd perfundere solebant Romani de rheumatismo curando nihil memi- nerunt; neque dubium, quin podagrae chiragraeve speciem duxerint " E Gaxeni temporibus usque ad seculum decimum sextum, de hoc morbo, deque curatione ejus, nihil pror- sus repertum; nee apud Arabes quidem, ubi, Europi ig- norantisBque barbarisque nebulis obumbrata, omnes ^Es- culapii filii discipulique concesserant Sub finem seculi decimi sexti, rheumatismum ab arthritide et catarrho, quibuscum tarn saspd confusus esset, discriminavit Bal- lonius, eique iterum rheumatismi nomen, forsan parum feliceter, indidit Sydenhamius hunc morbum ex artis medicae regulis submovere, et sub morbi accessionem ante omnia sanguinis missioni fisus videtur. Ferd nullus alius morbus est, cujus in curatione plura medicamento- 684 RHEUMATISM—Treatment of Acute and Sub-acute. 97. i. Treatment of acute and sub-acute Rheumatism—Having taken a view of the modes of treatment and means of cure which have been recommended for these forms of the disease, and having given my opinion respect- ing them, I shall next state the treatment which I have employed for these forms of rheuma- tism since the earliest period of my practice, and which I have found most beneficial in the simple forms of the disease, when no complica- tion nor metastasis had supervened. It may, however, be remarked that the treatment of the several forms of rheumatism must necessarily vary with the locality in which persons who are the subjects of them reside, according as the patient resides in the country, in a healthy and dry atmosphere, or in a humid and malarious air ; or in a close, low, crowded, and large town, and as he has been well or ill fed and clothed. Neither should it be overlooked that a somewhat different treatment may have been required by our ancestors, who drank malt liq- uors, and not tea, and spirituous liquors, as in modern times. These latter, taken even in mod- eration, especially when taken habitually, im- pair more or less the primary and secondary processes of assimilation, impart more of a nervous character to diseases, and contra-indi- cate the employment of vascular depletions, unless with caution and in moderation. 98. A. Blood-ktting was recommended by Syd- enham at an early period of his practice, and certainly to an extent which could not fail of being injurious in many instances. Of this he appeared to have been afterward convinced; for, in a letter to Dr. Brady, he admits that it impaired the strength, and favoured attacks of other diseases. He therefore trusted,.at a later period of his practice, to a diet consisting chief- ly of whey. Sydenham had probably been in- duced to adopt frequent bleedings for this dis- ease at the commencement of his practice by the advice of De Baillou or Ballonius, and Riverius, who had advised this practice. Boer- haave also recommended large blood-letting early in the treatment; but his very able and learned commentator, Van Swieten, and about the same time Stoerck, saw reason to be more cautious, and advised it only for the young and plethoric, and when the pulse is strong and full. Tissot, Pringle, D. Monro, and Stoll, also recommended free or repeated blood-letting, aided by diluents; and the practice was fol- lowed byTHiLENius and Bang, and adopted by Cullen with more reservation, he bringing to its aid local bleedings, diaphoretics, and purga- tives. Heberden was still more cautious, and contended that venesection was not suited to the majority of cases, and ought to be prescrib- ed only for robust persons. Dr. Fordyce had at first recourse to blood-letting; but his experi- ence led him to infer that it favoured the oc- currence of internal metastasis, and he there- fore abandoned the practice.. Dr. Fowler re- sorted to bleeding in 41 out of 87 cases, and found that only three were cured, seven much relieved, seven partially relieved, twenty very rum genera medici neoterici adhibuisse videntur. Nee mirum, quoniam unusquisque eorum, prout ipse de prox- imis morbi cansis judical, vel haec remedia vel ilia adhi- bet. Eventus felices quos a remediis quaj absolutoria ex- istimaverint, affici sibi gratulentur, afiroitpartia potius.sive viribus naturaB medicatricibus posse attribui,haudmedio- cris suspicio habenda est"—(Op. cit., p. 82.) little relieved, and four not at all benefited. Dr. Latham regarded blood-letting as not re- quired, although he did not object to local bleed- ing by leeches, as advised by Dr. Fowler, and trusted chiefly in diaphoretics, diluents, laxa- tives, and rest. Ultimately, Dr. Wells and Willan came nearly to the same conclusion, as respects the treatment of the disease in London and large towns, namely, that blood- letting is either unnecessary or injurious, by enfeebling the patient and favouring internal translations of the malady. More recently, Mr. Bedingfield and Dr. Craigie have advocated early and large blood-letting. But the former wrote when venesection was a common rem- edy, and was certainly less prejudicial, as re- spected the prevailing epidemic constitutions (from 1810 to 1825), than it has heen subse- quently. Doctors Craigie, practising in Edin- burgh, has declared in favour of blood-letting, aided by diaphoretics and cathartics, and con- tends that, " in order to be beneficial, it ought to be performed early in the disease, and car- ried to a considerable extent." He considers that the best time is within the first three or four days, or, at all events, within the first week. It should be carried, he adds, " to twenty, twen- ty-five, or thirty ounces at once, and within twenty-four hours to as much more ;" and he attributes the want of success of Fowler and others to the smallness of the quantity taken. M. Bouillaud has advocated a somewhat simi- lar practice to the foregoing; but, instead of ab- stracting at once the quantity advised by Dr. Craigie, he has adopted the abandoned method of Sydenham,, and has advised a smaller quan- tity, on more frequent occasions, to be drawn. 99. I believe that the treatment of any form of rheumatism by blood-letting, as a general principle of practice, however early in the dis- ease, to be productive of injury in some cases —of rheumatic inflammations of the internal and external membranes of the heart, of the peritoneum, pleura, synovial membranes, &e.; of delirium, prolonged convalescence, and of the degeneration of the more acute into the chronic states. I will not deny that the robust, or those in the prime of life, who live well and enjoy a wholesome air, will bear full or even copious depletion at an early period of the disease, gen- erally without detriment, and possibly with ad- vantage ; but I am convinced that in large cit- ies or towns, in persons employed in warm, ill- ventilated factories, or those living in crowded rooms, low apartments, cellars, &c.; in the very young, and in the old especially; wherev- er Inhere is any indication of deficiency or poor- ness of blood ; and, a fortiori, in the ill-clothed and ill-fed, vascular depletion in any form is often most injurious, and always unnecessary —rarely required, even for the apparently ro- bust, nnless it be conjoined with the method of cure which.I shall recommend in the sequel {<) 115, et seq.). [We fully agree with Dr. Copland in the opinion that blood-letting is not adapted to the treatment of rheumatism as a general rule, and that much injury has resulted from its indis- criminate employment. In very robust habits we have found one venesection early in the dis- ease of considerable advantage, especially when conjoined with antimonials, nitrate of potash, or Dover's powders; but we have seen so much RHEUMATISM—Treatment of Acute. 685 injury from its repeated use that we never re- sort to its repetition except under very urgent circumstances. When complicated with endo- carditis, as it often is, blood-letting, conjoined with mercurials freely administered, is indis- pensable to control the disease in limine, and prevent those cardiac organic lesions which lead to a fatal result. But even here free cup- ping and leeching over the praecordial region, aided by a succession of blisters, dressed with mercurial ointment, will often suffice to arrest the inflammatory action and produce speedy resolution. The choice of remedies must, as in all other cases, be determined by the age, constitution, habits, etc., of the patient, and es- pecially by the period and severity of the dis- ease. No rule can be given to meet all cases. American practice in rheumatism, as it seems to us, is more bold than judicious, more hap- hazard than discriminating, and in many cases more injurious than beneficial.] 100. B. Mercurials alone^ or with opium, have been advised for the acute and sub-acute forms of rheumatism, since the benefit produced by them in inflammations of serous membranes was shown by Dr. Hamilton. The practice was adopted by Niemann, and by many modern writ- ers, with the view of preventing the effusion or formation of coagulable lymph, especially in the internal extensions or metastases of the disease. But there is every reason to believe that mercurials, prescribed so as to produce their specific constitutional effects, will exert but little influence either in removing rheuma- tism, or in preventing the affection of internal parts; although they, especially calomel, will be of service in removing biliary accumulations and congestions, in rousing the torpid functions of the liver, and, when conjoined with opium, in promoting the excreting function? of the skin : an intention always necessary to be accom- plished in rheumatism. But there is another preparation of mercury which, when conjoined with other medicines, is often of service in cer- tain forms of rheumatism, viz., the bichloride ; this, when taken in minute doses with the com- pound decoction, or fluid extract, of sarsa, or with the decoction of cinchona or infusion of serpentaria, &c, is often of great service in some sub-acute and chronic states of rheuma- tism of the joints. Attempts to cure the more acute forms of rheumatism by salivation, as suggested by some writers, while by no means preventing, if not increasing, the risk of intern- al metastases, always render convalescence prolonged, and favour the degeneration of the acute and sub-acute into the chronic forms. 101. C. Emetics, followed by cholagogue pwr- gatives or eccoprotics, were much praised by Lentin, Thilenius, and Stoll, at a very early period of the disease, and more especially in that state of acute rheumatism which they de- nominated bilious, or in which biliary disorder was manifestly present. Clossius recommend- ed the repeated exhibition of emetics. There can be no doubt of the propriety of the practice, in the circumstances just stated, and if the treatment be not otherwise depressing. Emet- ics have been rarely given in rheumatic fever in recent times; but I have prescribed them in a few cases at the commencement of the attack, conjoining them with warm cardiacs, or aromatics, or stimulants, so as to produce not only full vomiting, but also copious perspira- tions, as early in the disease as possible. 102. Purgatives, especially cholagogues, are generally required early in the disease, although they have been but little insisted on by writers, excepting Boerhaave and a few others. But they should be prescribed only so as to procure a free alvine evacuation and discharge of bile, without occasioning severe catharsis; for a too violent action on the bowels, and more espe- cially if it be conjoined with vomiting, will re- markably risk the suppression of the local af- fection, and cause some internal complication or metastasis of the disease, as in the very re- markable instance adduced above. In the more acute states of the disease I have usually pre- scribed, as early as possible, a moderate or full dose of calomel, with ipecacuanha or James's powder at bed-time, and a purgative draught, as the compound infusions of gentian and senna with the sulphate and carbonate of magnesia, in the morning ; the satisfactory operation of these being introductory to other more efficient means. In some instances I have preferred half an ounce each of spirits of turpentine and castor oil, taken on the surface of milk, or of some aromatic water; and when the bowels do not act copiously, an enema, containing about an ounce of turpentine, with ten grains of cam- phor, or half a drachm of asafoetida, and some common salt, will always be most serviceable. The evacuations ought to be carefully exam- ined ; and if, from their appearances, there is any reason to infer either the retention of dis- ordered intestinal excretions, or retention or disorder of the biliary secretion, the purgatives now mentioned, or such other as the peculiari- ties of the case may suggest, avoiding violent measures, should be repeated occasionally, un- til the motions present a more healthy charac- ter. This end is not always attained by pre- scribing cold saline purgatives ; but it will be more certainly and speedily reached by conjoin- ing stomachics and bitters with the purgatives. 103. D. Diaphoretics have been recommended by many for all forms of rheumatism, but they are not equally beneficial in all, nor ares all di- aphoretics equally efficacious. The medicines of this class which are most serviceable are the preparations of antimony, either alone or with opium ; Dover's powder, or ipecacuanha and cal- omel with opium; the liquor ammonia acetatis with sesquicarbonate of ammonia, in full doses, and with the spiritus atheris nitrici; guaiacum, in the form of decoction or tincture, with ammonia; and camphor With nitre and opium, or camphor with James's or Dover's powder, or with anti- mony, or with preparations of ammonia. Al- though the most acute states of rheumatism are generally attended by abundant sweats, which produce no relief, yet these do not contra-indi- cate a recourse to diaphoretics. If this course of treatment be adopted, there are certain points whjch should receive due attention in connex- ion with it: 1st. All retained, accumulated, or morbid, biliary and intestinal excretions should be previously Temoved by the means already noticed, so that the patient may not be chilled, during the diaphoretic operation, by getting up to the night-stool. 2d. The patient should be enveloped in, or have next his skin, a long flan- nel night-gown ; or, in default of this, a cotton one; and he should sleep in soft woollen or flan- 686 RHEUMATISM—Treatment of Acute. nel blankets, or in cotton sheets. 3d. A suffi- ! cient supply of warm antacid and saline dilu- | ents, and especially an abundance of fresh whey, . or of very weak, but fresh mutton or veal tea, ! or barley water, should be always ready.which may be made the vehicle for diaphoretic or oth- er medicines, and which, taken abundantly, may j promote diaphoresis. 104. a. The antimonial diaphoretics are the tartar emetic in small doses ; James's powder or antimonial powder, either aione or with oth- er substances, as with alkalies, opium, cam- phor, &c. The alkalies and magnesia, in the state of carbonate, aid the effect of these, and neutralize the acids present in the prima via. Opium increases or insures a'sudorific effect, and is generally of more or less service when thus conjoined, if biliary and intestinal accu- mulations and retentions have been removed, and when the symptoms are very acute, and when vital power and vascular fulness have not been too much reduced. When, however, the patient has been too freely depleted ; or when there is much exhaustion, and especially if the urine indicate much free acid ; or if the perspi- rations have an acid smell, &c, then other di- aphoretics are indicated, and antimonials should be relinquished.* • 105. b. The preparations of ammonia, with or without guaiacum, or the spiritus atheris nitrici, or camphor, or other medicines, are then, I be- lieve, the most beneficial. If the liquor ammo- nia acetatis be prescribed, it should be conjoined with full doses of the sesquicarbonate of am- monia and the spirits of nitric aether; or, if guaiacum be preferred, it may be given with am- monia or camphor. Guaiacum, either al6ne or with ammonia, was formerly much employed in rheumatism, and much praised by Dr. Fowler, and more recently by Dr. Seymour, the former preferring the simple tincture, the latter the mixture of the pharmacopoeia. I have pre- scribed either, but generally in conjunction with large doses of the carbonate of ammonia, or some other alkali, for reasons which will ap- pear hereafter. The gentle operation which it often exerts on the bowels, when given in a suf- ficient dose, is also advantageous, but its free diaphoretic effect should always be aided by di- luents, and by the regimen advised above ($ 103). 106. c. Dover's powder has been very gen- erally employed in the several more acute states of rheumatism; but it should be pre- scribed either in its original form, the nitrate of potash being substituted for the sulphate, or the ipecacuanha should be given in larger doses in the form of pill. One grain of ipecacuanha, with one of opium and eight of nitre, should be given in the form of pill every two hours, until three or four doses are taken ; and then this dose should not be given oftener than every tenth or twelfth hour, the operation upon the skin and urine being promoted by a copious use of diluents, containing nitre and, the sub-car- bonate of soda or potash, that may be rendered pleasant by the addition of the usual spices and aromatics. At the commencement of the at- tack, the ipecacuanha, in doses of two or three grains, may be given with an equal quantity, or somewhat more, of calomel, and a grain of opi- * [A very good formula in these cases is Vin. Tart. Ant., f. f ij. Tinct. opii, 3J8S. Dose, 3J. every hour, if the stom- ach does not reject it] urn, and be followed, after three or four doses, by a stomachic purgative, or by either of those already mentioned (y 102) ; and after the bow- els have been evacuated, the ipecacuanha, opi- um, and nitre maybe taken, so as to procure a copious perspiration, which should be promoted by the regimen and medicated diluents already recommended. In some cases I have prefer- red a combination of ipecacuanha, camphor, and opium, the camphor in doses of three or t)ve grains, with the same quantities of the ip- ecacuanha and opium as already advised, nitre and carbonate of soda or potass being taken freely, in large quantities of diluents or demul- cents. 107. d. Calomel and opium have been recom- mended for their diaphoretic and alterative ef- fect ; but they should be given only at the com- mencement of the disease, and should then be combined, at first, with full doses of ipecacuan- ha, and afterward with camphor; but after a few doses—not more than three or four—a pur- gative should be taken, and its operation pro- moted by an enema (see v 102). 108. E. The nitrate of potass was much em- ployed for acute rheumatism by Brocklesby, Ranoe, and Thilenius, who gave from one ounce to an ounce and a half in the twenty- four hours, copiously diluted, and continued thus to exhibit it for five or six days, when the disease generally began to subside. I have pre- scribed it for many years, but not in so large doses, using it chiefly in the drink of the pa- tient with the carbonate of potash or of soda, or prescribing it in the decoction of bark, either combined thus, or with the liquor ammoniae ace- tatis, and spiritus aetheris nitrici. The inten- tion of these writers was to excite the skin and kidneys to the due elimination of hurtful ma- terials from the blood; my object being to rouse all the. emunctories to increased action, to de- velop organic nervous energy, and to counter- act the .morbid disposition and condition of the blood. [We have known the nitrate of potash used with much benefit in acute rheumatism, in do- ses of i., ij., or even jiij. in twenty-four hours, largely diluted. In most cases the pulse re- mains unaffected, the digestive functions do not suffer, and the urinary secretion is slightly in- creased in quantity, and has a high specific gravity. The most obvious effect is the abate- ment of the heat, pain, and swelling in the af- fected joints, while the tendency to cardiac complication is materially lessened, or, if it ex- ists, is rendered more controllable. It is very probable that the beneficial effects of nitre in this disease may be owing to its property of diminishing the amount of fibrine and increasing the saline constituents of the blood. A solu- tion of the nitrate, and also of the iodide of pot- ash, has been found extremely useful when ap- plied tepid to the affected parts by means of a linen roller or other cloth kept moistened by the solution.} 109. F. The treatment of acute rheumatism has been confided chiefly to opium by Brugna- telli, and more recently by Dr. Corrigan. It has been recommended, also, by other writers in large doses, but generally with antimony, ipecacuanha, calomel, &c. I have given as much as seven or eight grains in the twenty- four hours, in the form of the pilula saponis RHEUMATISM—Treatment of Acute. 687 comp. of the pharmacopoeia ; but I have con- sidered the free use of opium most advanta- geous in conjunction with ipecacuanha or with camphor. In the most acute stales of the dis- ease large doses of opium are easily tolerated, especially when conjoined with warm spices or aromatics, or with ipecacuanha and capsicum, and are often indispensable and most beneficial in conjunction with the alkaline and tonic treat- ment which I have long employed. 110. G. Peruvian or Cinchona bark was first recommended for acute rheumatism by Mor- ton. It was, however, objected to by Cullen, while Pringle and Heberden gave only a some- what favourable, but an undecided, opinion re- specting it". Hulse, Fothergill, and Saun- ders wrote.more decidedly in favour of it, and Haygarth entered upon an elaborate defence of the use of it for this disease ; and his infer- ences received the support of Fordyce and Willa^ although Drr Parry offered certain ob- jections to it, which can have no weight when duly examined by the physician who has had any experience of the operation of this medi- cine in acute rheumatism. I have always em- ployed cinchona for this disease, in various states of combination, since 1819, and have, up to the present day» preferred the decoction of the cinchona cordifolia, in full doses, conjoin- ing it with other remedies which the stage and peculiarities of the case have suggested. But the bark should be prescribed as early in the attack as possible; and if the alvine evacua- tions have not been sufficient, or if biliary and intestinal colluvies still remain, it may be pre- ceded by an emetic, and by a dose of calomel and James's powder at night and a purgatiye draught in the morning ; or these means may be occasionally resorted to without materially interfering with- the due employment of the bark. At an early stage of the more acute ca- ses, I have generally prescribed the decoction of cinchona with the liquor ammoniac acetatis and nitre, often also with full doses of the spir- itus aetheris nitrici, the patient having been al- lowed a large supply of diluents, consisting ei- ther of whey, dr of water gruel or barley water containing nitre and the spirits of nitric aether. If the disease was not soon afterward mitiga- ted, the decoction was taken with the liquor ammoniae acetatis, with sesquicarbonate of am- monia in full doses, and sometimes also, espe- cially if the disease had been of some dura- tion, with the tincture of serpentaria. In cases where the perspiration was copious and the urine scanty, the decoction was prescribed with the carbonate of potash or soda, to which the ammonia and spirits of nitric aether were often added. The patient's drink generally contained an alkali instead of nitre ; and the weak animal tea, mentioned above (v 103), was often given thus medicated, and rendered palatable by spice or aromatics; and while it quenched thirst, it furnished all the nourishment required. In some cases the decoction of bark was given with a preparation of colchicum, but very rare- ly, unless ammonia in full doses was conjoined with it. (See v 105.) 111. Since the introduction Of sulphate of quina into practice, the other preparations of cinchona have been much less employed. Yet in rheumatism, as well as in several other dis- eases, I have preferred the decoction, or the | compound tincture, especially in the combina- tions just mentioned. In some instances, how- ever, of the sub-acute and chronic disease, I have given the quina with much benefit, espe- cially in conjunction with camphor, in the form of pill; and where there has been much evi- dence of anaemia, the sulphate of iron has also been added. In some such cases, or when cer- tain peculiarities of the case suggested a com- bination of tonics and purgatives, then the qui- na, either alone, or combined as now stated, has been given, in the form of pill, with the purified extract of aloes, or with the compound rhubarb pill, or the aloes and myrrh pill, two or three grains of either acting freely when thus com- bined. , 112, H. Colchicum has been much employed in acute and sub-acute rheumatism since 1815 or 1820, but not always with sufficient caution. I have rarely given it, even in the most acute states of the disease, unless in Conjunction with cinchona and an alkali; or in the evening and at night, these other medicines having been taken in the morning and during the day. One or two grains of the powder of the cormus, or of the extract, have been thus conjoined with an equal quantity of the powder of capsicum, and with three to six grains of the soap and opium pill; the smaller doses having been tak- en at six and ten P.M , or the large dose at nine P.M. only ; the morning and middle of the day, when the remission of fever is generally ob- served, having been devoted to the administra- tion of the preparations of cinchona and of the alkalies. The following has been found very serviceable. No. 331. K Magnesiae Carbon., gr. xij.; Ammoniae Car- bon., gr. vj.; Vini vel Tinct. Seminum Colchici, Tt[ xx. ad 3ss.; Tinct. Cinchonae Comp., jjss. vel 31J.; Tinct. Capsi- cl, T\[ iij.; Tinct Opii, HI v.; Aquae Cinnam. vel Carui, et Aq. distil., aa, 3vj. Misce. Fiat Haustus bis terve in die sumendus. 113. /. Aconite, in the form of expressed juice, extract, alcoholic extract, or tincture, has been recommended by many in rheumatism, since it was first employed by Stoerck, especially by ThiIlenius, Ranoe, Gesnek, and Lentik. I have triedMt in several cases, both simple and complicated, having always preferred the ex- tract or tincture prepared with rectified spirit, and according to the formula recommended by Dr. Pereira. Of the former, from one sixth to a fourth 1 or half a grain may be taken every sixth or seventh hour, or from three to five drops of the latter; but either preparation should be given with caution, and the effects duly watched. I have usually prescribed the tinc- ture in distilled water only; and the extract, in the form of pill, intimately mixed with liquorice powder and simple sirup ; and directed which- ever was prescribed to be taken in the intervals between the administration of the other medi- cines employed. I have considered the aco- nite, when cautiously used, as a powerful agent in removing the morbid sensibility and excited vascular action in acute rheumatism; but I have employed it chiefly in aid of the other means already mentioned, especially the decoc- tion of cinchona in the states of combination noticed above (y 110). In the cardiac or peri- cardiac complications of the disease it is a val- uable auxiliary to other remedies, as will be mentioned hereafter. 114. K. A method of cure, which Dr. Todd 688 RHEUMATISM—ACUTE—Treatment advised by Author. has called uthe treatment by elimination" has very recently been recommended by this phy- sician. " It is probable," he observes, " that the materies morbi in rheumatic fever is lactic acid. We know that the natural emunctory of this is the skin. Many chemists maintain that it will also escape by the kidneys ; and if it ever does so, perhaps this is more likely during rheu- matic fever than at any other time." The in- dications he suggests, in conformity with this view, are " to promote the action of the skin, the kidneys, and the bowels; to use antacid remedies, and to give large quantities of fluid for the free dilution of the materies morbi, and in aid of the drainage by diaphoresis and diu- resis."—(Lond. Med. Gaz., vol. xiii, p. 573.) To obtain these ends, he recommends Dover's powder, and the other means usually employed. But I may remark that this acid is not the only materies morbi: there is an increase of fibrine and colourless corpuscle^ in the blood, as shown above (y 62), and when treating of rheumatic inflammation of the surfaces of the heart (y* 20, 129-133), with a disposition to their exudation on the serous surfaces, espe- cially those of this ergan, while the quantity of red globules is diminished. The predominance of acid has been long ago contended for; but whether the acid is formed in the stomach, as Dr. Todd supposes, or by the emunctories from the constituents of it existing in the blood, or partly by both, has not been satisfactorily shown. However this may be, the treatment it suggests has been long employed in acute rheumatism, as already noticed (y 84). The means of cure, however, should not be limited to this single morbid material, but be extended so as to comprise other changes' in the blood and nervous system, which, as Dr. Todd very judiciously argues, and as was shown above, and when describing the treatment of rheumat- ic endocarditis and pericarditis (see art. Heart, y 144, et seq.), can never be removed by blood- letting alone. Indeed, in many cases of the disease, especially in, those of some duration, and when there is a deficiency of red globules inferred, I have prescribed the preparations of iron, as the oxydes or carbonates, with the car- bonate of some one of the alkalies. 115. ii. Treatment advised by the Author. —This may be partly inferred from the remarks already made ; but it depends much on the du- ration, seat, and form of the disease, and upon the means which have been already resorted to. The indications or intentions of cure should be directed to the removal of the morbid condi- tions which constitute the disease, as far as these are known, and as far as experience may have proved the efficiency of the means recom- mended for thi§ purpose. We should more es- pecially endeavour to develop organic nervous energy, so as to promote the assimilating, the depurating, and excreting functions; to dimin- ish morbid sensibility; to counteract whatever disposition may exist to form acid in the prima via; to remove from the blood, or to neutral- ize the materials from which acid is formed, as well as whatever acid may be present; to in- crease the quantity of red globules in the blood when these are deficient; to correct the mor- bid condition of the liquor sanguinis; and to prevent the exuberance of fibrine and the tend- ency of it to concrete, and to exude in the form of a fibrinous plasma or lymph, on serous surfaces. As a prelude, however, to the ad- ministration of such means as may seem most efficient in attaining these ends, disordered or accumulated secretions and excretions should be evacuated by appropriate agents ; by medi- cines which moderately evacuate without oc- casioning vital depression or exhaustion. 116. A. If the patient be seen by the phy- sician early in the attack, and if the symptoms are acute, he should be placed in a strong flan- nel night-gown, or between flannel or soft wool- len blankets; the other parts of the regimen specified above (y 103) being also observed^ If there be no cardiac complication, if bilious col- luvies be inferred to exist, if the tongue be load- ed or covered by a yellowish fur, and if the al- vine excretions have not been hitherto natural or free, an emetic, consisting either of ipecacu> anha or sulphate of zinc, with two or. three grains of capsicum, should be given, and its op- eration promoted by drinking a warm infusion of chamomile flowers. Soon after the emet- ic action has ceased, especially towards even- ing or night, four or five grains of calomel, and one and a half or two of ipecacuanha, and an equal quantity of opium and capsicum, should be taken, and be repeated in five or six hours, if a free perspiration or some action on the bowels has not resulted from the first dose. If the bowels continue insufficiently Open four or five hours after the second dose, or the stools offens- ive or morbid, a purgative draught may be giv- en ; or an enema, containing an ounce of tur- pentine and two of sweet oil, with a scruple of asafatida, ten grains of camphor, and a little salt, may be administered. Faecal and bilious accumulations having been evacuated by these means, the decoction of cinchona ought then to be given in such combinations as the existing state of the patient will suggest; with liquor ammoniae acetatis, spiritus aetheris nitrici, and nitras potassae, if the febrile action is great and the urine scanty and high-coloured, and at an early stage ; with the carbonate of the alkalies, or with ammonia or magnesia and colchicum; or with^either of the alkalies and serpentaria, if the disease is farther advanced. During the Iid- eral use of cinchona, of alkalies, &c, the states of the bowels and of the urine and perspiration should be carefully watched. If the bowels are not sufficiently open, a dose of calomel, ipe- cacuanha, and opium may be given at night, and a draught, with half an ounce each of turpen- tine and castor oil, in the morning. If the bili- ary and intestinal excretions are sufficiently free, two grains each of opium and of ipecacu- anha, with five of nitre, or three of camphoi, may be taken in the evening. If the excretions manifest much acidity, the alkalies should be given liberally, both in the patient's medicine and in his drinks; and if the pain continue se- vere, notwithstanding the liberal employment of them, either an increased dose of opium should be given at night, or ammonia and col- chicum, as noticed above (y 110, 112), ought to be added to the cinchona and the alkali. I have rarely found the above means fail of pro- ducing a very decided relief in the course of three or four days, when commenced early, and when no cardiac or other complication exists. But when a joint is attacked, some ! external means, especially such as I shall here- RHEUMATISM—CHRONIC—Treatment of. 689 after suggest, may also be employed with ad- vantage. 117. B. In more prolonged cases, and when the disease had not been seen during its early stage, instead of the colchicum I have prescrib- ed the aconite, as noticed above, in the intervals between the taking of the cinchona and alkalies; and in those cases where the patient has been reduced by the duration of the disease, or by vascular depletions, or where a deficiency of the red globules of the blood was inferred, I have employed with marked advantage the iodide of iron in the sirup of sarza, and the com- pound decoction or fluid extract of sarza. This medicine was of the most remarkable and im- mediate service in the case of a medical officer from India, which presented features of the greatest severity and obstinacy, no other sub- stance, excepting an occasional purgative, hav- ing been required to effect a cure, which took place in a very short time. 118. In the class of acute cases now being considered—in the prolonged, neglected, or in- judiciously treated, where the red globules ap- pear to be deficient, but where no internal com- plication or metastasis can be detected—the preparations of iron with the carbonates of the alkalies, especially the mistura ferri composita, with the addition of the carbonate of potash or soda, will be found of great service. The following pills will also be most beneficial. If the bowels be confined, from five to ten.grains of the extr. aloes purificat. may be added to the mass. No. 332. R Ferri Sulphatis, gr. xij.; Quinae Disulpha- tis, gr. xviij.; Camphorae rasae, gr. xij.; Pulv. Capsici, gr. vi. Pilulae Galbani comp., jj.; Sirupi Tolutani, q. s., mis- ce, et contunde bene. Divide massam in Pilulas xxiv,; e quibus sumantur binae vel tres, ter in die. 119. G. When the disease attacks the large joints in the capsular or sub-acute form, the ap- plication of leeches has been advised, especial- ly if external redness or swelling is observed. The practice is of service in recent attacks, and in young or robust persons, more particularly if the internal treatment be such as I have al- ready recommended, or am about to suggest. The number of leeches* should depend upon * The mode in which local bloodletting is practised in the Shetland Isles is curious. I here adduce the descrip- tion I have given of it in another place. 1 have seen a similar mode adopted by the native Africans on the Grain, Ivory, and Gold Coasts; the only difference being that, in- stead of a ram's horn, the chief instrument in the opera- tion among the native Zetlanders, a small gourd is em- ployed by the Africans, as it was from the earliest times in countries bordering on the Mediterranean.—"Mentio hujus rei, quae quidem in insulis Zetlandicis mihi contigit vidisse, ea mihi in mentem reducit. Scarificant et sangui- nem ab ultimis usque temporibus hoc modo eliciunt: Quam partem volunt scarificare, hanc aqua calida fovent. Qui medici partes agit, is cutem sexies aut septies noya- culd perquam leviter perstringit, et cornu arietinum mo- dice recurvum, quod cucurbitulEe vice fungitur, apice per- forato, et corio molli circumdato, partem leviter resectam applicat Tunc foramini labia admovet, et quantum fieri poterit, aera inclusum exsugit Quum cornu exinanisset, corio torquendo et in foramen linguS protrudendo aeris irruentis impetum prohibet. Postquam cornu partem scarificatam arripit, deinde pannos ex aqua calida paulum exsiccatos circa imum cornu superimponit, qui sanguiiujm ad partem provocent Quum sanguinis semiplenum sit, cornu turn cutem relinquit et decidit Eadem res iterum et iterum repetitur, donee satis sanguinis mittatur. Muli- eres et mares, scarificatione et cornu hujusmodi uti vidi- mus. Res memoratu forsitan digna est, ut enim Romani antiquiores cucurbitis, sic Gets (sive quis eos Gothoa nominare malit), et omnes eorum posteri, cornibus ad sanguinem eliciendum uti videntur." III. 44 the circumstances of the case ; but the benefit derived from them will be only temporary, un- less the internal means used at the same time be appropriate, and unless the rest of the ex- ternal treatment following the application of leeches be suitable to the local affection. Aft- er fascal accumulations and disordered secre- tions and excretions have been evacuated, the means already prescribed (y 116, etseq.) should be employed ; and if the more acute symptoms lapse into the sub-acute, or if a joint becomes especially affected, ou if effusion within the capsule takes place, the decoction of cinchona may be given with the iodide of potassium, and the solution or the sub-carbonate of potash. In these cases, it is important to procure as speedy absorption of the effused fluid as possible, and thereby to prevent the irritating effects of this fluid on the membranes inclosing it. This end will be best obtained by subduing, by the intern- al means already advised, the morbid action in the joint, by correcting .the altered state of the circulating fluid, and by procuring a free dis- charge from the external surface of the joint. After the operation of leeches, in such cases as may appear to require them, or without hav- ing recourse to them in other cases, where they are contra-indicated by the local or con- stitutional symptoms—when there is little or no local redness, and no marked increase of heat, but considerable intra-capsular swelling— small or moderate-sized blisters may be placed near each side of the joint, as when the knee is affected, and these may be-repeated, or kept discharging, according to the effects produced. In other respects, the treatment of this form of the disease, as well as of the other sub-acute states, may be conducted conformably with the views already entertained. It may, however, be remarked, that the preparation of iodine, conjoined with cinchona, alkalies, &c, or with iron, sarsaparilla, &c, when there is a deficien- cy of red globules, are more especially indica- ted in these forms of the complaint; and that colchicum, conjoined,with the iodide of potas- sium, the alkalies, and cinchona, in these forms, is often very beneficial, especially in the more active states. When the disease attacks the more superficial joints, leeches and blisters should not be placed immediately over the joint, but at a short distance from it, so as to occa- sion a derivation of the morbid action from the affected parts. 120. In some cases of acute and sub-acute rheumatism, I have employed the oil of turpen- tine differently from the manner noticed above. After having evacuated disordered alvine secre- tions and excretions, and given a few doses of the decoction of cinchona, with an alkali and nitre, I have occasionally prescribed this oil in the following, or in a similar manner ; endeav- ouring, however, at the same time, to preserve the bowels sufficiently open, and to prevent the irritating action of the oil on the kidneys, by a liberal use of demulcents containing nitre and an alkaline carbonate : No. 333. R Olei TerebinthinsB, 3j.; Sodae vel Potassae Bi-carbon., 3j.; Tinct Cinchona? Comp., 3Jss.; Tinct. Capsici, tti v.; AquaB Menthae Piperitae, fjss. Misce. Fiat haustus bis terve in die sumendus. 121. iii. The Chronic Forms of rheumatism, when they appear primarily, more especially in an active form, or with nocturnal exacerbations, 690 RHEUMATISM—CHRONIC—Treatment of. should be treated very nearly on the principles now stated.—(a) After evacuating morbid ac- cumulations and excretions, the decoction of cinchona, or the guaiacum mixture, may be giv- en with alkalies and with colchicum. The prep- arations of guaiacum, especially when thus com- bined, arid after the biliary and alvine secre- tions have been duly evacuated and promoted, I have always found more or" less beneficial in this state of the disease, as well as in the sub- acute and in the more passive conditions. The good effects of these are more certainly secured if free excretion by the several emunctories be promoted by a liberal use of diluents, more es- pecially those already mentioned (y 103). 122. (b) In the states of the complaint now being considered, as well as in the advanced stages of the acute, and in the sub-acute and arthritic forms, manifest advantage will accrue from the iodide of potassium in such combina- tions as the experience and tact of the physi- cian will suggest, more particularly when giv- en in the decoction of bark or in the guaiacum mixture, with the solution of potash, or of car- bonate of potash, or with colchicum, or aconite. Besides the forms of the disease just mention- ed, both the active and passive states of chron- ic rheumatism will be remarkably ameliorated by these means, which may be aided by the ex- ternal measures about to be noticed, and by a suitable diet and regimen. In these states of combination I have found the iodide of potas- sium extremely beneficial, and while less than two grains, given thrice daily, were rarely pre- scribed, more than five grains were as rarely taken at one dose, a free use of diluents being always allowed1.* 123. c. The cod-liver oil once enjoyed a con- siderable reputation for the cure of the sub- fi"ute and chronic forms of rheumatism, and ,vas much employed in Manchester since 1766, when.it was first introduced by Drs. Kay and Percival. Owing to the writings of this latter physician, and the reports of Dr. Bardsley, it came into use in Germany, where it is now one of the most commonly used medicines forthe chronic forms of the disease. The work of Dr. Hughes Bennett on this oil has revived the credit of this remedy for rheumatism ; and it is now very generally prescribed for some obsti- nate states of the complaint. It has from time immemorial been employed as a popular reme- dy for this and some other chronic disorders, both in Norway and in the Shetland Isles ; the liver of the torsk, the Gadus brosme, being, how- ever, preferred to that of the cod, the Gadus morhua. The oil prepared in the manner de- scribed by my friend Dr. Edmondston, of Shet- land, in his communication'to Dr. Hughes Ben- nett, is that which I believe to be the best. This latter physician has adduced the opinions of the earlier writers on this oil, and added his own, which are both discriminating and judi- cious. Dr. Percival remarks, that he had the fullest evidence of the successful exhibition of it in rheumatic complaints, and considered it * [The Iodide of Potash is a more valuable remedy in rheumatism than might be inferred from the slight men- tion made of it by our author. We have used it for many years with the most decided benefit in this disease, giving it to the extent of 3J. or more in twenty-four hours. In some cases it is found to arrest or control the disease very promptly. This is preferable to any of the other prepara- tions cf iodine in these cases.] superior to the preparations of guaiacum. Dr. Bardsley, much later, 1807, states that he is enabled to speak of it, from long experience, " as a medicine of efficacious but limited pow- ers. In some instances, where every means has proved unsuccessful, it has operated in a manner so decidedly beneficial as to excite as- tonishment." The circumstances under which he found it most advantageous were, 1st. In the chronic rheumatism of elderly persons, when the muscles and tendons have become rigid, and the joints nearly inflexible, owing to ex- cessive labour, dampness, hard fare, and cold ; 2d. In women whose constitutions have been worn out by repeated rheumatic attacks after parturition, and more especially iu the decline of life. Dr. Hughes Bennett states that, judg- ing from the mass of observations published in the German periodicals, and from what he has heard and seen connected with this subject, he considers this oil to be more especially indica- ted in three distinct forms of chronic rheuma- tism and gout, which may be denominated the general, erratic, and local. 124. I have prescribed the cod-liver oil in several cases of rheumatism since 1844, and chiefly in similar cases to those mentioned by Dr. Bardsley, and certainly with nearly simi- lar results, the quantity having been from two to three or four table-spoonfuls in the course of the day. It was commonly taken on the surface of milk, of cold coffee, or mint-water, or of some aromatic water; and, in some cases, on the surfuce of the infusion of orange peel, to which a small quantity of the iodide of potas- sium was added. In two cases of sciatica in elderly persons it was quite successful; but in two cases of erratic chronic rheumatism, for which the patients had been, and still continu- ed, in the habit of resorting to opium, the oil had no effect. Was this result to be ascribed to the influence of opium on the system 1 Much useful information on this subject will be ob- tained from Dr. H. Bennett's treatise, referred to in the Bibliography to this article.—'-(Op. cit., p. 70-92.) 125. (d) The compound decoction of sarza, or the fluid extract of sarza, largely diluted, espe- cially when conjoined with the solution of pot- ash or the sub-carbonate of potash and the iodide of potassium, I have found one of the best medicines for the cure of the chronic and sub-acute forms of rheumatism. In order, how- ever, to secure the good effects of this combi- nation, the functions of the skin should be free- ly promoted by regular exercise in the open air; and the other secretions and excretions ought also to receive due attention. I have preferred the compound decoction of sarza to other prep- arations, in doses of about six ounces or half a pint, twice or thrice daily, as it produces a much more decided effect upon the skin, especially when taken in a tepid or warm state. 126. (e) The decoction of senega is also often extremely beneficial, when conjoined with the iodide of potassium and potash, and with some aromatic water, which will enable the stomach to tolerate this decoction in full doses. In the complications of rheumatism with endocarditis or pericarditis, the combination of this decoc- tion with the substances just mentioned is oft- en most beneficial. It was found most effica- cious in several cases of this complication RHEUMATISM—CHI which came under my care, two of these cases having occurred in medical men. While this decoction, especially as thus combined, pro- motes the excretions, it also tranquillizes the increased action of the heart. It may be given in the sub-acute, as well as in the several forms of the chronic disease. 127.. (/) The Datura stramonium, or thorn- apple, first employed for rheumatism by Sto- krck, and subsequently by Wedenburg and Odhelius,. and by Cooper and Bartram in America, has been found of service in the chron- ic and sub-acute forms of the complaint, and especially in sciatica and other cases of nerv- ous rheumatism. It may be given in the form of extract, thrice daily, commencing with a quarter or half a grain, and increasing the dose until dilatation of the pupil and giddiness are produced. I haVe prescribed this medicine in a few cases; but although it had considerable effect in alleviating the pain, the benefit derived from.it was generally transitory. The Rhodo- dendron chrysanthum has been recommended for the sub-acute and chronic forms of rheumatism by Pallas, Home, Koelpin, Loeffler, Willi- met, and others. I have no experience of its use in this disease, but Dr. Craigie remarks, that two drachms of the dried leaves may be in- fused in ten ounces of boiling water all night, and the 6trained liquor may be taken either at once or in divided doses during the day; and that, a repetition of the remedy for three or four days in succession generally effects a cure in the forms of the complaint j ust specified. Very probably this infusion, as well as the extract of stramonium, may prove much more beneficial when conjoined with alkaline medicines, or with other substances already mentioned, than when given alone; but under any circumstari- ces the effects should be carefully watched. 128 (g.) Arsenical preparations have been recommended for the more chronic states of rheumatism by Jenkinson and others. Dr. Bardsley considered them to be of essential service in these states of the disease when con- joined with opium. I have recently given, in a very few instances, the combination of the iodide of arsenic and mercury—the liquor' iodidi arsenici et hydrargyri as prepared in Donovan's solution, both with and without opium ; and in these this solution appeared of service ; but it requires a further trial before a decided opinion as to its merits in this disease can be given. 129. (h) Naphtha was prescribed for chronic rheumatism by Thomann, and several forms of bitumen, rock-oil, or Barbadoes tar, or petroleum, have also been employed, most frequently as popular remedies. The petroleum is used both internally, a3 a sudorific, in doses of from ten niipims to half a drachm, three or four times daily, and externally as a liniment or embroca- tion. The substance called British oil, procur- ed by distillation from the .stone-coal of Shrop- shire and Wales, and the empyreumatic oil ob- tained during the formation of coal gas, are also popular remedies for this complaint. Of these I have had no experience, but I have seen very decided benefit produced by the use of tar-wa- ter, and of the Norwegian tar, this latter being taken in the form of pill with liquorice-root pow- der and magnesia. The exaggerated accounts of the virtues of tar and tar-water, which ap- peared at the commencement of the last centu- LONIC—Treatment of. 691 ry, and the ridicule to which the use of it was soon afterward subjected, have led to the dis- use of a substance which is calculated to pro- duce' very salutary effects when judiciously employed, not only in chronic rheumatism, but also in several chronic and cachectic diseases. 130. (i) Besides the cod-liver and empyreu- matic oils just mentioned, several vegetable or essential oils have been recommended by writ- ers, both internally and externally, for rheu- matism. I need not here add to what I have already stated in favour of turpentine. It was many years ago praised by Koeler and myself as an internal and external remedy for this dis- ease ; and the cajeput oil, much used in the East, and brought to the notice of European physicians, is often a useful adjunct to turpen- tine, especially in the external use of this lat- ter substance. It should not be overlooked that olive oil was recommended, both internal- ly and externally, for chronic rheumatism by Brocklesbury; and,-when taken frequently, or in sufficient quantity, and so as to preserve a regular state of the-intestinal secretions and ex- cretions, it is certainly of considerable service. 131. (k) Sulphur has long been employed as a popular remedy in both the active and passive states of chronic rheumatism, although it has been overlooked by writers with reference to this complaint. The precipitated sulphur may be taken nightly, either alone or with the car- bonate of magnesia, this combination being preferred when, with a dry or harsh state of the skin, there is flatulence or acidity of the prima via. It exerts a very decided effect upon the functions of the skin, both promoting and altering the excretions from this surface, an intention of the greatest importance in the chronic and sub-acute forms of this complaint. I have usually prescribed the following every night,' exhibiting occasionally, or once in the week, a purgative draught in the morning, con- sisting either of the compound decoction of al- oes, or of equal parts of the compound infusions of senna and gentian with sulphate of mag- nesia, &c. No. 334, R Sulphuris praecipit., 3vj.; Magnesias Car- bon., ^ss.; Pulv. Ra'd. Glycyrrh., 3JS8.; Pulv. Zingiberis, 3J. Misce. Capiat aeger cochl. j. vel ij. minima, in aquaa vel lactis pauxillo, omni nocte. [We have for several years past treated rheu- matism on the plan of elimination, or the re- moval frorn the system, through the several emunctories, of the materies morbi, which, with Drs. Williams, Todu, and others, we hold to be chiefly lactic acid. This is the product of vitia- ted digestion, as well as of the decomposition of the tissues, and under ordinary circumstan- ces of health it is carried off through the me- dium of the skin, though a portion also escapes through the intestinal canal and the kidneys, as stated by Dr. Todd. The indications then are, as this writer suggests, to increase the natural functions of the skin, kidneys, and bowels ; t.o use antacids and fluids in large quantities, to dilute the morbid matters and aid the opera- tion of diaphoretic and diuretic remedies. One of the best modes of effecting elimina- tion and removing the disease is, in conjunc- tion with the vapour bath, to give a powder com- posed of opium, ipecacuanha, and nitrate of pot- ash, in variable quantities, every two, three, or six hours, according to the urgency of the ous Medicines advised for. 692 RHEUMATISM—Of vark symptoms, increasing the quantity of opium if there is much pain present, or if a full anodyne effect is desired. It is important to allay the erethism of the nervous system, while at the same time we operate upon the skin and kid- neys. In many cases a mild mercurial, as cal- omel or blue pill, may be substituted for the nitre with advantage. The bowels are to be kept, in the meantime, freely open by small doses of a solution of the sulphate of magne- sia, in which a portion of calcined magnesia is blended. We generally aim to procure two or three evacuations in twenty-fours, being care- ful, however, not to lower the vital forces by purging too freely, nor by.depressing doses of antimony, as is too often witnessed. We have never derived much benefit from leeching the swollen and painful joints in these cases, as the inflammation is pretty certain to recur, or to attack other joints, when the same results follow on a repetition of the local treatment. The best plan is to envelop them in a large quantity of cotton batting, over which a piece of oiled silk is carefully bound, to prevent the access of the atmospheric air ; by which means, if the patient be quiet, the limb is steeped in a pleasant vapour bath, the perspiration which is thus elicited having a strong acid smell. The same treatment is found most beneficial also in gout. If the pain is aggravated by the heat, thus confined, the cotton is to be re- moved and a lighter covering substituted. The continuance of the treatment must depend on the nature and persistence of the symptoms. The food is to be nutritious, and liberal in quan- tity, remembering to enjoin the free use of di- luents containing a small quantity of bicarbon- ate of soda. Pure air, suitable clothing, abso- lute rest, and a cheerful mind are powerful auxiliaries in accomplishing a speedy cure. Since we have adopted the above plan, which is in substance that advised by Dr. Todd, we have rarely failed in controlling attacks of acute rheumatism in a very few days.] 132. iv. Of various other Medicines which have been advised for the several forms of Rheumatism.—Having noticed the plans and means of cure most appropriate to the princi- pal forms of rheumatism respectively, I shall briefly mention some others which have been employed more indiscriminately, especially by some writers, and remark upon their applica- tion to certain states of the complaint, before I proceed to notice those external measures and reg- imenal means vihich have at sundry times and by numerous authors been recommended to the pro- fession and the public. 133. (a) Of purgatives, little mention may be here made beyond what has been stated when treating of acute rheumatism (y 102). This class of medicines was much employed in the several forms of the disease by Riverius and Buchhave, and in the bilious complications by Stoll and others. They are certainly required in all circumstances, especially early in an at- tack, but only to the extent of completely evac- uating all faecal accumulations, and morbid se- cretions and excretions, and of preserving and promoting a free discharge of these. If em- ployed beyond this intention, they may reduce vital power and resistance without producing any beneficial effect on the disease in any of its forms. The choice of purgatives and aperients in this complaint is always a matter of import- ance. I have already remarked on this topic (y 102), but I may here add, that the stomach- ic, warm, or cardiac should be preferred, and that these may be conjoined with alkalies or other deobslruents. 134. (b) Emetic tartar was much employed in small doses by Brocklesbury, and much more recently by Balfour, in all the forms of the complaint; but it has most commonly been con- joined with opium or with other diaphoretics. Unless James's powder, it is the only prepara- tion of antimony on which reliance should be placed in this complaint. It is most appropri- ate in hot, dry, or harsh states of the skin; when the pulse is tolerably strong and full, and when the cutaneous excretion has been sud- denly suppressed ; but attempts at the restora- tion of this excretion should be made by other diaphoretics, when constitutional poweris much depressed, and the pulse is very rapid or com- pressible,, more especially by the liquor ammo- niae acetatis, with excess of ammonia, with camphor, and with the spiritus aetheris nitrici in full doses. 135. (c) Various narcotics and sedatives, be- sides those already noticed, have been advised for the several forms of rheumatism. Of the preparations of opium, morphia, &c., as well as those of colchicum, I may here remark that they should rarely be confided in alone, or given, un- less in such combinations as will promote their excreting operations—the former by the skin, the latter by the intestines and kidneys—and at the same time prevent, especially as regards colchicum, their depressing influence on the nervous system, the combination with ammo- nia being one of the best which can be employ- ed. In chronic forms of rheumatism, the prep- arations of colchicum are productive only of temporary benefit, and are often prejudicial, un- less conjoined with cinchona, or quina, or with guaiacum, or with camphor or alkalies. Aco- nite is most appropriate to the more acute states of the disease, and to. certain complications about to be noticed. Conium, which was praised, by Stoerck, has comparatively little influence, unless continued in considerable doses. It is most serviceable in the forms of rheumatism which occur in females, and which are conse- quent upon suppression, interruption, or diffi- culty of the catamenia; and in these circum- stances the stramonium, and even digitalis, are often of service, especially when conjoined with aloetic aperients, or with the iodide of iron, or with the biborate of soda, or with capsicum, ac cording to the peculiarities of the case. 136. (d) Several stimulants have been ad- vised for the more chronic states of the dis- ease.— a. Phosphorus was recommended by Buchner and Hufeland ; but it is a too haz- ardous medicine to deserve adoption unless with great caution. The phosphoric acid, which may be employed with safety, has not been hith- erto prescribed for this complaint. Probably neither this aoid nor the mineral acids may be appropriate in rheumatic cases, unless in as far as they may promote the digestive and primary assimilative functions, and may thereby pre- vent the generation of the lactic and uric acids. —(3. Asafcetida was praised by Theden in the chronic states of the disease; and certainly both it and several other of the gum-resins and RHEUMATISM—Ext balsams Axe not devoid of efficacy in these states, especially when used as adjuncts to oth- er appropriate means. I have prescribed the Peruvian balsam in some instances with very decided success.—y. Mezereon has been em- ployed by some writers ; but it is in combina- tion with sarza and sassafras and guaiacum, as in the compound decoctipn of sarza, that it is most serviceable.—J. The Geum urbanum has been recommended by Buchhave ; the Solanum dulcamara by Linnaeus, Pressavin, and Vieus- seux ; and the bark of the Magnolia glauca, which is tonic and aromatic, by Barton. An infusion of either of these may be made the ve- hicle of other medicines, may promote the cu- taneous functions, and, by this operation, as well as by their stimulant and tonic action on the organic nervous system, may remove at- tacks of the disease.—e. The Trifolium fibrinum' was praised by Aaskiem and Brocklesby in the form of infusion, with the volatile tincture of guaiacum.—(,. The Phytolacca decandra was pre- scribed by Barton. My friend, Professor Dun- glison, remarks that it is celebrated as a rem- edy for chronic rheumatism, and is given in the form of tincture of the ripe berries. An infu- sion and an extract of the leaves.of the Taxus baccata, or yew tree, have been given in this complaint, but I am not acquainted with the results.—n. The powder or extract of nux vom- ica has been recommended by Oberteuffer in chronic rheumatism, and for the removal of the stiffness and partial palsy of the limbs often at- tending the complaint. I have tried the alco- holic extract in a few instances, in doses of a quarter of a grain increased to a grain, twice or thrice daily, preferring it to strychnine. It will be found of service in very chronic cases, when aided by other means ; but it is apt to produee headache, which, however, may some- times be prevented by conjoining it with ape- rients, as the purified extract of aloes, soap, and the ox-gall.—Capsicum, or Cayenne pepper, was praised by Adair. It is the common re- source of many of the dark races, especially the Negro, in all the chronic and sub-acute states of rheumatism; and while they use it abund- antly internally, they apply it externally over the pained part. I have frequently had recourse to it, but chiefly as an adjunct to other means, and it has in thjs way always appeared to be of service.—Mustard seed has also been gfven by Adair. About 1825 it was an almost univers- al popular medicine, not only for rheumatism, but for all diseases. It soon, however, fell into disuse ; most probably because it really pos^ sessed some claims to attention in chronic rheumatism.*—The athers and athereal prepa- rations have been prescribed for the several forms of rheumatism, but chiefly as adjuncts to other means; and probably chloroform will soon be added to the list of means available in the * A credulous disposition to believe in quackeries of some kind or other—religious, political, and medical—is inseparable from the English character; and the more ab- surd the doctrine, the more ridiculous the means, the more gross the humbug and imposture, the more credence such impositions acquire, and the more generally are they adopted, not by the ignorant only, but by the elevated in rank and social position more especially. The public re- semble a flock of sheep, of which, when one breaks off in an eccentric direction, all run the same way. A facetious contemporary would be inclined to impute this tendency to the quantity of mutton annually devoured by our coun- trymen. ersal Treatment of. 693 more acute or neuralgic states of this complaint, and he exhibited either by the mouth or by in- halation, the former being obviously the safest method. 137. y. Of various external Means recom- mended by Writers.—All external means of cure, unless employed as adjuvants of internal remedies, and judiciously prescribed, are at- tended, either immediately or remotely, by more or less risk. Rheumatism, in all its forms, is an external manifestation of a constitutional malady, in which the organic nervous and vas- cular systems and blood are chiefly affected ; and if this manifestation be suppressed in one quarter, before the evil is removed in the sys- tems more especially implicated, it will most assuredlyappear in some other quarter, and not improbably in some important or vital organ. External means, excepting such as promote the depurating functions of the skin, ought there- fore never to be resorted to unless in aid of, and contemporaneously with, or consecutively of, appropriate internal or constitutional treat- ment. 138. (a) Of the numerous external means and applications which have been recommended for the different varieties of this disease, the selec- tion is most difficult, and it should be guided entirely by the peculiarities and duration of the attack. The number of these means, although not so great as that of internal remedies, is al- most sufficient to distract the inexperienced when an attempt is made to employ them ap- propriately to the circumstances of the case. Yet will a due knowledge and recognition of these circumstances and peculiarities prove the best guides to the selection of them, and to the periods of having recourse to them, this knowl- edge constituting the best kind of experience ; for without it experience is only gross empiri- cism. The enumeration of this class of means may in itself appear somewhat formidable'; but it will furnish, with the remarks which I shall append to each, an imperfect guide upon which the reflecting practitioner will make the re- quired improvements when he comes to apply them to practice. 139. (b) Acrid topical applications of various kinds, and irritating plasters, have been employ- ed empirically as domestic means, and prescrib- ed professionally. Lentin and others have rec- ommended them ; but Bang, the very practical writer of Copenhagen, considers them not de- void of risk, unless they are prescribed in aid of judicious internal remedies. Sinapisms, the moistened bark of the mezereon, and vari- ous similar applications have been resorted to, and often with benefit, when vital energy is duly supported, and when the excreting functions are promoted at the same time: a principle of cure which ought never to be overlooked in the treat- ment of diseases caused by depressing causes, and attended by pain and impaired power as well as by morbid states of the circulating fluids. 140. (c) Acupuncture, or the gradual introduc- tion' of a sharp and fine needle or metallic wire through the integuments down to the seat of the complaint, in very painful cases of muscu- lar or aponeurotic rheumatism, has been prac- tised for many ages in the Far East, especially in Japan and China. It was treated of, and the safety of the practice shown, as well as the temporary efficacy of it, by Mr. Churchill ; 694 RHEUMATISM—External Treatment of. and it was also frequently employed in France. I have seen it resorted to in several instances with some success, but I am not aware of much permanent benefit having been produced by it. The practice has fallen into its deserved disuse. 141. (d) Artificial eruptions have been resort- ed to in rheumatism, more especially in chronic and sub-acute cases, by Thilenius, Lentin, Pi- derit, Vicat, Antenrieth, and Jenner ; and emetic tartar, added to an ointment or plaster, has been commonly used to produce these erup- tions, which, however, especially when plas- ters have been employed and allowed to remain too long, or when the constitution has been ca- chectic, has sometimes been followed by foul, spreading, and obstinate ulcers. If resorted to at all, they should be watched ; and thCy ought not to be produced immediately over a joint, although they may be brought out in the vicin- ity in obstinate cases. I tried them many years ago in dispensary practice, in several internal complications of rheumatism, with but little or doubtful advantage. 142. (e) Baths, warm, vapour, and medicated, have been long recommended for the more chronic cases of the disease. Of thermal min- eral baths mention will be made hereafter, but considerable advantage will often be derived from warm baths, which may be prepared at any place, under due direction, and which may be general or local, according to the peculiari- ties-of the case. Warm baths, at a high tem- perature, or vapour baths, axe generally most beneficial in chronic, passive, or cold states of the complaint, and for these the addition of salt or mustard, or both, to the warm bath, whether general or local, will be of service. Even when sea water is used for a warm bath these addi- tions are often of service, especially when the regimen and internal treatment are judicious. But baths are not confined to chronic cases only. Even in the sub-acute and acute states benefit will be derived from warm baths of a somewhat lower temperature, or tepid baths, containing an alkali, or alkaline sub-carbonate. Indeed, warm alkaline baths will be found use- ful in both states of the disease, and more par- ticularly when the skin is hot, dry, and harsh, during the evening and early part of the night. —Vapour baths, both general and local, have been much recommended by Du Moulin, Bards- ley, and Blegborough, and their efficacy is un- doubted in chronic cases, especially when the joints are affected, and when aided by a resto- rative treatment and regimen, and due exercise in the open air.—Sulphur baths have been em- ployed with marked benefit in similar cases, and warm baths containing the sulphuret of potash have also been resorted to. These baths, gen- eral or local, or in whatever way they may be medicated, should be employed chiefly in aid of judicious internal treatment, and of a proper regimen. 143. (/) The warm douche and vapour applied locally have been found of service in many ca- ses ; but the remarks just offered are equally applicable to the use of these. To obtain ad- vantage from them, they ought to be daily em- ployed, to be followed by friction, exercise, and warm clothing, and accompanied by the intern- al treatment recommended above. 144. (g) Blisters have been generally employ- ed as external or local aids of constitutiona! means; but unless these latter means are appro- priate, the benefit derived from blisters is only temporary. Fowler, Rouppe, and others have advised them ; but Hufeland, finding the ad- vantage procured from them by no means per- manent, recommended them to be kept open by the substances usually employed for this pur- pose. Blisters are seldom of use early in acute attacks ; they are most useful towards the de- cline of the disease, and when the action of the several emunctories has been duly promoted. They are more beneficial in sub-acute cases, and when the joints are affected ; but they should not be employed immediately over su- perficial joints, but only near to them. The re- peated application of blisters is generally pref- erable to keeping them open. 145. (h) Embrocations, linimemts, and rubefa- cients of various kinds have been employed, both empirically and with rational intentions, as afds in the cure of the several forms of rheu- matism. They have been even resorted to as the only means, and often as popular* remedies and without medical advice. Several nostrums are employed in the form of embrocation or lin- iment ; and, although relief has often been pro- cured by them, yet their inappropriate use, and the application of them while the morbid con- ditions of the nervous and vascular systems re- mained unabated, have been followed in some cases by dangerous and even fatal consequen- ces—by internal complications, or by the super- vention of disease of internal surfaces or or- gans, with effusions or adhesions. A few in- stances of these results have come under my observation, and have demonstrated the dan- ger of having recourse to means which may suppress the local manifestation of a constitu- tional evil, without having prescribed judicious internal remedies for that evil, and without having employed agents calculated to throw off or to resist the tendency to internal complica- tions. It would be endless, and of doubtful ad- vantage, to enumerate the various embroca- tions, liniments, and rubefacients which have been praised for the several forms of the com- plaint. Most of the formula comprised under the head Lihimcnta, in the Appendix (Form. 295-314), may be used also as embrocations and rubefacients in this disease with great ad- vantage, when a judicious internal treatment has preceded or accompanies the use of them Under such circumstances, warm rubefacient poultices and rubefacient plasters will also be found of service, more especially in chronic cases. 146. '(i) Frictions, shampooing, percussion, and flagellation have been much employed in the more chronic and obstinate states of the com- plaint ; but these means, especially frictions and shampooing, are most serviceable after warm salt-water or medicated baths. The fric- tions may be only simple, as with the hand, os with sweet oil, or with variously prepared oils or liniments, or with the hard Indian glove, or With the hair-brush, or with any of the lini- ments prescribed in the Appendix. Percussion not infrequently relieves for a time the chronic pains of muscular or aponeurotic parts; and flagellation may have a similar effect; but it has been little used since the practice of medicine was rescued from the hands of monks in the RHEUMATISM—External Treatment of. 695 dark ages, although it was employed by the ancients. 147. (k) Galvanism and electricity have had numerous advocates in the chronic forms of rheumatism, and they are sometimes of service, especially electro-magnetism, in the more passive states of the chronic disease. Several recent writers have furnished evidence in favour of the use of magnetic electricity in these forms of the complaint; but I am unable to give an opinion respecting it from my own experience. I have, however, seen benefit derived in a few instances from galvanic electricity. 148. (I) Insolation, or exposure of parts af- fected with chronic rheumatism to the sun's rays, has been advised, and I have prescribed it with benefit in the passive or cold form of the complaint. The effect probably depends not merely upon the warmth thereby produced, but also upon the electrical agency of the sun's rays. Much of the benefit derived from migrating to a warm climate in cases of obstinate rheuma- tism arise from this cause; but the change should be made to a dry climate and a clear at- mosphere ; for if the. situation abounds in hu- midity or malaria, however warm it may be, the rheumatism will still continue, or even be aggravated. 149. (m) Issues and setons have been men- tioned favourably by some of the writers who have recommended the production of artificial eruptions for this complaint. They are rarely required, or submitted to, in cases of simple chronic rheumatism ; but I have prescribed them with marked advantage in certain of the complications, or internal extensions of the dis- ease, more especially during, or subsequent to, rheumatic endocarditis or pericarditis, or when the spinal membranes have become affected. They are also of use in sciatica, and when the large joints are implicated, and in these cases they have been recommended by Bardsley ; but they should be prescribed in a suitable sit- uation, so as to produce a derivation from the part or joint itself, and yet not be far removed from it. Two, or even three issues may be re- quired in some cases. 150. {n) Moxas' have been recommended, from the most remote times in the Far East, for chronic rheumatism, especially when seated in the joints ; and they have been praised by Thi- lenius, Bese, Pascal, Naudau, and more re- cently by Larrey, Dunglison, and Boyle. They are often of service when applied in the situations advised for issues, and when a puri- form discharge from the parts cauterized by them is obtained. They, as well as issues and setons, are suitable to the more chronic cases, or, rather, to the effects of rheumatism than to recent attacks. 151. (o) Mineral waters and mineral baths axe among the most beneficial and popular reme- dies for the several states of chronic rheuma- tism. Much of the benefit derived is, however, due to the change of climate, air, scene, and occupation consequent upon visiting watering places. The natural thermal springs have been most generally recommended for the more chronic and obstinate states of chronic rheumatism, and for sciatica, especially those of Bath and Buxton, in this country ; of Wis- baden, BadCn-Baden, Karlsbad, &c, in Germa- ny ; of Bareges, in France • and of several in Italy. The chemical composition and temper- ature of these several springs will suggest the propriety of having recourse to them in the cir- cumstances of each case ; and it is chiefly with a strict reference of this composition to the peculiarities of individual cases, that a selec- tion of both thermal springs and of other min- eral waters should be made. Much informa- tion will, however, be obtained on this topic from the writings of Falconer and Barlow on the Bath waters ; from those of Robertson and Squdamore on the waters of Buxton ; from those of Granville, Osann, Lee, and Gaird- ner on the German thermal springs ; and from Carmichael's account of the water of Bareges and Bagneres de Bigorres. Not only may these waters be taken internally, but they are still more beneficial when used as general or local baths, or in the form of douche. The duration of these baths should depend upon the strength of the patient. It should he short at first, and prolonged with repetition ; but benefit will sel- dom be derived until a number of baths have been taken. The circumstances of the case should, however, suggest both the duration and the frequency of them. The same remark ap- plies to the use of the douche. Immediately after the bath or the douche, the surface should be rubbed with dry hot towels, anduhe patient wrapped up in flannel or in blankets, so as to promote, for several hours, a copious perspira- tion. The use of warm chalybeate baths in chronic states of the complaint was much in- sisted upon by Brandis ; of the waters of Reh- burgh by Albers ; of sulphureous waters and baths by many writers ; and of numerous min- eral springs by authorities of every kind, some of which will be found in the Bibliography. [Much benefit has often been derived in this disease from the use of the sulphur waters of Virginia, or of Avon, Richfield, or Sharon, New- York, in connexion with the pure country air, and the freedom from care and anxiety, and the agreeable society met with at these watering places. The White Sulphur Springs of Virgin- ia are perhaps the most celebrated in the cure of rheumatism, although the same ingredients are substantially found in several others, as the Red and Salt, Sulphur, and the Avon Springs. That they are curative in this and other chron- ic diseases, independent of the other adjuncts above named, is fully established, and what we might a priori be led to believe, when we re- flect that they are cathartic, diuretic, tonic, and alterative. They are to be used both in- ternally and externally in this and other dis- eases in which they are indicated, and their employment be persevered in for a considerable period. The ioduretted and carbonated saline waters of Saratoga have also been found effi- cacious in relieving chronic forms of this dis- ease, and are well worthy of a trial.] 152. (p) A form of physical traininghas late- ly come into vogue for chronic rheumatism and other chronic ailments, more especially such as result from dissipation, excesses, irregularities, &c, of various kinds ; and this training, con- joined with change of air, occupation, scene, and mode of living, forming part of the system, and with bathing, the copious use of diluents and exercise, so as to produce a very free cu- taneous discharge, is often productive of mark- ed benefit, which is the more striking in those went of its Complications. 696 RHEUMATISM—Treatj obstinate cases, which have often become ob- stinate from the fault and neglect of^ the pa- tient, and from recourse having been had to many physicians in succession without allow- ing any one of them time or opportunity to em- ploy the salutary resources of science. What, however, is denied the honest advice of a phy- sician, is readily accorded by the patient to the confident humbug of the charlatan, especially when it is sought for at a distance, and ac- quired at an expense which is felt as a recom- mendation, although the only one. Regular modes of living, active and regular exercise, temperance, and a copious use of diluents, a free excretion from the skin, procured by baths, diluents, and exercise, and change of air, of oc- cupation, and of scene,have been recommended by physicians in all ages for many chronic com- plaints; but they have generally been imper- fectly followed out, or partially adopted, or al- together neglected by those for whom they were prescribed. When, however, they were ushered to the public, sane and insane, as the results of inspiration; were surrounded by appliances cal- culated to excite the senses of the weak-mind- ed, to attract the credulous, to allure the idle, the frivolous, and the intriguing, and to strike those whose consciousness reaches but little farther than their sensations, and who are in- capable of observing and of reasoning on facts and occurrences ; and when they were moulded into a plan, and popularized under the name of " water-cure," and were thus recommended by every means of publicity to that largest class of the community now specified as a universal remedy, beyond all remedies the most effica- cious, then were the results such as might have been anticipated by the philosophic observer of human nature,,and of the constitution of the human mind as influenced by existing states of society. The most remote of these results al- ready appear in a more accurate estimation of this universal " cure," and in the recognition of the fact that, of all the "vanities under the sun," the greatest and the shortest lived are those by which charlatans gull the public, and jeopardize not only the lives of the credulous, the thoughtless, and the worthless, but also the most important interests of families. [These very judicious remarks on hydropa- thy (water disease, correctly translated) will meet with a willing response from every re- flecting and candid mind. If we abstract from this system of cure all the adventitious aids of change of air and seepe, freedom from care, anxiety, and labour, a properly regulated diet, regular and abundant exercise, the gentle ex- hilaration of spirits caused by the bold prom- ises of amendment or cure, and the cheerful- ness produced by the agreeable society of the better classes of both sexes : if all these be ab- stracted, we fear there would be little for wa- ter-cure establishments to boast of, certainly nothing which could for a moment commend them to the notice of any rational being. The dishonesty of their proprietors and supporters consists in claiming in behalf of water what more justly belongs to other agencies. Indeed, we have often been led to believe, from person- al observation, that greater and more frequent cures would be accomplished at these estab- lishments if the water part of the treatment were entirely omitted, while the other influ- ences remained the same. But this would be the tragedy of Hamlet, the part of Hamlet omit- ted by request. There would be no chance to glorify and deify water at the expense of the other good things of God. Othello's occupation would be gone, and men, who might have made Useful mechanics and labourers, would have to go back to their original calling, the humbug being exploded, and their business at an end. From a personal examination of most of these institutions in the Northern States, we are fully satisfied that, notwithstanding cures are some- times accomplished at them, yet that very great injury is often caused by the hap-hazard and in- discriminate use of cold water. We have seen patients reduced to great debility, and with fee- ble recuperative powers, subjected to the douche and the plunge, both with the effect of pros- trating their strength still more, and in some cases with a speedily fatal result. We have nowhere found cold water used with that cau- tion and discrimination which so powerful an agent requires; nowhere have we found any r rational or scientific rules for its employment; a blind routinism prevailed in them all, and the results, of course, were such as might have been anticipated. All this the enlightened mem- bers of the profession well understand : the pub- lic would not believe it were an angel, trumpet- tongued, to proclaim it in the sky.] 153. (q) Sulphur, in the form of sulphur fu- migation, the oil of sulphur of former times, and the carburet of sulphur, have been locally or externally employed for the more obstinate forms of this disease. Otto, of Copenhagen, recommends, either alone or in conjunction with vapour baths, two drachms of carburet of sulphur in half an ounce of rectified spirit of wine, four drops of which are to be taken in- ternally every two or three hours, and the parts affected to be rubbed with a liniment consisting of two drachms of this carburet and half an ounce of olive oil. This treatment is most suit- able to those cases in which the secretions and excretions have been duly improved and pro. moted by the appropriate means before it is en- tered upon. 154. (r) Urtication, or stinging, or flagellation with nettles, has been advised for chronic rheu- matism, as well as for some forms of palsy, by many of the older writers, and it has in more recent times been prescribed by Hufeland. It may be resorted to with advantage after warm or vapour baths, or in similar circumstances to those in which other rubefacients and external derivatives have been recommended, as warm terebinthinate embrocations, &c. 155. vi. Treatment of the Complications of Rheumatism.—A. It has been stated above that acute rheumatism may extend to the mem- branes of the brain, the disease either continuing in its more external seats, or subsiding in, or disappearing from these (see v 50 and 51). When head symptoms occur in the course of acute or sub-acute rheumatism, the chief object is first to ascertain the cause and nature of this complication ; to determine in how far it may be caused by the treatment; and to observe the evidence for or against the existence of inflam- matory action in the membranes, or of simple nervous disturbance, or of a combination of both. Delirium, if slight, wandering, and noc- turnal, the external disease continuing but lit- RHEUMATISM—Treatment of its Complications. 697 tie or not at all ameliorated, may arise from the narcotics prescribed, or from too lowering or depressing agents, or from the exacerbation of the fever (see y 50), and in these circum- stances the indications are obvious. Violent or distracting pain in the head may also depend on the same causes, and be removed by similar means to those which these indications sug- gest, or by such as are prescribed for this form of headache at another place. (See art. Head- ache, y 50, et seq.) But when the head affec- tion appears to be dependent chiefly upon in- flammatory action in the membranes, then the subsidence of the external disease, especially that of the joint, will indicate its nature and the danger of effusion: In these circumstances, while active revulsion or derivation should be attempted by sinapisms applied to the parts af- fected previously, local depletions should be or- dered, and be followed by blisters on the nape of the neck and occiput, or behind the ears. Calomel and antimony, purgatives and terebin- thinate enemata ought also to be administered ; and if somnolency, or sopor, or coma be threat- ened, the head should be shaved and surround- ed by a cloth which has been just soaked in spirit of turpentine, or which is imbued with an embrocation consisting of equal parts of the ter- ebinthinate and compound camphor liniments. 156. B. The complications with the several forms of cardiac and pericardiac inflammations and (heir consequences axe the most frequently met with in practice (y 48 and 49). The na- ture and treatment of these complications have been so fully discussed when treating of dis- eases of the heart, that I have left nothing to add respecting them at this place. I may, how- ever, remark that further experience has prov- ed the accuracy of the opinions I then stated, and the propriety of employing the means of cure there advised. Rheumatic endocarditis and pericarditis, so common irt' children and young subjects, especially in cold, humid, and variable climates, depend chiefly upon the fash- ions in clothing; upon low, damp, and ill-ven- tilated places of abode; upon modes of living; and more especially upon the unnatural prac- tice of hardening children by exposure and by fashions in dress. Hence the necessity of avoiding these causes, and of pursuing a treat- ment calculated to diminish or remove morbid effusion or change of structure, and at the same time to improve the constitution of the blood, and to promote vital action and constitutional powers—objects which may be attained when these complications occur in young subjects, although they may be only partially or contin- gently accomplished in older subjects. (See Treatment of Rheumatic Endocarditis and Peri- carditis, in art. Heart and Pericardium, y 144, et seq.) 157. It is not unusual to meet with cases in which this complication has occurred in early life, or has appeared at some previous period, the acute rheumatic attack having been entire- ly removed, but the cardiac or pericardiac af- fection continuing either with or without detec- tion. In some cases which have come under my observation, for very many years after the rheumatic fever, complicated as now stated, had occurred, and even after every rheumatic symptem had disappeared, little or no ailment had been exoerienced, until shortness of breath on exertion, or dropsical effusion evinced the mischief produced in the heart. In other cases, .however, attacks of acute, or sub-acute, or chronic rheumatism, have followed at periods more or less remote from that attack in which this complication first appeared, generally ag- gravating the cardiac or pericardiac lesion, but not having always this effect; for I have met with instances, one of them in a medical man, in which an attack even of acute rheumatism has not increased the organic disease of the heart which had taken place during a previous seizure. ^ 158., A reference to the histories of cases of this complication, which have come under my care in the course of a practice t)f thirty years, and of'which I have preserved notes, suggests their classification as follows: 1st. Cases in which rheumatic fever complicated with car- _diac-disease had been experienced in early life, but many years had passed without any ailmenj; having been experienced, until shortness of breathing on exertion and. dropsy ultimately su- pervened, the patient dying of the cardiac dis- ease, no second attack of rheumatism having occurred. In a case now under my care, twen- ty-three years elapsed between the rheumatic fever thus complicated and the present devel- oped state of the organic disease of the heart, no rheumatic disease or other ailment having been experienced during all these years, al- though the cardiac affection had been slowly progressing until it has reached its present state. 2d. Some years after the occurrence of this complication, the cardiac disease still ex- isting, latent or detected, another attack of acute rheumatism has supervened, and has ag- gravated the oardiac complication, or even di- minished the physical signs and symptoms of this complication, these different effects de- pending much upon the treatment and consti- tution of the patient. I have thus seen two at- tacks of rheumatic fever take place after inter- vals of years, the cardiac complication at last destroying the patient. Jn the case of a med- ical man, two such attacks, after intervals of some years, have left the cardiac disease, in respect of both the physical signs and the symp- toms, much less extensive and severe than when I first saw him, fifteen years ago. 3d. Much more frequently the patient who has ex- perienced an attack of cardiac disease' in the course of, or consequent upon, rheumatic fever, has suffered recurrences of the rheumatic affec- tion in a slight or chronic form, without any very manifest aggravation of the cardiac disease, which, however, has either slowly advanced, or has proceeded .more or less rapidly according to his habits, modes of living, constitution, and treatment. 4th. In several instances rheumat- ic fever has occurred in early life, accompanied or followed by a cardiac complication, and no second attack of rheumatism has appeared, or merely slight or chronic rheumatic affection; but the cardiac symptoms, as well as the phys- ical signs of cardiac disease, have gradually subsided, until they have, after several years, nearly altogether disappeared, or have been at- tended by little inconvenience. 159. It is obvious that, in these several states of complication, the exact nature, and extent, and consequences of the cardiac and pericardiac lesions, demand the chief attention, and that the 698 RHEUMATISM—Treatment of its Complications. treatment of whatever rheumatic affection may be present should be a secondary object. Fortu- nately, however, the very means in which I have. for many years confided for the several forms of rheumatism, are also such as are most ser- viceable in the cardiac lesions most commonly associated with them. After what F have stat- ed, when treating of diseases of the Heart and Pericardium (see y 144, et seq.), I need only enumerate some of the most efficient means which may be prescribed in these complications, and which moderate powers of observation will enable the physician to apply to the peculiari- ties of particular cases. Upon the approach, or in the early stage of the cardiac complica- tion, calomel with opium, or with aconite; or the tincture or extract of aconite with biborate of soda ox with alkalies; spirits of turpentine given by the mouth ; alkaline aperients with colchicum; camphor with digitalis and henbane; the alkalies in large doses with demulcents and-diluents, and external revulsion, are most efficacious in preventing the deposition of lymph or fibrine, and the effusion of fluid. At an advanced stage, when either fibrinous lymph or serous fluid has been effused, or when hypertrophy has follow- ed obstructive or other changes of the valves and orifices of the, heart, then the iodides of mercury or potash ; borax in camphor mixture ; the iodide of potassium, and the solution or car- bonate of potash, with the compound decoction of sarza, or the decoction of senega and an aro- matic water ; camphor with digitalis, and with either of these decoctions, or with the infusion or tincture of hops; the iodide of iron in the sirup of sarza; and an issue or seton near the margin of the ribs, are the means in which I have most confided. ; 160. C. When the membranes of the spinal chord axe affected (y 52, 53), the treatment should depend much upon the duration of the disease in this situation. If the patient be seen early, local depletion, chiefly by cupping, fol- lowed by calomel and opium with colchicum ; by purgatives and terebinthinate enemata ; by terebinthinate embrocations in the course of the spine, and by blisters, are most serviceable. If the case come under treatment at a more ad- vanced period, or if the above means have fail- ed, partial palsy or paraplegia, or other symp- toms of increasing congestion, effusion of lymph or pressure on the chord appearing, issues or setons in the back or loins, the bichloride-of mercury, or the iodide of potassium in the de- coction of sarza, and the other means advised in the articles on Palsy and Spinal Chord, will then be appropriate. 161. D. When the diaphragm, or either its pleural or peritoneal surfaces axe implicated, or when the costal pleura, or the peritoneum (y 54, 55,56) reflected over the abdominal parietes, is attacked, the lymph thrown out soon excites inflammatory action in the opposite parts of these membranes, and agglutination of the sur- faces soon follows. This complication not in- frequently came under my notice many years ago in public institutions, the affection of these surfaces having been an extension of disease from the adjoining, parts the tenderness and pain of which often masked the more internal mischief. When, however, the diaphragm is implicated, the symptoms of diaphragmitis are generally present in a very manifest form (see art. Diaphragm, y 9, et seq.). In these associa- tions of the disease, the means already advised, especially local depletions, calomel, colchicum, and opium ; terebinthinate embrocations, blis- ters, issues, &c, and various other means rec- ommended in the articles on inflammations of these surfaces and on their consequences, may be resorted to. In many instances these forms of disease are not brought before the physician until they have arrived at advanced or chronic states ; until effusion, adhesion, &c, have tak- en place ; and then a judicious and persevering treatment will be required to produce any ame- lioration, aided by change of air, by suitable diet, and by whatever may promote the gener- al health and constitutional power. In many cases, however, the iodides already mentioned, taken in suitable vehicles ; bichloride of mer- cury in small doses with sarza ; alkaline solu- tions with iodides ; Plummer's pill with soap and taraxacum ; repeated applications of the terebinthinate embrocation ; repeated blisters and issues, when aided by proper regimen, will be productive of some benefit. These external means are more efficacious than the applica- tion of the tartar-emetic ointment, which I have not found of much service in these cases. 162. E. The association of affections of the sex- ual organs with rheumatism, or the supervention of the former upon the latter (y 57), requires means adapted to the states of sexual disorder, such disorders being duly considered under their respective heads. But, in respect of these, as of other associations of internal disease with rheumatism, it should not be overlooked that it is not only such internal disease which re- quires appropriate treatment, but also the rheu- matic diathesis—the constitutional affection, whether depending upon or seated in the or- ganic nervous system, or in the blood, or in both—and to this diathesis, and to the condi- tions constituting and indicating it, our means of cure should also be directed ; using means calculated to support the vital power of this system, and to remove the morbid conditions of the blood—objects which are more certainly attained by the remedies I have advised for the treatment of rheumatism than by any other. Rheumatism in females being so frequently connected with suppression, or irregularity, or difficulty, or the cessation of the catamenia, or with leucorrhceal affections, due attention in the treatment should therefore be devoted to these disorders. 163. F. Gonorrhceal Rheumatism, or the states of rheumatism consequent upon gonorrhoea (v 44, et seq.), is one of the most difficult to re- move. A severe case of it occurred in my practice very lately,-and presented the mixed form of capsular and aponeurotic rheumatism, the knees and limbs generally having been se- verely affected. The iodide of potassium and solution of potash, in the decoction of bark, or in the guaiacum mixture, and frequently with colchicum, were the medicines chiefly prescrib- ed. The case proceeded favourably, and after a few weeks the patient was able to have change of air, and to take regular walking ex- ercise. In more obstinate cases, I have given the spirit of turpentine internally until the uri- nary organs were affected with success; or bark with alkalies and the iodide of potassium, while terebinthinate epithems, or blisters, were RHEUMATISM—Treatment of its Complications. 699 applied on or near to the affected joints. In this form of the disease, a full dose of calomel, colchicum, and opium, taken at night, and a draught with castor oil and spirit of turpentine the following morning, in addition to these means, and repeated at intervals of one, two, or three days, will generally be of great service. I have seen the tinctura lyttae and capsicum given with the medicines now mentioned until some degree of irritation was produced in the urinary organs by the former, and until heat or smarting at the anus followed the latter, prove most beneficial in this form of the com- plaint. If the affection of the joints become chronic, the internal use of the iodides, and the repeated application of blisters, or the forma- tion of issues near the joints, and recourse to thermal springs, are among the most efficacious means of cure. If this form of the disease be neglected at an early stage and becomes chron- ic, it is not only removed with the greatest dif- ficulty, but organic lesion of the joint is very apt to supervene. , v 164. G. Rheumatism is often associated with influenza or catarrhal fever, or with ague, or with a remittent form of fever, and I have already shown that the complication is due chiefly to the presence of malaria in the humid and cold air to which the patient has been exposed, or to his having previously been the subject of ague (y 58). In cases of either of these associations the treatment which I have recommended for the rheumatic affection is equally appropriate to the associated disorder, the lowering means too frequently prescribed for the former aggra- vating not only it, but also the complication, and favouring the supervention of still more se- rious internal disease, especially of the fibro- serous or serous surfaces. 165. H. If Pneumonia or pleuro-pneumonia supervene in the course of acute rheumatism, a moderate general or local vascular depletion will be prescribed with advantage, if the pa- tient be strong or plethoric ; and calomel or antimonials with opium, and saline diaphoret- ics, will generally be required. Blisters will also be of service. In a case which was under my care, caused by removal in an unfavourable state of weather and season into.a damp house, rheumatism, in a sub-acute form, disappeared from the arm after two doses of the wine of colchicum, of ten drops each, had been taken, and was immediately followed by asthenic pneu- monia with rusty expectoration. A small cup- ping on the chest (seven ounces), and camphor with ammonia, small doses of the decoction of senega and terebinthinate rubefacients, and due attention to the several secretions and excre- tions, especially to those from the skin and kid- neys, were soon followed by recovery. Pneu- monia and pleuro-pneumonia associated with, or consequent upon rheumatism, have but rare- ly come under my observation; and the asso- ciation of scurvy with rheumatism is not more frequent, although these complications appear to have been of more common occurrence dur- ing the early part of the last century, according to the best practical writers on medicine in that period. More recently, lemon-juice, which has been found so beneficial for the prevention and cure of scurvy, has been said to have been serv- iceable in rheumatism, but I have had no expe- rience of it in this latter complaint. [There is a rheumatic affection not infre- quently met with, which may be termed hepatic, in which we find pains in the back, shoulders, breast, and superior extremities, and even of the larger joints, as mentioned by Sir W. Phil- ip. Dr. James Fountain, a distinguished practi- tioner of West Chester county, New York, call- ed attention to this complication in an article on " Diseases of Irritation," published in the New York Medical and Physical Journal in 1826. Dr. Fountain describes these pains as the effect of nervous irritations, symptomatic of the internal hepatic affection, and states that he has known people labouring under slight hepatic derange- ments, who for years have seldom been free from these pains wandering from one joint to another. «' Some," he remarks, "enjoy a de- gree of health, while others are feverish. Like sub-acute hepatitis, these pseudo-rheumatic pains may exist an indefinite length of time without inducing organic derangement. But where, from any cause, they become aggrava- ted, a real inflammation is developed, and from an effect they become a cause. Instead of an irritative symptomatic, we have now an inflam- matory affection to encounter, frequently in- volving in the excitement the whole vascular system, producing a symptomatic fever. The former pains are supplanted, and a new feature is given to the primary disorder of the joints ; and on the principle of counter-irritation the original hepatic disease is sometimes wholly removed. Now it must be evident that this complication, from beginning to end, must be totally different from ordinary rheumatism from cold. This form is quite commoii; and the ill success of the means ordinarily employed has contributed not a little to strengthen the preju- dices of people against the use of medicines in that disease." Dr. Fountain divides the means of cure in hepatic rheumatism into two classes, those required during the irritative, and those during the inflammatory stage. During the ir- ritative stage, the indication is, of course, to remove the exciting cause—the hepatic de- rangement. For. this purpose he recommends mercurials and laxative medicines. Four or five grains of blue pill, with the same quantity of rhubarb, should be administered twice ev- ery day, and as much sulphur, magnesia, and senna as will open the bowels fully, is to be given every second morning. After using these remedies for a week or ten days, an infusion of quassia or Colombo may be taken every morning, using at the same time some moderately stimu- lating embrocation to the painful parts. During the second or inflammatory stage we have he- patic derangement, universal debility, and local inflammation to encounter. Moderate vene- section is here recommended by Dr. Fountain, for he thinks that rigorous depletory measures are unsafe, in which opinion we agree with him. The bleeding is to be aided by the ad- ministration of ten or twelve grains of a pow- der consisting of one part of calomel, two of antimonial powder, and four of nitrate of pot- ash, every three hours from mid-day till nine in the evening, followed next morning by an op- erative dose of sulphate of magnesia and infu- sion of senna. Dr. Moore, in his New York Hospital Report, has noticed the same hepatic complication, and derived much benefit from the cathartic plan. The whole body, and the 700 RHEUMATISM—Biblioc oints especially, are to be carefully enveloped in flannel. The Phosphate of Ammonia is strongly rec- ommended in rheumatism by Dr. T. H. Buck- ler, of Baltimore, under the belief that it tends to eliminate uric acid from the blood, by form- ing with it a soluble urate of ammonia, the phos- phoric acid being neutralized by the soda with which the uric acid may be combined in the blood. Dose ten to twenty grains, from three to six times in twenty-four hours, in all forms of rheumatism. (American Journ. of Med. Science, N. S., vol. xi., p. 108.) Dr. Ruschenberger, of the United States Navy, has derived much benefit in this disease from cold water dressings to the joints, and the use of from three to six grains of opium at night, with an equal quanti- ty of sulph. quinine. (American Journal of Med- ical Science, N. S., vol. xiv., p. 263.) Professor Wood, of Philadelphia (A Treatise on the Prac- tice of Medicine, 2d ed., vol. i., p. 435), speaks favourably of bleeding once or, twice in acute rheumatism, followed by active purging with salts, jalap, and bit. potassa, calomel, or colchi- cum and magnesia, with refrigerant diaphoret- ics, as a combination of tartar emetic and nitre, from one twelfth to one sixth of a grain of the former and five to ten grains of the latter in water, at intervals of one, two; or three hours ; or nitrate of potash in the form of an efferves- cing mixture, and the occasional use of the warm bath. Pain is to be alleviated and sleep procured by full doses of Dover's powder at night. If the powder be rather feeble, pulver- ized guaiacum, in doses often to twenty grains, is to be combined with the Dover's powder. Should the disease not yield to these measures in ten days or two weeks, then calomel is rec- ommended, with a view to its alterative influ- ence, but not previous to a decided reduction of the general excitement. , It is seldem neces- sary to carry it to the point of salivation. At this period, also, Professor Wood thinks the colchicum most beneficial with one of the salts of morphia, and it may be given before or in aid of the mercurial. If an adynamic condition of the system supervene, then the sulphate of quinia, in doses of one grain every hour, is strongly recommended as highly beneficial. If the heart or brain become seriously involved, venesection is to be carried as far as it can be borne with leeches or cups, succeeded by a large blister, while calomel is pushed to speedy sali- vation, and attempts are made, by sinapisms, &c, to invite the disease back to its original seats. In chronic rheumatism, Professor Wood recommends mercurial alteratives as by far the most successful remedies, often carried so far as to induce ptyalism. The attention of the profession in this country was. first strongly called to this mode of treatment by the, late Dr. Otto, of Philadelphia (see Eclectic Repertory, vol. ix., p. 528). Dr. Chapman speaks strongly of savine as a remedy in chronic rheumatism ; others have found great benefit from cimicifuga, Phytolacca, and the xanthoxylum or prickly ash. That a course of hydropathic treatment often breaks up the disease no one will deny, al- though it is not unattended with danger. In one instance we knew it bring on universal and severe inflammation in all the joints of the body, attended with long-protracted confinement to bed, and total inability of motion for several sraphy and References. months, from which the patient has not yet en- tirely recovered, nor does he enjoy as much ex- emption from suffering as before subjection to the water cure. Such cases are by no means of rare occurrence, while in other instances great benefit has resulted from this powerful alterative treatment.] 166. vii. Regimen, Diet, and Change of Air. —There are few diseases which require great- er attention to these than rheumatism. Dur- ing an attack of the acute form of the disease, the regimen and diet should be antiphlogistic. Such articles as are the least likely to occasion acidity should alone be taken. Saccharine sub- stances ought to be avoided. As soon as con- valescence has proceeded sufficiently far to ad- mit of removal, change of air should be recom- mended, more particularly to a warm and dry air, or to a place where warm salt-water baths may be procured, or thermal springs may be used, especially to Bath or Buxton. If the at- tack has not been complicated with, or follow- ed by, any affection of the heart, regular and active exercise in the open air ought to be tak- en as soon as the patient is able, so as to pre- serve a free excretion from the skin. If any cardiac affection is present, an issue should be kept freely discharging near the margins of the ribs. In more chronic or mild cases, the regi- men and diet ought to be regulated according to the peculiarities of individual cases ; but, in every instance, change of air, active exercise in the open air, when it can be taken without detriment to the affected part, flannel clothing nearest to the skin, a diet regulated conforma- bly with the state of the complaint, and due regulation and promotion of the several secre- tions and excretions, are most important aids to a permanent recovery, and to the prevention of a future attack. Bibliog. an!) Refer.—Aretaus, De Caus. et Sig. Morb. Diutum., 1. ii., cap. 12. (Considered by him as a disease of t!ie joints, intimately allied to, goat, sciatica, &c). — J. Vi- gier, Tractatus de Catarrho, Rheumatismo, &c. Genev, 8vo, 1620, in Halleri, Biblioth. Med. Pract., vol. ii., p. 376. —G. Ballonius, Lib. de Rheumatismo et Pleuritide Dorsa- li, 4to. Paris, 1643; et Consil., 1. iii.. No. 67; Opera, t. iv., p. 313.—Riverius, Observat., cent, iii., No. 22,41.—J. Cottier, De Rheumatismo ejus Natura et Curatione, 12mo. Paris, 1653. — Glisson, De Ventriculo et Intestinis, t. ii., c. 25. (Diagnosis of Rheum.).—T. Sydenham, Opera Omnia, Edi- dit G. A. Greenhill, 8vo. Lond., 1844. impensis Societatis Sydenhamianee, p. 255-261,299-303,556.—E. Baynard, Of the Causes of Pain in Rheumatism, in Philos. Transact., abridged, vol. iii., p. 265.—R. Blackmore, Discourses on the Gout, Rheumatism, and King's Evil, 8vo: Lond., 1726.— Molineux, in Philosoph. Transact.; No. 209. — Dumoulin, Nouveau Trait6 du Rheum, et des Vapours, 12mo. Paris, 1710. — D. Bottoni, Febris Rheum. Historic Medica, 8vo. Messina, 1712.—J. Cam, Essay on Rheumatism, Gout, and Stone, 8vo. Lond., 1722. — Dover, Legacy, axtTr]c, spinal), Glisson. Rachitis, Suavages, Vogel, Boerhaave, Cullen. Tabes Pituitosa^Morbus Anglicus, Osteomalacia, Mol- lities ossium, Osteosarcosis, Auct. Innutritio ossium, Darwin. Osteomalakia, Swediaur. Scrofula rhachitis, Young. Cyrtosis rhachia, Good. Tabes pectorea, Spina nodosa, Rachitis- mus; Rachite, Rachitisme, Riquets, Fr. En- glische krankheit, Germ. Rachiti.de, Ital. Rickets, softening of the bones. Classif.—Class 3d. Cachectic diseases ; Ordered. Swellings (Cullen).—Class 5th. Diseases of the Excernent Function.— Order 1st. Affecting the Parenchyma (Good). IV. Class, IV. Order (Author). 1. Defin.—Softening and curvature especially of the long bones, and swelling of their extremities; the head being large, the spine bent, the abdomen en- larged, the flesh emaciated and flabby, with all the signs of general debility and impaired assimilation. 2. This disease was first described by Dr. David Whistler, in his inaugural dissertation (De Morbo Puerili Anglorum dicto " the Rickets." Lugdun. Batav., 1645.) Glisson, who soon aft- erward wrote oh this complaint, states that he was induced to give it the name of Rhachitis, because the spine was so often affected in its course, and because'the term nearly resembled rickets, the name by which it was commonly known in England before the time at which he wrote. Dr. Cummin remarks that the works of Whistler, Glisson, Bate, and others procured a currency for their opinion that the disease made its first appearance in the western parts of England towards the middle of the seven- teenth century, and that it hence was called the English malady. The first of these writers published in 1645; the second edition of Glis- * [There is no proof whatever that this disease origina- ted in England, or that it is a new complaint The kinds of deformity which it produces are described by both Grecian and Roman authors as existing in ancient times. It was not until the seventeenth century that the disease was distinguished by any particular name from other af- fections which occasioned deformity of the limbs: there is no doubt whatever that it has existed in all ages, espe- cially in cold, variable, and humid climates, like that of Greaf Britain. We have records of its very extensive prevalence in England long before the period mentioned by Dr. Copland, and also of the great mortality which it occasioned. We know that some of the English medical historians represent it as having originated in Dorsetshire and Somersetshire, and from these counties to have spread over the world ; but there is no foundation for snch a be- lief.] RICKETS—D may be associated with a variety of ailments of the digestive and assimilating organs. The transition from apparent health to the incipient state of the disease is always gradual, and con- sequently more or less slow; but it may be masked by some other disorder, and hence not be recognised until this period has made con- siderable progress. The impairment of vital power originating the nialady is most frequently associated with indigestion, or with chronic ir- ritation of the gastro-intestinal mucous surface, or with bronchitis, or with hooping-cough, or even with lobular pneumonia, and with more or less change of the urine, which, however, has generally been imperfectly examined. Nev- ertheless, cases occur in which but little or no ailment-, or merely slight debility of the digest- ive and assimilating functions, has been re- marked up to the time of the manifest appear- ance of the complaint. r 5. With the approach of rickets, the child is dull, or sad, or peevish ; is averse from play or any action ; prefers to sit or lie, appears feeble or indolent, or complains of inability to use ex- ertion, and of pains in the joints and along the bones ; the appetite is impaired or is capricious ; the bowels are irregular or relaxed, and the stools morbid, or pale, or deficient in healthy bile; the face is pale, and the flesh becomes soft and flabby; perspiration is 'free on slight exertion, and is weakening and colliquative dur- ing sleep, and the skin often moist during the day. The pulse is quick, soft, and broad or open, the external veins are large, and the jugular veins much dilated. Thirst is generally pres- ent ; emaciation becomes evident, and the ab- domen tumid. With all these symptoms, how- ever, no evidence of rickets may exist; for they may accompany or usher in other maladies; but when with these the urine is more abund- ant than in health, and when it deposites a co- pious calcareous sediment, or abounds in the phosphates, then the early or precursory stage of the complaint may be considered as already present; and it is in this stage especially that the salts are most abundant in the urine (f) 16). 6. The duration of this period necessarily va- ries with the number and severity of the symp- toms now enumerated, with the age and consti- tution of the patient, and more particularly with the quantity of phosphates contained in the urine. It may thus vary from one or two months to six or seven ; but when the head is very large, and the bones of the head imper- fectly developed, dr the sutures not closed, when the abdomen is very tumid, the bowels lax, the stools pale and deficient in bile, and the urine abundant, the second or developed state of the complaint, appears early. The continued oper- ation of the causes, neglect or injudicious treat- ment, and the occurrence of some local inter- current affection, may shorten this period; while a proper treatment and regimen may re- move all the symptoms, and prevent the devel- opment of the disease. In some cases, also, the precursory stage may be hardly apparent, the first indication.of the complaint being the actual deformity of the limbs constituting the second stage; the child may have appeared, up to the detection of the flexure of the long bones, in good health ; although closer observation and an examination of the urine would have detect- ed more or less evidence of disorder. escription of. 703 7. B. The second period is that which is char- acterized by more or less deformity of the bones. The extremities of the long bones, especially those of the ankles and wrists, and the sternal ends of the ribs, are the parts which first evince this stage, by their swollen or knobby appear- ance ; and the lower portions of these bones now begin tb yield, especially those of the low- er limbs, when the child is so old as to attempt to walk. The increasing softness and yielding of the bones are now apparent in the gradual change of their forms. The lower extremities are usually curved by the weight of the body, while their bones yield more or less to the ac- tion of the most powerful of the muscles. They generally present the convexity of the curvature outward, and (he concavity inward. The fe- murs are sometimes curved forward, but more frequently outward, as are the tibiae. The knees are sometimes bent inward, and the feet thrown outward, so that the knees press against each other, and the patient rests on the inside of the foot; and as often the knees are separated tc an unnatural distance by the'continued curva- ture outward of both the thighs and legs, the whole of the lower extremities forming irregu- lar curvatures, with the convexities outward and greatest at or near the knees. In some cases the angle formed between the neck and shaft of the femur is changed from an obtuse to a right or an acute angle. Much of the de- formity which takes place in this stage is owing either to the manner of carrying or placing the child, or to the weight of the body and head upon the lower extremities when attempts are made to stand or walk, and upon the upper ex- tremities also, when the child crawls about on its knees and hands. 8. The head of the rickety child is generally unusually large. The vertex is often flattened; the forehead is prominent and broad; and the centres of the parietal bones expanded. The fontanelle is wide and unclosed; and, if the* child be very young, the sutures expand or re- main open. The bones of the face are imper- fectly developed, or are partially arrested in their growth ; and the under-jaw is often elon- gated. The process of dentition is arrested or delayed ; or, if they have been formed, they soon decay, owing to softening of the fangs, and of the alveolar processes. The clavicles are, after the bones of the'lower extremities, the most frequently deformed. The long bones of the upper extremities are much less frequently curved than those of the lower. The spine is generally also curved, owing as much to yield- ing of the ligaments as to softening of the bod- ies of the vertebras. The curvature is com- monly outward, but it is sometimes also lateral- outward in the back or between the shoulders, where the curvature is also to one side, and to the opposite side in the lumbar region, where also there is sometimes a curvature inward The curvatures of the spine, especially outward, are generally connected with a flattening of the ribs laterally. The ribs are turned inward, and their sternal extremities, at their connections with their cartilages, are swollen into knobs. While the sides of the chest are thus compress- ed, the dorsal spine is pushed outward, and the sternum also outward, the diameter of the chest, from right to left, being thus much diminish- ed, and the " pigeon breast" formed. (See art. 704 RICKETS—Description of. Chest, Deformities^/.) The flat bones, as those of the shoulder and pelvis, are also sometimes affected. The shoulder-blade is, in a few in- stances, so deformed as to embarrass more or less the movements of the shoulder ; but when the bones of the pelvis are softened, the de- formity is of the utmost importance, especially to^the female, in after life. The change of form in the pelvis is often remarkable, and is ex- tremely various, the sacrum and pubis being carried either backward or forward, the ilia di- rected inward or otherwise altered, the lower part of the sacrum pushed upward, and the out- let of the pelvis variously altered in form and diminished in-diameter. The progress of de- formity is generally from the extremities to the center of the frame, and more especially from below upward, particularly after the first year. 9. The relative proportion of the alteration of the different bones in rickety patients has been stated by M. Guerin. But it should not be over- looked that, as the bones nearest the centre of the frame are the last affected, or are liable to deformity only at an advanced stage, and in neglected or ill-treated cases, the statistics he has furnished are open to the objections which may be urged against the statistics of other diseases; whether the relative proportion, or numerical calculations, be applied to symptoms, or to organic changes, or to remedial results ; objections based on the differences of disease owing to varying combinations of predisposing and exciting causes ; to endemic and cpidemie influences ; to seasons and weather, to modes and manners of life, and to numerous circum- stances, to which it is needless here to advert. M. Guerin states that, of 496 cases of rickets, 11 only had swellings of the extremities of the bones without curvature ; and of the 485 with curvatures, 59 had at the same time deformity of the thorax, 48 deformity of the spine, 17 en- largement at the same time of the cranium, and 14 only deformity of the upper extremities si- multaneously with these alterations. 10. During this stage, the deformity of the bones is not the only change. The alterations mentioned in connexion with the first stage con- tinue during this. The abdomen continues tu- mid, or increases in size, and is more tympa- nitic, the limbs more emaciated and flabby; the child more languid and weak ; the perspiration free and readily increased; the thirst increased; the pulse quick, small, and weak, with slight hec- tic symptoms ; and pains are complained of in the bones and joints. The bowels are irregu- lar, or loose, and the stools pale or almost de- void of healthy bile. The general emaciation and change in the bones allow the head to ap- pear larger than usual, while it is often only large in proportion,to the rest of the body; and while all other parts of the frame, the bopes es- pecially, cease to grow, during this stage, the head appears even to enlarge, and the faculties of the brain to be developed, sometimes preco- ciously.* The cessation of growth, particularly * Mental precocity is not, however, always seen; for sometimes the child continues dull, taciturn, or stupid, or even idiotic. These opposite states have been explained by supposing that the openness of the sutures has allowed the circulation and development of the brain to advance at an increased rate, and the faculties of the mind to ex- pand ; while the closure of the sutures, and the conse- quent unyielding state of the cranial bones, have confined and embarrassed the functions of the brain, and occa- of the bones, during this period, is most remark- able in the lower extremities, and less so from below upward. M. Guerin states, that his com- parisons of the skeletons of rickety -subjects with those of the same age and sex who had not been rickety gave the following per cent- age of reduction in the different bones : in the fibula, 26 per cent. ; in the tibia, 25; in the fe- mur, 22; in the cubitus, 19 ; in the humerus, 15 ; in the clavicle, 9 ; in the sternum, 8 ; in the spine, 5 ; and in the pelvis, 17 per cent. 11. The duration of this stage necessarily varies with the persistence or removal of the causes during treatment, with an early or de- layed recourse to judicious means, with the diet and regimen, and with the local affections which may complicate the disease. In the more rapid states of the complaint this stage may not continue longer than two or three months, while in more chronic forms, and when the complaint has been long neglected, and un- favourable circumstances continue their influ- ences, this period may extend even to several years, the deformity and its attendant symptoms either very slowly increasing or remaining near- ly stationary. 12. C. The third- stage, or period of restoration, or that attended by either a favourable^ un- favourable change, is marked by no yery sud- den alteration from the state above described; it appears gradually,'but rarely rapidly, unless some intercurrent disease or local affection su- pervene ; and this is not infrequent.—(a) If the disease does, not tend towards recovery, the ema- ciation increases, the abdomen is more distend- ed, and the bowels more disordered, while the secretions and excretions are still more morbid than before. The deformity of the bones con- tinue or increase; and ultimately the child is carried off by disease of the lungs or of the ab- dominal viscera, or several lesions of the tho- racic and abdominal organs may coexist in the same case and terminate life, as congestion of the lungs with effusion into the pleura ; general bronchitis with gastro-intestinal irritation ; le- sions in the digestive canals with enlargement of the mesenteric glands ; crude tubercular for- mations in the lungs, with tubercles in the mem- branes of the brain, and effusion in the ventri- cles or between the membranes, &c. If the child is not carried off by one or more of these, and continues deformed, without any amend- ment of the symptoms, the softness of the bones is much diminished, their flexibility is lost, they are more atrophied, and they are more readily broken ; the deformity often still increasing. Recovery then rarely takes place ; a complica- tion of internal disorders, consequent upon structural changes, and upon a morbid state of the blood, ultimately terminating life. 13. (b) A favourable change from the second stage is evinced at first by the states of the se- cretions and excretions. The urine assumes a more natural appearance and composition ($ 16); the stools are more healthy, and coloured sioned the opposite state of the mental powers. But, as far as I have observed, precocity has not always existed in connexion with openness of the sutures, nor stupidity with their closure. Perhaps -the chemical pathologists, who attempt to explain all by chemical changes, will ac- count for. the different phenomena by ascribing them to the state of the blood and to the excess of phosphates in it during their passage from the bones to the kidneys, by which they are eliminated. RICKETS—Description of. 705 more deeply by bile ; the abdomen appears less tumid and less tympanitic ; the pulse is less fre- quent, and pains in the limbs are not so much complained of. The countenance presents more animation, and the hectic or remittent febrile symptoms and thirst subside gradually. The appetite is less capricious and more natural; and, with the continuance of these changes, the flesh becomes firmer, and voluntary motion is made with greater activity. The growth of the limbs, which had been suspended until now, proceeds with remarkable vigour; the bones are gradually restored, and, if the deformity is not very great, it disappears by degrees ; the curv- atures are either diminished or altogether re- moved ; the swellings of the epiphyses of the bones subside, and ossification proceeds with great rapidity, the affected bones acquiring greater density and strength than usual. The muscles also acquire a more powerful develop- ment, so that persons who have been rickety in childhood have afterward become remarkable for strength. 14. (c) During recovery an excessive ossific action often occurs, more especially in the parts which had been swollen, and softened during the stage of defornuty. Not only are the sound bones more dense, but, in some instances, a state of hyperostosis or extoses more or less numer- ous, especially near the epiphyses and sutures, is observed. I have seen this occur most re- markably at the terminations of the ribs and commencement of the cartilages, the whole be- ing more or less soldered together, and also with the sternum. Occasionally slight acces- sions of fever are observed during recovery, and either advance the process of restoration, or are the mere concomitants of the change taking place in the bones and system generally. If the complaint, occur in children about the second year of age, or later, although it may be of considerable duration, amendment is gen- erally rapid when it commences; and even when the growth is stunted, and the deformity is still considerable, still the period of puberty may remarkably develop growth and diminish the deformity, especially when the advantages of a favourable change of air and out-door ex- ercise are enjoyed. 15. When the disease is attended by an out- ward or lateral curvature of the spine, or with flattening of the ribs and protuberance of the sternum (see art. Chest, Deformities of), recov- ery is imperfect and protracted, and the more so the greater the deformity arising from the curvatures of the spine and the flattening or bending inward of the ribs. In these cases the functions of the lungs are impaired, and the more advanced parts of the assimilative pro- cesses are impeded. In many of these cases, especially in those which are the most deform- ed, and when the spinal curvature is so extreme as to form a dorsal hump, the deformity con- tinues through life, the duration of which it may considerably abridge, by favouring the su- pervention of congestion of the lungs, or bron- chitis, or pneumonia, or even asphyxia, by pressure on the origins of the spinal nerves. In some the curvature diminishes with the res- toration of health, aided by suitable treatment and regimen ; but in others it increases, some- times after having been long stationary, owing to some change in the general health, or to de- III 45 bility, or to disease, when ultimately a fatal termination takes place in the way now stated. 16. D. The urine in rachitis presents more or less change from the healthy state. Generally it is much more abundant than might be ex- pected, considering the free transpiration from the skin. It is commonly pale, but it is some- times of natural colour. The urea and uric acid are diminished, while the salts are increas- ed. A free acid is sometimes observed, which has been said to be the phosphoric, but this re- quires farther investigation. The phosphates are more abundant than in health, and more especially than in healthy children ; and a con- siderable sediment of oxalate of lime is not in- frequent ; and it has been observed that urinary calculi are frequent in. rachitic children. As far as my own observation enables me to .state, the increase in the fixed salts is most consid- erable during the advance of the first stage, and when the deformity begins to appear in the bones : it is less remarkable when the disease is far advanced, and the softening and flexures the greatest. The phosphate of soda and the earthy phosphates are most abundant. In a case examined by Marchand (Lehrb. der Phys. Chemic, p. 338), the urine contained much lac- tic acid and lactates, and a great excess of the earthy phosphates. In a case by Mr. Solly (Transact, of Roy. Med. and Chirurg. Soc, &c, vol. xx., p. 448), three or four times the usual amount of phosphate of rime existed in the urine. The exact composition of the urine during the third stage, especially during a re- turn to the healthy stale, has not been shown. 17. E. Various complications often occur in the course of this complaint. These may be either of an acute or chronic nature. Rickety Children may be the subjects of the usua} dis- eases of childhood, as hooping-cough, measles, scarlet fever, small-pox, &c, or of bronchitis, pneumonia, inflammatory irritation of the di- gestive canal, enlargement of the spleen, scrof- ulous enlargement of the gjands, tubercular productions in the lungs and other organs, cu- taneous eruptions, &c. Most of these are ac- cidents by no means necessarily consequent upon the rickety constitution ; but when the disease is far advanced, or is attended by de- formity of the spine or chest, then the affec- tions of the lungs, pulmonary congestion', effu- sions into the shut cavities,,and disorders of the digestive organs, may be favoured by such deformity. The complications now mentioned, which, are not specific, and which result not from infection, are often produced by certain of the causes which combine to produce this mal- ady, or by influences to which children in this state are often exposed, more especially to va- rious endemic influences, as a close, cold, and humid air, and injudicious diet. M. Guersent remarks that he has seldom found rickety chil- dren the subjects of tubercles, although he has observed two thirds of children who have died of other diseases present tubercular formations in some of their organs. M. Rufz also states, that in twenty rickety subjects he found tuber- cles only in six. There can be no doubt of these complications having the effect of aggra- vating and accelerating the unfavourable prog- ress of the disease in most cases, the only ex- ceptions being when the eruptive fevers occur in a mild form, and then, in a few cases, they 706 RICKETS—Description of. have appeared to impart a new and favourable state of vascular action to the frame. In the most severe and advanced cases, other compli- cations than those already mentioned often oc- cur, and, in the weakened state of constitution, frequently terminate life. These are chiefly colliquative diarrhoea ; hectic with colliquative, sweats ; congestion of the brain, with or with- out effusion, and attended either by coma or convulsions, fractures of the long bones on sud- den motion, retention of urine, complete or in- complete palsy, chiefly in the form of paraple- gia, and loss of one or more of the functions of sense. 18. F. The appearances after death possess interest, not merely as respects the state of the internal organs, and the lesions in them to which death is more directly owing, but as re- gards the changes observed in the bones them- selves. These latter changes can be observed in the early periods of the disease only when the patient is carried off by some complication or intercurrent disease. M. Guerin has ob- served the alterations which take place in the bones during the three periods of the disease, and from his researches I am enabled to give the following account: (a) When death is caus- ed by some acute disease affecting a rickety subject during theirs* stage, as sometimes hap- pens, the long bones, when quite fresh and not previously exposed to the air, are congested with a large quantity of dark blood, which ex- udes from all parts when the bone is divided either longitudinally or transversely. This blood appears not to be contained in blood-ves- sels, but to be effused on each side, in the me- dullary canal between the medullary membrane and bone, in all the areolae of the spongy struc- ture of the diaphyses, of the epiphyses, and in the intermediate tissue which unites these two portions of bone, and under the periosteum, which is evidently injected and thickened. Blood is also interposed between the lamellae of the compact structure of the bones, these admitting of an easy separation, and allowing this fluid to exude in numerous minute points. The blood is at first very fluid, and is readily removed from the surfaces on which it exudes ; but, at a more advanced stage, it loses its dark colour, becomes gelatinous,and semi-transpar- ent, and adheres firmly to the surface of the osseous tissue. It then presents the rudiments of minute capillary vessels. During these changes in the blood the vessels of the bones acquire an increased development; the open- ings through which the vessels pass to and from the interiors of the bones are much dilated, and the osseous system is the seat of a remarkable sanguineous congestion, in which the small and flat bones also participate more or less. 19. (b) In the second stage the osseous tissue is manifestly more or less softened, admitting of flexures according as the weight, pressure, position, or muscular actions of the body may direct them. On examining closely the struc- ture of the long bones, the swellings Of the di- aphyses and epiphyses are found to be owing to the development of a very fine spongy tissue, of a new formation, which M. Guerin has named the " spongoid tissue," to distinguish it from the ordinary spongy structure. This tissue consists of very fine irregular areolae, which replaces the sanguinolent fluid charging the bones in the first stage, and is found spread out underneath the periosteum, forming a coat from one to two lines in thickness. It is found also between the lamella? of the bones, where it may be de- tected by its darker color, and between the bone and the medullary membrane ; but it is abund- ant around the epiphyses. It is also abundant, and more dense, at the concavities of the flex- ures than at the convexities ; and it is found in both the long and flat bones. The periosteum is more or less vascular and thickened. 20. (c) The third stage presents changes in the bones very different from each other, ac- cording to the termination it assumes. When recovery and consequent re-ossification take place, the spongoid tissue of the new formation is nearly altogether transformed into a com- pact structure, especially in the concavity of the curvatures ; and it is so abundant toward that part where the inedullary canal is most contracted, as to invade the greater part of the canal by osseous lamellae. While the com- pact structure acquires a very great density, it becomes the whiter the longer the duration of the consolidation, until it assumes the hardness and appearance of ivory. Disseminated through this structure in the diaphyses, and in the epiph- yses as well, irregular open spaces are some- times observed, apparently resulting from a par- tial absorption or from a retraction of the solid parts. When re-ossification does not take place, the compact structure is thin, fragile, dry, or compressible, especially around the epiph- yses. The areolar tissue found within this thin osseous shell consists of large unequal or irregular cells, which extend throughout the whole of the medullary canal, which is filled with very fine osseous lamellae surrounded by an oleaginous fluid. This alteration, which is found also in the epiphyses, M. Guerin has named " Rickety consumption of the bones." 21. (d) It must be evident from these altera- tions that the bones will present important chemical results upon analysis, and that the chemical changes will vary with the amount of softening and of the alterations just described, and as these latter vary in different cases, in the same case at different periods, and in dif- ferent bones in the same subject. According to Bostock and Becquerel, the earthy constit- uents of the bones are remarkably diminished during the early stages of the complaint. In two children who died of pneumonia during the early period of rickets, the bones of the cra- nium presented but a slight diminution of the earthy phosphates, while the femur, the tibia, and the sternum contained only from a fourth to a twelfth part of the proportion usually ob- served in health. 22. (e) The complications of the disease above enumerated will suggest many of the visceral lesions observed in fatal cases of rick- ets, for to these death is generally more im- mediately owing. The brain is found more or less large relatively to the rest of the body; and fluid is often effused within the ventricles and between the membranes, which in a few cases have presented small or crude tubercular formations. Effusion of serous fluid is some- times found in the pleural cavities, and the lungs often are pushed downward by the. lateral pressure of the ribs. The bronchi are often in- flamed or congested, the lungs are congested, RICKETS—Pathology, Prognosis, etc 707 or in parts resemble the structure of the spleen, or contain, in some instance's, tubercles in va- rious stages of development. The heart is often paler than natural, and, in a few instan- ces, has presented incipient organic lesions, especially when the complaint has been oblong duration and the deformity of the chest has been considerable. The liver and spleen are often pressed downward by the thoracic de- formity ) and both organs are sometimes found more or less enlarged—the liver frequently paler than natural. The alimentary canal is generally very much distended by flatus, and the mesenteric glands are more or less enlarg- ed, and occasionally contain crude tubercles. The different series of glands contained in the digestive villous surface are either enlarged or ulcerated, particularly when the disease has been complicated with intestinal disorder. The muscles are generally very flabby, pale, and wasted; the adipose tissue is wasted by ab- sorption ; and what remains appears soft and almost fluid. The whole of the structures, vis- ceral and external, present a state of flabbiness or softness. 23. ii. Diagnosis and Prognosis.—A. The Diagnosis of this complaint is sufficiently easy, excepting in the precursory, stage, and then it is often as difficult as it is important to detect the approaching mischief. In this stage the complaint may be mistaken for several incip- ient diseases, especially for tubercles in the lung, for tubercular peritonitis, for tubercular disease of the brain or of the cerebral mem- branes, or of the spine. A short time and an attentive observation of the symptoms will soon show whether or not they agree with those described as characterizing the first stage ($ 4, et seq.) ; and when enlargement Of the ends of the long bones, ahd especially when these become at all deformed, the diagnosis will be manifest. If any mistake should be made, or any difficulty of diagnosis between the incipient states of these maladies should arise, but little evil need result, as the treatment would not. be inappropriate to either of them. It is evident from the changes observed in the bones, especially those evincing re-ossification, that the softening of the bones of children, or true rickets, is, in very essential points, a dis- tinct disease from the softening of the bones sometimes observed in adults, especially in fe- males, although I have considered it at this place as a species of rickets, from the softening and deformity attending it. This latter, the true osteomalacia, or mollities ossium, is never followed by re-ossification, especially when it is consequent upon chronic or malignant dis- eases, or the puerperal state. Curvatures of the spine supervening in the course of rickets should not be confounded with those curvatures caused by tubercular or scrofulous disease of the vertebrae on the one hand, or by relaxation of the ligaments, &a, on the other. (See art. Spine.) Nor should it be overlooked, that the curvatures of the spine, so frequently observed connected with deformity of the chest, may ex- ist in children as well as in adults, or young persons about the age of puberty, without the least degree of rickety change in the bones; that this curvature, as well as the deformity of the chest and sternum (described in article Chest, Deformities of), may exist, on,the one hand, either separately or together, both in children and in adults, no other deformity of the bones being present; that either or both de- formities may, on the other hand, supervene in the progress of true rickets, and of mollities os- sium, or the rickets of adults ; and that, when curvatures of the spine are thus associated with true rickets, or with mollities ossium, the bones of the pelvis are generally also deformed or con- tracted in various directions, more especially when the lower extremities continue much bent and shortened by true rickets, and when the softening occurs in adult age. It is worth no- ticing, also, that the extremities, especially the lower, not, only cease to grow during the dis- ease, but also continue much shorter during life, although they have acquired remarkable strength. 24. B- The prognosis depends not only upon the progress and severity of the complaint, but also upon the combination or persistence of the causes, and upon the.' effects produced by treatment. If the child be not remarkably de- bilitated, if the disease be not far advanced, and if the deformity have not invaded the spine, or pelvis, or parietes of the chest, a favourable result may be expected from treatment; but when vital power is much reduced, when the deformity is great, and has extended to the spine, or to the chest, or to the pelvic bones; still more especially when it is complicated with serious visceral disease or lesion, and when the deformity is such as to impede the respiratory functions, or when the head is af- fected, and sopor, coma, or convulsions super- vene, or when the urinary functions are disor- dered, then complete recovery should not be expected ; and, although life may in many cases be indefinitely prolonged, yet it may be very rap- idly^terminated, particularly in the latter cir- cumstances. An unfavourable issue is the more likely to occur the earlier in infancy the com- plaint appears, the more serious the disorders which usher it in, and the more manifest and marked the predisposing causes existing in the parents. 25. iii. Causes.—A due recognition of the remote causes of rickets is of the utmost im- portance in preventing and in curing the dis- ease.—A. The predisposing causes axe not mere- ly those which act externally on the child, but those also, and often especially, which are de- rived from the parents and the nurse—these latter sources, which have been too much over- looked at the present day, but to which Boer- haave and his commentator have directed at- tention : "Maxime autem infestus habeturpro- li, cujus parentes laxa et debili conditione cor- poris, otiosi, molles, opipara mensa, cibis pin- guibus, saccharatts, pauca pane, vinis dulcissi- mis, et aqua multa calida, usi, morbis chronicis, venere, aetate, exhausti, tabi inprimis venerea;, et iteratis gonorrhceis, multum obnoxii, effig- tam ferme genituram impenderunt generandis liberis." (§ 1482.)—There is much truth in this enumeration of the predisposing causes deriv- ed from the parents. In respect of the influ- ence to be ascribed to the exhaustion produc- ed in the parents by chronic diseases, venere- al excesses, and age, Van Swieten remarks ; " Tales parentes,. debiles, morbosos, langui- dos, infantes gignere, nemo dubitat. Unde in- ter signa sanitatis optimae numeratur, si quia, 708 RICKETS—Causes. natus sit parentibus sanis, vegetis, plenae aeta- tis, rara sed fervida venere utentibus. Lycur- gus qui validis exercitiis firmabat virginum cor- pora, antequam viris jungerentur, voluit, ut re- cens nupti non cohabitarent, sed clam et fur- tiva quasi venere uterentur tantum, adeoque rara et fervida. Talem curam gessit robustae et bellicosae posteritatis. Facile patet, qualis proles expectanda sit a decrepitis, uti et ab il- lis, qui, in ipso aetatis vigore, libidine ac per- ditissimo vivendi genere exhausti, conjugia am- biiint, dum, ante trigesimum annum jam im- belles senes, lectissimas virgines turpiter de- cipiunt." (Vol. v , p. 587.) 26. There can be no doubt that these causes, so strongly insisted upon by Boer"haave and Van Swieten, predispose to this disease in the offspring, by imparting an innate or congenital debility to the infant constitution, although they cannot be viewed as imparting a more especial tendency to it than to scrofula, or to other dis- eases of debility to which this is more or less closely allied. The children of parents who have married at a premature age, or who have indulged in sexual excesses, or who have been guilty of self-pollution, or who have become de- bilitated by other causes of exhaustion, as by living in unhealthy localities, or in the foul air of crowded factories, or by sleeping in close or crowded sleeping-chambers, are predisposed to this, among other maladies, which are allied more or less, to each other, as respects their causes, rather than as regards their forms or seats. Certain of the predisposing causes ex- isting in the parents, to which Boerhaave im- puted a considerable influence, and which prob- ably did, at the time he wrote, and still more so when rickets first became a frequent disease, possess this influence, namely, the taint or con- stitutional debility consequent upon venereal or gonorrhceal affections, may not, in the present day, produce this effect upon the offspring in so remarkable a manner as in those times; still I am convinced that they are not without some effect, although I believe that they are more influential in developing a scrofulous di- athesis than in predisposing to rickets. 27. The effect of lucorrhaa upon the offspring, more particularly as predisposing to rickets, may admit also of doubt; still some of the best medical authorities have insisted upon the in- fluence of this complaint in the parent. Sto- erck contends that females who are subject to leucorrhcea are liable to suffer abortion, or to have rickety children. " Monebat, tales muli- eres, nisi integre curentur antequam nubant, facile abortiri, si conceperint. Dum felici arte cavebatur abortus ita, ut foetus ad maturitatem perveniret, notavit sequentia. Tales autem fce- minapariunt plerumque infantes crassos, pingues, robustos, et hi tales manent per plures menses: postea vero emaciuntur, lassifiunt et membra pen- dula gerunt; tandem subsequilur pessima rachitis, qua raro hue usque sanari potuit." 28. The predispositions referable to the chil- dren themselves have not been sufficiently in- vestigated. Rickets have been observed in all constitutions: in the dark, the fair, the delicate, and the apparently robust; but most frequent- ly in the delicate, in the sickly, in the soft and flabby, and in infants with large heads, whose fontanelles remain open, and whose dentition is delayed. Insufficient nourishment, unhealthy milk, early weaning, or "bringing up by the hand," a watery farinaceous diet after weaning, a too exclusive use of vegetables, and the want of animal diet in cold and damp localities, and the periods of the first and second dentition, favour the occurrence of the complaint, espe- cially in the constitutionally or hereditarily pre- disposed. Indeed, whatever debilitates the frame not only predisposes to rickets, but also sometimes more directly develops it. 29. B. No particular exciting cause can be adduced in some cases to account for the ap- pearance of the disease, besides those which I have enumerated as being occasionally predis- posing influences. But when these act in com- bination, and when other fortuitous circum- stances aid their operation, they produce a more direct and exciting effect. Probably, however, residence in a cold and damp locality has a still more direct influence in developing rickets, even than those causes already mentioned, al- though without their aid this cause may not produce this effect. Indeed, the disease is even endemic in those places which are cold and damp, and where the poor are insufficiently fed and clothed. I believe that'the abuse of spir- ituous liquors by either parent is not only a pre- disposing, but also an exciting cause of the complaint, and that it is more especially such when the vice is indulged in by the mother dur- ing the period of lactation. The murderous practice of giving narcotics to infants, so noto- riously prevalent among many of the physically and morally degraded of the manufacturing pop- ulation, may produce a similar effect where it fails of causing a more rapid extinction of life. 30. C. The proximate cause of the change in the bones, of which rickets is the result, is still unascertained. No satisfactory explanation of the changes which take place in this part of the frame has hitherto been adduced. It has been suggested that a superabundance of acid in the blood may cause the removal of the phosphates from the bones ; but there has been no analysis of the blood in this disease, and the existence of an acid, and still less the kind of acid, in the blood have not been shown.* id in its accession than that which follows in the last stage as a process of desquamation; and hence the consequences are generally not so severe nor so fatal in this last stage, espe- cially when due precautions are used during the period of desquamation. 30. B. Inflammation of a more or less asthenic or diffusive kind may extend in more than one direction from the throat, especially in the more malignant states of scarlet fever ; and this com- plication may be more frequent in certain sea- sons and epidemics than in others.—(a) The most dangerous and rapidly fatal of these ex- tensions of the local affectionare laryngitis and tracheitis. When the angina attending scarla- tina is not of a malignant kind, and when the pulse and affection of the throat do not indicate much vital depression or malignancy, the epi- glottis and larynx very rarely betray any disor- der. But in malignant cases, and in adults, es- pecially those who have been addicted to the use of spirituous liquors, or whose constitu- tions are broken down, this extension of inflam- mation to the larynx and trachea, and conse- quent asphyxia, are not rare. In most of these cases the larynx is only or mainly affected; but in others, especially in children, the trachea is also implicated. In the more malignant cases, death may occur in little more than twenty- four hours from the commencement of the at- tack, owing to this complication. Of this I have met with two or three instances in adults, one in a man aged between fifty and sixty. In the cases of this kind which I have had an op- portunity of examining after death, there was much firm lymph exuded over the tonsils and pharynx, extending into the larynx, the tissues underneath being swollen, injected, and cedem- atous. 31. (b) Pharyngitis is generally present in a greater or less degree in most of the severe cases of the anginous form of scarlet fever, and more especially, and in a most asthenic form, in the malignant variety. In many of these, especially in certain epidemics or seasons, the morbid action extends to the posterior nares, the nostrils and fauces, on the one hand, and to the upper portion of the oesophagus on the other, and is accompanied with the exudation of grayish lymph, which coagulates on portions of the affected surface, and imparts the appear- ance of sloughs. In some cases, instead of this exudation, an acrid or sanious discharge of an excoriating nature is observed, with sloughing ulcers; but these latter are more frequently found in some epidemics of this malignant mal- ady than in others,. In most of these cases at- tempts at deglutition are.either very painful and difficult, or altogether abortive, matters being thrown out through the nostrils on at- tempting to swallow them. Sloughing ulcera- tion is most frequently-observed in the tonsils, and is more rare in the fauces, pharynx, or its vicinity ; but this and other changes in the throat vary much in different epidemics. They are observed chiefly ip the most malignant ca- ses ; and even in more rare instances of this kind which recover, the morbid action has ex- tended posteriorly to the tissues and parts be- tween the pharynx and bodies of the cervical vertebrae, until these latter, and the interverte- bral substances and ligaments, have become implicated, and dangerous, if not fatal, sequelae have followed the pharyngeal complication. Of this I have met with several instances in the course of practice (y 47). 32. (c) The extension of the anginous affec- tion along the Eustachian tubes to one or both ears, is a frequent and most distressing com- plication of the more severe states of this fe- \ex{ and is not infrequently attended by de- struction of portions of the soft palate, and of the small bones and merabrana tympani of the ears. In some instances, caries of a portion of the temporal bones, and the extension of irrita- tion and inflammation to the membranes, and even to the substance of the brain, have fol- lowed, either immediately or remotely, upon the occurrence of an asthenic otitis in the course of malignant or severe scarlatina. In these cases, a discharge more or less copious, and always offensive, takes place from the ears, and in rare instances even hamorrhage from the ears occurs. I have not observed any instance where the haemorrhage from the ear has been excessive ; but Dr. Graves has adduced a case in which it was so great as to prove fatal; and it has also been noticed by Fothergill. 33. (d) Epistaxis may occur in the course of scarlatina from very different pathological states. It may attend, or appear early in, the stage of eruption, especially in plethoric chil- dren, in those accustomed to epistaxis, or in those of a sanguine temperament and haemor- SCARLET FEVER—P. rhagic diathesis. If it be moderate, or even considerable, it may alleviate the cerebral symp- toms, and be even critical or beneficial. This, however, occurs chiefly in the more inflamma- tory states of the disease ; but when it is ex- cessive, or when it accompanies the malignant form, it may be only one ofthe modes in which a fatal issue takes place. Even in the more in- flammatory or sthenic forms of scarlatinal an- gina, an intercurrent epistaxis may be so ex- cessive as to lower the power of vital resist- ance, and the patient may sink either from ex- haustion, and from the want of correspondence between the capacity of the vascular system and the amount of blood contained in this sys- tem ; or he may suffer another complication, favoured, if,not more directly caused, by the haemorrhage, namely, the extension of inflam- mation, in an asthenic or diffusive form, to the cellular tissue and glands ofthe neck. When epistaxis occurs in the course of malignant scarlatina, and ispreceded.by an offensive dis: charge from the mouth, nostrils, or ears, it may be viewed as a consequence of gangrenous or sloughing ulceration Of the fauces, pharynx, or posterior nares, and, generally, it then hastens or causes dissolution. Epistaxis and bleeding from the throat, in these circumstances, are not rare, and have been noticed as more fre- quent occurrences in some epidemics than in others. These complications have been men- tioned by Huxham, Fothergill, Graves, and others. Fothergill remarks that "the sick sometimes bleed at the nose towards the com- mencement of the disease; and the menses very often appear in those of the female sex who are of an age to have them." (Works, vol. i, p. 375.) And at another place he states that " it has happened in this distemper that haemor- rhages from the nose and mouth have sudden- ly carried off the patient. I have heard ofthe like accident from bleeding at the ear. But these^fatal discharges most commonly happen after the patient has been ill several days ; and it seems more probable that they proceed from the separation of a slough, rather than from a fulness ofthe vessels, or an effort of nature to relieve herself by a salutary crisis." (P. 376.) 34. (e) Diffusive or asthenic inflammation of the cellular tissue ofthe neck is one of the most dangerous complications of scarlatina, and is apt to occur when the throat is most malignant- ly affected. Dr. Johnstone has remarked upon the frequency of this complication in the epi- demic scarlatina of 1778. " The parotids also swell," he states, "grow hard and painful to the touch, and, when the disease is violent, a large oedematous tumour surrounds the neck, extends to the breast, and greatly increases the danger. The breathing then becomes more dif- ficult, with a kind of rattling noise as if the pa- tient was suffocating." This extension ofthe disease to the glands and cellular tissue Ofthe neck is frequent during the prevalence of ma- lignant scarlatina. I have often observed it, and it has been duly remarked upon by Dr. Ken- nedy, Graves, Osbrey, Charlton, and others. This diffusive state of inflammation may be greatest on one side, or it may surround the whole neck and throat and descend to the pec- toral muscles. It may accelerate or cause death before passing into gangrene or suppura- tion, into either of which it may rapidly lapse ; iominknt Affections in. 735 and it may exist with the eruption or without it, or the parts affected only may present a dark or dusky erysipelatous hue. It is evidently the result of local contamination, spreading from the ulcerated and infected throat; and it may supervene either as a complication or sequela of the distemper ; but', however it may appear, it requires the intentions and means of cure de- scribed in the article on diffusive inflammation ofthe Cellular Tissue. 35. C. Asthenic or 'diffusive gastro-enteric dis- order is a very frequent complication or prom- inent affection in the more malignant cases of this malady. It may occur either with or with- out vomiting, or it may only commence with this symptom ; and it may be attended by an eruption of a more or less deep tint; or it may cause the sudden suppression, or the non-ap- pearance ofthe eruption. - It may be caused by the passage of the excoriating discharge from the throat into the stomach, especially in chil- dren, who seldom spit out the discharge, the gastro-enteric surface being irritated or excori- ated by this morbid matter; or it may arise primarily as a prominent phenomenon of this fever, and by its increase, or general diffusion over the digestive mucous surface, prevent the evolution ofthe efflorescence on the cutaneous surface. Dr. Johnstone remarks, that the ac- rid matter passing from the throats into the stomachs of children is "one reason why they are attacked with those violent gripings, dys- entery, and excoriations of the anus and but- tocks which sometimes attend the distemper, and show that the sanies retains its virulence throughout the alimentary canal." (P. 39.) The same statement had, however, been made by Dr. Fothergill thirty years previously, and nearly in the same words (see his Works, vol. i., p. 374). Huxham, also, remarks that a sudden stoppage ofthe discharge from " the mouth and nostrils actually choked several children ; anJ some swallowed such quantities of it as occa- sioned excoriations of the intestines, violen* gripings, dysentery, &c.—nay, even excoria- tions of the anus and buttocks." (On Fevers, p. 280.) Dr. Graves adduces a case in which these excoriations were observed around the anus, but in it the cutaneous eruption was in- tense. In most of the cases in which I have observed irritability of stomach and diarrhoea', with or without.excoriations ofthe anus, in the course of scarlatina, the eruption was either suppressed, or partial and scanty, or prevented from appearing ; the throat, however, being more or less affected. In the first two cases of this complication which came under my care, and which I attended with Dr. Clutterbuck in 1821, the eruption disappeared, diarrhoea oc- curred, and profound coma, with unconscious evacuations, supervened and farther complica- ted the disease. Nevertheless, both cases re- covered. When diarrhoea complicates this dis- temper, especially in children, coma, or convul- sions, or insensibility from vital exhaustion, not infrequently supervenes. When the diarrhoea is moderate and not attended by vomiting, and when the evacuations are bilious or feculent, then it may be salutary, or at least not injuri- ous ; but when it is consequent upon severe affection ofthe throat, or is attended by oedem- atous swelling of the neck, or is severe, the stools being watery or slimy, muddy, and very 736 SCARLET FEVER—Prominent Affections in. offensive, it is liable to be followed by coma or fatal exhaustion. 36. D. Convulsions, coma, and tremours are fre- quently observed in the course ofthe more se- vere cases of scarlatina, and in the more nerv- ous form of the disease; or in children of a nervous and susceptible temperament, convul- sions, delirium, coma, and tremours may occur in succession. These complications, like many others, may appear either when the eruption is very full and general, or when it suddenly or prematurely fades, or when it becomes partial or recurrent; but generally the skin continues hot and dry.—(a) In very young children, con- vulsions may take place at or during the com- mencement ofthe distemper—and in this case they generally usher in a malignant or severe attack—and they may not appear afterward; but they may occur at any period, or not until near the fatal termination ofthe disease. They are seldom attended by squinting, and the pu- pils of the eyes are rarely dilated ; generally they are contracted.—(b) Coma may supervene very early; but in children above five or six years of age it is generally preceded by deliri- um, and, in children under this age especially, it is often attended by partial convulsions. When coma takes place early in the disease, it can not be imputed to serous effusion between the membranes or in the ventricles ofthe brain, but rather to congestion or to a loss of cerebral power; and even when it supervenes at a more advanced period, it is to be attributed rather to these states than to effusion, although vital ex- haustion and the morbid state of the blood may also be concerned in causing it. In most in- stances, and in whatever stage of the disease in which it occurs, the pupils are generally con- tracted. Although a dangerous, it is not a fatal complication, for I have seen several patients recover from it.* When, however, it is attend- ed by disappearance of the eruption, by a glassy state ofthe eyes, pallor and sinking ofthe feat- ures, tremours or startings of the tendons, and other signs of sinking ofthe powers of life, a fatal issue soon follows. Coma, convulsions, and other nervous symptoms, may occur also as sequela of scarlet fever, but generally in con- nexion with renal obstruction and anasarca (v 41, et seq.). 37. E. Congestion of the lungs, bronchitis, con- gestion, or asthenic pneumonia, and even combi- nations of these, with or without pleuritis, axe frequently prominent affections in the course ofthe more severe forms of scarlet fever. In most instances both lungs are affected, and bronchitis and lobular pneumonia are not in- frequently associated, or are rapidly consecu- tive of each other. In the most severe cases, the general diffusion of disease through both lungs, added to other existing morbid condi- tions, has terminated life in from thirty to forty hours, or even in a shorter time, after the first appearance of the pulmonary complication. In * Hildenbrand observes: " Insignem vero, et quasi innatam, febris scarlatinas miasma ad membranas seroeas, et in primis ad membranam arachnoideam encephali ha- bet proclivitatem, ita quidem, ut non solum exanthemate derepente represso vicaria? in cerebro libentissime sub- nascantur rgactiones, verum etiam lsetissimc florente man- ifesta evolvantur congestionis cephalicai, aut verte enceph- alitidis, indicia. Quod autem arachnoidea, et non alia pa- tiatur meninx, effusiones serosa* in peremptorum cadave- ribus conspicusa evincunt."—(Institut. Pract. Med., t. iv., p. 383.) these cases the substance ofthe lungs soon be- comes solidified, especially in parts, and infil- trated with a bloody serum ; the state of con- gestion insensibly passing into asthenic solidifi- cation or splenization, especially in the posterior or depending parts. The complications now mentioned may also occur in the milder or less malignant states of the disease, but generally either in an advanced stage or as sequelae ; and in these circumstances they approach nearer to the usual character which these affections pre- sent, although more or less modified, and re- quiring, owing to the state and nature of the constitutional disturbance and contamination, a peculiar mode of treatment. 38. F. Pleuritis and pericarditis may take place either separately or in combination, or in con- nexion also with affection of the lungs. The occurrence or association of these varies much in different epidemics and seasons, whether appearing as complications or as sequelae of scarlatina. As complications, they are met with chiefly in severe or irregular cases, in which the eruption either is suppressed or does not appear; and, as sequela, they most frequently follow mild cases, and in connexion with ana- sarca and disorder of the urinacy excretion; and, in these circumstances, they are soon fol- lowed by effusion, especially into the pleural cavities. These prominent lesions may exist and escape detection, either until they are far advanced, or until disclosed by a post mortem examination. This is particularly the case with respect to pericarditis, and even as regards pleuritis. A very careful and frequent exam- ination is required to determine its presence in young children during the severer states ofthe malady. 39. G. Peritonitis may appear as a complica- tion of scarlatina, either consecutively of diar- rhoea and vomiting, or independently of these. I have, however, rarely met with it during the stages of the eruption ; but more frequently as a sequela ofthe malady, and in connexion with obstruction of the kidneys and anasarca. It may generally be recognised, at whatever pe- riod it occurs, by the tenderness, fulness, and tension ofthe abdomen ; by vomitipg, and the heat and dryness of the surface ofthe trunk; and most frequently by the disappearance of the eruption. It usually soon terminates in ef- fusion and in death, if not early detected and treated by means which will arrest the morbid action without depressing the vital energies, an intention which on a few occasions may be ac- complished. 40. H. Affections of the joints, erysipelas, gan- grene, &c., may occur during an advanced stage ofthe more malignant states ofthe distemper, or even as sequelae, during the period of des- quamation, and, with the rest of the compli- cations already noticed, are to be attributed chiefly to the following pre-existing changes: 1st. To the change produced by the infectious miasm upon the organic nervous influence and vascular system. 2d. To the alteration ofthe blood arising from this primary change, and from the action of the miasm on the constitu- tion ofthe blood itself. 3d. To the active con- gestion, obstruction, and consecutive changes taking place in the kidneys at an early stage, as well as during the periods of desquamation and convalescence, whereby the blood is farther SCARLET FEVER—Sequelae of. 737 changed by the accumulation of excrementitial elements or materials in it, owing not only to the obstruction ofthe kidneys, but also to sup- pression of the functions of the skin—two of the chief emunctories, by means of which effete and hurtful materials are carried out ofthe cir- culation—these two chief organs of depuration being more or less obstructed or interrupted in their functions during this disease. Owing to these consecutive series of changes, serous ef- fusions take place not only in the larger shut cavities, with more or less irritation or asthenic inflammation of serous membranes, but also into the cavities of the joints, irritating the synovial membranes and eroding the cartilages. Owing to these changes, also, the internal surface of the blood-vessels, in predisposed parts, become inflamed or obstructed, and eliminating surfaces irritated or diffusively inflamed ; the affected parts, owing to the depressed state of organic nervous power, and to the morbid condition of the blood circulating in it, soon losing their vi- tal cohesion, and passing into sphacelation— changes readily accelerated and increased by pressure and the contact of morbid secretions or excretions. 41. III. The Sequels of Scarlatina.—Hav- ing given the complications or prominent local affections of scarlet fever that amount of con- sideration which their importance demands, and which has not been accorded to them by previous writers, and having pointed out the sources or causes of their origin, of their sever- ity, and of their fatality; iand having stated that an attentive examination of the early as well as of advanced phenomena of scarlatina, and the lesions observed after death, show these sources or causes to be chiefly, or in great meas- ure, the changes which take place in the kidneys at a much more early period of the distemper than has hitherto been believed, I now proceed to con- sider the more important sequela ofthe malady, and with due reference to their sources. If the inferences at which I have arrived from an at- tentive observation ofthe phenomena of scarlet fever be received, the sequelae as well as the complications of the disease may be assigned to nearly the same sources. The primary ob- struction ofthe kidneys is chiefly concerned, as shown above (y 28, 29), in rapidly developing or increasing the complications, aided, however, by obstruction ofthe functions ofthe skin ; and the secondary or consecutive obstruction of the same organs is equally concerned in producing the sequela, as already stated (§ 29), and with the same aid. The very same organs, surfaces, or parts, which are the seats of the complica- tions or prominent affections, may also be seats of those lesions which constitute the sequelae. Indeed,the local changes described above as complications may appear so late in the disease as to be considered with propriety as sequelae, while those usually denominated and viewed as sequelae may supervene so early as to deserve the former appellation. 42. It has been stated above that the compli- cations are most apt to occur in the more se- vere states of the distemper, whether inflam- matory or malignant; and that the early affec- tion of the kidneys—as early, probably, as the occurrence of horripilations, faintness, vomit- ing, pains in the back and limbs, &c, ushering in the attack, or soon after this period—by ob- III. 47 structing the functions of these organs, and thereby augmenting the contamination of the blood, increases, in the first place, the intensity and malignancy of the febrile action—of the constitutional disturbance ; and, with such in- crease, next develops local lesions of a severe or fatal character. The state ofthe skin prob- ably aids, also, in producing these effects. If this be admitted in respect of the more severe cases, it follows that the milder cases of the malady are attended by a much more slight af- fection of the kidneys, and that the urinary se- cretion does not manifest so much disorder or obstruction in these latter cases as in the for- mer. Now this is exactly what is usually ob- served. But it has been very generally stated that these milder cases are most likely to be followed by renal disease and dropsy. This is partly true, and is observed to obtain in some seasons more than in others, and more espe- cially in certain epidemic prevalences ofthe dis- temper. It may be inferred, from what I have stated, that the sequelae should be the most se- vere after the most malignant cases ; but the obstruction of the urine in many of these is such as fatally to increase the malignancy; and those who recover very frequently experience a general and profuse perspiration, or copious discharges from the alimentary canal or other parts, which are somewhat vicarious ofthe ob- struction of the kidneys, or which derive from these organs and diminish the consecutive af- fection. Besides, the amount of the consecu- tive obstruction may not be always great in proportion to that ofthe primary affection ; for this may be rapid in its accession, and great in its amount, in respect both of the secreting structure and of the uriniferous tubes, and yet the obstruction caused by the desquamation of the epithelium, or the accumulation or infarc- tion ofthe desquamated epithelium in the tubes, may not be so great as to cause any serious change either in the blood, or, through it, in other parts. When the functions of the skin are restored, and determinations of blood to- wards the kidneys, and congestion of these or- gans, by exposures to cold and other causes, are prevented, the desquamation ofthe urinif- erous tubes may take place gradually and with- out obstructing the urinary excretion, while such obstruction would very probably occur if the kidneys were the seats of vascular determ- ination or congestion, caused by constriction of the cutaneous surface, and by the arrest of the cutaneous excretion. 43. The frequency of sequelae arising out of the obstruction of the kidneys, and the severity of these sequelae, often are greatest after very mild cases, and in the latent stales ofthe dis- ease (y 26). So very remarkably is this the case, as respects the latent form, and so dan- gerous are the associated affections sometimes attending this form, that I have had reasons to doubt whether the obstruction of the kidneys was, in this form, actually consecutive of an antecedent febrile attack, unattended by erup- tion or sore throat, or whether it was the pri- mary change produced by the infectious miasm* which, instead of developing either a cutaneous eruption or a sore throat, had affected the kid- neys in so severe a manner as to prevent the more external evolution of the disease, and to obstruct the urinary excretion, thereby increas- 738 SCARLET FEVER—Sequel.e of. ing the contamination of the blood and the amount of its watery constituents, and occa- sioning other dangerous consequences, more especially the several forms of dropsy, with or without irritation or inflammation of vital or- gans or of serous membranes. However the renal obstruction may arise—whether second- arily, as usually admitted, or both primarily and secondarily, as now first contended for, or some- times primarily only, as just suggested—the consequences of its existence upon the state of the blood must be most serious. The blood necessarily becomes altered, both as respects an increase of its watery constituents and of its saline and solid ingredients, and as regards the formation of injurious materials from the elements furnished by the processes of ultimate assimilation, of absorption^ and of imbibition or endosmose, even independently of, and in ad- dition to, the more special changes produced by the poisonous miasm, or infectious ferment, in the progress ofthe development of its effects and of the multiplication and dissemination of its kind. The more manifest consequences as regards the blood are an increase ofthe serous portion, and a diminution ofthe vital crasis, of the fluid and ofthe cohesion ofthe crassamen- tum. The globules or molecules which con- crete into fibrine, either partially or altogether cease to cohere in such a manner as to form this substance, causing an apparent deficiency of fibrine, although these globules or materials which form it are actually not deficient, or are even in excess. The depression of organic nervous or vital influence, and the primary and secondary changes of the blood, diminish or otherwise affect the fibrine by depriving the globules, or the material principle constituting this substance, either partially or completely, of the power of cohering so firmly as to pro- duce it, with its characteristic properties, more especially in the advanced stages of the dis- temper. 44. The consequences of an excess ofthe wa- tery portions of the blood, and of the other ex- crementitial matters, and of the existence of other injurious products, which may be reason- ably inferred to be present, although not ad- mitting of demonstration, may be briefly stated as follows : 1st. The development of irritative fever, the pulse becoming very rapid, vital pow- er depressed, and the skin burning, &c. 2d. Over-distention, oppression, or congestion of the vascular system, more particularly of the veins and capillary vessels in predisposed and weakened organs. 3d. With the continuance or progress of these states, asthenic irritation or inflammation, with more or less effusion, se- rous or sanguineous, into serous cavities, or into cellular or parenchymatous structures, ac- cording as pre-existing conditions, or previous lesions or predispositions may favour their oc- currence. Thus we observe, not only as com- plications ofthe several stages of scarlet fever, but also as sequela during desquamation and convalescence, various modifications and asso- ciations of the pathological conditions just stat- ed—modifications and associations caused by states of predisposition, by the dose or amount of the infecting animal poison, and by the grade and kind of alteration produced in the circulat- ing fluids, and consecutively in serous, mucous, and cellular parts. 45. Having shown the origin ofthe chief se- quela of scarlet fever to be obstruction of the kidneys,frequently aided by constriction ofthe vessels, and obstruction ofthe functions ofthe skin, but as frequently arising without such aid, it is unnecessary to add more than to briefly notice the chief affections which supervene, ei- ther from this cause, or from the disease ofthe throat, during desquamation and convalescence. Certain of these require merely an enumeration at this place, although they are most important ass respects the amount of lesion which attends them ; but these lesions, when thus produced, are more fully considered under those heads to which they more legitimately belong, namely, as consecutive alterations or diseases of the structures or organs in which they are seated. Although obstruction of the functions of the kidneys and skin, with more or less of struct- ural change of the former, is productive of a large proportion of the sequelae of this malady, still the lesions, which were situated in the throat and its vicinity during the early stages, either by their continuance, their extension, or their severity, or by their recrudescence, ow- ing to obstruction of the depurating functions, or to exposure to cold, or humidity, or currents of air, sometimes deserve to be ranked among the most serious sequelae of scarlatina. 46. A. The most important of the sequelae which are produced chiefly by the affection of the throat are, the extension of disease to the ear, with the consequences of this extension, espe- cially destruction ofthe small bones ofthe or- gan ; inflammation, ulceration, and pefforation ofthe tympanum; chronic otitis, with offensive discharge; inflammation and ulceration ofthe membrane lining the cochlea and semicircular canals ; caries of the petrous portion, or mas- toid process, or other parts of the temporal bone ; and even the extension of inflammation, suppuration, or ulceration, to the membranes and substance ofthe brain, may supervene, and, as respects these latter changes especially, not infrequently at remote periods from the prima- ry affection ofthe throat and the extension of lesion to the internal ear. When disease of the ear is so far advanced as to implicate the bone in which the organ is lodged, the conse- quences are serious, not only as respects the organ itself, but also as regards adjoining vital parts, the affection of which often occasions great and protracted suffering, and ultimately fatal results. (See arts. Brain and its Mem- branes, v 58, et seq., and Ear, y 20, et seq.) 47, B. The extension of inflammation, and even of ulceration, from the posterior pharynx to the cellular, muscular, and ligamentous tissues interposed between this part and the base of the cranium and upper cervical vertebra, has been no- ticed above in connexion with the advanced course of the malady (y 31). But this lesion is met with not only as a complication, but also as a sequela of scarlet fever. In either form, in the latter more especially, it is often attended by spasm, contraction, or painful distortion of the head or neck; and in this state, the lesion has often been viewed as merely consisting of irritation, or of simple " crick in the neck," or of rheumatism from cold, and been overlooked until it has advanced to disease ofthe interver- tebral substance, to destruction ofthe ligamen- tous or cartilaginous structure, and even to ca- SCARLET FEVER—! ■Sequel.® of—Dropsy. 739 ries ofthe nones at the base ofthe skull, or of one or more of the cervical vertebrae, with thickening of the ligaments and ofthe theca of the canal, and complete or incomplete, partial or general paralysis. Of this sequela I have seen several instances, and two of complete re- covery, with much shortening and stiffness of the neck from destruction of one or two of the cervical vertebrae, and ossific adhesion of those adjoining. 48. C. The parotid glands, the lymphatic glands, and the adjoining cellular tissue, are not infre- quently enlarged, congested, or inflamed after an attack of scarlatina, especially ,in scrofulous subjects, and in delicate persons residing in low, damp, or unwholesome situations. These are often merely the persistent or exacerbated states of the same affections which commenced at an early period of the fever; but they some- times do not appear until much later, and al- though the connecting cellular tissue may be somewhat swollen, it is much more rarely the seat of diffusive inflammation than in the early stages of the malignant form of the disease. Whether existing merely as the remains of an early complication, or as a more or less remote sequela, these affections are often troublesome, especially when they advance to chronic sup- puration or abscess, as most frequently is the case in these circumstances; enlargement of the parotids often accompanying the other se- quelae of the disease. 49. D Affection ofthe Kidneys after Scarlatina, audits Consequences.—(a) When the pulse con- tinues very quick or sharp after scarlatina, for a longer time and in a more marked degree than may be attributed to debility merely, or to some degree of anaemia, the continuance of irritation in an internal organ or part, or the existence of obstruction of a depurating or excreting or- gan, may be inferred; and the same inference may be drawn, although the febrile symptoms had subsided, from the recurrence or superven- tion of this state of the pulse, during or after desquamation, especially if there be also pres- ent languor and peevishness, heat and dryness of the skin, nausea or vomiting, pain or aching in the loins and limbs, drowsiness or stupor. When these symptoms appear, or if, with these, the tongue is loaded or furred, th_g bowels cos- tive or irregular, and thirst increased, with or without horripilations, then should the urine and the region of the kidneys be carefully ex- amined, and the approach of oedema or anasarca be expected, if, indeed, either be not already present. In many cases the symptoms which precede the anasarca are so slight as to escape observation, until cedema or fulness ofthe face, or indications of commencing anasarca evince the nature of the affection. In other instances the febrile commotion, with the symptoms now mentioned, are more or less manifest for a short time before, and contemporaneously with, the first appearance of anasarca. In every case the urine is at first scanty, often high-coloured, or turbid and albuminous; it is more rarely bloody, or of a pale red colour; sometimes it resembles water in which flesh has been wash- ed, and there is always a frequent desire to pass it. In the less severe cases the urine is more copious, but is still turbid, and sometimes it contains numerous small fibres, consisting chiefly of epithelium, floating in it. After'the face, the feet, ankles, wrists, and hands first become oedematous ; and in some instances the dropsy may not advance much farther; but more frequently the trunk and body generally become anasarcous; and in the more severe cases, or when the urine is very scanty, bloody, and albuminous, or altogether suppressed, ei- ther contemporaneously with the incipient ana- sarca or during its progress, symptoms of effu- sion on the brain, or in the cavities ofthe chest, or in the abdomen, or even in all, make their appearance, and sometimes rapidly terminate life. These rapid and complicated cases of ef- fusion are, in some epidemics, more frequent than in others, and are more especially so in the latent form of the disease (y 26), or when there has been no antecedent eruption or sore throat, or when the disease is apparently at- tacking the kidneys and serous surfaces pri- marily, the evolution of its more external feat- ures being thereby prevented. The vascular excrementitial plethora produced by the ob- struction ofthe kidneys occasions effusion into cellular parts, effusion from serous membranes, and asthenic or diffusive inflammation or oede- ma of parenchymatous organs, which, with the morbid state of the blood produced by the urin- ary obstruction, become the more immediate causes of death, but chiefly in the severer forms and more complicated states of the disease. 50. (b) Anasarca and its morbid associations may occur at any period after the eruption, as well as more rarely, but occasionally, in some epidemics, even during the eruption ; but com- monly from the fourteenth to the twenty-eighth day from the commencement of the disease, the 21st, 22d, 23d, and 24th days being those in which it most frequently appears. The pro- portion of instances in which these sequelae or reliquiae of scarlatina are observed differs much in different seasons and prevalences ofthe dis- temper. The dryness or humidity and temper- ature ofthe air, the weather, the prevailing ep- idemic constitution, and the treatment, must necessarily cause considerable differences in the ratio of these sequelae at different times. Dr. Williams states that at Heriot's Hospital, in 1832 and 1833, nine cases of dropsy occurred in forty-five; and that in the London Found- ling Hospital only three were affected with dropsy out of 100 cases of scarlatina. Mr. Hamilton says, that a larger proportion of the numerous cases of scarlet fever which he at- tended in Edinburgh in 1832 and 1833, became dropsical. According to my observations, drop- sy from obstructed kidneys, in all its forms and associations, has been a common consequence of scarlet fever for several years up to 1848. during which year it was most frequent and most complicated. But it appears to have been more or less frequent in all epidemics of this fever which have been fully described ; the two occasions of its rare occurrence just mentioned being the most remarkable with which I am acquainted. 51. (c) The origin of this dropsy was former- ly ascribed to the state of the skin, and espe- cially to obstruction of transpiration from this surface, in connexion with loss of tone of the capillaries supplying the parts in which the ef- fusion occurred. More recent researches have shown that, however these states may aid in the production of these sequelae, the affection 740 SCARLET FEVER—Sequels of—Dropsy. of the kidneys should be viewed as the chief source of the effusion, and even also of the as- thenic or diffusive inflammation and irritation of one or more vital organs sometimes associ- ated with effusion into the shut cavities, wheth- er occurring as complications during the erup- tion or as sequelae (y 28, 41). 52. (d) In the most favourable cases, oedema, or slight anasarca, may only occur and be ush- ered in, as already stated ($ 49), with accelera- tion of the pulse, scanty urine, and other fe- brile symptoms. But the anasarca may be ex- cessive ; or, even without being excessive, ef- fusion of serum may also take place in the brain, in both cavities of the chest, in the pericardium, or in the peritoneal cavity. It more rarely is con- fined to one cavity than extended to nearly all, although in different degrees. As far as I have observed, when it takes place into the pleural cavities, a slight effusion is not infrequent into the pericardium also ; and the lungs and pleura axe then sometimes inflamed, but more fre- quently congested; inflammation rarely advanc- ing farther than the state of splenization, hut usually evincing the appearances of congestive or diffusive inflammation. 53. (e) Effusion into the ventricles, or be- tween the membranes of the brain, may take place without effusion into any other cavity, and even without anasarca ; but it may also be associated with one or more of such affections. When it occurs as a sequela of scarlatina it is generally not so rapid or acute as when it ap- pears as a complication, nor is it so frequently attended by convulsions ; although the stupor' or coma may be as profound, and the organs of sense as much affected. 54. (/) Effusion into the cavities of the chest is generally preceded by anasarca, by conges- tion or inflammation of the lungs or pleura, or of both ; and is sometimes attended by oedema ofthe lungs, and by.effusion into the pericar- dium. The affections of the lungs and pleura, with effusion, are the most frequent internal complications of the anasarca, or remote con- sequences of the renal obstruction, effusion into the peritoneum being very much less com- mon. The associated affections of the lungs and pleura are generally far advanced hefore they are fully manifested—are more or less la- tent in their early stages, and are seldom con- fined to one side, although one lung or pleura may be more diseased than the other. Drop- sical effusion into the peritoneal cavity is gener- ally preceded by oedema or anasarca, being in some instances an association ofthe latter; or by diarrhoea. It is occasionally attended by signs of inflammatory irritation of the mem- brane, but these signs may have been wanting or obscure, although indications of general per- itonitis with effusion are found upon dissec- tion ; the early supervention of effusion prob- ably removing the more severe local symptoms, as well as partially resolving the attendant in- flammatory state. 55. (g) Renal disease and dropsy, as sequelae of scarlet fever, may occur in patients of any age, but much more frequently in children from two or three years of age up to thirteen or four- teen. They are most common in the ill-cloth- ed and ill-fed, and in those who live in low cel- lars or on ground floors, and in cold, damp sit- uations, or who are exposed to cold or vicissi- tudes of weather soon after or during desqua- mation. They are much more rare in the chil- dren of parents in comfortable circumstances than among the poor ; from a fourth to a third or even more of the cases of the latter being probably thus attacked, especially in some epi- demics, and late in autumn and beginning of winter. There is probably hardly a case of dropsy after scarlatina, or of inflammation of an organ or serous surface, particularly when associated with dropsy in connexion with this disease, that has not its origin in renal obstruc- tion, although the interrupted functions ofthe skin, and the antecedent states of the blood, caused by the infectious miasm, may be admit- ted as concurrent causes. The kidneys are, however, so generally implicated, as I have contended above (y 24, 28, et seq.), in all the stages of scarlatina, both primary and second- ary, as to allow the inference^that the affection of these organs may exist in a grade sufficient to occasion indications of its presence, if atten- tively inquired after, and especially the symp- toms mentioned above (y 49), with more or less alteration of the quantity, appearances, and constituents of the urine, without producing such obstruction of this excretion, or such change of the constitution of the blood, as to be followed by dropsical effusion, this result supervening chiefly in the more acute and com- plete states of the affection of these organs. The consecutive inflammations, so frequently associated with the dropsy, also chiefly depend upon the renal obstruction, aided, however, as just stated, and as already more fully shown (y 44, 45), by the states of the skin and ante- cedent alterations of the blood. 56. (h) The renal and dropsical affections con- sequent upon scarlatina, especially when se- vere, are often followed, during convalescence from them, by more or less anamia; the alter- ation ofthe constitution ofthe blood—the con- tamination ofthe blood, directly and indirectly, bythe infectious miasm, and consecutively by the obstructed emunctories—not only impair- ing the vital crasis of this fluid, but also hast- ening the changes in, and the destruction of, the red globules or haemato-globulin, while the primary and secondary functions of assimila- tion—the formation of healthy chyle and the conversion of chyle into blood, or of the chyle- globules into blood-globules — are slowly and imperfectly accomplished, owing to the debili- tated state of the several assimilating organs. 57. (i) Inflammation, generally of a diffusive or asthenic kind, and attended with more or less effusion of a turbid serum when the serous surfaces are implicated, not infrequently is a6- sociated with the censecutive dropsy; but il also, although much more rarely, occurs inde- pendently of any antecedent or attendant oede- ma or anasarca. When thus complicated, and even when occurring simply, it is generally ow- ing to the state of the blood, arising, as shown above (y 43, et seq.), from the primary and con- secutive changes of this fluid, and the existing disturbance of the urinary and cutaneous ex- cretions. The organs and surfaces which are most liable to be thus secondarily inflamed, ei- ther in connexion with, or independently of, dropsical effusion, are the membranes of the brain, the lungs or' pleura, or both, the pericar- dium, the peritoneum, the synovial membranes, SCARLET FEVER—State the parotid glands and the integuments; and it is not rare to find not merely one, but two or more of these to be affected in the same case, more especially when the affection is associa- ted with dropsy, and with manifest disorder of the kidneys, and with albuminous or otherwise morbid urine (y 60, et seq.). 58. (k) Enlargement and chronic inflamma- tion of the parotid glands, with effusion of se- rum, lymph, and puriform matter into the sur- rounding cellular tissue, and engorgement or in- flammation of the lymphatic glands, axe among the most frequent sequelae of scarlet fever, and are often associated with oedema or anasarca, or with inflammation of the organs and parts just enumerated, and not infrequently with chronic disease of ope, or of both ears, produc- ing offensive discharge, perforation of the tym- panum, and caries of the bones of the ear. Chronic otitis following scarlatina is generally of long continuance, sometimes occasioning ca- ries of the mastoid cells and process, and even more extensive disease of the temporal bone. In some cases the disease extends to the mem- branes and sinuses of the brain, and even to the brain itself, as shown at another place (see art. Brain, y 58, et seq.); but these results sel- dom sopervene until after several months, or even years. 59. IV. State of the Blood in Scarlet Fe- ver.—Notwithstanding the chemical analyses Which have been made in Germany and France, of the blood taken from the subjects of scarlet fever, it is doubtful if any real or useful prog- ress has actually been made in this department of pathological research during the last century and a half. The analyses, especially as regards this fever, have been few, and the results, in connexion with the visible appearances and physical states ofthe blood, and with the stages and state of the disease, have not been stated with the least degree of precision. As regards the appearances and physical states of the blood, it may be remarked, that these depend upon the type of the fever, or the states of vital power and vascular action, and vary most remarkably with these states, as observed in other fevers and maladies attended by contam- ination of the circulation, and as described in the articles Blood (y 115, et seq.), Fever (y 93, 110, 520), and Puerperal Fevers (y 215, et seq.). It is chiefly in the more inflammatory types of scarlet fever that blood has been taken and its appearance observed. In the more ma- lignant forms bldod has rarely been taken from a vein, and on the few occasions on which this has been done it has presented similar charac- ters to those stated above (y 43, 56), and to those mentioned in connexion with the fevers just referred to, and in the article Blood (y 78, et seq.). Andral and Gavarret analyzed the blood of three persons in scarlet fever, and Le- canu in two cases ; but the results which these analyses furnish are not materially different from those obtained from the analysis of the blood of a healthy person. It is chiefly in the more malignant, or putro-adynamic type, and in the advanced course of the malady, that the blood presents morbid appearances such as are stated in the articles referred to; but in these circumstances it has not been chemically ex- amined. 60. V. The Urine.—The urine in scarlet fe- >f the Blood in—The Urine. 741 ver presents the most important changes as re- spects the pathological states characterizing the several stages of the disease, and as regards the treatment of these states. These changes are various, not only in different cases, but also m the same case at different periods, and even in the course of a few hours, and hence have arisen the opposite or varying statements re- specting this excretion which have hitherto ap- peared. The appearances and constitution of this fluid, moreover, have been very imperfect- ly investigated during the early stages of the malady, and the symptoms connected with the kidneys at these periods very insufficiently in- vestigated, if not entirely overlooked, by most observers and writers on this disease. 61. The urine is always paler in children than in adults, and hence the deep colour of it in the former should attract more particular attention when observed in them, the most frequent sub- jects of scarlatina.-^(a) The urine at the com- mencement, and during the early stages of scar- latina, is always scanty and very high colour- ed, and often of a deep red hue when there is much fever. It generally has an acid reaction in $he mild and inflammatory or sthenic forms of the disease. In the septic ox asthenic types, and especially when the affection of the throat or the eruption presents malignant characters, the urine is either neutral or alkaline and very tur- bid ; sometimes it contains blood-globules ; and is always very scanty, although in these, as well as in the more sthenic forms, it is voided frequently, or is attended by dysuria or scald- ing. In most instances, even very early in the disease, it rapidly becomes ammoniacal; but in the more malignant states it deposites a vis- cid, whitish sediment at an early period, con- sisting of the earthy phosphates and mucus, and it contains urate of ammonia and uric acid. When the urine is of a dark brown colour and turbid, or deposites a loose sediment of this hue, the presence of partially decomposed blood- globules in it may be inferred. Albumen is also sometimes present in the early stages, but in various or slight quantity; and it may be de- tected, or even be considerable, at one period, and not be found some hours afterward, and yet be soon again present. 62. (b) During the advanced stages ofthe mild and more sthenic forms of scarlatina, the urine becomes^ more abundant, of greater specific gravity, from the abundance of saline matters, and presents the characters usually observed during the decline of inflammatory and contin- ued fevers. In asthenic, septic, or malignant cases, the urine becomes, with the progress of the malady, of a dark brown or yellowish col- our, is very scanty, and of a specific gravity varying from 1020 to 1025. It has an alkaline reaction, with adisagreeabie ammoniacal odour, and it occasionally contains blood and mucus, or partially-dissolved haemato-globulin, either diffused or in flocculent deposits, but rarely any or much albumen. It throws down a dirty white sediment, consisting of earthy phosphates, urate of ammonia, urate of soda, and mucus, with other animal matters. In these cases particu- larly, and less rapidly in others, the urine be- comes more decidedly ammoniacal and offens- ive. 63. (c) When the disease is complicated in the early stages or in its advanced progress, the urine 742 SCARLET FEVER—Appearances after Death. is even still more changed from the natural state than above stated. If the attack be ma- lignant or complicated from the commence- ment, and more especially if there be coma, or signs of inflammation of the lungs, pleura, or other internal organ or surface, with or without effusion, or external oedema, or if these com- plications occur in the latent and non-eruptive forms of the disease, the urine will be either bloody or albuminous, and scanty, or it will be found to have been for some time previously either altogether suppressed or remarkably scan- ty, and high-coloured or bloody. Sometimes it appears like to the washings of meat, and is voided either frequently or involuntarily ; and in others hamaturia is decidedly present. In some cases urine has not been passed for many hours, and yet little or none has appeared to be retained in the bladder, indicating an arrest of the secreting function, owing either to suspen- sion of the organic nervous influence of the kidneys, or to extreme congestion, or to both. In these cases, aching in the loins and lower limbs, nausea and vomiting, with general tur- gescence or oedema, headache, &c, may or may not be present, with one or more of the complications described above (y 27, et seq.); but the pain and aching of the loins and limbs are not so great as usually observed in acute suppurative nephritis, although sufficiently in- dicative of suspended function and congestion of the kidneys, especially when viewed in con- nexion with the state ofthe urine and the sym- pathetic phenomena. The connexion of the renal affection, of the morbid and deficient urine, ofthe states ofthe blood and of vascular action, and of the consecutive inflammatory ir- ritation, serous effusion, &c, with each other, and even the usual procession of these diseased states, in the course of scarlet fever, will be more readily understood by a due and practical consideration of this topic, and of what I have already said respecting it (y 28, 41). 64. (d) During desquamation the urine gener- ally contains albumen. Simon remarks, that observations regarding the presence of albumen during this period are so contradictory as to render it a matter of interest to have the mat- ter settled by farther researches. " We have dropsical symptoms with albuminaria, dropsical symptoms without albuminaria, and albumina- ria without dropsical symptoms. Solon found albumen in the urine in twenty-two out of twenty-three cases of scarlatina. On the other hand, Philipp observed in Berlin at least sixty cases in which albumen was not detected." 65. In most cases, the urine is of a straw colour in this stage, contains mucus-corpuscles, and is turbid, owing to this circumstance, and to the quantity of epithelium, either in single scales, or in fragments of a connected series of scales, swimming in it. The sediment contains much epithelium, occasionally formed by lymph into cylindrical, fibrinous casts ofthe tubes, and crystals of lithic acid. These changes arise from the desquamation ofthe uriniferous tubes, and are sometimes antecedent to the desqua- mation ofthe cuticle. This early desquama- tion of these tubes furnishes a proof of the ear- lier and more constant affection of the kidneys than has hitherto been supposed, and is evi- dence of the important part performed by the pathological conditions of these organs at the commencement ofthe malady for which I have contended (y 28, et seq). In favourable cir- cumstances, no albumen is found in the urine, in most cases, during desquamation and conva- lescence, or the quantity is slight. But it is found in small or moderate quantity, in a few instances, without either inflammation, or oede- ma, or dropsy in any form being present. In some of these a slight febricula is observed, and soon passes off without either of these results. When, however, dropsy or inflammation follows scarlatina, the urine becomes albuminous gen- erally with, or previously to, the febrile symp- toms ushering in, during convalescence (y 49), the dropsy or inflammatory affection, and con- tinues to present this state, more or less man- ifestly, during the persistence of these sequelae. It is often most remarkable in those cases of dropsy or inflammation which are consequent upon the latent and non-eruptive forms of the disease ; and is sometimes farther attended by disease ofthe glands ofthe neck. When the urine becomes very albuminous during desqua- mation and convalescence, then acute febrile symptoms, and inflammation of some internal organ or part, or dropsical effusion, or both, ei- ther pathological state preceding the other, soon supervene, and rapidly assume a severe or dan- gerous form. The urine, during this stage, oft- en contains an increased quantity ofthe animal extractive matters usually existing in this ex- cretion. 66. VI. Appearances after Death.—These differ remarkably, according as this issue takes place at an early or an advanced stage, and more especially according to the nature of the local affections complicating or following the disease. In the malignant form, decomposition follows dissolution sometimes with remarkable rapidity.—A. When death occurs at an early period, (a) the surface ofthe body appears either of a livid or of a violet coloured hue, generally in patches, when the eruption was present; but not infrequently all traces ofthe exanthem have disappeared. Upon dividing the integuments, the vascular rete is usually found more than commonly injected, and the subjacent cellular tissue is less turgid than during life.—(b) Gen- erally, also, the redness of the mouth and phar- ynx disappears after death. The tonsils present different states, according to the prevailing type of the disease. They aTe frequently enlarged, softened, pultaceous, or gangrenous; and some- times they are covered by a soft, membranous exudation. The mucous surface of the pharynx and oesophagus is considerably softened, and that of the former is occasionally ulcerated, softening and infiltration ofthe adjoining parts being manifest. The palate sometimes is par- tially destroyed by sphacelating, or septic ul- ceration, especially when the tonsils are gan- grenous, or the pharynx ulcerated and softened. —(c) The digestive mucous surface varies with the character of the fever. In the more as- thenic or malignant cases, it is softened, dis- coloured, and readily detached. Generally, Brunner's glands are more developed than nat- ural, and the agminated glands of Peykr more tumid. The mesenteric glands are only occa- sionally enlarged and more vascular. The spleen is frequently enlarged, softened, and fri- able ; sometimes it is almost pultaceous. The liver and lungs axe often more or less congest- SCARLET FEVER—Appearances after Death. 743 ed, and the blood found in the auricles of the heart and veins is dark, semi-fluid, or grumous ; and, in the malignant cases especially, this state ofthe blood is still more remarkable. The bronchial mucous membrane is injected with dark blood, and the bronchi often contain some mucus.—(d) The kidneys axe always congested, tumid, and often of a dark mottled hue extern- ally ; while an increased vascularity, varying in degree, in the different structures, is found at this period of the disease, upon dividing the organ longitudinally. The urinary bladder is commonly contracted, and contains little or no urine. 67. B. When scarlatina presents any of the primary complications, or prominent affections mentioned above (6 27, et seq.), during the sec- ond stage especially, the appearances are very different from those just stated; for, while those exist more or less manifestly, others are superadded.—(a) If the patient have been the subject of cerebral complications, the mem- branes, and even the substance of the brain, pre- sent increased vascularity, with some serous effusion between the membranes, especially at the base ofthe brain and in the ventricles, par- ticularly in those cases in which the urine has been very scanty or suppressed.—(b) When the patient has been suddenly destroyed by the ex- tension of the pharyngeal disease to the epi- glottis, larynx, and trachea, considerable oedema ofthe glottis, between the chordae vocales, &c, and general tumefaction of these parts, some- times with the effusion of a dirty friable lymph upon the surface, partially detached, or but slightly adherent, and occasionally spreading down a portion of the trachea, are observed. This state of parts was seen by me, at an ear- ly period of my practice, in a man, aged about sixty, who died of scarlatina with sore throat in twenty-four hours from the commencement of the disease, owing to the extension of the local affection to the larynx. In these cases, the lungs are always found remarkably congest- ed with black fluid blood, and the surfaces of the bronchi are dark or livid, and injected, the tubes often containing a bloody mucus.—(c) When the parotids are much enlarged, and the neck tumid, and the surrounding cellular tissue is the seat of asthenic or spreading inflamma- tion, then these glands, and generally the lym- phatic glands, are found enlarged, injected, and softened, and the adjoining cellular tissue is infiltrated with a sanguineous serum, or lymph, or puriform matter, each of three several kinds of morbid effusion predominating in differ- ent parts of the neck in the same case. If the patient have lived a few days, the morbid fluids infiltrating the cellular tissue have some- times contaminated, and ultimately destroyed the vitality of this tissue; until the sphacela- tion which results has left the muscles and ves- sels ofthe neck almost as if dissected, and has even spread to the sternum. In a case to which I was called, the gangrene advanced as far as the pectoral muscles ; but death gener- ally takes place before disorganization proceeds so far as this. The changes observed in the ear and its vicinity have been already noticed (v 32, 46); but these are chiefly of the nature of spreading inflammation along the Eustachian tube to the internal ear, and sometimes also to the mastoid cells, cochlea and semicircular ca- nals, arid are occasionally remotely followed by disease of the bone containing these parts. 68. (d) When pneumonia complicates the dis- ease both lungs are generally affected, although in different degrees, and the appearances vary somewhat with the type of the fever. Most frequently the lungs present in various grades, in different parts, but most remarkably in the posterior aspect, congestion, with effusion of a serous or fluid lymph, or with a more firm lymph in some places, giving rise to varied grades of splenization, death or recovery tak- ing place before the change can proceed far- ther. The pleura is frequently either decidedly inflamed, or contains fluid with Or without man- ifest inflammatory changes, and often in con- nexion with pulmonic congestion or inflamma- tion. In the more sthenic forms ofthe disease, lymph, in some instances, is exuded, with or without, most frequently with, serous effusion, and sometimes with adhesion of the opposite surfaces by bands of fibrinous lymph, or more continuously.—(e) In the asthenic or malignant states, the marks of inflammation are less ob- vious, but the effusion into the pleural cavities is greater; and similar changes are sometimes observed, also, in the pericardium.—(/) Inflam- matory appearances, generally with a turbid, serous effusion, and occasionally with slight or partial adhesions, are sometimes found in the peritoneum.—(g) The synovial membrane ofthe joints, in a few instances, has presented marks of inflammatory action, with more or less effu- sion into its cavity. 69. C. When death occurs during desquama- tion, or subsequently, owing to either of the sequela, or secondary complications, noticed above (y 41, et seq.), the appearances differ but little from those just mentioned, with reference to their respective affections, excepting that they either consist, in great measure, of drop- sical effusion of greater or less extent and amount, or are associated with other lesions of an inflammatory, congestive, diffusive, or of a mixed kind.—(a) The most frequent changes exist in the kidneys, and in the shut cavities and cellular tissue, in the form of effusion, often with inflammatory appearances. The kidneys, in the more rapidly fatal cases, and in those which occur at an early period of desquamation, are frequently injected, or congested, mottled or marbled externally ; and internally, the constit- uent tissues present various appearances, cer- tain of them being very vascular, others pale or anaemic. Hence the substance of the organ often is mottled, and generally not much in- creased in bulk, unless when the congestion and vascularity predominate. On examination by the microscope, the Malpigbian bodies are often seen to be pale, and the surrounding cap- illaries injected, while the tubuli are filled with epithelium cells or scales. In those cases in which dropsy occurs later in the course of re- covery, and which are of longer duration, the kidneys generally present somewhat different appearances, which more nearly approach those observed and described in the articles Dropsy (v 13) and Kidney (y 23, et seq.), when treating of the changes connected with albuminaria. Although the surfaces of the organs are some- times mottled, and more or less congested, their structures, on division, are pale, especially in spots, as if anaemic, or from the deposition of 744 SCARLET FEVER—Diagnosis. lymph or albumen, and approach the characters of granular degeneration. The Malpighian bod- ies and the surrounding capillaries appear pale and bloodless under the microscope, and the tubuli are filled, in various places, with epithe- lium cells, and in others with what appears to be a mixture of albuminous matter or lymph, and oil-globules, or of these with detached epi- thelium.*-— (b) As respects the cellular tissue * After this article was sent to, and while it was passing through the press, Dr. G. Johnson's very excellent article on the kidney, in the Cyclopaedia of Anatomy and Physiol- ogy (art Ren), was brought to my notice, as well as his valuable paper in the Transactions of the Medico-Chirur- gical Society (vol. xxx.), in both which places the morbid anatomy of the kidneys after scarlatina is ably described. Dr. G. Johnson, who was the first to detect oil or fat in the kidneys, in granular disease of these organs, states that he has not found oil in the urinary tubes after scar- latina. I observed some oil-globules in two cases of a more than usually chronic duration, as stated above ; but Dr. Johnson, who has examined more of these cases than I have, without meeting with thhi change, justly consid- ers the scarlatina affection of the kidneys as very distinct from the granular disease of the kidneys described by Dr. Bright ; and while he denominates the former " acute des- quamative nephritis," he terms the latter "fatty degenera- tion of the kidneys." I believe that the more acute or rap- idly fatal cases of dropsy or inflammation after scarlet fe- ver rarely present any oil-globules in the urinary tubes; but that, when the scarlatinal nephritis becomes chronic, and is followed by change of structure, then oil-globules are found in the tabes. In one of the cases in which I observed them after scarlatina, the man who was its sub- ject was between thirty and forty years of age, and was Erobably irregular in his habits, the consequent anasarca aving been of considerable duration. " Acute desquamative nephritis" of Dr. G. Johnson oc- curs frequently as a consequence of scarlatina, and is oc- casionally produced by other animal poisons, as that of typhus fever, small-pox, or measles. I have noticed, in the article Kidneys (& 56, et seq.), the connexion of this form of nephritis, which I have named " consecutive or seconda- ry asthenic nephritis," with febrile and other diseases, and the various circumstances of this connexion. In relation to scarlatina, I have contended above that it occurs either primarily or secondarily; and that often there is thus a "primary scarlatinal nephritis" and a " secondary scarlati- nal nephritis" (see, also, art. Kidneys, § 56), or inflamma- tion of these organs either associated with the scarlet fe- ver or occurring as a consequence of this fever. Dr. G. Johnson describes the nephritis consequent upon scarlati- na as follows: " The kidney in these cases is enlarged, apparently by the deposite of a white material in the cor- tical substance; the vessels in the cortical portion where they are not compressed by this new material are injected, and of a bright red hue ; the medullary cones are of a dark-red colour, in consequence of the large veins which occupy these portions of the gland being distended with blood. The appearance of the entire organ is quite that of a part in a state of acute inflammation. " When the kidney has been in a softened condition be- fore the occurrence of the inflammatory disease, as often happens in elderly persons, the lobules on the surface ap- pear larger and coarser than natural; the veins, being less compressed than when the natural texture of the kidney is firmer and more unyielding, are much distended with blood, so that the entire organ is of a dark slate colour. " On a miproscopical examination, the convoluted tubes are seen tilled, in different degrees, with nucleated cells, differing in no essential character from those whioh line the tubes of the healthy gland. The Malpighian bodies j are for the most part transparent and healthy, but the vessels of the tuft are sometimes rendered opaque by an accumulation of small cells on their surface. Some of the tubes contain blood, which has doubtless escaped from the gorged Malpighian vessels. There is no deposite exterior to the tubes. " The condition of the urine in these cases is clearly in- dicative of the process going on in the kidney. After it has been allowed to stand tor a short time, a sediment forms; and on placing a portion of this under the micro- scope, there may be seen blood-corpuscles, with epithelial cells in great numbers, partly free and partly entangled in cylindrical fibrinous casts of the urinary tubes, and very commonly numerous crystals of lithic acid are present "As the disease subsides, which, under proper treat- ment, it usually does in a few days, the blood, fibrinous casts, and epithelial cells dimmish in quantity, and finally disappear; but traces of the casts may be seen some days and the serous cavities, it need only be added that the former is generally more or less load- ed with serum ; the latter sometimes contain effused fluid, with or without slight or marked inflammatory appearances, although these lat- ter are not so frequent or so marked as in the primary complications noticed above (y 27, et seq.). The effusion, as well as inflammatory changes, may exist only in one ofthe cavities, or may extend to two or more. Both pleural cavities ate generally implicated, but some- times in different degrees ; and the parotid and lymphatic glands axe often enlarged, and the joints occasionally inflamed.—(c) I have like- wise seen the vertebra of the neck, their liga- ments and intervertebral substance seriously affected, caries of the former with chronic in- flammation, thickening, &c; of the theca su- pervening, and occasioning cervical paraplegia or general palsy (y 47). 70. VII. Diagnosis.—Scarlatina can be con- founded only with measles (Morbilli), or with the mixed or hybrid disease which I have de- scribed by the name of Rubeola. — A. Dr. R. Williams has stated that the earlier appear- ance of scarlatina after exposure to infection, and ofthe eruption after the primary fever, may serve to distinguish this disease from measles. But, although these circumstances frequently obtain, and may be viewed as the law, still the exceptions furnished by different epidemics and by individual cases are so numerous, that but slight importance should be attached to them. This will be still more apparent upon referring to what I have adduced respecting the periods of latency in these maladies in the article on Infection (y 31, 32). The appearances ofthe efflorescence in both maladies, and the signs furnished by the inlets to the digestive and res- piratory passages, and the states of the urina- ry functions, are chiefly deserving attention in establishing a diagnosis between scarlet fever and measles. In the former, the tongue pre- sents redness ofthe point and edges and straw- berry surface, and the fauces more or less red- ness at an early period, while the tonsils are enlarged, or soon afterward are ulcerated. There is seldom, or very rarely, sneezing or coryza, both which usher in measles; and in the latter the affection of the throat is either altogether absent or very slight, while cough is often severe. The period at which the eruption appears differs much with the constitution of the patient, the season, and character or type ofthe prevailing epidemic, as regards both mal- adies ; and although deserving of mention as respects the description, cannot be depended on in the diagnosis. In scarlatina the patches are large, and the surface covered by them gen- erally ample ; but in measles the eruption con- sists of small circular dots like flea-bites, and when most confluent the patches or clusters are small. The colour of the rash is that of a vivid red in scarlatina, while it approaches a raspberry hue in measles. The former can hardly be mistaken for roseola, which is preced- ed by very little fever, and rarely by any affec- tion of the throat, and the rose-coloured and irregular spots of which differ much from the large patches of scarlatina. In most cases, the after the urine has ceased to coagulate, on the application of heat or nitric acid."—(Cyclop, of Anal, and Physiol., art. Ren.) SCARLET FEVER—Prognosis. 745 eruption of scarlet fever is more general than that of other exanthematous diseases, while the fever is more persistent, and does not abate with the development of the eruption, and but slightly, or not at all, with the disappearance of it, but often continues many days, or even some weeks afterward, or is sometimes con- siderably exacerbated after having abated. In measles the fever usually subsides with the dis- appearance of the rash. 71. B. The kidneys axe not nearly so liable to be affected in measles as in scarlet fever, in which they are remarkably disordered, both primarily and secondarily, and the urine is ei- ther partially or altogether suppressed, or other- wise morbid. The infectious miasm of scarla- tina has a special influence on the states ofthe kidneys, as shown above (y 28, et seq.), and thereby often induces several secondary affec- tions not observed to follow, or very rarely, the other exanthematous fevers, more especially dropsies, diffusive or Congestive inflammations with serous effusion, &c, affections of the joints, gangrenous erysipelas, &c. 72. C. The diagnosis of the primary fever of scarlatina is often difficult or impossible, if the anginous affection be absent, and if no eruption have appeared. The circumstance of the dis- ease being in the same family, house, or imme- diate vicinity; the states ofthe tongue, throat, flexures of the joints, and urinary excretion, and the character or type of the fever, will sometimes aid the diagnosis, although the se- verity of the disease, the affection of the head, the convulsions or delirium, the vomitings and thirst may lead to the belief that the first stage of meningitis is actually present. In most cases, however, of this period of scarlatina, the severity of the vomiting ; the pains in the back and loins ; the remarkable scantiness and mor- bid appearances ofthe urine ; the burning heat and dryness ofthe skin ; the enlargement ofthe parotids, or the existence of some complica- tion ; the great rapidity of the pulse, and the acuteness of the attack, should induce suspi- cions of scarlatina, especially in the circum- stances just mentioned, although neither erup- tion nor throat-affection is present (see above, y 4, and art. Measles, y 48). 73. VIII. Prognosis, &c.—It has been at- tempted by some writers to impart an ad cap- tandum precision to the prognosis of scarlet fe- ver that the subject does not admit of, by cal- culating the proportion of deaths in this dis- ease ; but it is obvious that the rate of mor- tality will vary with the several forms, types, complications, &c.; with the combinations of predisposing causes, and with the treatment.— A. In the simple, mild, and more sthenic types ofthe malady, the prognosis is favourable, al- though the contingency of secondary disease should be taken into account, yet this may be generally guarded against and prevented. When the malady is complicated, irregular, malignant, or asthenic, then the danger is con- siderable, although numerous circumstances may indicate either a diminished or an increased risk. It is chiefly from the existence of certain symptoms that danger is.to be inferred ; but there are circumstances connected with the pre- existing state of the patient which often in- creases the risk, as the first period of dentition, the period of weaning, the cachexia produced by unwholesome or insufficient food; a bloated, leucophlegmatic or plethoric habit of body, and the pregnant and puerperal states. In some epi- demic visitations, and in some seasons more than in others, pregnant and especially puer- peral females are liable to be attacked by scar- latina ; but the liability is not so great as the danger to those who are infected; for the preg- nant are prone to abortion, and when this oc- curs the disease often assumes a most danger- ous form ; and if the disease occurs soon after parturition, recovery rarely takes place, more especially as observed in some epidemics. In these latter circumstances the scarlatina often assumes the appearance of, and can hardly be distinguished from, the most malignant form of puerperal fever. Scarlatina thus occurring soon after parturition, has been described as fol- lows by Malfatti : " It usually attacked pa- tients immediately after delivery, and caused the utmost prostration of strength and slight pain in the throat. The eruption assumed ei- ther the miliform or levigated character, and was of a dark violet hue. The strength ofthe patient now sank rapidly, and to a burning heat succeeded coldness of the extremities, and a very frequent and small pulse. To these symp- toms were added great anxiety, haemorrhage from the nose, and a foetid and copious lochia." He adds, that the infected in this state all died, " qualiscumque adhibita fuerat raedela." 74. B. The symptoms which more especially indicate danger are the occurrences of convul- sions at or soon after the attack, or of delirium on the first and second day. In these cases the child often dies, as remarked by Dr. R. Will- iams, on the third or fourth day, and the adult on the eighth or tenth; but this issue some- times in these takes place even earlier, more rarely later. A severe affection, or sphacelat- ing or foul ulcerating state of the fauces and tonsils ; a brown state ofthe tongue, or a clean, raw tongue, or a glossy state of the tongue or throat, With a rapid, fluttering pulse, are very unfavourable symptoms, as also is a sudden fading of the eruption, or the changing of it to a livid hue, or the appearance of petechiae or of purple spots. The supervention of coma, or of pericarditis, or of double pneumonia, or pleu- ritis, or peritonitis is unfavourable, but not nec- essarily fatal; but the danger of these, as well as of all the other primary and secondary com- plications of the malady, is remarkably height- ened by suppression of urine, or by a very scanty or bloody state of this excretion, and by other indications of serious affection ofthe kid- neys. Persistent vomiting; a severe or obsti- nate diarrhoea; acrid or excoriating discharges from the mouth, throat, and nostrils, with or without haemorrhages; haematuria or melaena; the association of two or more of the compli- cations or local affections already described, especially in a severe form ; the appearance of diffusive inflammation ofthe cellular tissue in the vicinity ofthe parotids, and extending down the neck, or of extensive abscesses, or sphace- lation, in this situation, are very unfavourable occurrences. The same may be said of affec- tions of the joints, erysipelas or local gangrene, and affection of the cervical portion of the spine, with consecutive caries of one or more cervical vertebrae. But these are not neces- sarily fatal, although very dangerous ; even 746 SCARLET FEVER—Causes, etc from the last of these lesions recovery may take place, a result which was obtained in two case6 which were under my care, both of which are now alive and quite well, excepting a stiff and shortened neck. 75. C. Dropsy, in the form of anasarca, or taking place in any ofthe cavities, in connexion with scarlatina, varies much in danger with the season and the prevailing epidemic, with the seat of effusion, with the nature of other asso- ciated morbid states, and more especially with the states ofthe kidneys and urinary excretion. The occurrence of anasarca during the eruption, ox of effusion in any shut cavity at this period, with or without inflammation, is an indication of danger, more especially if the urine be very scanty, very deep-coloured, or suppressed. An- asarca occurring alone during desquamation or convalescence, although the urine is albuminous, is generally cured if no farther complication take place, and if the urine is not very scanty, or very albuminous, or bloody. But if the urine assume either of these states in a remarkable degree, the supervention of most dangerous in- ternal effusion or inflammation, chiefly of the meninges of the brain, of the pleura, pericardi- um, or peritoneum, or of the lungs, &c, may be expected. The danger and the frequency of these secondary complications of scarlatina, as well as of the primary associations, vary much in different epidemics, and with the numerous causes or occasions concurring to render the infection intense, or to re-enforce the operation of the poisonous miasm, and with those more especially which are about to be mentioned (y 84, et seq.). 76. IX. Causes.—i. The Specific Cause or Poison..—A. Scarlet fever is caused by a miasm or emanation from a person already the subject of this disease ; but the exact and intimate nature of the miasm, and the origin of it, are unknown. We know only the effects or phe- nomena which this cause produces, and most of the circumstances which favour its opera- tion ; and we farther know that, however these effects vary in severity, in form, or in charac- ter, they are always of a specific nature, the seminium attending them multiplying and dis- seminating itself, and spreading its kind when- ever circumstances favour the propagation. Upon these circumstances the prevalence of the malady chiefly depends ; for they favour the operation of the specific poison or infectious miasm which produces it: 1st. By predisposing the system of individuals to the invasion of this miasm. 2d. By concentrating and increasing the dose or quantity ofthe poisonous emanation invading the frame. During many ages, and especially when the earlier accounts ofthe mal- ady were furnished, either the combinations of these predisposing circumstances were greater at distant intervals, or their absence was more complete in these intervals than at the present day, or the infectious or poisonous miasm was entirely absent, or remained latent or concealed for prolonged periods. Either of these condi- tions may have existed ; or the infection, hav- ing produced its effects on all who had come within its sphere, had ceased to spread, and had ultimately disappeared from a place for a longer or snorter period, until it was intro- duced by a poisoned or infected person, or by contaminated articles or fomites. This latter circumstance—this reappearance ofthe malady in a place long entirely exempt from it—sug- gests the following questions as to its origin : 1st. Whether the disease is caused only by a specific seminium which had originated at some unknown period, and, having infected one and more persons, and subsequently all who were predisposed to the infection, had then ceased to produce its effects, but was retained by substan- ces capable of preserving it under certain favour- able circumstances until it was again brought to act on those predisposed to its influence! 2d. Whether the disease is always thus perpetu- ated by the preservation ofthe infectious semin- ium by individual, or rare, or scattered cases, and by fomites ; or is it produced, de novo, by the combination of those causes in an intense form which are usually viewed as concurrent and predisposing causes, and, being thus produced anew, is then propagated by the infectious ema- nation proceeding from those thus attacked! 77. I incline to the first of these opinions, be- cause we have no sufficient evidence ofthe re- production of this malady by the combination of the causes usually favouring it, predisposing to it, and rendering attacks of it malignant or complicated ; and because an infectious semin- ium, as in the case of small-pox, may be pre- served, propagated, and become epidemic—may almost disappear for a time, and then unex- pectedly break out—without the means of its preservation, the sources of its infection, or the causes of its prevalence and of its multiplied effects being made manifest, or even admitting of solution on many occasions. But the diffi- culty of tracing infection to its sources on all occasions, in this and in other infectious mala- dies, is by no means an argument against its existence ; for causes are often inferred from their effects with greater certainty than from some other proofs upon which firmer reliance is often placed. The laws of infection, and the numerous circumstances connected with the sources, the preservation, and the dissemina- tion of infectious seminia, admit not of a ra- tional doubt of the perpetuation of these se- minia, although their effects may be sparingly or rarely disseminated, or even developed, after long intervals. Indeed, much of what is known of these favours a firm belief in this source of scarlatina, as well as of measles and small-pox, on all occasions and in all instances. We know that the vitality of several kinds of seed may be preserved for many ages; and why should not the poisonous properties of an animal fluid or miasm be preserved for months, or even for years, when exclusion from the air and other circumstances favour the preservation 1 Ad- mitting this, allowing also that the seminium often requires many days to take root and to develop itself into full efflorescence, knowing, moreover, the diversified media by which the morbid or poisonous emanation may be pre- served, conveyed, and brought even into unrec- ognisable operation, it cannot be a matter of sur- prise that the source of infection frequently ad- mits not of demonstration. Two powerful cir- cumstances in favour of the existence and op- eration of a specific infection or poison have too frequently been kept out of view, namely, 1st. The non-existence or non-appearance at any time of this disease in several secluded or isolated localities and islands, although the sev SCARLET FEVE eral causes tending to favour the dissemination and malignancy of the disease — those very causes which have been believed by some to be capable of originating the malady tie novo—have been there present in the most pregnant forms of union and association ; and, 2d. The fact that, when the disease has made its appearance in such places, it has always been traced to the introduction of infection, and, having exhausted itself on all the predisposed to~ it, has entirely ceased and disappeared for years, until again introduced by the infected or by fomites. 78. If we refer to what is known (and our knowledge in this and in other allied topics is very imperfect) respecting the statistics of dis- ease in most of our cities and large towns, we shall find that at no time are cases of scarlatina altogether absent. I believe, moreover, that cases often occur which are either not recog- nised at all, or not as cases of this disease. Hence sources of infection are rarely absent from these localities, irrespective ofthe chances of transport to and transmission from them; or, if absent for some time in one place, they are present in other places, from which they are transmitted to those which have been for a longer or shorter time exempt' from them, and which, from this circumstance, furnish subjects predisposed to infection. • 79. B. The media by which this disease is transmitted from those affected to the healthy are generally the atmosphere surrounding the sick, and substances which imbibe the miasms emanating from those who are or have been recently attacked, and which retain it for a time, but soon impart it to the air—fomites (see art. Infection, y 16, 17). It has not been de- monstrated, nor, indeed, does the matter read- ily admit of precise demonstration, how far the miasm of scarlatina may extend by means of the atmosphere from a person sick of the dis- ease. Much will depend upon the state of the air as to humidity, motion, &c, and upon the predisposition of those exposed to it. It has been supposed, that the appropriation of a room in schools for such children as may be seized with either scarlatina or measles may prevent the spread ofthe disease among the healthy. This has been attempted in many instances ; and by myself, in respect of these diseases, on several occasions, and on two occasions with complete success, in others with partial but very considerable success. Much depends upon the size and construction of the building, and the strictness ofthe seclusion, and ofthe pre- cautions as to fomites. This measure failed in Heriot's Hospital, Ackworth School, and the London Foundling Hospital, where the build- ings furnished excellent means of isolating the infected. But I suspect that the precautions taken failed in preventing the transmission of the infecting miasm by persons or clothes. Be- sides, when a school is large, some of its in- mates may have been so long the subjects of the eruptive fever before the disease is recog- nised as to have infected others previously to their removal. When the building furnishes the means of complete isolation, the attempt at thus preventing the sp^ad ofthe disease should be made; for it is better that the infected should receive due attention in such circumstances at the place of infection than that they should be returned to their friends, where they may trans- !R—Causes, etc. 747 mit the disease to many others ; and it is even better that those in the infected school, who have not yet sickened, should not be allowed to leave it, inasmuch as they may convey the dis- ease in their persons or clothes to the families to which they would return. 80. C. Fomites, or substances impregnated with the miasm exhaled by persons sick of scarlatina, are frequent media by which this disease may be transmitted to the healthy, ei- ther in the vicinity of the sick or in places at a great distance. The duration of the period in which the capability of infection is possessed by fomites is uncertain, and it has not been ascertained. It may be inferred to be very short when the impregnated substances have been exposed to a free current of air, and much longer when they have been shut up and en- tirely prevented from imparting or losing the retained miasm. Feather- beds and woollen bed- clothes retain the infection for the longest pe- riod, especially when undisturbed or shut closely up. The^duration ofthe power of infection, in respect of these articles and of woollen body- clothes, has not been and is not likely to be de- termined ; for various circumstances will either shorten or prolong the period. Dr. Sims re- marks/that "the infection seemed to remain in a house some, but not many, weeks after all the family were recovered." In large, airy houses, where ventilation and means of purification are adopted, a very few weeks may be considered sufficient to remove the infectious property, es- pecially if the beds and bedding are subjected to a high range of temperature, as advised in the article on the prevention of Pestilence (y 77). But where these means are neglected, and in close, dirty, and low apartments and bouses, and in crowded localities and houses where the beds, bed-clothes, hangings, &c, are foul and insufficiently aired, the power of retaining and transmitting infection may exist for several, if not for many weeks. When fomites are shut up and excluded from imparting the retained miasm, the disease may be thereby conveyed to distant or remote parts, and even without the source of infection or the media of transmission either being recognised or admitting of recog- nition. 81. D. The propagation ofthe disease by in- oculation, and by the contact ofthe morbid se- cretions of the disease, has been demonstrated. Sir B. Harwood and others have tried to in- oculate healthy children with the fluid from vesicles sometimes intermingled with the erup- tion of scarlatina in hopes of producing a milder disease, as in small-pox; but although the dis- ease was thus communicated in many instances. no mitigation of its type was thereby obtained. In a case which came under my care, the dis- ease was produced by the contact of a small portion of the discharge from the throat of a person with malignant anginous scarlatina, and the patient thus infected had the disease in the most severe form, and recovered with difficulty 82. E. The susceptibility to the infection or contagion of scarlatina is exhausted or annihi- lated after the disease has run its course, after the scarlatinal poison has produced its specific effects. This law obtains as remarkably in re- spect of scarlatina as of small-pox. The im- possibility of being infected by this malady a second time has been fully ascertained by Dr. 748 SCARLET FEVER—Causes, etc Willan and many others ; but a very few ex- ceptions to the law have been recorded, so few as not to amount to more than one instance among two or three thousands constituting the law. This immunity from a second attack may be viewed as a proof that the disease is not merely one of the blood alone, but is also, if not chiefly, one primarily affecting and changing the susceptibility of the organic nervous sys- tem, the blood being altered by the state of this system, on the conditions of which this fluid is bo intimately dependent. 83. F. The coexistence of scarlatina with mea- sles, with the vaccine disease, with erysipelas, and with small-pox has been contended for by some and denied by others. I believe in its co- existence with measles, and in the production in consequence of the hybrid disease described under Rubeola ; and its coexistence with the other eruptive maladies just mentioned, espe- cially vaccinia, is not unlikely to occur under circumstances favouring the operation of their respective poisons upon the frame at the same time. Dr. Gregory states that he has seen at the Small-pox Hospital "several unequivocal cases ofthe simultaneous existence of small- pox and scarlatina anginosa." And Mr. Mar- son, surgeon to that hospital, remarks, that, in the course of eleven years, " he has seen seven persons who had variola and scarlatina simul- taneously."—(Med. Chir. Transact., vol. xxx., P" 121) 84. ii. Predisposing Causes or Circumstan- ces.—The causes predisposing to the infection of scarlet fever axe numerous, and may be refer- red to the states of individuals exposed to infec- tion, and to the circumstances or conditions fa- vouring the concentration and the invasion or operation of the poisonous miasm.—A. As the mode in which this disease is generally infected, whether the infectious emanation proceeds di- rectly from the sick or mediately, or by means of fomites, is by the inspiration of air contami- nated more or less with the poisonous miasm, which affects, nearly at the same time or in quick succession, the organic nerves of the respiratory surfaces, and the blood distributed to these surfaces — morbidly impressing the former, and passing by endosmose through the latter—it follows that the susceptibility to in- fection must depend much upon the states of the organic nervous power and ofthe vascular system, and that, when the energy of the one is impaired, and the action of the other is low- ered, the frame will be more liable to be invaded by the poisonous influence. Hence some indi- viduals are more prone to infection than oth- ers, and hence the same person is more predis- posed at one time than at another, according to the varying states of nervous tone and vascu- lar action. The conditions of the atmosphere, as powerfully modifying these states, have con- siderable influence in predisposing to infection; but to this and to the immediately preceding topic, I can add nothing to what I have stated in the article on Infection (see y 44-55). 85. B. There is no cause of predisposition more generally manifested than the age of child- hood. The susceptibility of infection appears to be greatest from the period of weaning to fully adult age. After thirty or forty years of age the susceptibility is remarkably diminished ; but al- though I have seen several cases from thirty- five to fifty years of age, I have met with one only between fifty and sixty, and he died in twenty-four hours, owing to the extension of the disease to the larynx. As the susceptibil- ity of infection is greatest in childhood, and as the proportion of those who have had the dis- ease at this epoch is very great, it follows that the number of non-infected at adult and ad- vanced age is comparatively small. Although cases ofthe disease at these ages are thus few, yet they are generally of a most severe charac- ter, especially about and after forty years of age, as respects not merely the complications, but also the type of the eruptive fever from its commencement, and the danger is thus increas- ed with advanced years. According to my ex- perience, the younger the child the milder is the attack; but there are numerous exceptions to this law, arising out ofthe aggravating circum- stances connected with weaning and dentition, and the numerous concurring predisposing causes observed among the poor, of which the most influential are, ill clothing; insufficient and un- wholesome food; low, ill ventilated, and ma- larious abodes ; exhalations front cess-pools, privies, and sewers, and inattention to cleanli- ness, with various others tending to lower the constitutional powers and the vital resistance to the invasion of infection, to concentrate the infectious emanation, and thereby to increase the dose of the poison. 86. Infants during the period of suckling very frequently escape the disease, although every other member of the family may be attacked. I have seen, on several occasions, every one of a family of eight or nine children affected in a very short period of each other, and the in- fant at the breast to escape. The cause of this comparative immunity is not very apparent. Probably infants at this period are less exposed to the infectious emanation ; but this depends much upon the circumstances of families; among the poor the exposure is not materially less. It is rather to be imputed to a less sus- ceptibility ortnfection at this period, depending, probably, upon the circumstances of the infant being then nourished by a secretion directly from the secreting organs of the mother, and thus possessing some measure of an invigora- ting vital emanation, thereby enabling the in- fant to resist the infection. I have observed, in many instances, that persons who have ex- perienced a very severe attack of measles have escaped the infection of scarlatina, although much exposed to it. This circumstance is de- serving of farther observation ; but, from what- ever cause, some persons resist this infection, although frequently exposed to it from an early age. Out of 2614 cases recorded by Mr. Farr in his fourth report, 2419 were children, 182 adults, and 13 aged persons. Scarlatina may attack the foetus in utero. Instances of this have been furnished by several writers. Dr. Gregory states, that "on the 28th of April, 1839, his youngest child was born, evidently suffering from fever. The throat was affected the following day, obviously from angina ma- ligna. Eruption was never developed. The infant drooped and died on the first of May." (P. 146.) 87. C. Scarlet fever affects both sexes in equal proportions, and very remarkably so. In Lon- don it destroyed, in 1838, 747 males and 777 SCARLET FEVER—Causes, etc. 749 females ; in 1839, 1241 males and 1258 fe- males ; and throughout England and Wales, in 1840 (exclusive ofthe metropolis),* 8927 males * The following will show the comparative prevalence in the metropolis of scarlet fever, measles, and smallpox, from 1838 to 1848. both years included, during the last eleven years. It must be manifest that the numbers as- signed can be an approximation only to the true amount, as the causes of death are in many instances arbitrarily assigned in the returns, but they are sufficiently accurate to convey useful information: Years, Scarlet Fever. Measles. Small-pox 1838 . ....... 1524 .... .... 588 ... .... 3817 1839 . ....... 2499 .... .... 2036 ... .... 634 1840 . ....... 1954 .... .... 1132 ... .... 1235 1841 . ....... 663 .... .... 973 ... .... 1053 1842 . ....... 1224 .... .... 1293 ... ___ 360 1843 . ....... 1867 .... .... 1442 ... .... 438 1844 . ....... 3029 .... .... 1182 ... .... 1804 1845 . ....... 1085 .... ....2318 ... .... 909 1846 . ....... 928 .... .... 747 ... .... 257 1847 . ....... >433 .... .... 1778 .... .... 955 1848 . ....... 4756 .... .... 1143 ... ___1617 wing 11 years, 20,962___ .. 14,632 ... .. 13,079 During the last eleven years the deaths in the metropo- lis from scarlet fever have been greater than from measles, or from small-pox, or from hooping-cough, or from con- tinued fever. In only three of these years have the deaths by measles been greater than those by scarlatina, and in only two has the mortality from small-pox exceeded that of scarlet fever. In 1841 and 1846, the mortality of scar- latina and measles was low, and in the latter year that of smallpox was the lowest. In 1839, 1843, 1844, the mortality of both scarlet fever and measles was high. During 1848, the deaths from scarlatina were about three times greater than the average of the former years. , The maximum mortality from .measles occurred in 1845, and from small-pox in 1838. The greatest number of deaths from scarlet fever occur among the poor, owing to the circumstances which "both predispose to infection and render the disease more ma- lignant; and even those causes which develop the sequeta ofthe disease and render them fatal (see § 42), are also most prevalentin the lower classes. If the above amount do not comprise the deaths from dropsy, or other diseases consequent upon scarlatina, the mortality from this mal- ady must have been greater than here stated. The above results will show that there are few diseases—perhaps none—from which the general amount of mortality and of danger is greater than in scarlet fever, and yet there is not one of which the pathology and treatment has re- ceived less attention and elucidation in modern times than it The proportion of malignant to mild cases of scarlatina cannot be truly estimated, as it differs in different seasons, in different localities, and in different epidemic preva- lences. Dr. Willan found it to be one of the former to four of the latter ; and Dr. Clark one to two; and one of six had dropsy during-convalescence. The rate of mor- tality must necessarily also differ with the above causes— the fluctuation sometimes observed being remarkable— being from one in forty to one in six cases. Dr. Greg- ohy considers that the average mortality is about "six per cenf.; and that, while throughout England and Wales 19,816 deaths occurred in 1840 (a year of average mor- tality for London), the £ctal number of seizures must have amounted, according to this calculation, to about 330,266 in that year for the whole of England. [This disease, as our author correctly 'states, first ap- peared in this country, in an inland town of New Hamp- shire, Kingston, in May, 1735. The first child attacked died in three days. In one -week afterward three chil- dren in another family, four miles distant, were success- ively seized, and all died. In August following it ap- Ceared at Exeter, six miles distant; and in September it roke out in Boston, fifty miles distant though it did not appear at Chester, six miles west of Kingston, till Octo- ber. It spread very gradually west and south, and was two years in reaching the Hudson River, two hundred miles west. Noah Webster states that " it attacked the young in the most sequestered situations, and without a possible communication with the sick, although the dis- ease was very infectious." He also remarks^ that " for many years alter it was epidemic, it frequently broke out in different places without any apparent cause, but did not spread—a striking proof that such diseases will riot become epidemic by the sole power of infection, but that some general cause must aid its propagation, or it will perish in its cradle. This is probably true of every spe- cies of pestilential disease" (on Pestilence, vol. i., p. £11). Webster's philoeophy ofepidemics is, indeed, very and 8935 females. This disease appears to be most prevalent in temperate climates. It is stated to be comparatively rare in Bengal. Dr. comprehensive. "When observation and philosophy," he remarks, "shall prevail over the prejudices of men, in regard to the origin of these diseases from infection, it will be found that the angina, in its various forms, is only a particular stage or modification of the pestilence which spreads over the world at certain unequal periods. The milder forms of the pestilence appear in catarrh, measles, and chin-cough, which usually appear together, or nearly so, at the beginning of the more violent general contagion; the later and more fatal stages are marked by anginas, cynancha maligna, petechial fever, bilious and glandular plague in summer, and pestilential pleurisies in winter. There are certain times when the constitutions of men in all parts of the world contract a poison, which nature makes an effort to expel; and the different epidemics that accompany or follow each other in rapid succession, appear to be the different modes by which nature strives to rid the human body of the virus. These modes de- ' pend on the season of the year, the constitution or age of the patient and a multitude of subordinate circum- stances. Whether this poison is a positive substance in- haled by tjie lungs and pores, or is the effect of mere de- bility, which unfits the urinal parts of the body to per- form their functions, is a question of a curious natura"— (Loc. cit., p. 215.) The scarlet fever prevailed extensively in Boston in 1735-6; about 4000 persons were attacked with it, of whom 1 in 35 died. It spread very generally over New England at this period, carrying off whole families. In Kingston, where the usual annual mortality was not above 9 or 10, it rose in 1735 to 102, and an equal degree of mortality was not unusual in other places. It was com- puted that 500 children in Maine died of this disease in 1735, out of a population of 9000 whites. We read that the prominent' symptoms were " swollen throat, with ash-col- oured specks, efflorescence on the skin, distress in the head, great debility, and strong tendency to putrefaction." In Kittery 122 children died of it In 1736 it was not so general or mortal. In 17374t broke out afresh: 75 died in Nortel Yarmouth, 49 in Falmouth, and in some places not one attacked survived. Mr. Shattuck remarks (on Vital Statistics of Boston, in 27(h volume of Amer. Journ. Med. Sci., p. 373), that" it is somewhat singular that, after the lapse of just about a century, scarlet fever should have prevailed again as one ofthe most fatal diseases of New7 England." The following'table shows the comparative prevalence in Boston of scarlet fever, measles, and small-pox, from 1811 to 1839, inclusive: Years. Scarlet Fever. Measles. Small-pox. 1811 ....... 1..... .. 0 .... .... 2 1812 ....... 0..... .. 0 .... .... 0 1813 ....... 0..... .. 1 .... .... 0 1814 ....... 1..... .. 0 .... .... 0 1815 ....... 21..... .. 0 .... .... 4 1816 ....... 3..... .. 6 .... ... 0 1817 ....... 1..... .. 0 .... .... 0 1818 ....... 0..... .. 0 .... .... 0 1819 ....... 12..... .. 0 .... .... 0 1820 ....... 10 ..... .. 0___ ___ 0 1821 ....... 4..... ... 149 .... .... 4 1822 ....... 1..... .. 3 .... .... 0 1823 ....... 1..... .. 0 .... .... 0 1824 ....... 0..... .. 2 .... .... 1 1825 ....... 4..... .. 77 .... .... 1 1826 ....... 16..... .. 10 .... .... 0 1827 ....... 8..... 0___ 3 1828 ....... 3..... .. 0 .... ... 2 1829 ....... 4..... .. 78 .... .... 0 1830 ....... 5..... .. 13 .... ... 1 1831 ....... 84..... 2 ... 1832 ....... 200 ..... .. 70 .... ... 2 1833 ....... 90 ...\, .. 2 .... 0 1834 ....... 39..... -- 1 .... ... 4 1835 ....... 73..... '....... 31..... ....... 50..... .. 188 ___ 7 1836 .. 31 .... ... 6 1837 .. 23 .... ...13 1838 ....... 106 ..... -. 20 .... ... 3 1839 .......222 ..... -. 3 .... ...60 Total.. 924 ..... .. 368 .... .. 105 The deaths in Boston from the eruptive fevers, from 1811 to 1820, were 64, being 7-5 per 1000 of all diseases; from 1820 to 1830, there were 402 deaths from the same class of diseases, or 35-1 ratio per 1000; and from 1830 to 1839, there were 1402 deaths from eruptive fevers, being a proportion of 96-2 per 1000 of deaths from all diseases. During the same periods the total deaths from epidemic and endemic disease were, for the first period, 1193; foi 750 SCARLET FEVER—Causes, etc. Gregory remarks, that Dr. Jackson, formerly the second, 2037; for the third, 3622, being a ratio of 1408, 177-7, and 248-6 per 1000 of all the deaths. The same increase of mortality from the eruptive fevers has been observed in every part of this country. The following table shows the comparative prevalence of scarlet fever, measles, and small-pox in the city of New York, from 1819 to 1849, inclusive: Years. Scarlet FeTer. Measles. Small-pox. 1819 ....... 5..... ... 10 .... ___ 0 1820 ....... 5..... ... 74 .... .... 0 1821 ....... 3..... ... 109 .... .... 0 1822 ....... 1 ..... ... 1 .... .... 0 1823 ....... 2..... ... 117 .... .... 18 1824 ....... 3..... ... 100 .... .... 394 1825 ....... 10..... ... 53 ... .... 40 1826 ....... 24 ..... ... 31 .... .... 58 1827 ....... 4..... ... 172 ... .... 149 1828 ....... 11 ..^.. ... 28 .... .... 93 1829 ....... 188..... ... 91 .... .... 16 1830 ....... 246..... ... 22 ... .... 176 1831 ........258..... ... 39 .... .... 224 1832 ........224..... ... 290 ... .... 89 1833 .......179..... ... 38 .... .... 25 1834 .......408..... ... 212 ... .... 233 1835 ... 174 ..... ... 82 ... .... 351 1836 .......202..... ... 443 ... .... 173 1837 .......579..... ... 238 ... .... 164 1838 .......257..... ... 79 ... .... 91 1839 .......158..... ... 133 ... .... 68 1840 ........391..... ... 186 ... .... 232 1841 .......366..... ... 113 ... .... 209 1842 ........416..... ... 60 ... .... 181 1843 ........223..... ... 118 ... .... 117 1844 .......225..... ... 51 ... .... 29 1845 ........ 63..... ... 136 ... .... 425 1846 ....... 114 ..... ... 71 ... .... 141 1847 ....... 142..... ... 275 ... .... 53 1R4R ........ 93..... ... 77 ... .... 544 1849 .......266..... ... 125 ... .... 326 Total.. 5240 .... .. 3500 ... ... 4619 For the following tables and remarks relative to the comparative prevalence of scarlatina, measles, and small- pox in Boston and Massachusetts, we are indebted to Lemuel Shattuck, Esq., one of the ablest writers on medical statistics in our country. " Statement showing the total number of deaths from all causes in Boston, in different periods, and the number and proportion per cent, from scarlatina, measles, and small-pox during the same period. Causes of Death. Ten years. 1811-20. Ten years. 1821-30. Ten years. 1831-40. Nine years. 1841-49. All causes . . Specified causes 8,470 7,522 11,470 9,554 16,414 15,077 27,127 26,796 Special Causes. Scarlatina . . Measles . . . Small-pox . . 30 28 6 48 332 8 972 341 214 1,468 587 342 Per Ctntagt. Scarlatina . . Measles . . . Small-pox . . •40 •37 •08 •50 3-48 .08 6-46 2-26 1-42 5-43 2-18 1-28 It appears from this statement that thirty deaths only occurred from scarlatina in the ten years, 1811-20, being four tenths of one per cent, of the known causes of death, while in the nine years, 1841-49, there occurred 1468, or 5-43 per cent, from the same cause I Other zymotic dis- eases, especially fevers and those affecting the digestive organs, increase during the same period, and lessen the apparent increase which would otherwise appear in some of the above-named diseases. The following table exhibits the same facts relating to the deaths, returned under the registry laws, from all the counties in the state except Suffolk (Boston), for the years specified. Cause- of Death. 1842. | 1843. 1844. 1845. 1846. 1847. | 1848. All causes . . Specified causes 7,496 6,149 8,305 7,177 8,250 7,076 8,715 8,070 9,211 8,741 10,816 10,317 11,346 9,954 Special Causes. Scarlatina . . Measles . . , Small-pox . . 396 86 13 561 30 12 328 32 11 538 44 5 516 46 32 418 136 12 176 43 21 Per Ctntagt. Scarlatina . . Measles . . . Small-pox . . 6-44 1-40 •21 7-81 •42 •17 4-63 •45 •16 6-67 ■54 •06 5-90 •53 •37 405 1-32 •12 1-77 •43 •21 of Calcutta, could not recall to mind any cases which he had seen in India deserving the name of scarlatina. I never met with a case within the tropics. I believe that the disease has not yet been imported into Australia, Van Diemen'a Land, and New Zealand. It was brought to North America in 1735, and its progress was very slow, but very fatal. The epidemic in 1736 in that continent was most pestilential. " Villages were depopulated by it, and parents had to bewail the loss of all their children." 88. D- As to the complete immunity conse- quent upon an attack of this malady, it may be remarked, that this is to be imputed to the ex- haustion of susceptibility produced by this poi- son, as by several other animal poisons, as re- spects their several specific effects. That the poisonous emanation or material should fail of producing any effect upon a person who has, at Statement showing the influences ofthe age and season of the year on scarlatina. Age. Four years. 1845-48. SeTen years. 1S42-48. Month. Four years. 1845-48. Seven years. 1842-48. M. F. Both sexes. M. | F. Both sexes. Und. 1 1 to 2 2 to 5 5 to 10 10to20 20 to 30 30 to 40 40 to 50 50 to 60 i 60 to 70 70 to 80 80 to 90 Not stated 140 133 288 172 37 7 7 3 3 1 1' 1 5 113 142 309 152 68 35 4 2 3 7 14 412 456 1178 645 210 70 19 13 9 14 6 4 157 Jan. Feb. Mar. April May June July Aug. Sept. Oct. Nov. Dec. Not stated 79 72 95 58 68 57 73 89 65 58 41 44 85 76 93 86 66 69 52 67 58 70 63 64 280 281 328-266 269 268 244 273 241 333 212 204 94 Total 799 849 3193 Total 799 849 3193 The above table contains the returns of all the counties in the state excepting Suffolk. In four years the sexes as distinguished; for the whole seven years they are added together."— (Letter to the Editor, April, 1850.) On examining the medical statistics of Philadelphia, as furnished by Dr. Emerson (in the first volume of the Am. Jour. Med. Sciences), the same increased prevalence of the eruptive fevers is observed in that city. Beginning, for example, with the year 1807, there were not over three deaths annually reported by it until 1820, When there were thirty deaths by it; from this it gradually declined to 1826, when it amounted to only four; 6ince which it has again increased in a still higher ratio. From 1807 to 1827 there were reported 1080 deaths from small-pox, 667 from measles, and 102 only from scarlet fever; the greatest mortality from the latter disease, as well as small-pox, being between the second and fifth year, while that from measles was between the first and second year. In my paper on the " Medical Statistics of New York" (in the nineteenth volume of Am. Jour. Med. Sciences, p. 25-52), I have observed, " It is a singular fact, that while there has been a gradual and constant diminution of deaths from other fevers, especially typhus and bilious remittent, which were formerly quite fatal, there has been for sev- eral years a constant increase from scarlet fever, amount- ing, within the last six years (Nov., 1836) to 1500. The largest number of deaths from this disease for any one year was in 1834, when there were 418. In the year 1829, 188 fell victims to it within a few weeks. Until that year, from its commencement in 1817, the average mortality from it was only seven or eight per cent Since that time its ravages have been truly distressing; whole families of children having been swept off by it in a few days. In 1834, the deaths from all ttfher fevers, scarlet excepted, were 252, while those from the latter were 418; in 1833, 192 from the former, ani 179 from the latter; in 1832, the year of the cholera, 237 from the former, and 221 from the latter. In the six years from 1828 to 1833, in which were reported 1103 deaths from scarlet fever, an esrimnte for all the months gives the following result, commencing with the lowest: " In the month of June, from scarlet fever, 53 deaths; May, 62; April, 66: August, 70; September, 71; March, 74; October, 98; February, 100; January, 117; Novem- ber, 124; December, 191; thus showing that its fatality is greatest during the coldest months."] SCARLET FEVER—Pathological Inferences. 751 some more or less remote period, been affected by it, is a most important law in this and other exanthematous and pestilential maladies, espe- cially as respects the safety of the species. The protection thus obtained is the chief means of preventingthe depopulation of districts where any of these maladies break out; and, accord- ingly, it has been observed, that where scarlet fever, or measles, or small-pox has been intro- duced for the first time, or after the lapse of very many years, the whole, or a large propor- tion of the population being susceptible of in- fection, the destruction of human life has been there most terrific. That the immunity obtain- ed by an attack of those diseases which infect the constitution only once, cannot be imputed to any change in the blood consequent upon such an infection, may be inferred, 1st, from the impossibility of a permanent change in this fluid that could prevent the recurrence of any alteration in it which had taken place on some former occasion ; and, 2d, from the gradual and entire renewal of this fluid after longer or shorter periods, a renewal of susceptibility in- evitably supervening if this property resided in the blood. We must, therefore, refer the im- munity from a second infection to the organic nervous system, and view the susceptibility of this system to have been so affected or specif- ically changed by the first operation ofthe pois- on as no longer to be capable of being roused by any subsequent application of the same spe- cies of poison as previously affected it to a sim- ilar series of morbid changes and actions.* 89. E. The Period of Latency or Incubation— the precursory or formative Period.— The time which elapses between exposure to infection and the commencement of the febrile action may be expected to vary much, as it actually does vary, according to the susceptibility of the individual, either from constitution, or from the influence of predisposing causes, or from the concentration or dose of the poison. I have stated much of what is known as to this mat- ter in the article on Infection (y 32). All that can he advanced is, that the period is very un- certain. It may be only a few hours, or it may extend to ten or twelve days. Dr. Maton has recorded some cases in which he considered this period to have been prolonged to twenty- four or twenty-five days. The most common period is most probably three or four days, it being rarely shorter than two days, or longer than eight. In a case referred to by M. Ros- tan, in which the disease was induced by inoc- ulation, seven days elapsed before the appear- ance of eruption. 90. X. Pathological Inferences.—-It may be useful to conclude this view ofthe pathology of scarlet fever with certain inferences as to those topics connected with the nature of the malady that have an important relation to the treatment of it, and that should furnish the ba- * [We apprehend that the same objections may apply to this theory as to that which imputes the immunity of a second attack to changes in the blood ; for if this fluid is *' gradually and entirely renewed" from time to time, so also are the solid textures of the body, though not with equal rapidity and frequency. Moreover, we can almost as readily conceive of permanent changes in the one as in the other; the fact is, that the cause of this exemption from second attacks of disease is one of those mysteries which will probably always elude our grasp, being one of those ultimate facts of science the causes of which can- not be detected.] sis of our intentions of cure.—a. The cause of scarlet fever appears to be an animal miasm or poison of a specific kind—a specific animal se- minium reproducing itself to an indefinite ex- tent.—b. It is not proved that this seminium, or specific form of fever, is generated or appears de novo, from the combination of circumstances or states shown above to favour the extension of the malady ; but, on the contrary, it is much more probable that tlie disease occurs only from the operation of this seminium or specific in- fectious agent proceeding either directly from a person labouring under the malady, or medi- ately by fomites which retain, convey, and com- municate the seminium.—c. The origin or source of" this seminium is not known ; but very prob- ably, like small-pox, the disease was first gen- erated by the lower animals, or occurred among them as a pestilence or epizooty, and not un- likely among the equine race, and was thence communicated to man—the seminium formed among these animals having affected the hu- man species in circumstances favouring the ex- tension of it from the formerto the latter, among whom it has been preserved ever since.*—d. The spread of the disease is favoured by certain conditions of the air, but what these conditions are is chiefly a matter of inference : a humid, close, and malarious atmosphere appears to fa- vour the extension and operation ofthe poison; and all the other conditions shown in the arti- cle Infection to favour or to restrain the ex- tension of infectious agents exert similar in- fluences in respect of this. Extremes of tem- perature seem to diminish the spread of the malady, and to render attacks of it more mild. —e. The states of those exposed to the morbid poison proceeding from the affected appear ei- ther to favour or to resist the action of this poison, and, when favouring it, very remarka- bly to modify its operation and effects (y 84, ei seq.), conformably with predisposition, suscep- tibility, diathesis, temperament, and existing constitutional or visceral conditions, the sus- ceptibility of a second infection by the semini- um of the malady being annihilated by an at- tack.—/. The poisonous material infects the frame of the healthy in the manner fully ex- plained in the article on Infection (y 44, et seq.), and developes its effects in the course of a pe- riod varying in duration from two to twelve days, or even in a shorter, but very rarely in a longer time, according to the susceptibility and predisposition of the recipient, and the concen- tration or dose of the poison (y 76).—g. The effects of the poison, like those of all morbid poisons, are exerted primarily upon the organ- ic nervous system, and consecutively upon the * [If the disease was first generated by the lower ani- mals, the question naturally occurs, why, under similar circumstances, may the virus not be generated de novo, and reproduced as often as the conditions for its manu- facture exist i While we admit that the disease is always propagated by an animal poison or virus of a specific kind, we see no reason for believing it to originate among the lower animals, nor for supposing that it has never been generated except on one occasion, and that un- known ; on the contrary, we hold that like syphilis, itch, and other acknowledged contagious diseases, it may be produced de novo whenever favouring circumstances are present. We have seen that the scarlet fever was first ob- served in this country in an interior town of New Hamp- shire, in 1735, from whence it gradually spread over the country. There is no proof of its importation, but, on the contrary, very urgent and satisfactory reasons could be urged against such a supposition.] 752 SCARLET FEVER—Pathological Inferences. vascular system and the blood ; and as re- spects this malady especially, secondarily upon the kidneys, the throat and skin, either of these parts, or any two of them, or even all of them, evincing these effects in a more or less mani- fest manner, these latter or local effects con- stituting the specific characters of the disease. —h. The early affection of the kidneys in this disease, especially when the affection is such as to impede or to interrupt, or to altogether arrest the urinary excretion, produces a change in the blood, in addition to that already occa- sioned by the infectious agent acting either di- rectly upon this fluid or through the medium of the organic nervous system, the change in the blood thus produced often occasioning asthenic or diffusive inflammation of serous surfaces, or of predisposed organs, with serous, or sero-al- buminous, or sero-fibrinous infiltration or effu- sion of a watery lymph—causing the several primary complications described above (y, 27, et seq.), and already more fully explained ($ 41, et seq.).—i. After this malady has run its usual course, it is more liable than any other exan- thematous fever to be followed during desqua- mation and recovery—during a period varying from seven or eight days after the fading of the eruption, to four, or even six weeks at the ut- most—by a consecutive affection ofthe kidneys, indicated by scanty, albuminous, or even bloody urine, and by the presence of epithelial cells in this fluid, sometimes moulded in the fibrin or lymph into the form of the urinary tubes, and consecutively by adema, anasarca, or inflamma- tion of internal parts, or by effusion into serous cavities.—k. These sequela or secondary compli- cations result from the consecutive affection of the kidneys (v 42, et seq.)^ which appears to con- sist chiefly of an obstruction caused by the ac- cumulation of exfoliated epithelium in the tu- buli and of a deposition of albuminous lymph in the structure of the organ, this latter ob- structing the circulation in the capillaries by its pressure, while the accumulated organic detri- tus in the tubuli obstructs the passage of the secretion along these canals, and impedes or interrupts the function of the organ.—/. The consequences of the affection of the kidneys at an early stage of the disease, and of the con- secutive obstruction of these emunctories at a much later period, are, as shown above (y 41, et seq.), morbid or contaminated states of the blood—a state of excrementitial plethora, con- sisting of an excess of watery elements, and of effete, deleterious, and irritating materials and saline ingredients. The accumulation of these excrementitial matters in the circulation, as well as of those usually eliminated by the skin, occa- sions the several complications—whether in- flammatory or dropsical—observed in the course of the malady, or subsequently as sequelae or reliquiae.—m. Not the least important of these latter is the anamia observed not infrequently to follow the renal and dropsical affections dur- ing or consequent upon scarlet fever—n. The occurrence of the usual sequela of scarlatina is favoured by several physical causes, to which the patient is liable to be exposed during the process of desquamation and recovery; and it is often prevented by measures calculated to restore the functions of the skin, and to pre- vent vascular determination to, or congestion of the kidneys, and to diminish these, with the other consecutive or associated causes of ob- struction of these organs.* * [M. Billard treats of this disease under too usual forms of simplex, anginosa, and maligna, and states that ft is always accompanied with violent fever, very often with angina or ophthalmia, and sometimes with pneumonia, gastro-enteritis, or encephalitis ; while of all complica- tions, that of the throat he regards as the most frequent and serious. He states that inflammation of the larynx or tonsils exists in a greater or less degree in almost ev- ery case of scarlatina, either at the commencement or in the course of the disease, while the other complications are only observed in such as are exposed by a particular predisposition to inflammations of the encephalon or of the alimentary canal. The table which I have given from Mr. Shatttjck (p. 750) shows also the truth of Biixard's statement, that scar- let fever prevails more particularly during second infancy and in youth than during the period of suckling, and when it does attack in the first infancy it does not affect chil- dren in the same manner as those of a more advanced age. See Stewart's Billard, ed. 1850, p. 104, and Ap- pendix, p. 556. From this I quote the following remarks furnished by request for that work: " I regard the local inflammation which attends scarla- tina as a specific affection, identical with the diphtherifis of Bretonneau and other French writers, and character- ized chiefly by a membranous exudation on the surface of the mucous membrane of the mouth and fauces. We see this tendency, also, after the application of a blister, and, indeed, wherever the cuticle has been removed by any cause whatever. We sometimes, though rarely, find it extending down the trachea and bronchi*, giving rise to all the symptoms that attend an attack of croup. " It is, however, important, when speaking of scarlatina, to keep in mind the two very different forms which it as- sumes; namely, the anginose, or purely inflammatory, and the malignant, or congestive form, in which we have a frequent feeble pulse, cold extremities, extreme pros- tration, and great determination of blood to the headT In the latter, patients often die after a short illness, some- times before reaction is established, and in such cases the scalpel reveals nothing. The citadel of life has been in- vaded by an invisible foe.'and its forces have succumbed, leaving behind no vestiges of the attack. " In treating of the pathology of scarlet fever, my re- marks will naturally fall under two divisions, namely, 1. Lesions of the Solids; and, 2. Lesions of the Fluids. " 1. Lesions of the Solids.—In scarlatina there is hyper- emia of the mucous membranes generally, and of the mouth and fauces in particular, which constantly tends to terminate, either by a membranous deposite of coagu- lable lymph or by ulceration; and the ulcerative process, when once established in any part is very apt to extend its ravages to the neighbouring parts of analogous struc- ture. This inflammation, we have reason to believe, ia of a specific character, depending probably on the pecu- liar impression made on the nervous system by the epi- demic influence. At a very early period in the disease, indeed, before any constitutional symptoms appear, we shall perceive, on examining the fauces, that the vessels ot the mucous membrane are highly injected, and upon the surface of the tonsils and soft palate gray patches of lymph, often mistaken for ulcers, which increase in ex- tent as the disease progresses. Preceding, or accompa- nying this appearance, we sometimes see small vesicles of a purple or whitish colour, and these are sometimes found also upon the skin. In severe cases the fauces as- sume a deep modena red or purple suffusion, and when this is the case ulceration is sure to follow. Flocculi of lymph appear scattered over the surface in irregular patches, resembling in appearance the purulent secretion of an ulcer, from which they can at first scarcely be dis- tinguished. In a short time, however, unless removed by gargling or some other means, these patches assume a dark or black colour, attended with a peculiarly oppressive fetor. On removing them the surface beneath appears red, spongy, and somewhat swollen. The tonsils are more or less enlarged from the commencement and in severe cases are almost uniformly the seat of extensive ulceration. "Autopsic examination by no means reveals the same appearances. In many cases where I expected to find extensive local ravages, there were scarcely any marks of disease present; and in others, where the constitu- tional symptoms were comparatively light, I have found the most frightful vestiges of disease. You will doubtless recollect the case of the child in Amos Street whose dis- section you witnessed a short time since. In this case the disease assumed a very mild form, yielding kindly to med- icine. In a few days the patient was apparently well, with tho exception of a slight cough, and the physician in SCARLET FEVER—Treatment. 753 91. XL—/Treatment.—The treatment of scar- let fever has hitherto been unsatisfactory, and attendance ceased his visits. In about a fortnight after- ward he was again called in, and found her labouring under an incessaut cough of a croupy character, though at this time she was playing about the house. In two or three days afterward she died from suffocation during a coughing fit. On examination, I found a great portion of the larynx destroyed by ulceration, and the fauces were completely honey-combed. Numerous perforations existed in the tonsils, palate, &c, of various sizes, while the mucous lining of the trachea was either softened or abraded through its whole extent. There was a vast col- lection of frothy, mucopurulent matter collected in the larynx and trachea, which doubtless was the cause of the suffocation. The other organs were healthy. " In another case, which happened not long after, you also was present at the examination, and can bear testi- mony to the great difference in the appearances, on dis- section, from those above given. The patient was a boy five years of age : at an early period there was consider- able redness about the fauces, and the tonsils were some- what swollen. The breath was hot and offensive, and the pulse ranged from 120 to 140. There was extreme restlessness and jactitation throughout the whole course of the disease, with frequent moaning and screaming, a wild expression of the eyes, irregular and often laboured respiration, temperature of the body very unequal, head generally hot and extremities cold. As the disease pro- gressed, his mouth and lips became incrusted with a dark brown sordes; the tongue was swollen, fiery red, and cracked; the throat became filled with a thick, glutinous, tenacious mucous; the stomach was extremely irritable, and the epigastrium tender on pressure. There was more or less delirium throughout the whole sickness. He sunk into a stupor, and died on the sixth day from the attack. " A utopsy eight hours after Death.—Body emaciated; a few black spots on the posterior part of the body ; a yel- lowish mucus discharging from the mouth and nose in considerable quantity. The lungs were found healthy, and remarkably free from blood ; no marks of inflamma- tion about them ; and, on cutting into them, we found but very slight effusion into the air-cells. The mucous sur- face of the traehea and bronchia was covered with a white mucus, which, on being removed, the membrane presented a healthy appearance. The liver was healthy; the gall-bladder full of bile ; the heart natural: and the per- icardium contained the usual quantity of serum. There was no ulceration about the fauces, tonsils, or palate, and the whole lining membrane of the mouth was perfectly healthy. It is proper, perhaps, to remark, that this pa- tient had been very freely bled and leeched. " We, however, generally find in this disease ulceration about the glottis and tonsils of greater or less extent, though the hyperemias of the mucous membrane, so. constant during life, is very apt to disappear after death. The same is also true of the vascularity of the mucous coat of the stomach and small intestines. The air-pas- sages very often present pathological alterations. We sometimes see merely a vascularity of the lining mem- brane, at other times a thickening, and occasionally ulcer- ation. It is not uncommon to find the trachea and brou- chie filled with a thick, tenacious matter, of a muco-pu- rulent character. In a few cases I have discovered marks of inflammation about the lungs and pleura; but this is by no means of frequent occurrence, and, when present, are to be viewed as an accidental complication. Where leeching and venesection have not been practiced, the lungs will frequently be seen gorged with blood. In those cases attended with an acrid, sanious discharge from the nostrils, and where there is a tendency to the formation of a glutinous, brown sordes on the month and teeth, I have invariably found more or less extensive marks of disease about the brain ; and the former symp- tom, particularly, I have been led to consider as a highly dangerous one, from its indicating with great certainty such a complication. In these cases the vessels of the brain will be found injected, particularly the membranes, andHiere will be found an effusion of turbid lymph be- tween the arachnoid and pia mater, and also more or less serum in the ventricles. In the highly congestive cases, where death has speedily resulted, we find few marks of disease about the throat; but the blood-ves- sels of the larger organs, particularly the brain, lungs, and liver, will be distended with dark-coloured blood. Dr. Armstrong, in his work on scarlet fever, remarks, 'From the examination of several bodies after death, I am warranted in affirming that the brain, the liver, the stomach, the intestines, and the lungs are the parts most often inflamed, and that the inflammation in these parts is generally the cause of death, together with the affection of the throat' But I have examined many oases where in the worst forms of this disease most unsuc- cessful. This has arisen chiefly from our im- perfect knowledge of the successive patholog- ical changes produced by the scarlatinal poison, and from the varied character of these changes with the dose of the poison, with the constitu- tion and circumstances of the recipient, with the season and weather, and with the prevail- ing epidemic constitution. It must be obvious that, if the earlier changes produced by the in- fecting or poisonous agent be either misunder- stood or not recognised, the consecutive alter- ations will be very imperfectly, if not most in- juriously combated, and that our means of cure will be either inappropriately selected or mis- directed. When treating of fevers, I have in- sisted in several places upon the importance of promoting the secreting and excreting functions in all our attempts to preserve from, as well as to cure, these maladies ; for it is chiefly by such measures as promote the depurating action of the emunctories on the blood, through the me- dium of the organic nervous system, as shown in several parts of this work, that these great ends of practical medicine can be attained. 92* i. Preservative Treatment.—The fatal- ity of the more malignant types of this malady induced physicians to recommend means for the protection of those exposed to infection; and these means were more frequently advised, and more generally adopted in former times than at present. The uncertain efficacy or death could not/be said to have resulted from either of these causes, for in two of them the patient died within nine hours of the attack, and nothing but congestion of the larger organs could be discovered. In some of these cases of congestive scarlet fever, the symptoms bear a striking resemblance to those produced by the narcotic poisons; there is the same abolition of sense, and the power of motion, frequently combined with convulsions, a contracted pupil, and laboured, or even stertorous res- piration. The appearances on dissection are also the same. Hence 1 have been led to conclude that the con- tagious principle occasioning the disease is a specific vi- rus of a gaseous nature, which, being introduced into the system through the medium of the blood-vessels of the lungs, acts, as narcotics also do, either upon the brain or spinai marrow, or both. These notions are in a great degree assumptions, it is true; but if any one can invent a more satisfactory hypothesis, I should be very glad to adopt it " 2. Lesions ofthe Fluids.—With respect to lesions of the fluids in scarlet fever, so little progress has hitherto been made in animal chemistry that but little can be said with any degree of certainty. You are doubtless acquainted with Naumann's* hypothesis, which supposes that some change is wrought by the epidemic influence upon the properties of the blood, rendering its albuminous constit- uents incapable of being held in solution by the serum, in consequence of which the former exude upon the sur- face of the mucous membranes in form of a deposit, as we see about the throat and fauces in this disease. Again, it is the opinion of Donne that in scarlet fever the secre- tions become highly acid ; and, as Geddings remarks, if we admit as valid the opinion of Raspail that fibrin is merely albumen coagulated by an acid, we thus acquire a reason why the serum loses its power of holding the .al- bumen in a state of solution. But however this may be, there is most obviously a deterioration of the secretory and nutritive functions, owing, doubtless, to an impair- ment of the nervous energy. There is, consequently, a change in the constituents of the blood, either as to quan- tity or quality, or both, and a derangement of the vital: forces, which renders them incapable of speedily repair- ing such lesions as are the result ofthe inflammatory en- gorgement, or even of throwing off the disease when vi- olent in its attack. Owing to this same impairment of nervous power, there is a strong tendency to dissolution, both in the solids and fluids, manifested both by the rapid changes which occur after death as well as during life. "The above remarks apply to scarlet fever at every age." * Handbucb der Medocinischen Klinik. III. 48 754 SCARLET FEVI frequent failure of these means, and the hopes of escaping the more dangerous forms of the malady, probably induced a want of confidence in them, of which they are not altogether de- serving, especially in some circumstances in which the disease presents itself. 93. Dr. Withering remarks, that during the prevalence ofthe malignant form ofthe disease in 1778, when every one was alarmed for him- self or his connexions, means of prevention were anxiously inquired after. " Some smok- ed, some chewed, and others snuffed tobacco : some daubed their hands and faces with thieves'1 vinegar; many wore camphor at the pit of the stomach; and still more swallowed bark and port-wine. But those who were much conver- sant with the disease had too ample occasion to observe that none of these metbodo were ef- fectual." But Dr. Withering had his own no- tions of prevention, based upon a supposition as to the mode in which the poison invades the frame. He believed that the scarlatinal poison " first makes its lodgment upon the mucus sep- arated by the pituitary membrane lining the nose and fauces," and that those- who are exposed to the infection should frequently spit out the mucus that collects in the fauces and promote the discharge from the nostrils. He farther ad- vised those who already had imbibed the pois- on, and had experienced the premonitory symp- toms, "immediately fo take an emetic, frequent- ly to wash their fauces with soap-leys diluted with water, and to snuff something up the nose that will make them sneeze." After the oper- ation ofthe emetic he directed the patient to go to bed, and drink plentifully of wine whey with spirits of hartshorn. He states that a large ex- perience enables him confidently to assert that, if these precautions be attended to, the infec- tion will be either altogether prevented, or else very trifling in its consequences. 94. In the latest edition of Dr. Withering's treatise, and after an extensive experience, he adds, that the progress of infection may be stopped by precautions which may be adopted in almost every house. He had observed that, when boarding-schools were infected and the children were sent home, the disease was more widely spread ; and that he, therefore, adopted the suggestion of Dr. Haygarth, and had for several years past never thought it necessary either to break up a school or to disperse a pri- vate family. "Allotting apartments on sepa- rate floors to the sick and the healthy ; choos- ing for nurses the older parts of the family, or those who had already had the disease, and pro- hibiting any near communications between the sick or their attendants and the healthy, with positive orders instantly to plunge into water all the linen, &c, used in the sick-chambers, have universally been found sufficient to check the farther progress of infection." These rec- ommendations are deserving of adoption, and confirm the opinion which I have stated above (y 79). [I have in many instances adopted these or similar precautions where this disease has appeared in boarding-schools, and with the result of preventing its spread when early prac- ticed. Free ventilation, however, is essential to its success. Where a person has been ex- posed, I have reason to believe that the liberal use of spirits of nitre, with magnesia or spirits of mindereri, will prove very successful in pre- 3R—Treatment. venting a severe attack, and, in some instances, of arresting it altogether. The depurating or- gans should all be kept active, if we seek to avert a severe attack.] 95. Dr. Sims remarks, that the best prevent- ive of the disease was found by him to be rhu- barb, taken in the morning, in such quantity as should produce one loose motion in the day. He did not see one who used this confined aft- erward to bed, though several persons began it after they were infected, but before the time of their sickening. Dr. R. Williams consid- ers Dr. Sims's authority to be quite as veritable a3 that of Hahnemann, and his charm even more valuable than that of the latter. Proba- bly any single prophylactic, of whatever kind, owes much of the influence it may exert to the confidence reposed in it by the person who has recourse to it. • As fear favours, so does confidence resist infection ; and when the ob- ject of confidence is such as promotes the sev- eral assimilating, excreting, and depurating functions, without lowering vital resistance, it combines the virtue of a charm — of a mental agent, with its physical operation.* The hy- pothesis of Hahnemann is, thai diseases are best combated by remedies which produce mor- bid actions similar to those constituting the dis- eases themselves ; and, consequently, as bella- donna is capable of producing an efflorescence similar to scarlatina, that it is a preservative against this disease. He asserts that one eightieth part of a grain of belladonna, given twice a day, will preserve a susceptible per- son from an attack of scarlatina ; or that three grains ofthe extract dissolved in an ounce of distilled water, and three drops of the solution given twice daily to a child under twelve months old, and one drop more for every year above that age, will be sufficient for this purpose. It is possible that belladonna, by its irritant and al- terant effects (see art. Poisons, y 537, et seq.), may render the system insusceptible of the scar- latinal infection, independently ofthe principle or law for which Hahnemann has contended, empirically and absurdly, and in defiance of both reason and argument. It may possess this par- ticular virtue, by producing its specific effects, without furnishing any support to the irration- al doctrine, the monstrous absurdity, and the most nefarious practice, which he has origina- ted and promulgated—a practice which knaves alone can adopt, and to which fools only will submit. It is obvious that belladonna can ex- ert no protective influence until it produces, by the continuance of its use, or by its dose, its specific effects, and hence that, even admitting its efficacy, in virtue of these effects, it must frequently fail when it is not given in due sea- son. As to its efficacy, opinions, even in Ger- many, are much divided ; some, with Ettmcl- ler, Speun, Berndt, Koreff, Hufeland, &e, confiding in it; others, with Salzer, and sever- al besides, stating that they have found it inef- ficacious ; while many agree with Hildenbrand in treating it with ridicule. [We believe that our author has conceded too much in allowing that belladonna may, by its " specific" effects, prevent an attack of scarlatina. We would al- most as soon believe in Hahnemann's absurd- [* As this disease chiefly occurs among children, it can- not be supposed that fear or confidence have any great influence either in promoting or warding off an attack.] SCARLET FEVER—Treatment of the Mild. 755 ities as in that of the specificity of remedial agents, in the sense in which the term is gen- erally used. Such a belief is the corner-stone of the homeopathic doctrine, and neither con- sonant to reason nor facts. Belladonna may, like other active perturbating and depurating agents, prevent an attack of scarlet fever after exposure, either by a powerful impression on the nervous system, or by promoting the activ- ity of the secretory and excretory organs : in no other mode is such a result even conceiva- ble by a rational mind. It is by virtue of its al- leged " specific" effects, that Hahnemann sup- poses belladonna to be a preventive of this dis- ease ; but the mode in which this charlatan in- troduced this " specific" to the world as a se- cret preparation, sold at a Louis d'or per ounce, ought of itself to stamp it as one of those base attempts at imposition which from time to time appear, to disgrace not only our profession, but our common humanity. As to the efficacy of belladonna as a preventive of scarlet fever, there is but one opinion in this country, and that is of entire incredulity. Where the degree of con- tagiousness of a disease is subject to so many contingencies as this, and so little settled, it is unnecessary to attempt to show the fallacy of experiments made with this drug, as heretofore published. We have used it extensively for this purpose, but have never seen any good reason to believe that it possessed any more virtue than a hundred other articles in warding off an at- tack.] 96. Calomel was recommended by Kreysig and Seliq as a prophylactic, and as tending to lessen the severity of the attack, when it failed of averting it altogether. Theussink advised the calomel to be conjoined with the golden sulphuret of antimony. Eichel believed in the efficacy of emetics, as advised by Withering, especially when they are followed by diapho- retics. Several writers have recommended the mineral acids. I have reason to believe that the nitro-hydrochloric acids are not devoid of efficacy as a prophylactic, and that capsicum may be placed in the same category, especially when conjoined with small doses of camphor and quinine. The most certain prophylaxis is, however, to be found in the adoption of those measures which I have fully detailed in the ar- ticle Infection (y 55, et seq.), when treating of its prevention and counteraction, and in that on Pestilence, Protection from. 97. ii. Citrative Treatment.—It is obvious from what has been advanced, that the treat- ment of scarlet fever should be directed with strict reference, 1st. To the type and form of the disease; 2d. To the character of the pre- vailing or stationary epidemic constitution, as insisted on above (y 10); and, 3d. To the path- ological conditions, primary and secondary, to which I have endeavoured to direct special at- tention. With these objects in view, I shall first describe the means which are most appro- priate in the different forms of the malady; and next remark upon the several remedies which have been recommended by the best authori- ties, and the circumstances in which they may be most beneficially resorted to; Without fail- ing to give these authorities their due weight, I shall be guided chiefly by the results of my own observation and experience. 98. A. Simple Scarlatina—£. mitis—S. sim- plex.—Mild or simple scarlet fever (y 18) may require but little treatment beyond attention to ventilation and diet, and to the several excre- ting functions, especially if the febrile symp- toms be slight. If, however, the pulse is quick, sharp, or rapid, or the skin hot, the quantity, appearance, and character of the urine should be carefully examined, and if this excretion be scanty, and the fever considerable, although the disease may appear simple and regular, yet it. may assume, even in the course of a few hours, a much more severe form. If there be vomit- ing at the commencement; and more especial- ly if the retchings be attended by pain in the loins or limbs, and scanty or suppressed urine, an emetic should be exhibited, and its operation be promoted by demulcent diluents and warm diaphoretics, and the functions of the skin be promoted by the tepid bath. The action of the emetic tends both to remove the congestion of the kidneys either already existing or apt to supervene in these cases, and to determine to the surface of the body. If the patient be strong or plethoric, and if the prevailing epidem- ic constitution do not contra-indicate this meas- ure, a small or moderate cupping over the loins ; and, in different circumstances, dry-cupping in this situation, may be practiced if the symptoms are not mitigated by these means. The bow- els should be evacuated by suitable aperients —by pne or two doses of calomel and antimo- ny, followed by saline aperients, as the phos- phate of soda, dtc., taking due care merely to promote and to evacuate the secretions and ex- cretions without causing unnecessary irritation. 99. The chief intentions directing our prac- tice, in the milder cases of the disease, are, 1st. To prevent the increase of febrile action ; 2d. To promote the excreting and depurating functions ; 3d. To remove local congestions and determinations, whenever and wherever they occur ; and, 4th. To preserve or to restore the functions of the skin and kidneys after the subsidence ofthe eruption, and during the pro- cess of desquamation. If we fail in the com- plete fulfilment of these intentions, the indica- tions and means about to be described should be adopted, appropriately to the phases through which the disease may pass, and to the compli- cations which may supervene. Although the mild and regular form of the disease generally proceeds favourably, yet, owing to many dis- turbing causes, and not infrequently in conse- quence of the nimia diligentia medici, it may assume a serious or complicated form, more es- pecially when vital power is suddenly reduced, when excreting functions are interrupted, or when local determinations are favoured or oc- casioned.* * [We must caution the American practitioner against the use of active cathartics, as the saline aperients, sen- na, jalap, &c, in this form of scarlet fever, and especially against the use of antimony, which is an absolute poison in every form of this disease. Owing doubtless to a change in the diathesis of this as well as other exanthe- matous affections, active cathartic or emetic substances are now known to exert a very deleterious influence upon their progress, and should therefore be sedulously avoid- ed. We have known senna develop intestinal irritation, followed by diarrhcea, recession of eruption, and fatal col- lapse in numerous instances of simple scarlatina, which doubtless only required a mild, cooling regimen to have carried them to a successful result And so also of anti- mony, which is extremely deleterious unless given in very minute doses and with great caution. Castor oil, lemonade well sweetened, and sponging the skin with 756 SCARLET FEVER —Tre 1ATMENT OF THE ANGINOSA. 100. B. Scarlatina anginosa—5. inflammato- ria.—The more inflammatory types or states of scarlet fever generally require prompt and active measures. But it ought not to be over- looked, that the terms here employed to desig- nate the more sthenic forms of the malady are altogether arbitrary—that many mild, as well as all the malignant states of the disease, are anginous; and that, whether simple, regular, mild, anginous, or malignant, it may also be inflammatory ; the great and essential difference being the degree in which sthenic or asthenic action is present—in the amount of organic nervous or vital power, and in.the state of the circulating fluids. This type or form ofthe dis- ease requires a modified, or even very different treatment, according to the phases it may as- sume, and the grades of vascular action and vi- tal power, as different or individual cases pass through the various phases from the mild to the inflammatory, or from the simple and reg- ular to the complicated or malignant (y 20). 101. (a) In the more sthenic diathesis, or in- flammatory type, of this fever, an emetic of ipe- cacuanha, or of ipecacuanha and antimony, is generally of service, especially at an early pe- riod ; and its operation should be promoted by warm diluents. It is not the less beneficial when vomitings are already complained of, and the urine is scanty, and pains in the loins are present. In these latter circumstances, espe- cially when the pulse is full or strong, the ab- straction of blood from the loins by cupping, the quantity taken being such as the age, hab- it of body, and peculiarities of the patient will warrant, is generally beneficial; but bleeding from a vein is seldom of service—more gener- ally prejudicial, unless in the more sthenic di- athesis and robust constitutions. If generally adopted, blood-letting is a destructive practice, unless in rare epidemic visitations, when the prevailing epidemic constitution admits of the practice, with such limitations and cautions as the nature ofthe disease and.the peculiarities of the case suggest. During the stationary ep- idemic constitution, from about 1810 to 1820 or 1825, blood-letting, even in this disease, espe- cially in its more inflammatory types, was much better tolerated than subsequently ; and some writers considered their recommendations of it as sufficient to constitute it the chief remedy, in all circumstances, and for all time ; denounc- ing those who had preceded them for advising different means, although more appropriate for the types of the disease for which these means were employed. More recently, and since late writers have ascertained that blood-letting should be most cautiously employed, even in the most inflammatory type, cupping on the nape of the neck, or the application of leeches behind the ears, has been advised for the more sthenic anginous form ofthe malady, and often practiced by myself for many years. But when pain in the loins and limbs, and scanty, high- coloured, or otherwise "morbid urine, or sup- pression of urine, are present, I then have pre- ferred the abstraction of blood by cupping over cool or tepid vinegar and water, and guarding against cerebral determination by cool applications to the head, and occasionally a mustard pediluvium, with the spirits of nitrous ether internally, will be found all the treat- ment necessary in the mild form of this disease, great attention, of course, being paid to ventilation and clean- liness.] the regions ofthe kidneys, to an amount dicta- ted by the peculiarities of the case, and have prescribed the following embrocation, to be ap- plied by means of flannel or spongio-piline around the neck and throat; or either of the liniments in the Appendix (see Form. 295, 296, 307, 311) to be thus employed. If either of these applications produce external inflamma- tion or discharge from the surface, the conse- quences are never troublesome, as sometimea observed when blisters are used. No. 335. R Linimenti Terebinthinae, f ij.; Linimenti Camphors Comp., ?j.; Olei Olivre, 3iij.; Olei Cajuputi, 3j. m. Fiat Embrocatio more dicto utenda. 102. When the emetic action has subsided, the bowels should be gently or moderately evac- uated by means of calomel, either alone or with rhubarb or jalap, or with the addition of mag- nesia or the dried subcarbonate of soda; and followed by manna, salts, &c, in the infusion of roses or of senna ; or by castor or olive oil, according to circumstances ; or by equal parts of the compound infusions of gentian and sen- na, with the carbonates of soda and ammonia. 103. The great heat of skin in this state of the disease suggested a recourse to the affusion of cold water on the surface, as too strenuous- ly and indiscriminately advised by Dr. Currie. When I commenced practice I adopted this treatment in scarlet fever, and extended it to several other diseases, and certainly with more benefit in them than in this; for, in the more sthenic forms, it was soon followed by an equal, or even by an increased heat of the surface, and in the more asthenic conditions it appeared to favour the development of internal compli- cations : in most ofthe forms of the malady, it contingently favoured congestion of, or determ- ination of blood to, the kidneys, and thereby ag- gravated the disease. I therefore relinquished the practice, and substituted the tepid oath, or the cold or tepid sponging of the surface, using simple or medicated fluids for this purpose, ac- cording to existing states of the fever, and pre- ferring of the latter such as were emollient and alkaline. 104. After moderate evacuations from the bowels, saline mixtures or draughts, of a dia- phoretic and diuretic kind, in a state of efferves- cence, will always be agreeable, and tend tn moderate the febrile action, as the acetate or citrate of potass, with the acid in excess, in the more sthenic cases ; or the acetate or citrate of ammonia, with the ammonia in excess, in the more asthenic ; and with the spirits of ni- tric ether with either, will be generally appro- priate. In this form of the disease, gargles have been very generally recommended, and are sometimes of service when their compo- sition is such as suits the state of the case, Those which are cooling, or which contain the nitrate of potass, or the hydrochloride of am- monia, are the most grateful and beneficial. Children can use them only as washes for the mouth ; but they are useful as such ; and they may be injected into the mouth and throat of younger children ; or a clean sponge, attached to a piece of whalebone, may be moistened with them, and be employed to cleanse the mouth and throat from time to time. The infusion of roses or of cinchona, or decoction of cincho- na, or red wine and water, or camphor or rose water, may be employed as the vehicle for these SCARLET FEVER—Treatment of the Anginosa. 757 salts, or for the other substances which may be used in this manner. (See Form. 158-167, in the Appendix.) 105. A prompt recourse to the means now ad- vised will generally prevent the occurrence of the complications (y 27, et seq.) often met with in this form of the disease, more especially if these means secure a free excretion of urine. But if any local determination or complication arise notwithstanding; or if it have taken place before the treatment was commenced, the agents used for combating it should have strict reference to the existing state of vital power. Local depletion will often be of service when power is not much reduced; but we must not expect that the complication, however inflam- matory it may seem, is to be removed by de- pletions only or even chiefly. The patholog- ical source of these complications, as already explained (y 28, et seq.), will show the futility of the expectation. While the local depletion may tend to reduce the vascular fulness, local and general, means should be employed to rouse the action of the kidneys, to determine to the cutaneous surface, and to promote the secre- tions and other depurating functions. In the circumstances now being considered, there are no means more efficacious, especially in restor- ing the functions of the skin and kidneys, and in deriving from the seat of local affection, than flannel cloths coming out of hot water, freely sprinkled with the spirit of turpentine, or with the embrocation just prescribed (y 101), and ap- plied either over the epigastric and abdominal regions or over the loins. This epithem should be covered with oiled silk or with a warm nap- kin, so as to confine the fumes from it as much as possible to the surface ofthe body. In most of the complications of this form of the dis- ease, the bowels should be preserved in a mod- erately open state, by the means already men- tioned (y 102), or by castor or olive oil ; and their action may be promoted by the occasion- al administration of an enema, containing either or both these oils, with spirit of turpentine. The cooling diaphoretics and saline medicines advised above (y 104) may also be given from time to time in a state of effervescence, or oth- / erwise. If the bowels be irritated or too much ' relaxed, the liquor ammoniae acetatis may be ' given with the ammonia in excess, and with the tinctura comphoraa composita or the siru- pus papaveris ; and the epithem or embrocation already prescribed should be assiduously appli- ed over the abdomen. 106. (b) When the anginous or inflamma- tory form of scarlatina assumes more of the asthenic diathesis or type, and according as it approaches the malignant form, the treatment should be modified. In these states even local vascular depletion is either inefficacious or in- jurious. But emetics, especially early in the at- tack, are generally beneficial. The other means already stated are also of service, more partic- ularly the terebinthinated epithem or embroca- tion, and the saline diaphoretics; and, if conges- tions of internal parts take place in this state of the disease, the epithem or embrocation should be energetically employed. If an aperient be required, a moderate dose of the spirit of tur- pentine should be added to the oils, advised above (y 105), and be administered by the mouth, or as an enema, as the circumstances of the case will suggest. In the less urgent or dangerous cases of this form, and in the com- plications which may supervene, the internal and external means already recommended will generally be appropriate ; but the urinary ex- cretion should always receive attention ; and when it becomes scanty or suppressed, an ipe- cacuanha emetic should be given, and the ter- ebinthinate epithem or embrocation be applied over the loins, and the spiritus aetheris nitrici and liquor ammonias acetatis be prescribed in sufficient quantity. In proportion as the case assumes, either primarily or consecutively, a malignant character, so ought the means about to be advised for the next form of,the disease to be employed. [The treatment of this form of scarlatina, as above directed, appears to us far more act- ive than the disease often requires or will safely bear in this country. More die in this malady from the nimia diligentia of the physi- cian than from the disease itself, and we there- fore deem it our duty especially to caution the young practitioner against active medication; the experienced physician needs no such ad- vice. With regard to general blood-letting, we have met with no cases for several years which would justify its employment, and leech- es and cups for the throat affection prove, ac- cording to our experience, far less efficacious than local applications of a solution of nitrate of silver frequently repeated. We must pro- test entirely against antimonial emetics, or ca- thartics of " jalap," " senna," or " salts"—none of these can be safely administered in any form of scarlet fever, as it prevails at present, or has for several years past. Twenty years ago, we found the disease would bear bleeding and these active medicines far better than at present, and in an extensive dispensary practice were in the habit of resorting to them, until from change of diathesis, or some other cause, we were com- pelled to adopt a milder and less perturbating course of treatment. The inflammatory com- plications, which so often exist, do not yield to depletion as they formerly did, but, on the con- trary, are aggravated by it. The injection of the capillary system, occasioning most of the phenomena of inflammation, is doubtless owing to depressed nervous energy, leading to loss of tone in the vascular system, and is to be combat- ed by a mild cordial and supporting course, and not by means calculated to lower the nervous power, and thus indirectly augment the existing local congestions. As above noticed, the local application of nitrate of silver will, when prac- ticable, be found one of the most important modes of meeting this indication, to be aided, of course, by mild stimulants, diuretics, and di- aphoretics, and other secretory excitants. Gar- gles can hardly ever be employed with much ef- fect in diseases of children, and we must there- fore trust to applications made by the physi- cian. Tepid sponging will prove equally bene- ficial with cold affusion, without being attend- ed with any of its dangerous consequences. If the excitement is very high, one fourth of a drop of the saturated tincture of aconite may be given in water every hour to a child of three or four years, until the arterial action, heat, to in- creased action, especially the skin and bowels. The existence of coma or convulsions should not prevent the administration of emetics, when the measures just advised have failed ; for the emetic action both rouses the action ofthe kid- neys and determines to the surface of the body, while it procures a discharge of fluid from the digestive mucous surface, thereby relieving the vascular system from a portion of the serous fluid over-distending it, and congesting the ves- sels ofthe brain. 119. (/) The appearance of either ofthe af- fections of the lungs, bronchi, or pleura (y 37, 38), or even of the peritoneum (y 39), which often complicate the severer cases of scarlatina, es- pecially the forms unattended by eruption, re- quires both judicious and prompt measures. If either occur during the eruptive stage, and more particularly if it be followed by the sud- den disappearance ofthe eruption, local blood- letting is generally necessary ; but the quantity of blood which may be taken, and the propriety of taking any, as in all other circumstances, should depend upon the state of the pulse, upon the existence of deficient vital power, or of putroadynamia, and upon the state of the urin- ary function. Cupping, or the application of leeches, followed by dry-cupping, and the tere- binthinate embrocation or epithems, assiduous- ly or repeatedly applied, are the principal means of cure. But we should not confide too much in vascular depletion even in these complica- tions, especially in some epidemics, and in cer- tain localities which depress vital power and render the disease either malignant or compli- cated (y 85). The external applications just mentioned are often more beneficial than any other means, especially when aided by appro- priate internal remedies, as the liquor ammo- nia acetatis, spiritus aetheris nitrici, and mod- erate doses of camphor. It sometimes becpmes a question as to the situation in which local de- pletion and external applications should be em- ployed. If in these complications, as not infre- quently observed, the urine is either suppressed or very scanty, or bloody, or albuminous, the local affections being the consequences of ob- structed elimination and depuration by the kid- neys, the loins are the situations in which these means should be applied, especially in the first instance ; but otherwise over or near the chief seat of local complication. In other 762 SC\RLET FEVER—Treatment op its Sequels. respects the treatment may be the same as just advised for coma or convulsions (y 118).* 120. G. The sequela of scarlatina axe some- times more dangerous than the primary dis- ease. The consecutive affection is generally caused by errors in diet or regimen during the process of desquamation, and during recovery ; and the treatment should, therefore, be direct- ed with reference to these causes. During early convalescence the digestive functions are weak, and the primary processes of assimilation are imperfectly performed, unless the nature and quantity of the aliment be such as will be readily and perfectly disposed of. As the ap- petite during convalescence is greater than the power of digestion, food is often taken of a kind and quantity furnishing a chyle unsuited, owing to imperfect digestion, to the state of the blood, and which, in conjunction with the large proportion of effete materials, absorbed from the various tissues and surfaces, and car- ried into the blood during the advanced stages of the disease and during convalescence, ren- ders the blood either too irritating or other- wise injurious to the excreting structure ofthe kidneys;,and this effect upon these organs is heightened by the interruption to the elimi- nating or depurating function of the skin dur- ing early convalescence, the kidneys thus sus- taining, during this period, the whole burden of depurating function, at a period, moreover, when the blood most remarkably and unusually abounds in hurtful and irritating materials de- rived from imperfect assimilation, and from the absorption and accumulation of effete mole- cules and structural elements derived from the several tissues — these elements or materials constituting the urea, uric acid, animal extract- ive matters, &c, forming the products of a de- structive assimilation, or the ultimate products of animalization. It must be further manifest that if the blood, thus loaded with effete or ir- ritating materials, be determined in unusually increased quantity to the kidneys by exposure to cold, by damp clothes, or insufficient cloth- ing or other causes, even by great humidity of the air, these organs will sustain, as respects their minute excreting structure, more or less irritation or other injury, interfering with or interrupting their eliminating function, the blood thereby becoming still more impure, and consisting of an increased proportion of watery and extractive constituents, as already more fully contended for (y 28, et.seq.). These causes and their effects upon the frame—the primary effects now shown, and the secondary effects, constituting the several sequelae of the malady —being manifestly and certainly those just stated, it follows, that the means most appro- priate to the removal of the secondary effects or sequelae are such as will most efficiently re- * [It is scarcely necessary to add anything to the very full history above given of the treatment of the various forms of this singular malady. It is impossible to give directions of uniform application, owing to the infinite shades of difference it assumes in different cases. Every- thing must therefore depend on the judgment of the prac- titioner and his skill in meeting existing indications. The congestion of the kidneys is a feature in the affection too much overlooked or disregarded in this country, and we would therefore call particular attention to the. patholog- ical condition of these organs in the treatment. Cups and leeches to the loins, as enjoined by Mr. Copland, should more frequently be resorted to in addition to the other means already recommended.] move the causes and primary changes which produce the secondary effects or sequelae, what- ever these latter may be. 121. Conformably wUh these pathological principles, the treatment should be directed, 1st. To the state of the kidneys, as indicated by the condition of the urinary function and excretion, and by other signs or symptoms; 2d. To the causes, extrinsic and intrinsic, re- mote or pathological, of the state of these or- gans ; and, 3d. To the secondary affection, or sequelae, resulting generally either from the persistence of some lesion which originated during the course of the malady, or from the affection of the kidneys caused as just shown (y 120). 122., (a) The prevention of the affection of the kidneys, upon which the most frequent of the secondary diseases or sequelae of scarlet fever chiefly depend, should be a principal object in the treatment of this malady. During desqua- mation and early or advanced convalescence —for a month at least after the disappearance of the eruption—the patient's diet and regimen should be strictly prescribed, however rnild the disease may have been. The food should be bland, light, and digestible, chiefly farinaceous, so that as little as possible of the irritating materials to the kidneys should accumulate in the blood. The beverages of the patient ought also to be of a bland or demulcent kind, and consist chiefly of soft or distilled water, wine and malt liquors being avoided. Exposures to cold, currents of air, to humid and cold states of the atmosphere should be carefully prevent- ed, and the clothing ought to be warm. The due restoration of the functions of the skin should be attempted early in the stage of des- quamation by recourse to tepid or warm baths, in which a quantity of the sub-carbonate of soda or potash, or biborate of soda is dissolved; and the secretions and excretions duly promot- ed by purgatives or aperients, and by diapho- retics. By attention to these, the sequelae of scarlatina proceeding from obstruction of the kidneys will rarely beebserved. 123. (b) If, notwithstanding these precau- tions, or owing to the neglect of them, the state of the urinary excretion or other symp- toms indicate congestion or obstruction of the kidneys (y 49), the treatment should be direct- ed chiefly to these organs. Unless the consti- tutional powers have been, or still are, ex- tremely depressed, the antiphlogistic regimen, medicinal and dietetic, ought to be adopted. As this affection is so often the result of over- feeding during convalescence, or of a too early recourse to animal food and exciting bever- ages, these causes should receive due atten- tion ; and if the mischief can be referred to them, not only ought they to be prevented, but the removal of the disorder should be attempt- ed chiefly by means of local depletion from the loins, of purgatives and diaphoretics, by the tepid and warm bath, and by terebinthinate ep- ithems or embrocations applied over the re- gions of the kidneys. The vascular depletion may even be repeated, for it is not unusual to find the sequelae of scarlatina to require, and the patients affected by them to tolerate, the bleeding more than in any of the previous sta- ges of the malady. 124. (c) When anasarca or effusion, into any SCARLET FEVER—Remarks on Remedies for. 763 serous cavity, or from any serous surface (y 50 -55), is consequent upon this disease, in the manner now shown, the effusion, in whatever situation it may occur—between the mem- branes, or in the cavities ofthe brain, in the pleura or pericardium, in the peritoneum, or in the capsules of the joints—is the consequence of active determination of blood to, or of irri- tation of, these membranes, caused by vascular excrementitial plethora, as above contendedibr (y 28, 120); and if it should occur independent- ly of these states of vascular action, it may be admitted as a very likely means to excite these states, owing to the morbid or irritating prop- erties possessed by it, especially when it is re- tained long in any of the cavities formed by these membranes ; so that upon post mortem examination it may be difficult to determine whether or no such inflammatory appearances as are found are actually the cause or the ef- fect of the effusion: it is not improbable that they are in some measure both the one and the other. But it is not merely effusion into shut cavities which may follow upon obstruction of the urinary and cutaneous excretions after scarlatina, but a form of congestive inflammation of parenchymatous organs ($ 57), characterized by more or less cedema ox serous infiltration of the affected organ, may supervene, or this lat- ter affection may be associated with serous ef- fusion into the adjoining serous cavity — an as- sociation which.is frequent, and although the extent of the internal lesion may escape detec- tion during life, or the one part ofthe mischief may mask the other, examination after death discloses the combination. I have on several occasions found, on inspection of cases of this description, the lungs condensed more or less by the infiltration of a watery lymph, and serous effusion in both pleural cavities ; and in other cases the substance of the brain vascular, wa- tery, or oedematous, although there existed also serous effusion into the ventricles and between the membranes. These are among the chief lesions which destroy life after attacks of scar- latina, and are merely the remote effects ofthe arrest of the eliminating or depurating func- tions, to which I imputed so great importance many years since, in the articles on the Blood, Disease, Fever, &c. 125. It is obvious that the treatment of these affections ought not to be directed to them only or chiefly, but to the pathological causes or states of which they are the affects—to the ob- structions of the kidneys and skin. However much blood-letting may be indicated by the state ofthe pulse and other circumstances of the case, a chief dependence ought not to be placed on it, even when apparently most re- quired, but other active agents should be brought into operation, more especially purga- tives, the tepid or warm bath, medicated as above (y 122), terebinthinate epithems or em- brocations over the loins or seat of local affec- tion, after local depletions in either or both sit- uations, and diaphoretics, followed by diuretics. These means are appropriate in the several se- quelae of scarlatina, the chief differences as re- spects either sequelae being the extent to which each of them may be employed, and the suc- cession in which they may be prescribed so as to obtain the greatest amount of benefit. Aft- er vascular depletions have been carried suffi- ciently far, dry-cupping will then be of service ; and after terebinthinate epithems have been ap- plied, oleaginous purgatives and enemata may be administered, containing spirit of turpen- tine iii sufficient quantity to excite the organic functions, to restrain effusion, and to stimulate the kidneys. In most respects the treatment of the sequelae of scarlatina is the same as that of the complications (y 114, et seq.); and it should be based on the same pathological and therapeutical principles. 126. (d) I have noticed among the sequelae of this malady, the extension of disease to the ear, to the cervical vertebra, &c, to the parotid glands, the surrounding cellular tissue and lym- phatic glands, &c. (y 46-48), giving rise to more or less chronic disease of these parts ; but it is unnecessary to add, at this place, anything to what has been stated respecting these lesions in the articles Cellular Tissue (y 34, et seq), Ear (y 29, 30), Paralysis (y 29, et seq.), Paro- tids (15, et seq.), and Spine. It has also been remarked that affections ofthe large, but more frequently of the small joints (y 57), or even of both, may occur at any period after the subsi- dence of the eruption ; and that erysipelas, or even gangrene of an extremity, may thus super- vene- When the joints axe affected, the syno- vial membranes are the chief parts implicated, and generally in consequence ofthe same path- ological conditions as have been shown to orig- inate with the emunctories; and these condi- tions, by contaminating the blood, affect these parts in an analogous manner to the affection of the serous membranes ; and in some in- stances, and in certain epidemics especially, give rise to severe pains, resembling those of gout or rheumatism of the joints. In these cases the treatment should not vary much from what has been advised for articular rheumatism or gout. Generally warm anodyne fomenta- tions, or a combination of these with terebin- thinate embrocations, and the use internally of the means already advised, and particularly of such as the state of the urinary excretion will suggest, are sufficient to remove this consec- utive affection. If erysipelas or either of its consequences should appear, the treatment for that disease ought to be adopted. 127. iii. Remarks on certain Remedies ad- vised for Scarlatina.—After the full exposi- tion of the treatment ofthe several forms, compli- cations, and sequela of scarlet fever, which I have endeavoured to give, my remarks on this head will be brief, and be confined to those means which are most important. — (a.) Blood- letting, either general or local, or even both, have been recommended by Borsieri, Schra- der, Grundmann, Armstrong, Craigie, and many others ; but the impropriety of having re- course to it generally, or even frequently, in some epidemic prevalences of the malady, has been demonstrated by very numerous authori- ties. It would be improper to decide categor- ically either in favour or against the practice ; for the character ofthe prevailing epidemic con- stitution, of the existing form or type of this fever, and the several circumstances ofthe case and of the patient, may render vascular deple- tion either most beneficial or most injurious. The propriety ofthe practice and the bei.efit re- sulting from it must necessarily depend upon the judgment ofthe physician, as respects not 764 SCARLET FEVER—Remedies prescribed for. only the peculiarities of the case that especial- ly require it, but also the extent to which it should be carried, and the period and mode in which it should be resorted to. If the practice be adopted sufficiently early in the attack, and be aided by judicious means, local bleeding by cupping over the loins will be sufficient. A quantity of blood, as large as the exigencies of the case can require, may be taken in this way, and with a more decided effect as respects the organ which is most concerned in develop- ing the most serious complications and symp- toms of the malady, and in producing those changes which are usually termed malignant. In very young children a few leeches may be substituted, but the quantity taken by cupping is correctly ascertained, and haemorrhage is pre- vented from being troublesome. The loss of blood in this way is also less felt, and less in- jurious than by venesection, in doubtful cases ; and even when early employed in those cases or epidemics which seem to contra-indicate the propriety of it, much less injury results-from this mode than by any other. 128. (b) Emetics have been strongly recom- mended by Fothergill, Withering, Stoll, Johnstone, Clark, Lentin, Hufeland, and many others ; but they have been unaccounta- bly neglected in modern practice. I can as- sert that there is no remedy more generally ap- propriate—so suitable to all forms of the dis- ease, if the substance be duly selected, and the periods of exhibition altogether proper. In most instances an emetic should be given as early as possible, and when given thus early, and before the type or character of the disease has fully declared itself, then ipecacuanha, or this with sulphate of zinc, may be preferred. When the disease is more fully developed, and assumes a sthenic or inflammatory character, then emetic tartar, or a combination of this with ipecacuanha, may be prescribed, and cupping over the loins to an amount indicated by the symptoms and its effects may precede the emet- ic. When the disease presents malignant char- acters or manifest adynamia or putro-adynamia, then sulphate of zinc with capsicum, &c, may be preferred, and dry-cupping only be employ- ed. An early recourse to emetics frequently prevents the occurrence of inflammatory symp- toms on the one hand, and of malignancy on the other. But the exhibition of them, espe- cially ofthe one last named, should not be con- fined to the earlier periods of the malady. The state of the throat, or the extension of dis- ease to the larynx, may require a recourse to this practice oftener than once during the course of the disease; and in the low or advanced states of the malady the combination of the emetic, whether ipecacuanha or sulphate of zinc, with stimulants and hot spices, will be of advantage. When tartar emetic is prescribed as an emetic in divided doses for children in scarlatina, it sometimes fails of producing this effect, and if the exhibition of it be persisted in, even for a short time, it may produce dan- gerous or even fatal sinking, although the form of the disease may have been more than usual- ly sthenic or inflammatory when it was first prescribed. 129. (c) There are few remedies which re- quire more judgment in their exhibition and se- lection in scarlatina than purgatives and aperi- ents ; for if they be given at the period of erup- tion, especially when the efflorescence is being evolved, they may interrupt the regular course of the disease ; and if they be too long omitted, the retention of morbid secretions and excre- tions may be equally detrimental. If, again, they are of a too irritating kind they may develop an enteric complication, or, in the more asthen- ic forms, seriously depress or exhaust the pa- tient. They are often exhibited with much benefit, as already advised (y 102, 165), after an emetic has operated, when the patient is first attacked, and before the eruption begins to ap- pear. After this period, or during the erup- tion, if the disease assumes a regular course, mild aperients, sufficient merely for the preven- tion of accumulations of the excretions, are only required. If, however, determinations to the head or suppressed function ofthe kidneys supervene, then the more active purgative, con- joined with calomel, terebinthinate enemata, &c, already mentioned, are of service. When the^disease assumes an asthenic or malignant form, the purgatives should be conjoined with tonics, stimulants, and aromatics, as with cin- chona, cascarilla, gentian, ammonia, spices, &c. In the more regular forms, purgatives are gen- erally of greater service upon the disappearance than during the continuance of the eruption, and in every circumstance the combination with them of the alkaline carbonates or sub-carbon- ates is most beneficial. The indications for or against a recourse to purgatives, and the choice of them, depend upon the type, form, and complication of the disease, and upon the states ofthe alvine functions and evacuations, which ought to be always carefully examined. 130. (d) Preparations of cinchona and other tonics have been much employed in the treat- ment of the malignant and asthenic scarlatina; and in these forms especially, after the exhibi- tion of emetics and after morbid secretions and excretions have been duly evacuated, and after cupping or dry-cupping has been employed, in cases requiring either or both, these medicines are most beneficial; much, however, depend- ing upon the selection and combination of them with other means. Vascular depletion early in the disease may be beneficial, and yet the exhibition of tonics may be imperatively requir- ed at a more advanced period. But a recourse to the latter should very much depend upon the state of the urinary function. Most of the ear- lier writers on the disease since the time of Morton, and especially those who observed chiefly the more malignant types, have insisted much upon the necessity of recourse to cin- chona, in the forms either of powder, decoction, or tincture, especially Huxham's tincture. But even in these types this medicine is best pre- scribed as just advised ; and if the urine be sup- pressed, bloody, very scanty, and very high- coloured, cupping even in these ought to pre- cede the administration of this remedy. In ca- ses which suggest doubts of the propriety of having recourse to it, the infusion or decoction, conjoined with the iiquor ammoniae acetatis, with the acid or with the alkali in excess, or with nitrate of potash, according to the pecul- iarities of the case, and with spirit of nitric ether, will never be injurious, but most fre- quently very beneficial. When symptoms of malignancy are unequivocal, and the urine not SCARLET FEVER—1 -Remedies advised for. 765 suppressed, the decoction with the compound tincture of cinchona, or with tincture of serpen- taria and carbonate of ammonia, and sometimes also with the bicarbonate of potash or soda, will be of service ; or the mineral acids, espe- cially the hydrochloric or nitro-hydrochloric acid, with the ethers, may be given in the decoction of the cinchona when the urine indicates the propriety of exhibiting these in preference to the alkaline carbonates. If the bark affect the bowels, the cascarilla or willow bark may be substituted, or salicine may be employed. Oth- er tonics, or tonic febrifuge preparations, may be prescribed in mild cases; but in the malig- nant type, these just mentioned, or the sulphate of quina conjoined with camphor, and other substances noticed when treating of the malig- nant form of the malady (v 107, et seq.), axe most deserving of adoption. 131. (e) Stimulants are required in the as- thenic forms ofthe disease, and often at an ad- vanced stage of the more sthenic type, but gen- erally in conjunction with other means. The sesquicarbonate of ammonia was strongly recom- mended by Peart, and is certainly often most beneficial when combined, as above advised, ac- cording to the peculiarities of individual cases. It is frequently prescribed in too small, and con- sequently in inefficient doses ; and the same re- mark applies to the ethers and their preparations. When a tonic and antiseptic effect is desired, ammonia should be conjoined with the prepa- rations of cinchona and camphor; and when a diaphoretic action is indicated it should be given with the solution of the acetate of ammo- nia and spirit of nitric ether. The ethers are most useful when the patient complains of sink- ing faintness, or leipothymia. With quinine and compound infusion of roses, sulphuric ether may be preferred ; and with the decoction of bark and hydrochloric acid, or the nitro-hydro- chloric acid, hydrochloric ether may be prescrib- ed. The chlorate of potash may be conjoined with tonic infusions or decoctions, or with al- kaline carbonates and ether ; and in the more malignant states of the disease these medicines should be ordered in frequently repeated doses, and be farther aided by camphor, musk,-serpen- taria, or capsicum. The combination of cam- phor with spiritNof Mindereri was much confi- ded in by Hufeland in this class of cases. A recourse to wine, or even to brandy, in the forms mentioned above (y 109), may not only be of service, but even indispensable, in the more as- thenic and malignant states ofthe disease. 132. (/) Diaphoretics and diuretics are med- icines of great importance in this disease. The functions ofthe skin and kidneys are interrupt- ed by the active vascular congestion, and by the alteration ofthe organic nervous influence of these parts, and therefore, while means are being used to equalize the circulation and to re- lax the cutaneous surface, medicines should be prescribed to aid these intentions, and to rouse the secreting and depurating actions of these organs. In the more sthenic or inflammatory types, and at the commencement ofthe disease, the antimonial diaphoretics, conjoined with the solution ofthe acetate of ammonia and spirit of nitric ether, or with nitrate of potash, will generally be of service, even although they may fail of materially promoting the functions in question. But, in other states of the malady, diaphoretics of a warm and restorative nature, or a combination of the more common diapho- retics with stimulants and antispasmodics, as with ammonia, the ether. &c, especially after the tepid or warm bath has been resorted to, will be found most beneficial. 133. Diuretics should be given in similar com- binations to those now advised, in the asthen- ic or malignant form of scarlatina ; but in this form, and in the advanced stages more espe- cially, the most certain diuretic is the spirit of turpentine administered in an enema, or the terebinthinate epithem or embrocation applied over the loins, as already mentioned. During desquamation, when the kidneys are frequently congested or the tubuli obstructed by the des- quamated epithelium, the supertartrate of pot- ash and biborate of soda, or the acetate or cit- rate of potash with either the acid or the alka- line carbonate in excess, or any of the saline diuretics, or others mentioned in the article Dropsy (y 135, et seq), when describing the treatment of anasarca, will be appropriate. 134. (g) Besides the above, various means have been recommended by writers, in the treat- ment of scarlatina, as either empirical reme- dies or as antiseptics and stimulants. The most serviceable of these, when judiciously em- ployed, are the mineral acids, the alkalies, and certain vegetable acids and products. Of the mineral acids, the most beneficial are the hydro- chloric and the nitro-hydrochloric, either in sim- ple dilution, or conjoined with the decoction or infusion of cinchona, or with camphor, or with these and the hydrochloric ether. Of the vegetable acids, the acetic and the citric are the most useful. The former has been frequently employed both internally and externally, since the earliest irruptions of the malady in an epi- demic form, chiefly on account of its antiseptic property; and with reference to this virtue I have often employed it; but more recently I have preferred the pyroligneous acetic acid, ei- ther combined as above, or given with crea- sote or other antiseptic agents, in the more malignant states ofthe disease. Citric acid is also beneficial in similar circumstances; but while I have considered it as preferable to the common acetic acid, I have believed it inferior to the pyroligneous. Either of these acids is often beneficial; but the vegetable acids now recommended should be given more liberally than they usually are. 135. Chlorine and the chlorides are also very excellent remedies in the more malignant states and advanced stages of scarlatina, their influ- ence being aided by other restorative means, as cinchona, serpentaria, camphor, musk, cap- sicum, &c. Chlorine was first prescribed by Braithwaite ; and its excellent effects in the more malignant states ofthe disease have been acknowledged by many British and foreign au- thorities. The chlorine-water of the Dublin Pharmacopoeia may be given in doses suitable to the age of the patient, in camphor mixture, or in any other proper vehicle. Alkaline car- bonates, both the volatile and the fixed, have been recommended by many authorities in scar- latina. They may be prescribed with the rem- edies just named, and in the states of the dis- ease, and in the combinations mentioned above (y 108). Nitrate of potash, in full and frequent doses, has been advised by Fkunk ; and it is 766 SCARLET FEVER—Remedies advised for. often of service when associated with other means which are appropriate to the peculiari- ties ofthe case, more especially with camphor and others already noticed. The use of colchi- cum has recently been recommended ; but it is a hazardous agent even in the more sthenic forms ofthe malady, as its injurious operation is liable to be confounded with the unfavoura- ble course of the disease. It should be given only in similar states and circumstances of the case to those for which I have admitted that the tartrate of antimony may be prescribed. 136. (h) Gargles, or, preferable to these, stimulating lotions or washes, with a strong solution of the nitrate of silver, or of powdered alum in the pyroligneous acid, are often ex- tremely beneficial, when employed early in the anginous form of the malady, especially when the affection of the throat assumes an asthen- ic, malignant, or Offensive character. Either of these solutions, or others already mention- ed (v 109), should be applied early by means of a camel's-hair brush, or of sponge, in the manner already pointed out; and the solution should be strong in proportion to the malignan- cy of the affection. At the same time as these means are being used, the external applications to the throat, about to be noticed (y 140), should be resorted to, and the tonic, restora- tive, and antiseptic medicines mentioned above ought to be administered. A strong solution of the bichloride of mercury has been recom- mended by Dr. Sauter to be used as a gargle in the more asthenic affection of the throat; and, judging from my experience of it as a gar- gle in analogous affections of this part, it is very likely to prove of service. In some of the more prolonged cases, and when the tonsils are much enlarged, I have directed the parts to be pencilled with the tincture of iodine, and if there be, as often observed, much external swelling after the eruption has disappeared, I have prescribed the same application exter- nally. In less malignant cases, the chloro-so- daic solution of Labarraque, in the proportion of an ounce to five of camphor water and half an ounce of honey, is a very useful gargle ; or the decoction of contrayerva with hydrochloric acid and tincture of capsicum ; or a filtered so- lution ofthe confection of roses with the same acid and tincture, or the tincture of myrrh, and camphorated spirit, may be employed in still less severe forms of the disease. 137. (i) Cold, in various modes of applica- tion, has been resorted to for the removal of the pungent heat of the surface, which is be- lieved to increase not only the distress of the patient, but also the vascular action and the exhaustion of organic nervous power. It may always be safely applied when the skin is very hot and dry. Various modes of employing it have been advised. Beddoes directed a free current of cold air to pass over the patient. But in resorting to this mode of reducing the temperature of the surface, the respiratory pas- sages and organs may suffer, and the compli- cations described above, especially bronchitis, pneumonia, pleuritis, or peritonitis, may there- by be occasioned; or the eruption may be sup- pressed. The obvious benefit resulting from treating the patient in a large, airy apartment, where the temperature is cool rather than very cold, and in which the air is being continually i renewed, should never be overlooked ; and the I bed and bed-clothing ought to be cool and light, ' especially during the eruptive stages ; but sub- I sequently both the one and the other ought to be so regulated as to favour the restoration of the cutaneous functions, and to equalize the I due distribution ofthe blood. 138. The affusion of cold water over the sur- face of patients in scarlatina, so strenuously advised by Dr. Currie, and so generally and in- discriminately practiced during the commence- ment of this century, has been found beneficial early in the more sthenic and regular forms of the disease. But an injudicious recourse to this practice in asthenic, malignant, and com- plicated cases has brought it into disrepute. In the hands, however, of a discriminating phy- sician— of one capable of interpreting aright existing pathological states, and of selecting and applying judiciously medicinal agents for the removal of these states—the cold affusion is still deserving of estimation. I have, how- ever, preferred in most circumstances cold or tepid sponging, of the surface, adapting the tem- perature, and the fluids employed, to the pecul- iarities of the case—cold or cool fluids at an early stage and in sthenic cases, and tepid, or even warm fluids, at an advanced period, and in the asthenic or malignant forms, whenever the skin is hot and dry. These are in many re- spects preferable to affusion, for they may be more frequently resorted to, and may be em- ployed for a longer time, without exhausting the patient. The fluids which may be selected for this purpose deserve some notice. I have usually directed equal parts of vinegar and wa- ter, or of spirit of Mindereri and water, or cam- phor water, during the early stages; but have subsequently employed a weak alkaline solu- tion, or a solution of borax, as being more like- ly to facilitate the restoration of the functions of the skin during the advanced stages, and to prevent the affection of the kidneys and the dropsy often supervening as sequelae of the disease. Frequent sponging of the surface with a solution of the nitro-hydrochloric acids, of a tepid or warm temperature, according to the state of the case, will be found of much service in the malignant and asthenic forms of the malady. 139. (i) Baths, tepid or warm, according to the period of the disease and the peculiarities of the case, are often beneficial. The tepid bath, in the earlier stages, generally lowers the heat of the skin, mitigates the uneasiness and burning attending the eruption, and relaxes the surface. When the disease is farther ad- vanced, especially if it be complicated, then the warm bath may be preferred; and when the eruption has suddenly or prematurely disap- peared, salt and mustard may be added to the water. If a warm bath be required during desquamation, or if any of the sequelae of the disease supervene, the alkaline sub-carbonates, or the biborate of soda, will be a very useful ad- dition ; and if the complication be of a very se- rious character, mustard may be added. A fre- quent recourse to warm baths, during desqua- mation, will generally prevent the sequelae of scarlatina, especially if the alkaline additions just mentioned be made to the baths. 140. (k) Embrocations and external applications of various kinds have been employed; but they SCARLET FEVER—Biblic are required chiefly for the severer states, and internal complications ofthe malady ; or when the eruption either does not come out, or pre- maturely disappears. Blisters axe most hazard- ous applications for children in this disease, and are generally so in proportion to their youth.* In the mild and regular forms they are not required, and in the malignant or compli- cated may produce gangrene of the part. They are sometimes of service in adults, especially at an advanced stage, and when due reference is made to the state of the urine. Mustard poultices axe often of use in the circumstances just mentioned ; but in the more malignant type of the disease, in very young subjects, they may be followed by effects almost as dangerous as those produced by blisters, if they be too long or injudiciously applied. The embrocations and epithems prescribed above (101) and in the Appendix (Form. 295, 296, 307, 311) are the most efficacious, and are attended by none of the risks and ill effects often produced by blis- ters, and other external derivatives and coun- ter-irritants. When properly employed, espe- cially soon after a warm or tepid bath, they powerfully promote the functions of the skin ; and, by the absorption of their fumes, chiefly by the lungs, they tend to restore the secreting and excreting functions generally. The application of these, in the several states of the disease, has been pointed out in the remarks already offered. 141. (1) The diet and regimen of the patient must depend, in some measure, upon the type and the stage ofthe disease, upon the peculiar- ities of the case, and the circumstances of the patient. In the more regular, sthenic, or in- flammatory forms, and in the more complicated cases, especially if the complications occur at an early stage, the diet and regimen should be antiphlogistic. Barley-water, thin water-gruel, &c, are generally sufficient during the earlier periods; but afterward, and from the com- mencement in the more asthenic or malignant types, Seltzer or soda water with milk may be given ; and as the disease proceeds, or begins to assume putro-adynamic or malignant charac- ters, spruce-beer, soda-water, or Seltzer-water with wine; sago, arrow-root, or tapioca with wine, or even with brandy in some cases, may likewise be prescribed; beef-tea, chicken or other broths being also allowed, according to circumstances. Due ventilation should always be insisted on, avoiding, however, currents of air, especially during desquamation; the bed and bed-clothes being regulated according to the type, character, and stage of the disease, as above advised (y 97, et pluries). In order to prevent the usual sequelae of the disease, dur- ing desquamation and recovery, the diet and regimen of these periods ought to be strictly prescribed, conformably with the advice al- ready given (y 120-123) ; and if anemia or much debility be observed, the treatment prescribed for these, in the places referred to, should be adopted. (-See arts. Blood, Deficiency of (y 48), and Debility (y 35, et seq.). Bibliog. and Refer.—J. B. Carnevala, De Epidemico Btrangulatario Adfectu, 4to. Neap., 1620. — F. Nola, De Epidemico Plegmone Anginosa grassante Neapoli, 4to. Venet., 1620.—J. A. Sgambati, De pestilenti Faucium Af- * [Blisters should never be employed in this disease under any circumstances.] ography and References. 767 fectu Neapoli sasviente, 4to. Neap., 1620. A. Tamayo, De Morbo garotillo, Svo. Madrid, 1622.—Af. A. Severinus, De Pedanchoni, seu pestilenti ac prasfocanti Pueris Ab- scessu, Diatri'ba singularis, 4to. Neap., 1641.—D. Senner- ti, Medicina Practica, t. ii., De Febribus, cap. xii. Viteb., 1654.—T. Sydenham, Opera Omnia, Edid., G. A. Greenhill, p. 243, 553.—Schultz, In Miscellanea Naturee Curiosorum, Ann., vi. et vii., p. 206.—De Garter, Prax. Med., t. ii., p. 196. — Morton. Opera, Exercit. i., cap. 2, p. 41; Exercit iii., cap. 5, p. 53.— W. Douglas, Practical History of an Epi- demic Fever, with an Angina ulculosa, 8vo. Bost., 1736. —J. Slorck, Practischer und Theoretischer Tractat vom Scharlachfieber, 8vo. Gotha, 1742.—J. B. L. Chomel, Dis- sertation Historique sur le Mai de Gorge gangreneux en 1748, 12mo. Paris, 1748. —J. Fothergill, An Aocount of the Sore Throat attended with Ulcers, 8vo. Lond., 1748. — Nath. Cotton, Observations on a particular Kind of Scarlet Fever,, 8vo. Lond., 1749.—J. Huxham, Disserta- tion on the Malignant Ulcerous Sore Throat, 8vo. Lond., 1751.—N. Tarranb, An, Historical Dissertation on a par- ticular Species of Gangrenous Sore Throat (Transl. from Chomel), 8vo. Lond., 1753.— Schmidt, Epist. de Febro Scarlatina, Hanover, 1753.—C. Colden, Letter concerning the Throat Distemper (Medical Obs. and Inq., i.), 8vo. Lond., 1755.—Ch. Bisset, Essay on the Medical Constitu- tion of Great Britain, with an Account of the Throat Dis- temper, 8vo. Lond., 1760. — J. Chandler, A Treatise on the Disease called a Cold; also, on the Putrid Sore Throat, 8vo. Lond., 1761.—Af. A. Plenciz, Tractatus de Scarlati- na (Wasserberg Opp. Minor. Fasc, ii.), 8vo. Vindob., 1775.—Vom Scharlachfieber, in Mohrenheim's Beytragen, b. ii., No. 2.— W. Grant, A short Account of the Fever and Sore Throat in London in 1776, 8vo. Lond., 1777.—Sau- vages, Nosolog. Methodica, CI. iii., Gen. 8, Sp. 6.—R. Saun- ders, Observations on the Sore Throat and Fever in the North of Scotland in 1777, 8vo. Lond., 1778.—J. John- stone, A Treatise on the Malignant Angina, 8vo. Lond., 1779. — W. Withering, An Account of the Scarlet Fever and Sore Throat in 1778, 8vo. Lond., 1779.—Aaskow, in Acta Reg. Soc. Med. Haun., vol. ii., p. 91. Bang, in ibid., vol. ii., No. 3.—J. Clark, Observations on Fevers, Scarlet Fever, &c, 8vo. Lond., 1780.—J. M. Aepli, Beschreibung eines Epidemischen Scharlachfiebers, 8vo. Winth.. 1785. —De Meza, in Acta Reg.1 Med. Soc. Haun., vol. ii. (Malig. Scarl.), vol. iii., No. 8.—J. Skeete, Experiments and Obser- vations on Bark, on Putrid Scarlet Fever, &c, 8vo. Lond., 1786.—Rush, Med. Inquiries and Observations, &c, Nos. 4, 5, p. 118, &c. (The epidemic in Philadelphia of 1783 and 1784.) — W. L. Perkins, An Essay for a Nosological View of the Cynanche Maligna and the Scarlatina Angi- nosa, 8vo. Lond., 1787. — Swediaur, Nov. Nosolog. Me- thod- Syst, vol. i., p. 164.—J. G. Grundmann, Abriss einer Scharlachsfieber-epidemie, 8vo. Gera, 1788.— W. Rowley, An Essay on the Malignant Ulcerated Sore Throat, Albumen is the most abundant constituent of morbid struc- tures. In this opinion—frequently stated in the course of this work — Vogel, Bruch, and Bennett agree, while they also admit that the more solid parts are fibrin, and that the fluid in which the corpuscles swim is albuminous, the one being necessary to form the filaments, the other the cells. Fibrin may thus be consid- ered as being formed from albumen ; for Zim- mermann has shown that fibrin results from a change in albumen, and has referred to the ex- periments of Tiedemann and Gmelin on the chyme, chyle, and blood of herbivorous animals, compared with those of carnivorous animals, which show that, notwithstanding the nature of their food, the chyme of the latter contains no fibrin, and their blood less fibrin, than the blood of the former; the fibrinous principle of the food of the carnivora being reduced to albu- men during the primary digestion. The exper- iments of Magendie, Nasse, and others have shown that blood deprived of fibrin transfused into an animal, contained fibrin and became coagulable after having circulated for some time. From these facts it is manifest tha the fibrin of the blood is developed chiefly dur- ing circulation. On this subject Dr. Bennett remarks, that " it seems extraordinary, if the muscular and fibrous tissues are formed from fibrin, that this principle should exist in norma] blood only in the small proportion of from one to three parts in one thousand—a quantity wholly inadequate for the purpose." 33. But it should be recollected that the nu- trition of muscular and fibrinous tissues is not merely an attraction of fully developed fibrin, but of the constituents or elements of fibrin, which are changed into, or incorporated with, fibrous structures by the influence of vitality, the fibrin existing in healthy blood being mere- ly the residuum ofthe conversion of these ele- ments. This view of the subject is supported by what is actually observed in diseases which impede the nutrition of fibrous structures, as in acute rheumatism, pneumonia, consumption, in- flammatory fevers, &c, in which the quantity of fibrin in the blood is excessive ; for in these diseases the nutrition of these structures is ei- ther impeded or arrested, and hence the accu- mulation in the circulation of the elements forming them favours the development of fibrin in the blood, when vital power is not so far re- duced as to prevent the attraction and cohesion of the constituents necessary to the production of fibrin. According to this view the increase of fibrin in the blood is a consequence of inflam- matory diseases ; the non-incorporation of the constituents of fibrin by fibrinous tissues — or the interrupted nutrition of these tissues—caus- ing an excess of these constituents, and the at- traction and cohesion of a certain proportion of them, according to the state of organic nerv- ous energy, in the form of fibrin, during the process of coagulation, when the blood is re- moved from the system. 34. The existence of casein in scirrho-can- cer and in other morbid growths is very doubtful, although its presence has been con- tended for by several chemical pathologists, in tuberculous and some other diseased struc- tures. Muller proved the presence of gelatin in enchondromatous and colloid formations. Dr. Bennett states, some preparations of col- loid in his possession are still perfectly trans- parent after long immersion in alcohol; while others have been transformed into a white opaque matter, resembling boiled white of egg Hence the chemical composition of this viscus fluid in cancer may be inferred to differ in dif- ferent cases ; but in what this difference con- sists, unless it be owing to the quantity of al- bumen it contains, has not been determined. The able investigator just mentioned remarks that, in a fluid state, the albuminous principles are, with the exception of casein, not affected by the addition of acetie acid ; but when once coagulated in the form of molecule, fibre, or membrane, they are again rendered more trans- parent by this agent. This property of acetic acid enables the histologist to render their sec- tions and filaments of structure transparent, and to partly dissolve cell walls. The fila- ments and cell walls of scirrho-cancerous and cancroid growths are composed of albuminous principles, and the more filamentous and dense the structure is, the more does it abound in this chemical constituent. SCIRRHOUS AND OTHER TUMOURS—Chemical Composition ok. 777 35. ii. Fatty Principles.—The modes in which fatty matters may be produced in the system, in health and in disease, have been much and differently discussed among chemists and chemical pathologists—a class or sect of pathologists which have again risen to celebri- ty, with Liebig at their head. Fatty matter ex- ists in scirrho-cancer and other morbid growths in four states—as a nearly pure fat, in an al- most saponified state, in a non-saponified state, and as a fatty acid. Dr. Bennett states that it is never structurally free, for, being invaria- bly associated with fluid albumen, no sooner is oil precipitated so as to assume form, than the minutest granule of it becomes inclosed in a thin coagulated film of albumen. Such gran- ules may be recognised by the resistance they offer to the action of weak acetic acid, or by their disappearance on the addition of ether; and their number, in any given point of a struc- ture, is a tolerable index of the amount of fat- ty matter present. Fat may also exist in the form of crystals of cholesterine, and of margar- ic acid. The French chemists insist that fat enters the body ready made in the food; while Liebig and his disciples maintain that it is form- ed in the system, 1st, by the primary digestion, and, 2d, by the decomposition of the tissues or by secondary digestion. It is probable that, in morbid structures, its presence may also be sometimes imputed to a transformation of the albuminous constituents, or of a portion of them. 36. The existence of fat in healthy and in morbid structures may therefore be more cor- rectly referred to the following different sour- ces : 1st. To the introduction of ready-formed fat in the food ; 2d. To the early processes of digestion; 3d. To the decomposition and ab- sorption ofthe tissues ; and, 4th. To the trans- formation of the albuminous principles. The first of these sources requires no remark. As regards the second, it cannot be doubted that animals which become very fat by feeding on grain must have the power of converting the constituents of these into adipose tissue, as the very small proportion of oil which these contain could not be adequate to this result. The third source may be less readily admitted, although various considerations suggest its existence. As to the fourth source of fatty production, it certainly exists in morbid formations, and es- pecially in albuminous exudations, more gen- erally than is supposed. I have seen it repeat- edly to a very great extent in the albuminous exudations formed between inflamed serous surfaces, more especially in the chronically in- flamed cases; and when the albuminous exu- dations had passed to the state of organized, or partially organized, areolar tissue, this ad- ventitious tissue appearing not only to contain oil-globules thickly disseminated throughout it, but, in some instances of long standing, grad- ually to pass into masses of fat, identical with other adipose parts. These changes in the ad- ventitious membranes, adhesions, and parts connecting inflamed serous surfaces have been already noticed when treating ofthe alterations consequent upon inflammations of the peritone- um and pleura ; but they have hitherto escaped the notice of pathologists. I have also ob- served this conversion of old exudations from, and adhesions between, serous surfaces into fat within the vertebral theca, in cases of pro- longed paraplegia; and very probably this con- version is one of the modes of reparation, or of removing these consequences of inflammatory action, the albuminous principles passing into the fatty to facilitate their absorption through fine vessels or canals. 37. Connected with this subject. Dr. Ben- nett remarks, that it is probable, under favour- able circumstances, that the albuminous prin- ciples may be converted into fat; for pathol- ogists are acquainted with numerous facta which prove that muscular, areolar, fibrous, and other albuminous tissues may be so converted. The universal occurrence of compound gran- ular corpuscles in old exudations is evidence of this, although it may be erroneous to sup- pose that the original transformation is con- nected with any influence possessed by cells. Donne, after carefully removing all the glob- ules from milk, and leaving no visible evidence of fat under highly magnifying powers, still succeeded in extracting it by means of ether. "Fat, then, is probably held in solution, and enters the cell wall by endosmosis, where it is precipitated in the form of granules, which become enveloped with a layer of albumen, and are prevented from passing out. In this man- ner fat, resulting from the disintegration of ex- udations, becomes accumulated in previously existing cells. Hence various kinds of these bodies act as mere store-houses for excessive formations of fat in morbid growths, as the ad- ipose cells proper perform the same function in healthy tissues. In one, fat exists in the form of granules, in the other as a fluid oil, because pre-existing cells generally have for their con- tents albuminous matter in a state of solution, which is not the case with the adipose cells."— (Op. cit., p. 166.) 38. When the muscular system undergoes the fatty degeneration, it has been supposed that the deposition of fat by its excess causes atrophy, and subsequently destruction of the muscular fibres. But Dr. Bennett states that, in watching carefully the progress of fatty trans- formation, he has convinced himself that it oft- en commences in the very centre of the mus- cular fasciculus, apparently by the fibrillae break- ing up, losing their continuous and character- istic transverse markings, and assuming the form of minute fatty molecules, which after- ward become larger and larger, so as to con- stitute granules of various sizes. The same ehange is observed in muscles in the vicinity of diseased parts which for a long time have not been called into action. This observer adds, that " the whole fasciculus becomes thus affected, and at length large drops of oil accu- mulate in the interstices ofthe fasciculi, which gradually assume all the appearances of adipose cells, and, by their increase at the expense- of the muscular fibre, communicate to it the yel low colour and other physical characters of fat. This conversion of the albuminous principle into the fatty, is brought about independently of the agency of cells or nuclei, and shows that, in the retrograde as in the advancing process of nutrition, the molecular and granular ele- ment is the form of structure which is the ba- sis of every other." 39. iii. Mineral Principles.—In scirrhous, cancerous, and various other morbid growths, 778 SCIRRHOUS AND OTHER TUMOURS—Described. as in every other exudation from the blood, more or less of mineral or saline matter is pres- ent, the amount, however, of which varies much in different cases. These form into crystals with the progress of decomposition, crystals of the ammoniaco-magnesian phosphate being not uncommon. More generally small collections of phosphate of lime are found either in gran- ules or in masses, or in irregular fragments, which are soluble in the nitric and hydrochloric acids Sometimes the mineral substance is so abundant as to impart to the dried growth an osseous appearance. This change may take place in cancerous as in tubercular formations, although not so frequently, converting portions of either into calcareous concretions. Dr. Ben- nett states, that in some forms of cancroid growth, the mineral principle, like the fatty, seems to enter pre-existing cells in a state of solution, and to become afterward precipitated, so as to assume somewhat of an organized ap- pearance. 40. iv. Pigmentary Principles.—The exu- dation of blood into the substance of scirrhous, cancroid, and other morbid structures, and the change in the exuded blood, as well as the al- teration thereby occasioned in the tissues in which the blood exudes, are manifestly the causes of the different tints of colour which these structures present. The deeper hues are probably owing to some chemical change in the exuded blood and other fluids, and probably the colouring matter of bile may sometimes aid in modifying or deepening the tint. Dr. Walshe considers the bright yellow matter, associated with fatty matter, sometimes forming a retic- ulum, or collected together in masses, to be analogous to the kirronosis of Lobstein ; but Lebert views it as a peculiar kind of fat, which he calls xanthose. The black matter some- times found in cancer, is owing either to the action of the morbid secretion ofthe diseased part upon the globules of the blood in the cap- illaries or exuded from them, or to the associ- ation of melanosis with cancer (see art. Mela- hosis, y 4, et seq.). That it originates in some change which the blood undergoes, is shown by the circumstance of this change having been traced in the same specimen through all the intermediate tints from blood-red and rusty brown to the deepest black. Dr. Bennett has ascertained that the colour of the black matter occasionally found In cancerous growths is de- stroyed by nitric acid and chlorine—a change which distinguishes it from the black matter which commonly accumulates in the bronchial glands and lungs of old people, and in the black phthisis of colliers. In the latter instance the black matter is undoubtedly carbon, in the for- mer its nature is unknown.*—(See arts. Lungs, y 185, and Melanosis.) * According to Simon and Day, the following proximate analysis of scirrhus have been made by M. L'Heretier : OfBre«t. Of Uterus. °^> Water................29-75___2115___2480 Albumen..............28-lfl___29-85___21-70 Fibrin................. 18 80___1520___2715 Gelatin................ 7 60___ ___ 817 Fat................... 200--- ___ 805 Phosphorized fat...... ___ 6-00___ Proxide of iron........ 115___ 1-25___traces Yellow pigment........ ___ 7-00___ Salts.................. 12-60--- 9-55___1013 A fatty growth analyzed by Ness von Esxnbeck con- 41. III. General Anatomy ok Scirrho-can cerous and other Growths.—i. Of Scirrho- cancerous Growths.—Continuing to adopt the description of Professor Bennett, these growths are constituted of nucleated cells, pre- senting the characters attributed above to can- cer-cells (y 13, et seq.), and infiltrated among the meshes of a fibrous stroma. Conjoined with the fibres and cells there is invariably pres- ent a viscous fluid, in which the cells swim, as seen under the microscope. The fibres, the cells, and the viscous fluid, are the three essen- tial elements of these growths ; and it is the relative amount of each which determines the species of cancer. " If the fibrous element be in excess, it constitutes scirrhus, or hard can- cer ; if the cells be numerous, encephaloma, or soft cancer; and if the fluid abound, or be col- lected into loculi or little cysts, it is colloid can- cer. All these forms of cancer may frequently be observed in the same tumour—in one place hard or scirrhus; in another soft or encepha- loid ; and in a third jelly-like collections, or col- loid. Yet, although they may pass into or suc- ceed one another, they are not infrequently dis- tinct from their origin to their termination." 42. A. Scirrhus.—Hard cancer has been fully described in the article Cancer ; and I have therefore only to add at this place, that at all times a pulpy substance may be removed from a fresh-cut surface of it by scraping, which, on microscopic examination, is seen to contain nu- merous cancer-cells, mingled with molecules, granules, and fragments of fibrous tissue, an appearance which distinguishes scirrhus from certain forms of fibrous tumour, which to the naked eye exactly resemble it. A thin section of the scirrhous growth is seen to be principally composed of filaments, of various sizes, run- ning in different directions, sometimes forming waved bands, at others an inextricable plexus, among which the cells may be seen infiltrated, or forming loculi or cysts inclosing masses of these cells. 43. B. Encephaloma.—Soft or brain-like can- cer has been considered in the article Fungoid Disease. It consists of a soft pulpy growth, of a whitish, yellowish, or bluish tint, breaks) down on moderate pressure, and yields a copi- ous milky or creamy juice. It presents differ- ent degrees of vascularity; reddish parts or spots appearing, owing to extravasations of blood, or to degrees of vascularity. On exam- ining a fresh-cut section, it presents a very loose fibrous texture; but in the denser parts it approaches the character of the soft portions of scirrhus. In the pulpy parts no trace of fibres is visible, or merely fragments of them. Yellowish parts, either reticulated or collected into masses, generally consist of fatty degen- eration of the cancerous tissue, and form the tained 230 of solid fat; 120 of extract of flesh; 110 of gum-like animal matter; 230 of albumen; 190 of phos- phate of lime; and 1-5 of carbonate of magnesia. It il not stated whether this solid fat contained cholcstcrine; in all probability it did, as this substanoe is often found in fatty tumours. In a fatty tumour examined by Muixb» acicular crystals were found mixed with a gray substance which was deposited in vesicles and dissolved by boiling water, from which it was not precipitated by acids or the ordinary metallic salts. The crystals were insoluble in acids, water, or alcohol, but dissolved in ether; hence they probably consisted of cholesterine. Another fatty tumour contained some casein, precipitable from tie aqueous solution by acetic acid. SCIRRHOUS AND OTHE cancer reticulare of Muller. This yellow mat- ter is often of cheese-like consistence, friable, and resembles tubercle, for which it has been mistaken. The blackish tinge is owing to black pigment (y 40) infiltrated in the cancerous el- ements, or existing within the cells, constitu- ting the malignant melanosis, or melanic can- cer of some authors. The cream-like fluid pre- sents, under the microscope, a numberjof the cancer-cells already described (§ 13, et seq.), sometimes mingled with, a large number of molecules, granules, compound granular cells, blood-corpuscles, and more or less ofthe fibrous element. (See art: Fungoid Disease.) 44. C. Colloid or Gum Cancer.—Glue cancer, or collections of gelatinous matter resembling glue, calves'-foot jelly, or semi-fluid gum, are found in masses varying from a minute point to the size of a large orange. In colour colloid is yellowish, grayish, brownish, or reddish ; very rarely green or black. It may be trans- parent or amber-like, or semi-transparent or opaque, resembling honey. It may be dissem- inated in a fibrous texture, giving it a pearly aspect, or it may be collected in distinct cysts. " It is one of the most common constituents of compound encysted growths of the ovary, and it is not infrequently seen in cysts of the kid- ney, and follicular swellings of the skin."— (Bennett.) On examination with the micro- scope, this substance is occasionally seen quite structureless, or exhibits only a fine molecular appearance, and it then has been called colloid tissue. At other times numerous nucleated cells, presenting all the characters of cancer- cells, in various stages of development, are found in it as a blastema; and it is then ob- served that the growth has a tendency to spread. This is colloid cancer. 45. "When colloid cancer is formed on a free surface, as on the peritoneum, it often pre- sents small grains of a gray colour, resem- bling coagulated gum-arabic. When collected in masses, these have an irregular nodulated aspect. A fresh section presents a surface with numerous loculi or cysts, which vary from the size of a pin's head to that of a walnut, filled with a clear glistening gelatinous matter, surrounded by fibrous substances or mesh- work." Cancer-cells originate in colloid mat- ter, as in other kinds of blastema, by the for- mation of granules, nuclei, and cells. The fibrous structure of colloid, according to Dr. Bennett, never contains permanent nuclei, or affords any evidence of being developed from nuclei or cells; it seems rather to be formed by precipitation alone. 46. D. These three forms of true cancer are vascular, but in different degrees. Scirrhus is least so ; colloid is more so than scirrhus ; and encephaloma is most vascular—sometimes so much so as to bleed readily and profusely. These forms pass into each other, sometimes so imperceptibly as to render the arrangement of several specimens a difficult matter; more especially as respects scirrhus and encephalo- ma or fungoid cancer. 47. ii. Other Morbid Growths.-—Morbid structures, which, to the unaided sight, to the touch, and often in the progress of the case, so closely resemble cancer as to be frequently mistaken for it, and yet which present on mi- croscopic examination differences of a very R TUMOURS—Described. 779 marked character, have been termed cancroid by Dr. Bennett. Hitherto, he remarks, this distinction has not been very accurately attend- ed to ; for, although practitioners have recog- nised the existence of fibrous, sarcomatous, warty, fatty,and other so-called non-malignant growths, experience every day proves that there are no symptoms which enable them to detect these with certainty. 48. A. A fibro-nucleated cancroid growth is de- scribed by this writer to consist of filaments infiltrated with oval nuclei. It can be distin- guished from scirrhus and from encephaloma only by microscopic examination, as it some- times closely resembles the one, and at other times the other. As to its minute structure, this growth ought to be separated from true cancer on the one hand, and from fibrous tu- mours on the other. It is deficient in cancer- cells, which are essential to the first; and it possesses numerous naked nuclei, in no way connected with cell-formation, which are not found in the second. This form of cancroid growth, however, evidently so closely resem- bles cancer, or possesses so much of what has been usually called the malignant character in other respects, that a diagnosis is difficult. The most important distinction between it and true cancer is that, although it may return in the place originally affected, after excision, it does not appear ever to occur secondarily in the glands or other organs. 49. B. Epithelial Cancroid Grmoths.—Dr. Ben- nett considers that cancer of the lip, chimney- sweeper's cancer, noli me tangere, malignant ulcer ofthe face, cauliflower excrescence of the uterus, and other appellations are given to morbid growths, which have been considered cancerous or malignant, but which possess a very different structure, and are therefore only cancroid. Mr. Paget pointed out the identity of several of these, considered them as warty in their nature, and ascribed them to hypertro- phy of the papillae of the skin. Dr. Simpson classed cauliform excrescence of the cervix uteri with soft warts and condylomata, and stated that it had often been confounded with carcinoma oi" medullary fungus. Examined by Reid and Goodsir, it was shown to consist of groups of large nucleated cells. These and similar alterations of the epidermic and mucous surface Dr. Bennett views as epithelial can- croid growths, and as essentially consisting of an hypertrophy of the mucous or epidermic layer, composed of numerous epithelial-cells more or less impacted together (v 18). They may occur on large free surfaces, as the skin or digestive mucous membrane ; or within mu- cous follicles, and the minute ramifications of secreting glands, as the mammae, kidney, and it then resembles that of young animals, the cells being unusually large. When the fibrous ele- ment abounds, then the whole mass is identical with fibro-cartilage, as in sarcomatous tumours (y 58-61). Between these extremes there are infinite varieties, many of which may often be seen in one tumour. Occasionally a bony nu- cleus is found in a nodule of enchondroma, and sometimes these nodules present all the stages of transformation into bone. 67. Notwithstanding these peculiarities of structure, these tumours are often mistaken for osteo-sarcomatous or cancerous growths, chiefly j owing to their occasional softening, and to their presenting, in such circumstances, the external characters of encephaloma. The softened por- tion, even under the microscope, may, without | great care, lead to error, as the cartilage-cells which float loose, mixed with granules and de- bris of the tumour, closely resemble those in cancerous growths. SCIRRHOUS AND OTHER TUMOURS—Described. 783 68 E. Fatty cancroid growths, in the form of tumour, when mingled with fibres and other el- ements, may be mistaken at first sight for scir- rhus. " Fatty tumours vary in size, but they may reach a growth weighing 30 lbs. Some- times their surface is smooth, at others lobula- ted. They are of a yellow colour, resembling adipose tissue ; sometimes divided into bands by white fibrous tissue. The relative amount of these two elements varies greatly in different specimens; some being soft, oily, containing few fibres ; others being harder, dense, the are- olar tissue preponderating. For the most part they are very sparingly supplied with blood-ves- sels, but these abound more in the fibrous va- rieties. In the latter case they are liable to ul- cerate, and, under such circumstances, have fre- quently been mistaken for cancer. Some of these tumours, indeed, may be considered as fibrous or sarcomatous, combined with an unu- sual quantity of fat. Occasionally they are con- nected with the ordinary adipose tissue of the body. They are often surrounded by a delicate cyst or envelope; sometimes this is not per- ceptible. When the collection of fat resembles the ordinary adipose tissue, the tumour has re- ceived the name of lipoma. When it is more lardaceous, some have applied to it the term steatoma, in the same manner as when the sub- stance is encysted."—(Op. cit., p. 193.) 69. The minute structure of these tumours varies with the amount of adipose or of fibrous tissue. The former is composed of vesicles of a round or oval form, altered more or less in shape by pressure. The vesicles vary from the l-20th to the l-50th of a millimetre in diam- eter. They are composed of a diaphanous cell wall, frequently including a nucleus. The nu- cleus is round or oval, about the l-100th or the l-200th of a millimetre in diameter. Occa- sionally it appears stellate, of a crystalline as- pect, from the formation of crystals of marga- rine or margaric acid around it. On rupture of the cell wall the oil may be made to flow out, and the cell wall shrinks up. Collapsed cells may often be seen among the more perfect ves- icles, mixed with globules of oil and fat gran- ules. The fibrous element consists of filament- ous tissue running between groups of adipose cells, but is denser, and occupies more space, according to the proportion in which it enters into the tumour. Steatomatous and meliccrous fatty matter may sometimes consist chiefly of the cells or vesicles just described; or these may be mingled in various proportions with granular matter. In some melicerous encyst- ed growths Dr. Bennett found the whole to be composed of granules, among which faint traces of delicate cell walls might be observed more or less compressed together. In all such productions the relative amount ofthe vesicu- lar and granular element varies greatly. 70. Another form in which fat may occur is that of atheroma, consisting, for the most part, of numerous fatty granules, varying in size. Atheroma may constitute the contents of cysts, or the entire degeneration of certain glands, es- pecially the mesenteric and lumbar. The fat- ty granules composing it vary from the l-600th to the l-400th of a millimetre in diameter. They almost entirely disappear in ether, leav- ing only a molecular albuminous matter. Sim- ilar fatty granules are also associated with most morbid formations, sometimes free, at others existing within cells. " This kind of atheroma is identical in structure and chemical composi- tion with certain forms of the reticulum in can- cer. The granular fatty matter is often com- bined with crystals of cholesterine, more or less numerous." Sometimes they accompany vari- ous kinds of chronic exudation, and formations of epithelium, as above noticed (v 53). 7L F. Tubercular growths resembling cancer axe not uncommon. Dr. Bennett remarks, that a mass of enlarged tubercular lumbar glands in his collection presents all the external charac- ters of cancerous growths, and that he has no doubt that many cases of so-called cancer of the brain and other structures in youth are only tubercular; for, however easily the tubercular structure may be distinguished in its miliary or infiltrated forms, it may closely resemble can- cer when it exists only in one or two large rounded masses in an organ, and is more or less softened. In such cases it can be distinguished only by a microscopic examination. The char- acters of tubercle which readily distinguish it from cancer, therefore, require to be pointed out. A tubercular mass presents a yellowish or dirty white colour, and varies in consistence from that of tough cheese to that of thick cream. Sometimes it is soft in one place and indurated in another. On dividing the harder parts, the surface is smooth or waxy; the softer parts present a slightly granular surface. On pres- sure they are friable, and break down into a pulpy matter, but never yield a milky juice. " A small portion squeezed between glasses, and ex- amined under the microscope, presents a num- ber of irregular shaped bodies approaching a round, oval, or triangular form, varying in their longest diameters from the l-120th to the l-75th of a millimetre. These bodies contain from one to seven granules, are unaffected by water, but rendered very transparent by acetic acid. They are what have been called tubercle corpuscles. They are always mingled with a multitude of molecules and granules, which are numerous as the tubercle is more soft. Occasionally, when softened tubercle resembles pus, constituting scrofulous purulent matter, we find the corpus- cles more rounded, and approaching the char- acter of pus-cells. They do not, however, on the addition of acetic acid, exhibit the pecul- iar granular nuclei of these bodies." Tubercle corpuscles are very readily distinguished under the microscope from cancer-cells. Compound granular masses and cells, mineral matters, crystals of cholesterine, and the debris of the texture in which the morbid product is found, are also often detected in tubercular masses of some standing. These masses may also be sometimes transformed more or less into creta- ceous and calcareous substances, and either re- main latent or be thrown off. 72. G. A tumour, which M. Velpeau has called fibrinous, is occasionally met with. It may, under certain circumstances, be mistaken for cancer. It is caused by an extravasation of blood, which coagulates, becomes paler, and ultimately yellow, like a clot of blood in the sac of an aneurism. These tumours vary in size, may occur in various situations, especially in the female breast, when they may be mistaken for cancerous tumours. Dr. Bennett has also seen these tumours in different textures, espe- 784 SCIRRHOUS AND OTHER TUMOURS—Pathological Relations of. cially in the placenta and in the spleen. The structure of one found in the spleen consisted of numerous molecules and granules, fusiform corpuscles, compound granular masses, and ir- regularly formed bodies, probably altered blood corpuscles, such as are commonly found in old extravasations. Instances in which these tu- mours in the breast were mistaken for cancer have been recorded by MM. Lebert and Be- rard. 73. H. A peculiar form of tumour, which Hen- le has called syphonoma, is described by him and Dr. Bennett. The specimen seen by the latter consisted of a large mass attached to the mesentery, that was in one place hard, fibrous, and nodulated, in another soft and cheesy, or even purulent, and in a third fibrous, but soft and of a dark red, resembling coagulated blood. Having been long steeped in spirits, its minute structure could not be exactly ascertained. The part examined resembled a vascular plex- us, anastomoses here and there having been distinctly seen. 74. /. The enlarged glands which accompany typhoid ulcerations in the intestines, and which are sometimes found, especially in the mesen- tery, will rarely be mistaken for cancer. They vary in size from that of a hazel-nut to that of a hen's egg. They are vascular externally, of a bright red or purple colour, are soft and pulpy to the touch, and on section present a slightly granular surface, of grayish or fawn yellow col- our, frequently exhibiting the commencement of softening. They are friable, and yield a gray- ish or dirty purulent-looking fluid on pressure. The matter infiltrated into the texture of the gland is the.typhous deposit of Rokitanski, Engel, and other German pathologists. The fluid squeezed from these glands was found by Dr. Bennett crowded with cells, naked nucleoli, blood corpuscles, granules, and molecules. The cells are generally spherical, varying in diame- ter from the l-50th to the l-35th of a millimetre. The nucleus occupies about three fourths ofthe cell, and is composed of an aggregation of nu- merous nucleoli, of about the l-200th of a mil- limetre in diameter. " Sometimes from one to four of these nucleoli are seen scattered within the cell, either with or without a round or oval transparent nucleolated nucleus. On the addi- tion of acetic acid the cell wall is rendered very transparent, while the nucleoli are unaffected. Many of them are free, and looked at first like altered blood globules, from which they are at once separated by the action of acetic acid. I have called these bodies nucleoli, from their holding that relation to the nucleus in well-de- veloped cells, although at other times they may be considered as nuclei, no other bodies being present within the cells."—(Bennett, Op. cit., p. 200.) 75. IV. Pathological Relations of Scir- rhous and other Tumours.—i. Of Scirrhous Growths.—A. The origin of these growths has been the subject of much discussion. In the article Cancer certain views of this matter have been noticed, but others have been recently pub- lished. It was supposed by Velpeau (Revue Medicale, t. i., 825, p. 357), from two cases in which encephaloid-looking matter was found in venous coagula, without disease of the veins, that cancer may form primarily in the blood; but there is no evidence that the matter was really cancerous in these cases. Virchow, however, states that he has seen cancer in the large venous trunks in six cases, and that he is convinced that they may thus arise locally in co- agula of blood. Gluoe and Nonat discovered cancer-cells in a clot in the right iliac vein, the walls of the vein being smooth and not red; but in these, as in several others which have been recorded, cancerous disease existed in the viscera, and the cancerous matter in the blood may have arisen from venous imbibition. In the present state of our knowledge there is no proof that cancer may exist in the blood prima- rily, or independently of similar growths in oth- er parts of the body. It is possible, however, that the liquor sanguinis may, in peculiar cir- cumstances, act as the blastema of cancer with- in the vessels as well as when exuded; such an occurrence, however, must be rare. Dr. Bennett, whose researches have been so able, infers that the filaments, cells, and fluid, which together compose scirrho-cancerous structures, originate in a coagulated exudation, which is poured out in the same manner as other forms of exudation—namely, by enlargement of the capillaries, their repletion with blood, and the transudation through their coats of the trans- parent liquor sanguinis, which, coagulating out- side the vessel, forms an exudation more or less solid. The exudation, when first perceptible, consists of a finely molecular and granular mat- ter, in which the cancer-cell arises as in a blas- tema, in the manner already described (y 14). This view accords with that which I have stat- ed in the article Cancer (y 26), and shows that the change in the blastema, or exuded fluid, de- pends upon the state of constitutional and local vital endowment. 76. The exudation constituting the blastema of cancer is generally infiltrated between the filaments of areolar tissue. The nature ofthe tissue influences the formation of adventitious growths ; and the areolar tissue, probably from its lower vital endowment, seems to favour the production of scirrho-cancer. While part ofthe exudation in this tissue passes into cells, anoth- er portion becomes fibrous, as observed to oc- cur in a simple exudation during the healing of an ulcer or wound. All that is known of this stage of the production is, that filaments and fibres are formed, which are interlaced among the-granules and cells of the blastema, to con- stitute the stroma ofthe growth, the form and density of which is dependent upon its arrange- ment and amount. " At first the cancerous ex- udation is fluid ; and some of the albuminous principle held in solution, by coagulating, allows a certain quantity of serum to be set at liberty. In most instances this is in a great measure ab- sorbed ; but in a few, owing perhaps to some peculiarity in its formation or amount, it is re- tained in the meshes of either the pre-existing or new areolar tissue." Such Dr. Bennett con- siders to be the origin of colloid cancer. The colloid matter so collected becomes in turn a blastema for the formation of cancer-cells, as above described (y 14). 77. It is obvious that the exudation produc- tive of scirrho-cancer must differ, either prima- rily or consecutively, or both, from the exuda- tion of inflammation, or of scrofulous or tuber- cular cachexy. In what the difference consists we are ignorant. In this the histologists have SCIRRHOUS AND OTHER TUMOl not enlightened us. Most probably the cancer- ous exudation is primarily different from these, owing to the state of vital endowment of the tissue affected, and that the difference increas- es with the retention of the exudation in the tissue which it infiltrates. The characters im- puted to the blood by Rokitanski, Engel, Hel- ler, and others, assigning a specific dyscrasia ofthe blood, or an excess of albumen or of fibrin in the blood, are vague, uncertain, and unsat- isfactory. Dr. Bennett believes"that the can- cerous peculiarity depends not upon the vascu- lar system, which is the mere apparatus for the production ofthe exudation ; not upon the nerv- ous system; and not upon the texture, which is merely the seat ofthe exudation, as that va- ries ; but in the inherent composition or consti- tution of the exudation itself. But in this be- lief this pathologist is not sufficiently precise ; for if he means by the nervous system the spi- nal nerves, then it may be admitted that these can have little or no influence in determining the nature of the adventitious growth produced from a fluid blastema. It is, however, by no means so certain that the soft or ganglial nerves, which supply the vascular system, and which preside over nutrition and secretion, are so unconcerned in determining the nature and growth of the morbid formation as here stated. We know that all the forms of scirrho-cancer appear in circumstances and from causes which depress organic nervous energy, and impair the activity of the excreting or depurating func- tions ; and which, moreover, diminish vital re- sistance, and favour the development of adven- titious cell-formations and of parasitic produc- tions. As these cell-formations become more perfect, and acquire the power of self-developr ment, so as to spread and invade adjoining tis- sues, they soon burst forth, ulcerate, contami- nate the circulation, and form exuberant fun- goid excrescences, filling up or even extending beyond the textures which they destroy; and they thus impoverish and infect the fluids, and exhaust organic nervous or vital power. (See arts. Cancer, y 11, et seq., and Disease, v 151, et seq.) 78. B. The growth of scirrho-cancer is merely the extension ofthe fibrous tissue, cancer-cells, and nuclei above described (y 41, et seq.). The old cell-walls dissolve or break down, and the included new cells and nuclei are liberated, and give rise to others in turn. For this purpose, however, a certain amount of blastema is req- uisite. " This is obtained at first from the orig- inal exudation poured out; but, after a time, as the fibrous tissue increases, new vessels are formed in it, which continue to furnish materi- als for the new growth, in the same manner as the old vessels furnish materials of growth to the old tissues." A pre-existing tissue exerts much power over new formations in its sub- stance or immediate vicinity ; and hence, when a bone is fractured, the matter exuded is trans- formed into bone ; and other tissues are re- stored when divided by a texture analogous to the one injured. " Very compound tissues, as the skin, lungs, muscle, &c, are never com- pletely restored, but a cicatrix is formed, com- posed of fibrous tissue. On the other hand, epithelial and epidermic structures are easily restored and reformed, and so are all textures which wholly consist of cells. Hence the more III. 50 URS—Pathological Relations of. 785 a cancerous growth abounds in cells, the more rapidly it grows, and the greater is its power of re-development." Some pathologists sup- pose that this power depends upon pre-existing and permanent nuclei, or germinal centres. But as to the truth of this, Dr. Bennett does not inquire, considering it sufficient to know— what, however, was sufficiently known before histology came into vogue—" that a tissue once formed and furnished with blood-vessels pos- sesses the property of growth ; that is, of exert- ing a species of selective vital attraction on the blood, whereby such matters are transuded through the capillaries as, are readily trans- formed into a substance like itself." But this act of growth, which I believe to be correctly attributed to vitality, the sect of chemical pa- thologists would consider as altogether chem- ical ; while another sect would consider it as simply one of endosmosis. Of the more prom- inent features of the growth of cancer, and of the extension of the malady and contamination ofthe circulation, I have nothing to add to what has already been stated in the articles Cancer and Fungoid Disease. 79. C. Is Cancer contagious ? This question has been answered in the negative by some, and in the affirmative by others. Inoculation has even been resorted to in order to test the fact.—(a) The negative evidence is chiefly the following. Dr. Walshe says that he has known women afflicted with advanced cancer of the uterus take refuge in hospitals from the impor- tunities of their husbands, and that these men were perfectly free, according to the assurance of their wives, from ulceration of any kind. Dr. Bennett states that his hands, more than once, have been immersed in the creamy fluid of encephaloma, while recent scratches have been upon them, without the slightest irritation having resulted. Vogel states that he injected fresh cancer-cells from a tumour into the blood- vessels of a dog, without any morbid change being manifest eight months afterward. Gluge has also been unsuccessful in his attempts to inoculate the disease. 80. (b) The affirmative evidence is chiefly the following : Langenbech injected the fluid from a cancerous tumour, while still warm, into the blood-vessels of a dog, with the effect of induc- ing secondary cancerous formations in the lungs of the animal. Dr. Watson states that he has known two cases of cancer of the penis in men, whose wives were afflicted with cancer of the uterus. Some years ago, a patient was attend- ed by Mr. Mayo and myself who was the sub- ject of carcinoma of the penis and inguinal glands, and who soon afterward died of the disease. The malady had commenced in the glans penis, and he had infected his wife, who was found on examination with open cancer of the os uteri; and she died of the disease a considerable time after her husband. In this ease there was no doubt ofthe husband having infected the wife, owing to the morbid matter from the ulcerated glans penis having been left in undisturbed contact with the os uteri. Mr. Mayo informed me that he had met with an- other case altogether similar to this. Dr. Ben- nett asks if the cases to which Dr. Watsom has alluded were proved to have been cancer by a microscopic examination I But he has al- ready shown that such examination adds but 786 SCIRRHOUS AND OTHER TUMOURS—Pathological Relations of. little to the diagnosis of cancer ; and it is well known that the majority of cases of open can- cer, as these were, are so obvious as not to be mistaken even by the most inexperienced. Dr. Bennett concludes that it is certainly opposed to experience that cancer can be communicated by contact or inoculation. I believe, however, that it can be so communicated, if circumstan- ces favour the communication, more especially if the recent discharge from a cancerous ulcer is brought into, and remains for some time in undisturbed contact with a mucous surface, or part denuded of its cuticle. 81. D. Degeneration of cancerous and cancroid growths.—Dr. Bennett remarks, that it is with the life of a cell as with that ofthe most highly organized individual: " It has its origin and birth, it gradually increases until it reaches ma- turity, then declines or degenerates until it has ceased to exist. The individual elements of a cancerous growth, like those ofthe healthy tis- sues of the body, are continually undergoing this process ; like them, it leaves germs which continue to regulate its growth so long as they receive nourishment, and thus the structure, as a whole, is perpetuated. Sometimes this process receives a check from the cells, which are the entire agents of growth, being rendered abortive, and the result may be, 1st. A fibrous cicatrix ; 2d. A fatty mass ; or, 3d. A calcare- ous concretion."—(Op. cit., p. 210.) 82. (a) It has been stated above (y 78) that the cell-wall of the cancer-cell dissolves and breaks down, and thus liberates the young cells. This is the natural completion of individual cell- life. It has been shown that the increase of cells is dependent upon a due supply of blaste- ma, in order to supply the materials of assimi- lation. Several cases are known, and one has come under my own especial and prolonged ob- servation, when a cancerous ulcer has under- gone the same changes as a simple ulcer; the cancer-cells in the one and the pus-cells in the other becoming gradually less in number, while the fibrous element has increased and terminated in the formation of a cicatrix. Dr. Walshe has adduced several instances of this trans- formation ; and Dr. Bennett thinks that this is a more frequent occurrence than is generally supposed. The only question is whether the pre-existing morbid growth was actually can- cerous or not; but the local appearances and sensations, and the constitutional symptoms, have certainly been such, in rare cases, as war- ranted the inference that the growth was act- ually malignant. This writer states that Dr. Bochdalek, of Prague, has met with instances of cancer of the liver, in which the diseased structure broke down into a cream-like matter, the fluid parts being absorbed, and the whole shrinking together, forming a puckering on the surface often corresponding to a fibrous mass, or a fatty material, in which collapsed cancer- cells may be detected. 83. (b) It has been stated above (Y 14) that the cancer-cell may be rendered abortive by the deposition of fat-granules between the nucleus and cell-wall, and by their pressure upon the former, and the ultimate disintegration of the whole body into numerous fatty molecules and granules. " This is a very common termina- tion of the life of individual cancer-cells ; and, when the process is carried on to any great ex- tent, the fat granules often collect in masses, and mingle with old cells, which exhibit various stages of their retrograde progress, and old nu- clei, which have more or less resisted disinte- gration, are at length observable to the naked eye. In this manner the yellow masses, and yellow reticulated appearance in certain can- cerous growths of some standing are produced —an occurrence so common that Muller de- scribed it as a particular form of the disease, under the name of cancer reticulare" (p. 212). 84. Professor Bennett, H. Meckel, and Vir- chow agree in describing the reticulum of Mul- ler as disintegrated cancer, or as composed of broken-down cancer-oells, the nuclei of which sometimes remain ; at other times the whole has undergone the fatty transformation, and been converted into compound granular cells; and not infrequently, in the last stage of the process, nothing but molecules and granules can be discovered. Dr. Bennett considers that this change is not a proof of so-called sec- ondary inflammation of the growth, as is sup- posed by Walshe, Rokitanski, and Lebert ; but that it is the same transformation that oc- curs in all old exudations, and in various organs where pre-existing cells undergo the fatty trans- formation, as in the liver, to constitute fatty liv- er, the kidney, to form Bright's disease, &c. The matter forming the reticulum occurs in two forms. In one it is seen in the fresh-cut sur- face, scattered throughout the growth, in the form of a net-work, more thick, however, and abundant in some places than in others. In the second form it forms masses of a bright yellow or orange colour, occasionally resem- bling tubercle, more or less friable, and of cheesy consistence. In the former compound granular corpuscles are most common ; in the latter, irregular bodies, resembling tubercle- corpuscles, resulting from alteration in the form ofthe nucleus, after the cell wall has been bro- ken down. These are called bodies of the re- ticulum by Bruc-h. Compound granular cells are very common in cancer, and are to be con- sidered as evidences of the cancer-cell. The greater their number and agglomeration, the greater the degeneration. The fatty degener- ation is rarely uniform throughout a cancerous growth ; commonly, while one part is convert- ed into a fatty net-work, another is only partial- ly so changed. This accounts for cancer hav- ing such a tendency to spread to other tissues, and for the destruction of one part being rarely attended by the reduction of the whole mass. Sometimes, however, the fatty degeneration is associated with the fibrous degeneration (Y 82), and extends to the whole morbid structure; and it may then be farther associated with an early stage of the calcareous transformation next to be mentioned.—(Bennett.) 85. (c) A cancerous growth may degenerate into an accumulation ofthe earthy matters orig- inally contained in the exuded matter. Thia form of cancerous degeneration is analogous to that sometimes observed in tuberculous forma- tions. The cells break down, the more fluid and soft parts are absorbed, and the mineral parts are left concreted in the form of a calca- reous mass or masses, of various sizes and shapes. This degeneration of cancer is very rare. Dr. Walshe appears not to have met with it; although he mentions the bony lamel- SCIRRHOUS AND OTHER TUMOURS—Pathological Relations of. 787 lae, which are continuous with part ofthe skel- eton, and which characterize certain cancers connected with the osseous structure. Dr. Ben- nett has, however, observed it in two instances. In one he observed mineral masses mingled with broken-down cancer-cells in the mesen- teric and epigastric glands, " some of which felt hard from calcareous depositions ; others were infiltrated with a putty-like substance; and a few were composed of an external shell of hard, cal- careous matter; while their interior consisted of a semifluid, gritty, diffluent material, which flowed out on breaking them." 86. (d) The three kinds of degeneration of can- cerous growths may be variously associated in retrograde cancer ; these may be the fibro-fatty degeneration, with either elerrient in excess, or one or both these conjoined, with the accumu- lation of mineral matters in smaller or greater masses. In these cases there is generally a loss of substance, occasioning a sinking in- ward, with puckerings of the adjoining surface. These changes occur only in cancerous growths of considerable duration, without ulceration or the formation of a cicatrix, as observed in the mamma when the nipple is retracted, and in the surface of some cancerous tumours. Virchow ascribes the central depression in the white en- cephaloid masses ofthe liver to this cause. Dr. Bennett views the stellate puckerings on the surface of cancerous growths as far from un- common ; and certainly, when this appearance exists, there must necessarily be loss of sub- stance and contraction of surrounding tissues ; and these changes can only result from a par- tial degeneration ofthe morbid structure, more especially of the older parts of it, although an extension of it to adjoining parts may actually be proceeding. I may, therefore, conclude, with the writer just mentioned, that cancer may undergo transformations, tending in very rare cases to a spontaneous cure ; and that these transformations are into a fatty or a calcareous matter—that the morbid growth is checked, and that it consequently shrivels up, some of the softer parts being absorbed, the rest remaining inert. The contraction ofthe surrounding parts in these cases, and the fibrous stroma of the cancer, constitute the puckerings and cicatrices observed as evidences of a cure. Dr. Bennett considers that the facts which he has adduced are unequivocal proofs that a cancerous growth may undergo spontaneous cure. In the case of a lady nearly related to, and almost constantly under the observation of the author, a cure cer- tainly took place without any local treatment, the constitutional means about to be mentioned (v 122,123) having been assiduously employed. 87. ii. The Pathological Relations of oth- er Growths—This subject has been noticed, as to most of what is known respecting it, when describing the anatomy of non-cancerous tu- mours, and in the article Disease ( $ 110). Fibrous, epithelial, cartilaginous, and fatty growths, or those formations which are not ad- ventitious as respects the economy (see Dis- ease, y 111, et seq.), may be ascribed to an error in nutrition, or to a hypertrophy or excessive deposition or nutrition of these several struc- tures in the parts in which they occur. The cause of their origin and development is not known, although certain circumstances con- nected with their formation have been noticed. But why either of these formations should oc- cur in preference to the others, we are ignorant. Certain of them may be caused by an injury of, followed by increased exudation into a part, the exuded fluid undergoing changes favourihg some form of nutrition in preference to others; but the same kind of tumour may occur without any such or any manifest cause. Tumours may form in the ovaria, or even in the substance of the uterus, or rather within the ducts and ute- rus, owing to an imperfectly developed or an unimpregnated ovum, detached partially or al- together, and arrested in either of these situa- tions, sexual excitement having been imperfect- ly gratified or insufficiently developed. Other morbid growths are to be ascribed to an origin- al constitutional vice, as the scrofulous and tu- bercular ; and some are more or less dependent upon a constitutional predisposition acquired at an antecedent period, as the sarcomatous, fatty, and some others described above. 88. A. May morbid growths, not originally scir- rhous or cancerous, be transformed into either ofthe forms of cancer ? This question has been dif- ferently answered. As respects certain tu- mours or growths, as the tubercular and en- chondromatous, no such transformations take place ; but as regards some others, the change is possible, although not demonstrated. Dr. Bennett remarks, that growths furnished with blood-vessels, such as. the fibro-nuclear, epi- thelial, and fatty, may possibly be so changed, although it would be difficult to establish the change. But with respect to fibrous growths, the result of a simple exudation, or hypertrophy, at first of purely local origin, its occurrence seems to him to be absolutely proved. " Ac- cording to Lebert, inflammation (simple exuda- tion), tubercle, and cancer are separated by dis- tinct characters, originate from separate blas- temata from the first, and never pass into each other. In this opinion, I think, he proceeds too far ; for why may not a cancerous exudation be formed into the filaments of a vascular, fibrous, or fatty tumour, as well as among the filaments of the normal areolar tissue of the body 1 We are continually meeting with cases where a blow or injury on a part producing a swelling with the ordinary symptoms of inflammation is, after a time, followed by cancer. An indolent tu- mour may exist for years, and then suddenly as- sume the characters of cancer. Are we to sup- pose that such a tumour was composed of fibres and cancer-cells from the first, and that the growth of the latter had remained stationary all that time ; or that nothing but a fibrous tumour existed at first, in which cancer-cells were aft- erward formed 1 The latter appears the most reasonable proposition"* (p. 217). 89. B. The enlargement of growths takes place from blood-vessels, which either permeate the mass or supply only portions of it, or reach to a greater or less extent of its surface. " In the first the growth is said to enlarge by intussus- * I have, in the foregoing pages, been much indebted to the work of Professor Bennett on " Cancerous and Can- croid Growths; but I have been unable to adduce more than a part only of his researches. His numerous and in- teresting cases, his careful microscopic examinations, and his graphic illustrations, should not merely be perused, but carefully studied, by every physician and surgeon, in connexion with his lucid descriptions of each kind of mor- bid growths, as exhibited in the pages of his very original and able work. 788 SCIRRHOUS AND OTHER TUMOURS—Patholooical Relations or. ception ; in the third by pure imbibition ; in the second by both means. These distinctions are less important than they on first view seem ; the perfect nutrition of the extra-vascular nat- ural tissues proves, as a general fact, the vigour and efficacy of the imbibition process ; and, in truth, imbibition is at play in all nutritions ; for the nutrient elements of vascular tissues must be imbibed through the coats of their vessels, and it may be in addition through a stratum of cells. Enlargement by intussusception differs, therefore, from that by imbibition, in degree rather than in kind. In whichever way convey- ed to the seat of growth-formation, the nutrient material, at first fluid, is evolved and appropriated by continuous cell-generation. Now this cell- generation may be affected on an endogenous or an exogenous plan. When the plan is endoge- nous, the germs of young cells are evolved and contained within older ones; those secondary cells are endowed with a similar procreative faculty; the tertiary series are in like manner fecund, and so on. Here a single cell may be regarded as the potential embryo of an entire growth. When, on the other hand, the plan is exogenous, the germs of new cells are not found within, but lie and are evolved outside old ones." 90. "Where endogenous evolution prevails, and a cell is, potentially considered, a tumour in futuro, the perpetual production of similar cells is easily intelligible ; the offspring that follows is as the parent that went before. But in ex- ogenous growths the continuous germination of infinite series of like cells is not readily con- ceived. It may be surmised that, when a series of cells has sprung into being, this series acts on the evolution of succeeding ones, as a nat- ural vascularized is known to do on the gener- ation of epithelium-cells ; the formed series so influences newly-exuded blastema (of which it constantly excites the accession), that this shall produce a new series of cells similar to itself. But, however the perpetuation of like cells be understood, be it remembered that the thing it- self has its limits; for deposits may appear in growths, pseudo-tissues are among their fre- quent constituents, and a growth of one kind may establish itself a nidus within the area of another generically dissimilar. Elder cells thus seem (within certain limits) to cause the in- crease, and regulate the qualities of younger ones. Younger cells are, on the other hand, more or less active agents in effecting the de- struction of the older ones ; less so in endoge- nous growths, where the elder may increase materially in size (as their contained brood mul- tiplies), and acquire thickened walls; more so in exogenous growths, where such enlargement of cells is not witnessed, and where the pro- duction of young is coeval with the disintegra- tion of old ones"—(Dr. Walshe, art. Products, Adventitious, in Cyclop, of Anat. and Physiol., vol. iv., p. 120.) 91. C. The reproduction of growths or tumours is of importance as regards the diagnosis as well as the treatment. Dr. Walshe, in his very able article just quoted, observes, that " growths of all descriptions are liable, when removed spontaneously or by art, to be reproduced in the spot they previously occupied, if the removal have not been absolutely complete. The parti- cles left behind act as attractive forces for new blastema convertible into cells, similar to those of which themselves are composed. This mode of reproduction (as it is erroneously called, for it is nothing more than enlargement, facilitated by removal of pressure of pre-existing sub- stance) occurs with growths of all kinds, can- cerous, sarcomatous, fibrous, fatty, enchondro- matous, erectile, &c. But it would appear that in some cases of surgical removal, when the whole mass has, as is presumed, been extirpa- ted, a new growth vegetates in its place. The difference ofthe cases is often rather apparent than real; we have distinctly found the germina of cancer in tissue, reputed healthy, surround- ing a cancerous mass ; and it is manifest that such germina, though invisible to the naked eye, may, quite as readily as a fragment of diseased tissue of even considerable size, act as the effi- cient agents of new development. When, in- dependently of this mode of generation, the dis- ease returns in the seat of its former growth, the occurrence must depend upon the continu- ance of that depraved state of the blood which is fitted to supply the necessary blastema, and likewise, possibly, upon some peculiar state of vessels of the part favouring its exudation here rather than elsewhere" (p. 121). That the blood and blood-vessels are thus more or less concerned in the re-development of morbid growths may be admitted; but something, if not more, should be imputed to the depraved in- fluence of the organic nerves supplying these vessels and the part affected. (See art. Can- cer, v 26.) 92. In cases where the growth appears in one or more places remote from its primary seat, Dr. Walshe remarks that the occurrence, which is termed the "distant reproduction" ofthe growth, is explicable in two ways. " The new- ly-discovered growth may have existed previ- ously to the extirpation of the old one, and, hav- ing simply acquired additional activity, so be- come obvious, after that extirpation ; or the new growth may have really first appeared sub- sequently to the removal of the older one." The latter alternative Dr. Walshe believes to be rare. There is, however, reason to consider it to be more frequent than he admits, and to be produced not merely in the way which he sta'.es, although that way certainly exists to a certain extent. Of this consecutive production of the morbid structure in distant parts, he con- siders the simple explanation to be that the vitia- ted state of the blood, proper for the supply of the necessary blastema, continues ; and that this blastema is poured out in some other part ofthe frame, the original tumour no longer ex- isting to attract its deposition within or around itself. That this explanation may hold good, either altogether or in part, I shall not here dis- pute ; but the organic nervous influence, con- trolling, as it does, the functions of assimila- tion, nutrition, depuration, and excretion, cer- tainly has a primary, and by no means a small share throughout, in the distant reproduction and extension of cancerous and other tumours. 93. D. The changes produced in tumours during their evolution may be viewed as departures from the regular processes of their formation. The most important of these changes are their degeneration, which has been considered as re- gards cancer, and the removal or conversion of some of the non-cancroid, spontaneously, or by SCIRRHOUS AND OTHER TUMOURS—Diagnosis of. 789 the aid of internal means. These, however, are only rare occurrences. Much more fre- quently morbid growths experience the princi- pal diseased actions to which the natural or healthy structures are liable, as congestion, in- filtrations of serum or of blood, haemorrhage, in- flammation, gangrene, depositions of matters foreign to their nature; and, as consequences of these, various discolorations and changes in consistence. ° 94. E. The effects produced by tumours and oth- er morbid productions upon surrounding struc- tures are most important, the injuries produced by them in many instances being chiefly of this kind. These effects are mechanical and vital. (Walshe.)—(a) The mechanical effects axe prin- cipally pressure, displacements, detrusion or extrusion, condensation, discoloration, infiltra- tions, interrupted circulation, occlusion of nat- ural cavities or canals. When tumours form between muscular or movable parts and the membrane covering these parts, they generally are detruded from the original seats of forma- tion, and, as they increase, they present stalks or peduncles by which they are attached to these seats, as most commonly shown by tu- mours in the uterus, which, assuming this shape from detrusion, and often subsequently from ex- trusion beyond the cavity of the organ, have been improperly called polypus. 95. (b) The vital effects of tumours on the sur- rounding tissues are softening or rarefaction, atrophy, hypertrophy, inflammation and its usual results, as adhesion, induration, ulceration, mor- tification, perforation; changes in the blood-ves- sels ; haemorrhages ; alterations of the sensi- bility, from numbness to the most intense pain ; and infiltration ofthe surrounding textures with matter similar to that composing the morbid growth — an effect observed chiefly in respect of cancerous tumours. Dr. Walshe considers this last effect to occur in connexion with no other growth except cancer, and to constitute one of the most evident distinctions between cancerous and other allied formations. 96. iii. The Seats or Localizations of Tu- mours ano Morbid Formations.—A. Certain tissues and organs are much more liable to be the seats of growths than others, more especial- ly the cellular tissue, and the female sexual or- gans. Dr. Walshe observes, that, while cellu- lar tissue is the favourite site of growths, fibrous textures but rarely afford them a nidus. The mammae, the ovaries, and the uterus are fre- quent sufferers; the lungs and brain are much more rarely affected. Certain parts of organs, also, are much more commonly attacked than other parts, as the pylorus and the epididymis, than the rest of the organs. Some organs, or parts of organs, are prone to be affected by cer- tain growths in preference to others, as the mammae, the stomach, the liver, &c, are most liable to be affected by cancerous productions ; the bones to enchondroma ; the neck of the ute- rus to cancer, in preference to the body of the organ, where fibrous tumours are chiefly devel- oped ; and the large intestines are very much more frequently the seat of cancer than the small. . . ., 97. B. Sex influences the site of growths. The female sexual organs are much more fre- quently their seats than the male organs; while the male urinary organs, especially the kidneys, are more frequently thus affected than the uri- nary organs of the female. Age has also con- siderable influence, certain epochs of life fa- vouring the development of certain growths in preference to others. Some tumours often ap- pear to be compatible, and others incompatible, with the coexistence of others. Dr. Walshe remarks, that some growths, as cystoma and carcinoma, are sufficiently prone to appear in the same person ; others, as fibroma and carci- mona, are rare coexistences ; none is actually incompatible, either as unconnected coexisten- ces, or as developments in each other. 98. C. The course of tumours, or other morbid growths, topographically, is either solitary, sec- ondary, or multiplied. — (a) A tumour may re- main solitary until the death of the person in whom it exists, no other organ or tissue than that in which it commenced being involved by similar disease. This occurs chiefly in respect of enchondroma, of cystoid tumours, and occa- sionally of fibrous growths. (b) Secondary growths arise by the spreading of the morbid structure from its original site to parts either adjoining or at a distance.—(1.) Ad- jacent parts axe secondarily affected by infiltra- tion or imbibition of the morbid matter from the site of preceding disease, a morbid mass thus gradually extending from the primary seat to circumjacent tissues, and co-ordinately enlarg- ing.— (2) Secondary growths in distant parts axe produced by the transmission ofthe morbid matter by either the lymphatic or vascular sys- tems. The matter, especially of cancerous and tuburculous growths, may sometimes be traced in the lymphatic vessels; and a lymphatic gland, in connexion with a cancerous mass, not infre- quently becomes cancerous also ; and, although the morbid matter cannot alw'ays be detected in the communicating vessels, there can be slight reason to doubt this mode of transmission. These glands may, however, be secondarily at- tacked, independently of this transmission ofthe cancerous matter; but this can rarely be the case where the vessels proceed from the pri- mary site to the secondarily affected glands, and, as transmission is demonstrated in some cases, it may occur in all. When parts far dis- tant are secondarily affected, these parts mani- festing no lymphatic connexions, then it may be inferred that the secondary growth has either originated independently of the primary one, or been produced by the transmission ofthe mor- bid matter from it through the medium of the veins, in which cancerous as well as other mor- bid matters proceeding from the primary seats of disease have been detected. (See arts. Ab- sorption and Abscess, Secondary.) 99. (c) Multiplied growths may exist primarily and independently of the transmission by the lymphatics or veins of morbid matters from pre- existing growths. The disease in distant and unconnected parts results from the constitu- tional morbid condition which thus manifests itself in sundry situations. This circumstance is often observed in cancerous and tuberculous maladies, and in cases of fibrous growths ; and of cancerous diseases, the encephaloid or fun- go-haematoid the most frequently manifests a multiplied origin. 100. V. Diagnosis of Scirrhous and other Morbid Growths.—The most important point of this part of the subject is the distinction be- 790 SCIRRHOUS AND OTHER TUMOURS—Diagnosis or. tween tumours or growths which are truly can- cerous, and those which possess a different structure, although resembling the former. His- tologists consider that " the local symptoms, and- the general signs observed in individual cases, have been found insufficient; such as the lancinating pains, unequal surface, hardness, elastic feel, softening, ulceration, the surround- ing tissue being affected, a general alteration of the constitution and return after excision," and have been, at various times, absent in cases un- doubtedly cancerous, while they have existed in growths the nature of which is doubtful, and often been connected with epidermic, fibrous, fatty, or cystic tumours of the most innocent nature. That this difficulty exists in rare cases; that the symptoms and signs of cancer have been absent in truly cancerous diseases, and have existed in cases of an innocent nature, may be admitted to have occurred in rare in- stances ; but these have not—at least rarely or never — furnished opportunities of examining the morbid growths microscopically until both diagnosis and treatment have been equally of no avail, or even until they have come under the knife ofthe anatomist. And even were op- portunities of microscopic investigation afford- ed, it is manifest, from what is above stated (v 5, 6), and from what has been advanced by the ablest histologists, that the diagnosis is by no means easy, even by the aid ofthe micro- scope. But I shall allow Dr. Bennett to state the case in favour of this instrument. 101. " Symptoms alone, however, from their very nature, are apt to mislead, caused as they are by a variety of disorders which may affect an organ ; while physical signs, once establish- ed and ascertained, are in conjunction with those of universal value. The only physical proof we can arrive at ofthe existence of can- cer is by means of the microscope ; not that this instrument is in itself capable, even in the most expert hands, of doing anything ; but, conjoined with a knowledge of symptoms, prog- ress of the case, form and appearance of the morbid growth, it offers us an additional and most valuable means of prosecuting our inqui- ries. It is from an union of these circumstan- ces, combined with a minute examination of the growth, under such magnifying powers as will clearly display its cells and other primary elements, that we ought to found a diagnosis, and not from one or the other separately" (p. 222) It is evident, however, from the admis- sions of Muller and others, and even from what has been stated by Professor Bennett, that the microscopic history of morbid structures is only in its infancy; that there still remains much to be known respecting it; and that the connex- ions subsisting between vital power, vascular action, and morbid growths—connexions ofthe utmost importance to the physician, in a thera- peutical point of view especially — have been generally over-looked ; while there has been much difference in the information furnished by thosewho have professed themselves to be ob- servers, gifted with the greatest powers of mi- croscopic research. 102. A. The diagnosis of cancer by means of the microscope, as already stated (v 100, 101), can seldom be determined until the disease has advanced so far as to become quite manifest without this aid. Dr. Bennett remarks, that wherever we see, in a morbid growth, cells in- cluding other cells, there can be no doubt of its cancerous nature; and that it is not by fixing attention on any one particular cell that we can discover a marked difference between it and a variety of others, but when grouped together we observe in different cells a variety in size and shape, some containing one nucleus, others two or three, and rarely more, and the nucleus con- taining one or two nucleoli. Such a group of cells is distinguished, 1st. From groups of epi- thelial-cells ; 2d. From fibro-plastic cells; 3d. From pus and plastic cells; 4th. From com- pound granular cells; and, 5th. From fat-cells. The difference of the cancer-cells from carti- lage-cells is also easily ascertained before soft- ening, but after softening the diagnosis is more difficult; but even in this latter case, the action of water and acetic acid on the cells, and an examination of different sections ofthe growth, will assist the diagnosis. In all cases, the situation and characters of the tumours, and the concomitant circumstances and symptoms, should be taken into account. Open sores, the ulcers formed on the tongue, lips, or faces on the genitals and os uteri, furnish the best occa- sions for microscopic diagnosis during the life of the patient; and even in these situations many difficulties will often occur.* 103. It is interesting to add what Professor Walshe has stated respecting this important matter. " A constant and unfailing microsco- pical characteristic of cancer has hitherto been vainly sought for ; the following propositions will serve as a commentary on, and, in some sort, a justification of, the statement. (1.) Par- ent-cells, containing within them sub-cells hav- ing darker nuclei, and these, in turn, bright nu- cleoli, are strongly characteristic of cancer; but such cells are rare in, and may be altogether absent from, scirrhus ; encephaloid, in some phases of its growth, may also be without them. (2 ) The shapelessly caudate-cell seems signifi- cant of cancer; but it may be absent from en- cephaloid, and it is excessively rare in scirrhus and colloid. (3.) A tumour may present to the naked eye the characters of encephaloid, be the seat of interstitial haemorrhage, affect the com- municating lymphatic glands, run in all respects the course of cancer, and nevertheless contain no cells but such as are undistinguishable, in the present state of our knowledge, from com- mon exudation-cells. (4.) Nay, more, while a primary " malignant" tumour alone contains these cells, the lymphatic glands secondarily af- fected may contain compound nucleated-cells, spherical and shapelessly caudate. (5.) The granular and imperfectly nucleated cell of scir- rhus is valueless as an evidence of cancer. (6.) The true fusiform cell is an adventitious formation when it occurs in cancer, and has no diagnostic signification. (7.) The association of fibre and cell-structure, which will distinguish scirrhus from fibrous tumour, may be totally wanting in encephaloid, and it exists in sarco- ma and enchondroma. (8.) If fat be associated [* M. Lebert states that the type ofthe cancer-cell is a small regular sphere with an elliptical nucleus, occupying about half of the interior of the cell, and containing one or more nucleoli, but that this type is not often pure ; the cellular envelope takes the ovoid, triangular, heart, and caudate shape. In no other cell do we observe the multi- formity of the cell-wall to the same decree. The nucleus is the constant element ofthe cancer-cell.] SCIRRHOUS AND OTHER TUMOURS—Diagnosis of. 791 in large quantity with fibre and cell-structure, the certainty that cancer is present becomes great, but not absolute. 104. "The property of infiltration, which serves well to distinguish cancer from other growths nosologically, fails practically in the dis- tinction of tumours generally, because a true cancer is not necessarily infiltrated, and because tubercle and exudation-matter may be infiltra- ted. In ultimate analysis the single character least likely to deceive is this: if a tumour be cancerous, it will yield, on pressure, an opaque, whitish (milky or creamy-looking), albuminous fluid ; if it be not cancerous, it will not yield a fluid of these qualities."—(Cycl. of Anat. and Physiol, vol. iv., p. 137.) 105. B. Fibro-nucleated tumours, or growths, distinguished by the presence of fibres, among which are infiltrated naked nuclei, have hith- erto been confounded with sarcomatous, ence- phalomatous, or osteo-medullary tumours. Le- bert considers this to be a peculiar form of fibro-plastic growth. Dr. Bennett has observ- ed but three or four instances of this tumour, and has viewed them as possessing marked peculiarities in structure, although presenting most of the appearances of those growths with which this has been confounded. 106. C Epithelial growths generally com- mence in an induration or wart upon the skin or mucous surfaces, and are harder in the former than on the latter. Occasionally they appear as cauliform excrescences or condylo- mata, made up of elongated papillae aggrega- ted together, with their summits more or less flattened. In this condition their diagnosis is easy. Sometimes they soften externally soon- er or later after their formation, and become covered with crusts of inspissated pus and epi- thelium. " This crust, on separation, leaves an an ulcerated surface, presenting irregular clefts between the hypetrophied papillae, the edge be- ing everted, and the base and margin greatly indurated. The ulcer may slowly spread over a considerable portion ofthe surface, and cause great swelling of the lymphatic glands from the irritation produced. In this condition such ul- cers are usually considered to be cancerous." But the progress of an ulcer commencing ex- ternally in warty excrescences, spreading lat- erally, slowly, and proceeding from without in- ward, is distinctly opposed to the progress of true cancer, which almost invariably is deep- seated at its commencement, produces ulcer- ation consecutively by thinning of the integu- ment, and throws out subsequently and rapidly fungoid masses. The progress of the case, the absence of cancer-cells, the microscopic appear- ance ofthe projecting papillae, will establish the nature of the growth. 107. D. Fibrous formations cannot, at an ear- ly stage, be distinguished from scirrhous. Dr. Bennett considers that at their commence- ment they are both identical, and remarks that experience is daily showing the truth of this statement ; and that the distinctions between them insisted upon in surgical works are illu- sory. When a hard knot or induration follows a blow or injury, it may result from a simple exudation; but it may nevertheless become cancerous ; although this conversion is much less likely to take place in a young than in a cachetic or aged person. When more ad- vanced, fibrous tumours are distinguished by partial elasticity, smoothness, and regularity of surface, from the irregular nodosities and stony hardness of scirrhus, and the pulpy feel of encephaloma. But these symptoms are sometimes deceptive. So that at an advanced, as well as at an early stage, the diagnosis may be occasionally impossible. Dr. Bennett ad- vises a cautious use of the exploring needle and microscopic examination. When the latter can be obtained, the presence or absence of cancer-cells will decide the question. But the former, however cautiously employed, will oft- en aggravate the local mischief, and prove of questionable utility as respects the results. 108. E. Cartilaginous growths, when occur- ring in the extremities connected with the bones, and surrounded by an osseous capsule, may readily be distinguished from cancer; but when they are deep-seated, covered by soft parts, and have no distinct bony capsule, their detection is very difficult. Enchondroma may thus be readily confounded with cancer of the bones, of which disease it presents all the general symptoms and signs; and, as already stated (y 66, 67), if it be softened it is not easily separated from cancer by the aid of the microscope, even after excision. In doubtful cases, during life, a microscopic examination can be obtained only by means of the explor- ing needle,, and even then it may be unsatis- factory. The progress of the growth is more distinctive, cancer of the bones being generally more rapid in its progress than enchondroma. 109. F. Fatty Tumours. — " Simple lipoma and most encysted fatty tumours are readily distinguished from cancer, the first by their lob- ulated, and the second by their rounded form, together with their doughy feeling and non- attachment to surrounding parts." A fatty growth may, however, assume all the symp- toms and signs of encephaloma. Sedillot excised a fatty tumour from a man aged forty- seven. The growth returned twice after re- moval, and was excised the third time. It was considered to be encephaloid, from the local and constitutional symptoms and its return ; and yet, on a microscopic examination, it was shown to consist only of adipose and filament- ous tissue, and a chemical analysis proved it tu be almost entirely composed of fat. 110. G. Tubercular growths can rarely be con- founded with cancer. They simulate it only when the glands are enlarged in youth, and at an age when cancer scarcely ever attacks the frame, unless in the form of encephaloma or fungo-haematoid cancer. " Undoubtedly many of the so-called cases of cancer in the young are softened tubercle. The nature ofthe growth may be suspected from its cheesy consistence and absence of cancerous juice ; while the dif- ferences between tubercle and cancer corpus- cles under the microscope are so great as to be unmistakable. The only danger is confounding tubercle with the reticulum of cancer, which it closely resembles, and is a mistake that a criti- cal examination of all the concomitant circum- stances will alone enable us to avoid."—(Ben- nett, Op. cii., p. 229.) 111. VI. Prognosis of Scirrhous and other Growths.—i. Of Scirrhous or Cancerous For- mations.—Little may be added at this place to what I have stated when treating of Cancer 792 SCIRRHOUS AND OTHER TUMOURS—Prognosis of. (v 11, et seq.) and Fungoid Disease (y 17)—A. Muller considers that growths which are truly eancerous when extirpated invariably return, and are inevitably fatal. Dr. Walshe observes, that •• cancer is not, as a matter of absolute ne- cessity, a fatal disease ; but the number of re- coveries is relatively so small that, practically speaking, they are almost without numerical value, and may be excluded from considera- tions." Professor Bennett states, that he can no more agree with the modified statement of Dr. Walshe than with the unqualified one of Muller ; and remarks, that the established re- coveries may be small in number, but their nu- merical value is altogether unknown in the pres- ent state of science. He believes that a cancer- ous growth is for some time purely local; that indolent tumours exist in the female breast or elsewhere for years, without making progress, or causing much inconvenience, and after a cer- tain time they often suddenly increase, and evince signs of malignancy; that a fibrous vascu- lar tumour may exist, in the filamentous meshes of which a cancerous exudation may be after- ward infiltrated, and that in this indolent state a tumour may often be discussed by suitable means, and, if excised, be permanently eradi- cated. These propositions may be conceded to Dr. Bennett; tbey have been long received as practical doctrines, and long acted upon by both j physicians and surgeons. Even when a growth has become undoubtedly cancerous, complete excision of it has been said to have been suc- cessful in a few instances; but still the actu- ally cancerous nature of the tumour has not been satisfactorily established, for the histolo- gists argue that it has not been determined by a sufficient microscopic examination. But even they admit, as stated above (Y 100, 101), that a microscopic investigation is not sufficient al- ways to determine the fact; so that the imper- fections which they impute to the infancy of the science may be admitted to belong to the nature of the subject — to the varying, ever- changing, and constitutional relations of these growths—to the alterations which take place in them under the influence of changes in the state of vital endowment and of vascular ac- tion, both of the growths themselves, and of the body in which they occur as parasitic or other productions. It is in vain to look for precise marks of demarkation, either in the diagnosis or in the prognosis, where none ex- ists, and where every phase, grade, and form of morbid growth is observed, although in dif- ferent cases ; each of which phases and forms is continually undergoing farther changes, and assuming varying local and constitutional rela- tions. The histologists, after all they have ob- served and written, leave the subject of prog- nosis, as well as that of diagnosis, pretty much in the state in which they found it; for one of the latest and best writers in this department has remarked, that " in the present slate of our knowledge, there is no possibility of pronounc- ing accurately whether an operation will be successful or not"* (p. 232). * [" Cancer," says Dr. Warren, h is not a specific dis- lose. It has a variety of forms, of causes, and of habi- tudes of action. It is one thing in the tongue, another in the skin, another in the breast. There is nothing specific in it, unless we call its incurable disposition specific; but Ibis it has in common with other disease. Besides, can- 112. ii. The prognosis of morbid growths which are not cancerous depends chiefly upon their situation and nature, and has reference to the probability of removing them by medical treat- ment, or by surgical means. The growth may appear in a situation which precludes an oper- ation, or in which an operation or simpler me- chanical means would be extremely danger- ous, and where a recourse to medicine, in or- der to arrest its progress or to remove it alto- gether, should be tried or chiefly confided in, although the chances of success from it may appear small. Adipose or fatty tumours, tu- bercular growths, and glandular enlargements, admit of a more favourable prognosis than others, and furnish the greatest number of chances of their removal by medical treat- ment. Dr. Bennett remarks, with reference to operations for the removal of tumours, that " it is now well understood that not only cancer- ous, but the most innocent growths may return after excision. It is generally supposed, how- ever, that in all such cases the second growth originates in some germ which had been left in the part. Hence it is of great importance to separate a recurrence in the seat of the for- mer tumour from that occurring in other places and textures. The former is not necessarily to be dreaded. Numerous instances are on record of fatty, fibrous, and encysted growths returning again and again, and finally extirpa- ted with success." Epithelial growths, also, occasionally return, but enchondroma, accord- ing to Muller, does not. It should, howev- er, be recollected that while truly cancerous growths generally return either in the same situation or elsewhere, non-cancerous tumours seldom return, even in the same situations, unless a portion be left behind, and when they return they appear not often in other parts. Warty and encysted growths may occur in sev- eral places ; several fibrous tumours may ex- ist in the body of the uterus ; and neuroma may affect several nerves. Although cancer, after a time, extends itself to the lymphatic glands in the neighborhood, the affection of these glands is not to be received as a proof either of the cancerous nature of the primary growth or of a fatal tendency ofthe malady; for a non-cancerous growth may cause, but much more rarely, enlargement of these glands, ow- ing to the amount of local irritation produced by it. When, however, this affection of the glands occurs, it indicates, even in non-scir- rhous tumours, a much more serious malady, than when no such glandular affection is ob- served. 113. VII. Treatment of Scirrhous and other Tumours.—i. The treatment of scirrhous growths I have considered fully in the article on Cancer (y 27, et seq.); but there are a few topics which have been agitated since that was written, which require a brief notice at this place. The means which Dr. Bennett advises for the " retardation and resolution" of cancel are cold, dryness, pressure, and locality; and these he views as the principal known meas- ures by which we can hope to retard the pro- cer, though rarely cured, !• not universally incurable. We see it disappear in various parts of the body without excision, though most rarely."—Surg. Observations cm Tumours, t)c, by John C. Warub, p. 351.J SCIRRHOUS AND OTHER GROWTHS—Treatment of. 793 duction and growth of cancer-cells. He re- marks, that " a cancerous growth is a vascular structure, which consists of nucleated cells in- filtrated among a fibrous stroma, and that its power of growth, extension, and redevelopment is dependent upon the amount of cells it con- tains. It follows, that to retard the growth of the cancer-cell when once formed, is to retard the advance of cancer itself, and that to render it unproductive is to arrest its progress." This view appears plausible at first sight, and the means proposed are to a certain extent appro- priate to the pathological doctrine entertained ; but it is questionable how far the doctrine is sound, and to what extent the means are bene- ficial. As to the former, if it be conceded that the formation of cancer-cells are the results of a low grade of vitality in the part—that can- cer-cells, like hydatidic formations, are parasi- tic productions, proceeding from low grades of vital power and of vascular action, and, like all such productions, consequences of these Btates, the treatment here advised has refer- ence merely to the morbid results, and has comparatively but little regard to the antece- dent vital conditions, of which the cancer-cells can be viewed only as the products. In this instance, as in many others, the histologists would induce us to grapple with the morbid product, to the total disregard ofthe vital con- dition producing that product — to the entire neglect of those states of vital power and vas- cular action upon which all morbid growths depend, whether parasitic, hydatidic, cell-for- mations, or simple exudations. 114. Viewing, therefore, cancerous produc- tions or growths as depending upon the causes, constitutional and local, which I have set forth in the article Cancer (y 26)—entertaining the doctrine there stated, and knowing that it is supported by the ablest and most experienced writers and observers, as well as confirmed by my own experience, I firmly adhere to this doctrine, and to the intentions of cure set forth conformably with it in that article (§ 40, et seq.), believing that they are the best calculated to enable the constitution to resist the inroads of the malady, to prolong life, and to give the patient a chance of throwing off, or resolving the local evil. The measures which have more recently been advised should not, however, be passed over without notice, although but little evidence of benefit from them has hitherto been obtained. Dr. Bennett observes, that " all eggs and young animals require warmth to fa- vour their growth, and maturity is reached ear- lier in the tropics than in temperate regions. In the same manner, excessive cold, dryness, want of room, and unfavourable position are circumstances hostile to cell-development; but it requires no lengthy argument to prove the great influence of these agents on vital growth." Without disregarding this view of the subject, I would still insist upon the importance of the principle for which I have contended, both in the article Cancer (y 26) and in that in Hyda- tids (y 24), that these and all other parasitic formations increase and multiply in proportion as the parent animal becomes weakened, and as the secretions arid excretions accumulate, and that those formations are most disposed to diminish and ultimately to disappear, with the full restoration of the vital power, and with the healthy nutrition ofthe animal which produced them. 115. A. Cold.—Dr. Bennett remarks respect- ing this agent, that "in a cancerous growth, the tendency of which is to excessive cell-for- mation, we evidently retard its advancement by the application of cold. Were it possible, indeed, to bring down the temperature of an entire growth below the vegetating point, we must inevitably kill it; but, supplied as it is with heat through the warm blood within, this is impracticable. Still, the external applica- tion of cold is one of the most powerful means we possess of retarding the progress of a can- cerous or any other kind of growth." The beneficial agency of cold has, however, to be proved. If it be employed so as to promote and develop organic nervous energy and vital power, there can be no doubt of its proving more or less useful. 116. B. Dryness.—It has been supposed that, as the development of cell-formations depends upon a blastema or nourishing fluid, it follows that, if this were cut off, the growth would die. In order to accomplish this intention, it would be necessary to tie the principal vessels nour- ishing the growth. This has been done by Magendie, Jobert, and Hossack, with partial success in some instances, and with complete success in others ; but it is doubtful whether or no the disease was cancerous -in all the cases. Dr. Hossack applied 'a ligature on the carotid artery in two cases of scirrhus of the parotid gland. In one case the growth of the tumour was arrested,' and the suffering of the patient relieved ; in the other a complete cure was produced. Lotions and humid applica- tions should be avoided, and those which pro- duce a drying or absorbent, with an astringent,, action ought to be preferred. 117. C. Pressure was first advised by Young, and has since been adopted for the cure of Cancer (see v 37) by several writers. Pres- sure acts, 1st, by diminishing the supply of fluids to the morbid growths ; 2d, by preventing the expansion and development of the cancer- cells ; and, 3d, by promoting the disintegration and absorption of the morbid growth. Dr. Bennett remarks, that " pressure applied ex- ternally to so-called cancerous tumours has been pretty extensively tried, and been found successful, sometimes in retarding, and at others in altogether removing them." Tra- vers has seen cases of this kind ; and Reca- mier gives the following results of the practice tried in 100 cases. He says, of these, "sixteen appeared to be incurable, and underwent only a palliative treatment; thirty were completely cured by compression alone; and twenty-one derived considerable benefit from it; fifteen were radically cured by extirpation alone, or chiefly by extirpation arid pressure combined ; and six by compression and cauterization. In the thirteen remaining cases the disease re- sisted all the means employed." Dr. Walshb states, that Dr. A. R. J. Bayle, out of 127 re- corded cases, gives 71 cured, 26 improved, and 30 unaffected. These results are certainly much more favourable than could have been obtained from the treatment of the several kinds of scirrho-cancer ; and I would therefore infer, either that the favourable results have been prematurely reported, or that cases actu- 794 SCIRRHOUS AND OTHER GROWTHS—Treatment or. ally not cancerous have been confounded with the cancerous. 118. Dr. Neil Arnott has greatly facilitated the employment of pressure by the invention of an instrument for this purpose, and which has been described by Dr. Walshe. It con- sists of a spring, an air-cushion, supported by a flat resisting frame or shield, a pad, and two belts. It does not interfere with the move- ments of the thorax, and the amount of pres- sure can be nicely regulated and equably ap- plied ; causing great relief from pain, and re- straining hemorrhage in ulcerated cases. It has been proved useful in cases in which I have seen it resorted to. Dr. Bennett remarks, that, if pressure alone be capable of producing such good results, its conjunction with one or more of the other means capable of retarding growth may be attended by even greater util- ity ; and thus the apparatus invented by Dr. J. Arnott, by means of which pressure maybe combined with external cold and dryness, is directly indicated, and deserves to be tried ; or his apparatus, applied when the patient is at rest, may be alternated with that of Dr. Neil Arnott, when exercise is desirable. I believe, however, that pressure will be found most effi- cacious when conjoined with those measures which are the best calculated to improve the general health, and to enable the vital power to throw offthe parasitic formation. (See art. Can- cer, y 40, et seq.)- 119 D. Locality has been shown, in the arti- cle Cancer, to have considerable influence in favouring the development of this malady. Cold, humid, and malarious situations, un- wholesome food, insufficient nourishment, and mental anxieties and depression, are among the most influential causes of scirrho-cancer. Therefore a choice of locality, and, with refer- ence to season, prevailing winds, and exposure, should be made with due care ; a dry, mod- erately warm, and bracing situation and air, being selected. A clay soil, or a low alluvial, wet, and swampy soil should be avoided, even to a considerable distance ; and food, exercise, and the regimen of both the body and mind, should be such as are most calculated to give due tone to the former, to refresh and agree- ably engage the latter; interesting occupations being calculated to promote both intentions, while the want of occupation leaves the pa- tient a prey to ennui and to his own depress- ing anticipations, or his still more lowering fears. 120. E. Excision.—The propriety of excising tumours, from a belief in their cancerous na- ture, or dread of their assuming this nature, or as the best mode of removing them, has been much discussed by both physicians and sur- geons, especially in recent times. It may have been supposed that the discoveries of the his- tologists would have gone far to determine the question of excision, in as far as the nature of the growth may be concerned. But they have left the matter pretty much in the same state as that in which they found it. Professor Bennett, after alluding to the discussion on this subject, and the differences of opinion ex- pressed by the most eminent surgeons of Paris, remarks, that "a knowledge of the struc- ture and natural progress of cancerous and cancroid growths must in future exempt sur- geons from the doubt and difficulty they for- merly experienced. At the same time, it can- not be denied that considerable obscurity still hangs over our knowledge of the pathology of cancer, and that there are no means of diag- nosing a cancerous from fibrous and other forms of cancroid growth at their commence- ment. It seems to me certain that a cancerous may supervene upon a cancroid growth, and that both for a time may be local, so that, un- der all circumstances, where the nature ofthe tumour is doubtful, after means of retardation and resolution have had a fair trial, excision should be at once had recourse to. As there is no possibility at early period of knowing whether the growth may or may not ultimately become cancerous, prudence demands that as soon as it becomes evident that these means hate failed to arrest Us progress, an operation should be performed. If early excision were more practiced, many ofthe lamentable cases which occur would never appear."—(Op. cit., p. 242.) This is sound advice; and the same eminent physician farther remarks: "The practical rule, then, which pathology and experience unite in causing us to adopt, seems to be this, that so long as cancer remains fixed in a part which is capable of being removed, and the strength of the patient is not loo much reduced, so long is the surgeon warranted to interfere. If this ap- plies to cancerous, it does with ten-fold force to cancroid growths, which, everything that we know warrants us in asserting, are much less fatal and malignant."—(Op. at., p. 245.) 121. F. Chemical Applications, 4-c.—The de- struction of morbid growths by various cauter- izing or dissolving applications can scarcely be accomplished, unless at very early periods of their production ; and, as regards cancerous formations, these applications would increase rather than arrest the disease. Dr. Bennett remarks, that " Acetic acid dissolves the cell- wall more or less, and strong potash reduces the whole to a granular mass. The continued application of these agents, therefore, would tend to dissolve if brought in direct contact with the cells, and need not necessarily excite such irritation as to cause fresh exudation. The only objection is, the utter impossibility of affecting the whole mass, even in cases of ulceration, and preventing the formation of deep-seated cells, while the superficial ones are destroyed. In certain cancroid growths, especially epithelial ones, the application of acetic acid is an established remedy, and should always be tried when it is thought possible to bring the fluid successively in contact with the entire mass of the disease" (p 250). The ex- ternal application of the chloride of zinc has been advised, and of iodine, and of several of its preparations. Probably the application of an iodide of zinc may deserve a trial. 122. G. Internal Remedies.—Before excision is attempted, and often contemporaneously with a judicious recourse to external means, several internal remedies, either singly or va- riously conjoined, may be tried, more especial- ly those which tend to promote the digestive, assimilative, and depurative functions, and to develop the powers of life. As respects can- cerous growths, this principle of treatment has been fully insisted on (see arts. Cancer, y 40, and Fungoio Disease, y 21); it therefore only SCIRRHOUS AND OTHER GROWTHS—Treatment of. 795 remains briefly to notice the importance of adopting it in our attempts to remove other morbid growths, especially before the constitu- tion is subjected to the shock of an operation ; and in cases where the situation of a tumour or other circumstances may render the success of an operation either extremely improbable or impossible. In three cases of large tumours— one seated superficially, evidently a fatty tu- mour, and about the size of a person's head, the others seated very deeply among the muscles of the upper half of the thigh—and in one case of tumour, apparently attached to the pericra- nium, a course of internal medicines entirely removed the disease. I had advised a recourse to surgical aid, but the patients having been de- sirous of trying medical treatment before any surgical means were adopted, a course of the medicines about to be mentioned was prescri- bed, very nearly the same substances having been employed for the four cases. Those cases occurred some years ago ; but the per- sons who were the subjects of them had not, up to recent periods, experienced a return of these growths. The medicines which were prescribed consisted chiefly of the iodide of po- tassium, conjoined with solution of potash, the decoction or compound tincture of cinchona, the internal use of tar-water, and the fluid ex- tract or other preparations of sarsaparilla, with due attention to diet and to exercise in the open air. When treating of Cancer (y 34-41), the propriety of prescribing the preparations of iron was insisted upon, especially in such com- binations as the peculiarities ofthe case would suggest; and the iodide of iron was then for the first time recommended in the treatment of cancerous diseases. This medicine has fre- quently been given by me in these maladies with sarsaparilla, or dissolved in the sirup of sarza, with more or less benefit; and the nitro- hydrochloric acids have been sometimes prescri- bed with vegetable tonics or bitter infusions. Considerable advantage has been derived, in several cases, from the use of inspissated ox- gall, as recommended in the first part of this work, and prescribed in numerous and varied formulae in the Appendix which accompanied that part, more especially in correcting and promoting the functions of the digestive canal. Conium, and other narcotics formerly much praised for cancerous maladies, have rarely proved of advantage beyond the temporary re- lief to pain, or to other urgent symptoms they have sometimes afforded. 123. H. Diet and Regimen.—These require to be adapted to the temperament, diathesis, hab- it of body, and other circumstances ofthe pa- tient, as well as to the presumed nature of the tumour. When treating of Cancer (y 44), I mentioned the advantages generally derived from attention to the secretions and excretions, and from promotion of the primary and sec- ondary assimilating processes. There can be no doubt of the good effects of moderate exer- cise in the open air, of a residence in a mild, dry atmosphere, and of pleasant occupations, with a cheerful state of mind. But the nature of the food admits of much more discussion. In the cancerous or scirrhous forms of morbid growth, the adoption of a farinaceous and vege- table diet has been advised by Dr. Lambe and a few others. I have seen this diet most bene- ficial in a case which was considered cancer- ous disease of the os and cervix uteri; but the patient enjoyed at the same time the advant- ages of removal to a good air, and her san- guine temperament and full habit of body fa- voured the change of diet. When, however, the patient is of the melancholic, lymphatic, or nervous temperature, or if anaemia or a cachec- tic habit of body be manifest, I believe that a judicious combination of animal with vegeta- ble food, and the promotion ofthe assimilating and excreting functions, are most beneficial. In all cases of a malignant or contaminating nature, and in all cases which are likely to as- sume this nature, the chief indication of treat- ment is to enable the vital energy, by the aid of diet, air, and exercise, to resist the extension of the local evil, and to favour its transfor- mation or resolution. [According to Wendt, Helm, and others, the preparations of gold have been found very use- ful in scirrhous induration of the tongue. The usual form of administration is to rub them on the tongue. A case of scirrhus ofthe pylorus is related by H. Hoffman, in which the chloride of gold effected a perfect cure ; and frictions of the chloride, as well as the oxide, on the labia pudendi, in cases of cancer of the uterus, have been recommended by Hufeland, Herrmann, Meisner, Grotzner, Gozzi, and others. Kri- mer advises that they be applied to the os ute- ri. According to German writers, scirrhosities have frequently been dispersed through their agency, and even in open cancer marked im- provement has been perceptible. Dr. A. T. Thomson has described a case of scirrhous mamma, which, after protracted and fruitless treatment by other agents, as other preparations of iron, with conium, ultimately was cured by a combination of iodide of iron and conium. The Calendula officinalis, garden marigold, has considerable reputation in Germany for the cure of scirrhus and cancer. Westring, a Swedish physician, called attention to it in 1817, having found it very useful in cancer of the breast and uterus. He used a decoction of it internally, and also applied the fresh plant to the part affected, when practicable, and it was found to allay the burning pain. Rudolph afterward used it with much benefit, in a case of induration of the mamma, in a young fe- male, applying the acetate of iron in solution, at the same time, externally. Fehr also found it useful both in incipient and advanced scir- rhus. Stein praises it highly in cancer Of the integuments, using an ointment made of the expressed juice of the young plant and flowers, with fresh butter, giving at the same time a decoction of the plant internally. The salve causes considerable pain at first, but in a little time the ichorous discharge is improved, the offensive odour corrected, and in from fourteen to twenty-one days the ulcer is converted into one of a benign and readily cicatrizable char- acter. Iodine is highly recommended in scirrhus of the uterus, mammae, &c , by Heim, Klaproth, Hennemann, Ullmann, Hill, Magendie, Wag- ner, Zimmermann, and many other physicians, applying it in the form of the compound oint- ment to the part affected, and also giving it internally. Magendie extols it in cancer of tht 796 SCIRRHOUS AND OTHER tongue, Jahn in incipient scirrhus of the stom- ach, while Dr. J. K. Mitchell, of Philadelphia, has found the iodide of potassium afford very marked relief in a scirrhus tumour ofthe neck. — (Medical Examiner, 1846.) I have seen, also, decided benefit from the use of different preparations of iodine, particularly the iodide of iron, used both externally and internally, but I cannot say that I have witnessed any perfect cures from their employment. The preparations of platinum have been rec- ommended by Duttenhofer, Prevost, and others, in different forms of cancer and scir- rhus, but I have not seen them employed, nor is there sufficient evidence in their favour to recommend them to our notice. I have more confidence in attention to the loss of health, as connected with proper food, exercise, pure air, suitable clothing, freedom from anxiety, &c., than in all the drugs of the Pharmacopoeia. The late Dr. Twitchell, of New Hampshire, was cured of a cancer of the face by an ex- clusive bread and milk diet; and since his case was published in the journals, I have known several others in which the disease was ar- rested by the same diet and regimen, without the use of any remedies whatever. There can be no doubt that early excision is in all cases advisable, where practicable, great care being taken to remove every portion of the scirrhous part. If this be done, they are not likely to return unless there be a strong hereditary tendency to the disease; in this case, however, excision is advisable, inasmuch as it tends to protract life, if it does not save the patient. There is danger that too much re- liance be placed on the means of retardation and resolution, mentioned by our author, to the neglect of the more important and radical treat- ment. But we are not to forget that cancer, like scrofula, is often a constitutional disease, and that if there be any remedy for it, it must be found in agents which influence the intimate structure of the body more generally and inti- mately than any medicinal substance can do, as proper diet, a healthy state ofthe excretory apparatus, a pure atmosphere, and exercise of the muscular system, suited to the constitution ofthe patient.] 1 Bibliog. and Refer.—Galenus, De Tumoribus prseter Naturam, Op., t. iii.—Avicenna, Canon., L. iv., Fen. iii., Tr. 2, c. iv.—Rneff, De Tumoribus Phlegmaticis non Nat- uralibus, 4to. Tigur., 1556.—J. P. Ingrassias, De Tumori- bus praster Naturam, Neap., 1553; in Holler's Biblioth. Med. Pract., vol. ii., p. 69.—D, Leonus, Methodus Medendi Tumores praeter Naturam, 8vo. Bonon., 1562. — Lami, Ergo Molles Tumores boni. Paris, 1571.—A. Read, Chi- rurgical Lectures on Tumours and Ulcers, &c., 4to. Lond., 1635.—F. Thevenin, OZuvres contenant un Traitfi des Tumeurs, 4to. Paris, 1658.—E. Rudius, De Tumori- bus prseter Naturam, 4to. Venet., 1600.—F. Blondel, Epis- tola de Cura Carcinomatis, absque Ferro vel Igne, 4to. Paris, 1666.—Brown,' Of Preturnatural Tumours, -+£-r* i-at r- i-. r- CI •^ \ Or-« ■ c* qg ci *c oj r* * '>cx,ooco:ocoi-ir- -h CO f-H i— O T CO CO CO COcMcScOrHCOOCOTpCCCNC'SoCO r-T CO ©I r-TrMr-r r-T ;28 O O O O O O o 22222222a 'omooooooi — at y> rr 10 tc t- O 5 I2CSI n |m *j- n lags _ inn -- t- r: t»to From this table we learn that tuberculosis is most fre- quent from 20 to 30, and next, from 30 to 40, that, at the ages of 20 to 30, the number of females who die of con- sumption is nearly double that of males, being 1409 of the former to 708 of the latter, while from 30 to 40 the num- ber of each sex is nearly similar. The following table of Mr. Shatttjck shows the rela- tive population of the sexes, victims of tuberculosis, in different places and countries. Places. Massachu-I setts ... J N. Y. City.. N. Y. State. Philadelph. London___ England ... 4 y'rs 7 " 2 " 10 " 4 " 8,827 9,606 6,715 7,666 27,788 52,176 Males 3,443 4,938 2,827 3,851 14,824 5,384 4,668 3,888 3,818 12,964 24,048] 18,088 Proportion of each. as 39 01 to 60 i 51-41 4208 5023 53 35 4613 48-59 57-92 49-77 46-65 53-87 It thus appears that, while the disease destroys more males than females in New York and London, it destroys nearly the same of both sexes in Philadelphia, and in the country towns of Massachusetts, the proportion of the sexes is as 39-01 males to 60-96 females ; in New York, as 4208 to 57-92; and in England, except London, as 4613 to 53-87, a striking difference appearing in all ages over 20. What are the particular causes which render the disease so much more rife relatively among females in the coun- try than in the city, remains to be shown, as well as the different causes existing in cities to aggravate the disease in the other sex. If we turn our attention to locality aa influencing this disease, we find, for example, that the pro- portion of deaths in the four western counties of Massa- chusetts from it does not vary much from that on the sea- coast being from 1829, to 21-67 per cent., or as 1 in 5-43 to 1 in 4'61 of all the deaths; the lowest number in the state having occurred in Boston, from 1830 to 1840, 14-04 per cent, or 1 in 7-11. In New York city, from 1811 to 1820, the mortality from tuberculosis was 23-40 per cent, or 1 in 4-27; while throughout the state, in 1847 and '48, the mortality was 25 per cent, or 1 in 4. A superficial survey of this subject would seem to show that the prevalence of tuberculosis is, to a considerable extent, independent of those causes above mentioned, for we have seen that it sweeps oft' nearly as many among the scattered country population of New England as among the crowded deni- zens of our large cities. There would, indeed, appear to be some constitutional taint, predisposing about one fourth of our population to this fatal malady; and this, too, when surrounded by circumstances apparently the most favour- able to health and longevity. Our manufactories are not so managed, as in England, as to develop scrofula or tu- berculosis to any great extent; while labour is so well re- warded, that the poorest can obtain an abundance of wholesome food. What, then, are the specific causes which predispose so many of the female sex to these mal- 828 SCROFULA AXD TUBERCLES—Treatment or. a wet-nurse of healthy constitution, and suitable as to the state of her milk, should be procured ; and if this be impossible, ass-milk, immediately upon being drawn from the animal, or goat's milk, may be given. Recourse may otherwise be had to milk expressed through a bag con- taining suet, as advised by Dr. Paris. Great care, especially as respects food and clothing, should be taken of the child at the periods of dentition and weaning. At these epochs, espe- cially the latter, ass-milk, milk boiled with suet T-cod-liver oil, or sweet oil, on the surface of the milk—small doses of liquor potassae, or of Brandish's alkaline solution, or of the iodide of iron, in the sirup of sarza, especially in older infants or children — salt-water bathing, the temperature being adapted to the strength of the child—and warm flannel clothing over the whole body, are the most beneficial hygeienic means. 151. The support of animal warmth, and the animal heat derived from a young healthy nurse, are most beneficial to delicate, and more espe- cially to scrofulous infants, and the more so the younger the child. An emanation of organic nervous power, as well as of warmth, may be furnished from this source to the delicate infant. The lower animals afford this protection to their young until growth is considerably advanced ; and yet the young animal which is most helpless in infancy, and requires this the most, is the oft- enest deprived of it, or is allowed to remain no longer in the bosom of its nurse than when it is suckled. During the coldness or coolness of night, and often in a chamber much below the usual temperature of the sitting apartment, the infant is often allowed to sleep in a cot alto- gether apart from the curtained and warmer bed ofthe nurse. 152. Change of air, or the migration from one locality to another, according to the circumstan- ces of the case, the age of the patient, and the season of the year; removal from crowded towns or situations; residence near the sea- coast, in a temperate and dry air, and on a grav- elly or sandy soil; sea-voyaging in some cases; sleeping in large airy chambers ; exercise in the open air, the enjoyment of light and sunshine during the waking hours, and limiting sleep to the hours of darkness, are generally of great serv- ice, especially in advanced, childhood, and dur- ing the progress to puberty. Cold-bathing, par- ticulary sea-bathing, frictions of the surface, a generous diet, with a due proportion of animal food, and regular meals, are also most beneficial in the early periods of life. While these means are pursued, the digestive and assimilative func- tions should be promoted, whenever they are insufficiently performed, by stomachic and tonic aperients, as the compound decoction of aloes with the compound steel mixture, or the com- pound infusions of gentian and senna ; and the use of unnecessary stimuli or stimulating bev- erages, of pork and indigestible meats, of sug- ar and saccharine substance, should be avoid- ed.* 153. As puberty advances, the utmost care should be exercised in all matters which may affect the sexual feelings or desires. A proper superintendence of both sexes ought to be insti- tuted, in order to prevent the tendency to mas- turbation, which is greater among scrofulous constitutions, at this epoch of life, than in oth- ers ; and which, if practiced at all, will certain- ly develop this diathesis into actual tubercular disease, especially.tubercular consumption. A careful supervision should also be exercised, after puberty, in order to prevent attachments being formed between scrofulous persons, or be- tween an individual of this diathesis and one who possesses a healthy constitution. This in- tention, however, will frequently fail; but where it is attempted among the well-informed classes, and the evils consequent upon the neglect of it are duly explained by members ofthe profession, it will receive attention, and the good results will ultimately become apparent. 154. V. The Medicinal Treatment of Scrof- ula and Tuberculosis.—The medicinal treat- ment of scrofula consists, 1st. In aiding the hy- geienic or regimenal treatment above discussed, when the scrofulous taint is suspected or appar- ent, especially in early life; and, 2d. In employ- ing such medicinal agents as are most likely to arrest the progress of the mischief when scrof- ula or tuberculosis is more or less manifest. In the first case, medicines are chiefly brought in aid to hygeienic means ; in the second, they are the principal agents, regimenal means being aids to their operation. 155. i. In scrofulous cases devoid of any very manifest local lesion, in connexion with the hy- geienic means now mentioned, various medi- cines possessing an alterative and tonic influ- ence may be used. One ofthe earliest indica- tions of scrofulous taint is furnished by the weak state ofthe digestive functions—a state evident- ly caused by the low condition of organic nervous power; and henee occur indigestion, flatulency, acidity of the prima via, irregular state of the bowels, torpid function of the liver, and consec- utively a poor or thin state ofthe blood. For- merly small doses of blue pill, or of gray pow- der, with soda or other antacids, were given lor adies 1 We suppose it will not be disputed that they are often, at least to be traced to a violation of some of the laws of health; as sleeping in close, ill-ventilated apart- ments ; neglect of out-door exercise ; tight lacing, and the present monstrous and absurd modes of dress; inattention to the functions of the skin and bowels ; sitting in rooms heated by air-tight stoves; sleeping in feather beds, be- neath thick cotton quilts; reading works of fiction, &c, Ate. In short, all causes which lower the vital forces, and tend to the deterioration ofthe general health, must predispose, to a greater or lesa extent, to the development of these diseases.] [* We have seen great benefit result from the use of the compound decoction of aloes in scrofulous and anaemic subjects, but we should hardly be willing to recommend any of the preparations of senna as a stomachic, or to aid the function of assimilation. With regard to sugar, we agree with Dr. Dunglison, who states that it is one of the most important agents for modifying the functions of nu- trition that we possess. Under the use of three or four ounces daily of sugar, in the form of sirup, this writer re- marks that " the patient has rapidly gained weight and the action of the system of nutrition were so much changed that the cachexy induced by poor living, and a residence in confined, unhealthy situations, as well as that which characterizes atrophy without any manifest cause, has been removed; a complete renovation has taken place; inveterate cutaneous diseases have disappeared, and old ulcers have filled up and cicatrized. The sugar in these cases appears to act as a substantive and adjective aliment; that is, it furnishes a richer and more abundant chyle; and, moreover, puts the digestive organs in a condition to derive a larger quantity of nutriment from the food than they would otherwise do, or it acts as a condiment" We have not observed the injurious effects of saccharine sub- stances in these cases, as pointed out by Dr. Copland, al- though, from our limited experience ot its use, we are not prepared to endorse freely the statements of Professor Dunglison.] SCROFULA AND TUBERCULES—Treatment of. 829 these, conjoined with stomachic aperients and tonics ; and very frequently with marked bene- fit, which, however, was very often counteract- ed by the excessive use of sugar and saccharine substances, the injurious influence of these ei- ther being not known in these cases or over- looked. This treatment, first advocated by the truly greatest name in medicine of his day—Mr. Abernethy—was afterward advocated by his pupil, Mr. Lloyd, and is still one of the best that can be adopted ; and has been employed by myself in numerous cases with marked advant- age and variously modified. Two grains of gray powder, with one or two of dry carbonate of soda, or four or five of magnesia, with rhu- barb and powdered cascarilla or cinnamon, taken once or twice daily, according to the features ofthe case, were generally most beneficial. 156. In cases which present increased fre- quency of pulse, with or without the disorder of the digestive functions, the use of the above means, modified to meet the circumstances of the case, will be advantageously assisted by small doses of either the infusion or the decoc- tion of cinchona, with the solution ofthe acetate of ammonia, sometimes with the ammonia in excess, and the sweet spirits of nitre ; or the infusion of cinchona may be given with moder- ate doses of the hydrochlofic acid and hydro- chloric ether. In cases where aperients are re- quired, and when a pill may be taken, Plbmmer's pill may be given at night with soap; and the citrate of magnesia, or the phosphate of soda, in some pleasant vehicle in the morning. 157. On the other hand, when, with disorder of the digestive organs in scrofulous subjects, there is more or less languor of the circulation and ofthe frame generally, Dr. Griffith's myrrh mixture—(one of the most valuable medicines in existence)—with the compound decoction of aloes, when the bowels require aid, sometimes with the addition ofthe solution, or ofthe car- bonate of potash and extract of conium, &c, will then be found most serviceable. 158. Since the introduction of iodine into prac- tice, there has been no other substance so gen- erally employed as it has been, in some one or other of its preparations, and especially in the form of iodide of potassium. Ii; has superseded the use of mercury even in the combinations mentioned above ; and certainly, when pre- scribed in small doses, as I have usually done since 1821, and in conjunction with the solution, or the carbonate of potash, with the mixture just mentioned, 6r with a tonic infusion, or with some preparation of sarza, it is a valuable rem- edy ; but it is one that may prove injurious if it be given in too large or frequent doses, or insuf- ficiently diluted, or if its effects are not careful- ly watched in all cases. . 159. Where scrofula is suspected or manifest by its taint, rather than by developed disease, other means may be employed, either alone or in aid of those already noticed ; and one ofthe best, both as a nutrient and as an alterative, is the cod-liver oil. When it is prescribed in full doses for the age of the patient, an alterative mercurial pill or powder may be taken occasion- ally at night <$ 155), and an aperient in the morning, in order to promote the functions of the liver and to prevent biliary accumulations ; and in cases where the debility is marked, and the surface is pallid and the structures flabby, the use of this oil should be aided by the prepa- rations of iron, or it may be taken on the surface of water containing a few drops of the hydro- chloric tincture of iron. 160. In cases of scrofulous taint conjoined with much debility, as well as in those present- ing manifest external or internal tuberculosis, various modifications and combinations of the above means may be brought in aid of hygeien- ic measures. The alteratives may consist of a combination of mercury and of iodine, or of io- dine and iron, with preparations of sarza, or with tonic infusions, according to the features of the case; and while these are being employed at suitable periods of the day, the cod-liver oil, or vegetable tonics, or bitters may also be taken. But in these the several means already advised, both for the prevention of the farther develop- ment ofthe malady and as regimenal treatment, should not be neglected, according as the pecul- iarities of the case may suggest. 161. In some cases of external scrofula, when there was a languid circulation, more benefit has appeared to accrue from the internal use of the muriatic or nitric acid, or the nitro-muriatic acids, prescribed in an infusion of cinchona, than from any of the preparations of iodine; while in others a course of two or three weeks of the former has been alternated with a similar course of the latter with obvious benefit. In some instances, also, the muriated tincture of iron, conjoined with an increased proportion of the acid, or with the hydrochloric ether, has been prescribed with the infusion or tincture of calumba or quassia, with even greater advant- age than either of the preceding. 162. A combination of small doses ofthe bi- chloride of mercury, with the compound or sim- ple tincture, or the decoction of cinchona, or with the preparations of sarsaparilla, has been long recommended both for the scrofulous taint and the more declared forms of tuberculosis ; and I have frequently had recourse to it in one or ether of these forms. In non-febrile cases, or where a tonic is required, this combination is often eminently beneficial; and a course of it is generally very advantageously followed, or alternated, by one of either ofthe preparations of iodine, as already advised (§ 158, 160, 161). 163. ii. The medicinal treatment of the more developed states of tuberculosis is not materially different from that already recommended ; but there is generally required a more appropriate application ofthe means already mentioned, as well as of others about to be noticed, to these states—to the particular forms and seats of tu- berculosis. When the malady affects external parts, as the lymphatic glands, the joints, the bones, &c, then the medicines above advised, more especially those last mentioned, will be found in general most serviceable ; and in these the cod-liver oil may also be taken. When the mesenteric glands seem to be chiefly diseased, the preparations of iodine should be given in very small and much diluted doses ; and this oil may also be brought to their aid; frictions over the abdomen, with oleaginous and stimulating liniments (Form. 306,311), being additionally re- sorted to. 164. When the glands go on to suppuration, or when a discharge is furnished by them, or when external sores, fistulae, &c , appear, then strict attention should be paid to the digestive 830 SCROFULA AND TUBERCLES—Description of. and assimilative functions, and more especially to the states ofthe circulation and ofthe blood Not only should the former functions be aided or corrected as advised above ($ 155, 156), but the blood should be improved whenever it appears to be thin or poor in red globules, by means of the preparations of iron ; and of these, the ju- dicious use ofthe compound steel mixture, or of the iodide of iron in the sirup of sarza, has proved most beneficial in my practice. In all scrofulous cases attended by suppuration or discharge, there is a marked tendency to alteration ofthe blood —to a state of anaemia, particularly as respects the coloured globules; and hence these medi- cines are the more required. In all cases, also, of open scrofulous sores, care should be taken to prevent, as much as possible, the access of the air to them ; as the air not only injuriously affects the diseased surface, but it also alters the discharge from this surface, and renders it more irritating. Local applications, therefore, in these cases, should be employed with the view not merely of removing the morbid action ofthe part, but also of completely excluding the air, and of correcting the acrimony ofthe discharge. 165. When scrofula, in any of its open forms, attacks females, it is often complicated with ei- ther a delay ofthe catamenia, especially about or soon after the period of puberty, or with ir- regularity of some kind, or an entire suppression of this evacuation. In many instances an ob- stinate form of leucorrhcea accompanies the cat- amenial disorder, and not infrequently the scrof- ulous as well as the sexual disease has been in- duced or aggravated by the baneful vice of mas- turbation. Due attention should be paid to this causation and to this morbid association, as due inquiries on the part ofthe physician, and a care- ful supervision by the friends of the patient, may be productive of ultimate success in the treat- ment, which in general should be chiefly consti- tutional. 166. In some cases, it will be found advanta- geous to commence the treatment of scrofula, especially when it is internal, or the glands are chiefly implicated, and the tongue is loaded, with a smart emetic of sulphate of zinc, and to promote the emetic operation by means of the tepid infusion of chamomile flowers ; and, hav- ing subsequently improved and promoted the secretions and excretions by the alteratives and stomachic aperients already mentioned (§ 155- 157), to enter upon a course of either of the more energetic medicines as advised above (§ 160-162) When the scrofulous affection is seated in a gland, and has gone on to suppura- tion and fluctuation, the integuments being thin- ned and purplish, there can be no doubt as to the propriety of procuring the discharge of the matter by a small incision of the integuments, and of afterward protecting the orifice from the air. In cases of this kind, as well as in those attended by open sores, the state of the consti- tution, particularly as respects the blood, should receive attention ; and the treatment ought to be especially directed to the improvement of the assimilative powers and ofthe blood, when- ever they are in fault, either by the means al- ready noticed, or by the other vegetable or min- eral tonics generally in use. 167. Whenever any sexual disorder compli- cates the scrofulous taint, or any form of tuber- culosis (v 165), as will be frequently observed in practice, meddling examinations, per vagi- nam, should not be instituted without sufficient reason. Most of these disorders will yield to the treatment advised for them severally, under their respective heads in this work, especially when conjoined with the medicines found most serviceable in scrofulous and tubercular affec- tions. Indeed.the general indications and means of cure most appropriate to the one class are very frequently suitable to the other ; and this remark need not be limited to the constitution- al treatment, but be extended to the local also. 168. After the operation of an emetic, when it is required, the alvine secretions and excre- tions ought to be duly promoted by a combina- tion of stomachics or tonics with aperients and alteratives, due regard being also had to the diet and regimen recommended above (§ 150, etseq). As occasion may offer, the mineral springs and baths about to be noticed ($ 193, et seq.) may ei- ther be brought in aid of other internal or con- stitutional remedies, or may follow the use of these latter, or even be alternated with them. 169. iii. Of the several Means recommend- ed for the Cure of Scrofula and Tubercles. —When a person possessed of common sense hears of the numerous spells, charms, incanta- tions, superstitious rites, &c, so frequently had recourse to in former days for the cure of scrof- ula, he considers them humiliating proofs ofthe credulity ofthe human mind, during ages com- monly called dark, or only partially enlighten- ed ; and he is induced to form a comparison between those ages and present times, and to draw inferences which will probably be by no means in favour of the former. Superstitious and absurd notions and practices were no more then than they are now, confined to the lower classes of society, or to the uninstructed mind; and however lowering they may appear to the dignity of human nature, however irrational and impossible the results imputed to them may seem to the thinking, however devoid of those connexions which entitje the imputed causes to the credit ofthe reported effects, when any ef- fect was even loosely observed, still greater absurdities, still more wonderful charms, more entrancing spells, more blind superstitions, and more gross impositions are credited, in this age of boasted civilization, of scientific advance- ment, and of mechanical contrivance and in- vention, and more numerous instances of blind credulity are daily manifested, than in ages of the darkest and lowest mental abasement. 170. Every where—in all ranks and classes, in all professions, and even among those reput- ed to be instructed, or learned, or even imbued with science—most absurd doctrines connected with the healing art, human impossibilities, the most ridiculous notions, the most extravagant assertions, are promulgated by knavish impos- tors, and believed in by credulous multitudes; the impudence of the former and the faith of the latter being the greater, the more devoid of truth these doctrines are, and the more they are opposed to good sense, to true science, and to honest dealing. When we find, as may be found at the present day, in the senate, in the hie- rarchy, in the judicial bench—among those who govern the country, who interpret and adminis- ter the laws, who profess to direct the religious belief of the community, not merely believers in, but also propagators of, the most absurd med- SCROFULA AND TUBERCLES—Treatment of. 831 ical doctrines and medical means —officious meddlers in what they are incapable of under- standing—abettors ofthe knavery of mischiev- ous quacks—can the decadence of true medical science be far off 7 What is neither honoured nor rewarded must necessarily cease to be suf- ficiently, ardently, and patiently cultivated. If the impertinences of the ignorant, the impu- dence of the vulgar, the professions of the un- educated, are to be esteemed above the acquire- ments ofthe scientific and philosophic investi- gator, there must, at no remote period, be an end of the learning and science of those who shall hereafter assume the office and rank of physician.* 171. A. Superstitious practices have been adopted for the cure of external scrofula since the earliest ages, and have been of various kinds, the oldest being more or less connected with pagan or religious rites, and the most re- cent with certain medical doctrines and quack- eries which influence more or less the faith or confidence of the patient. It is not unlikely that scrofulous sores formed no small part of the external maladies respecting which so am- ple a provision was made in the 13th, i4th, and 15th chapters of Leviticus, and for which the means were calculated no less to excite the faith and hopes of the patient, than to benefit the priests, who, in those ages and places of imperfect civilization, conjoined the healing art with the priestly office. During the earlier * It is very generally believed that the patronage of quacks and quackeries—of impostors and of impositions —is to be imputed chiefly to ignorance; but this is only one of several sources to which it should be referred. Credulity, a tendency, even in the incredulous, to believe in whatever is confidently asserted, a disposition to ad- mire whatever is unknown or unexplainable, the faith which many place in the impossible-—the Catholic dogma — "Credo quia impossibile est"—have collectively and severally an influence on the minds ofthe majority — on those who will not take the trouble of looking closely into matters, or of thinking sufficiently for themselves, espe- cially when they are either imperfectly or not at all ac- quttinted with the natures and relations of such matters. It ia not a little remarkable that since the founding of the College of Physicians at the commencement of the 16th century, expressly with the view of preventing the inju- rious and irregular medical practices of the day, down to recent times, most of the quacks and quackeries, against which the college had to contend, were patronized by bishops and dignitaries of the Church, and by persons of high rank, as sufficiently set forth in Ooodall's History pfthe College. It would appear, at the present day, as if the aberra- tions ofthe human mind apparent in all classes and places, in matters connected with the disorders of the body, were the humiliating inflictions of Providence on those to whom the professions are as a worldly craft, science as a matter of traffic, and learning as an occupation of the memory in- volving none of the higher manifestations of the mind. The history of human delusion as to matters medical, and ofthe fashions which have successively engaged the weak and selfish respecting the ailments of their debilitated frames, shows that, in an era of luxurious indulgence, of exhausting vices, and of enervating enjoyments, the im- pudent assertions of impostors have a more powerful in- fluence on the minds and bodies thus emasculated than the upright and rational advice of scientific and learned physicians. The victims ofthe former are either incapa- ble of reasoning upon, or are too indolent to examine, the opinions and assertions which they practically adopt; and hence of the several medical impostures of the present day, the most popular is that one which is the most ex- travagant in its pretensions, the moat abounding in absurd- ity, and the most deficient in the least approach to truth. " Probixas laudatur, it alget"—honesty, however, is hardly praised; but dishonesty and assurance are more than praised —they are worshipped with a fervency equal to the extent of delusion they achieve-to the amount of their success-a success acquired only at the expense of human suffering, and by the sacrifice of human life, but worshipped nevertheless. epochs of Jewish history, both prophets and priests had recourse to sprinkling with oil and touching the diseased parts for the cure of ex- ternal sores ; and, before the introduction of Christianity into northern countries, the Druids or priests, while they undertook the treatment of these affections, most probably adopted the same or analogous means. Pliny, Tacitus, and Suetonius furnish some doubtful evidence of touching the sick having been resorted to as one of the means of healing ; and it would ap- pear, from the Scandinavian Eddas and Sagas, and from some German and French writers in the seventeenth century, that the practice of healing external sores by the royal touch exist- ed in the northern countries of Europe as early as the eleventh and twelfth centuries, and was very commonly adopted from those times until the middle ofthe eighteenth century.* When the age and other circumstances in which ex- ternal scrofula presents itself are considered, it may be safely inferred that a very large pro- portion of those who were thus touched recov- ered at indefinite periods after it was resorted to. The accession of puberty, the influence of the mind on the body, the change of living, of season, of air and scene, and the journey, when this mode of healing was confided in, and vari- ous related circumstances, combined to produce no mean constitutional effects, and thereby to remove the local manifestation of the constitu- tional evil. The transfer of nervine influence from the healthy to the sick, or any other mode of explanation which the modern mesmerist adopts to account for the effect, when effect was observed, could have but a small share, if any, in producing it; but at the present day mesmerism usurps the place of the royal touch, although with doubtful efficacy, unless it brings to its aid all the accessories which I have now mentioned, as well as many others aiding more or less in producing a constitutional as well as a local change. 172. B. The preparations of iodine are among the most efficacious remedies which can be pre- scribed for scrofula, when judiciously adminis- tered and combined ; but, when improperly em- ployed, they may be most injurious. I have employed them extensively both in public and private practice, from 1820 until the present time ; and have generally commenced their ex- * During the seventeenth and eighteenth centurios, the seventh son of a seventh son, and, still more, the ninth son of a ninth son, divided the laurels with royalty for their success in curing scrofula by the touch; the old numbers, as well as the rare occurrence of so prolific offsprings in succession, producing the cures as effectually as the high rank of the royal competitors. At the present day, me passes ofthe mesmerist profess to effect more than either the royal touch or the humbler ministrations of even the ninth son of a ninth son, wherever he may be found. [With regard to the influence of the royal touch, it is well to recollect what is stated by Wiseman, who wrote ut the period it was practiced, viz., that part of the duty of the royal physicians and sergeant surgeons was to se- lect such patients afflicted with scrofula as evinced a tend- ency towards recovery, and that they took especial care to select those who approached the age of puberty; in short, those only whom nature had shown a disposition to cure. The patient was thus secured from the importunities of art and the efforts of nature left free and uncontrolled, and the cure not retarded or opposed by the administra- tion of adverse remedies. We have no comments to make upon the spirit-rapping and clairvoyant systems of practice; the knaves who practice them, we trust may yet be so situated as to do the state some service, if they cannot wholly compensate for the enormous evils they have inflicted upon communities.] S32 SCROFULA AND TUBERCLES—Treatment op. iiibition in small doses, and often much diluted, always preferring to give them very soon after a meal. The preparations of iodine I have pre- ferred are the iodide of potassium, the ioduret- ted solution of the iodide of potassium or the compound tincture of iodine, and the iodide of iron. The iodides of mercury are much more rarely indicated, and the iodide of sulphur is too irritating. The iodide of potassium I have oft- en combined with the carbonate of potash, or with liquor potassae, or with Brandish's alka- line solution, and sometimes also with prepara- tions of cinchona, or of sarsaparilla, or with one or other of both. The iodide of iron should be given in sirup, especially the sirup of sarza. When scrofula is associated with syphilis, then the iodides of mercury may be given, or mer- cury may be prescribed night and morning, or otherwise employed, while the preparations of iodine are taken as just recommended. 173. During the exhibition of iodine in any form, especially if continued above a few days, the state and functions of the liver should be carefully watched; for iodine may, by passing directly into the portal circulation, excite, or even irritate, the liver to a very injurious ex- tent. The preparations of iodine may be em- ployed externally in various ways, either to the part affected, or by means of local or general baths. When applied to the diseased gland or part, care should be taken that .they do not, by too great concentration, convert congestion into inflammatory action, or otherwise injuriously irritate the part. Baths containing the iodide of potassium, with or without the addition of sub-carbonate of potash, I have often found of much service, especially when brought in aid of internal means. Iodine, even when cautious- ly prescribed, may disagree with some constitu- tions. Its operation should, therefore, be care- fully observed. It ought not to be too long em- ployed without intermitting its use ; and, during its exhibition, the urine should be examined and tested, not merely with respect to itsi acidity or alkalinity, but also as to the presence of albu- men ; and if the latter appear, the use of the io- dides should be relinquished. 174. C. Mercurials.—Mercury, in the form of calomel, corrosive sublimate, and black sulphuret (Ethiop's mineral), was generally employed for scrofula during the seventeenth and eighteenth centuries. Mayerne,Bordeu, Marx, and others prescribed it not only internally, but also to the scrofulous sores. Hufeland resorted to mer- curials with the belief that they removed the scrofulous irritation by virtue of a law of the animal economy, that different kinds of irrita- tion destroy each other, or, in other words, that one kind of irritation removes, by superseding, the antecedent irritation. But in this he as- sumes two things, namely, 1st, that the morbid action consists of irritation ; and, 2d, that it or any irritation may be removed by an irritant, neither of which he nor any other one has proved. But, while Hufeland and others rec- ommended mercurials, even until they produced salivation in the more obstinate cases, others, with equal justice, contended, with Morton and Girtanner, that they were injurious when car- ried so far as to occasion salivation ; and they were fortified in this by the obvious impropriety of prescribing a debilitating medicine for a dis- ease essentially of debility. 175. At the present day, several other prepa- rations of mercury have been resorted to, espe- cially mercury with chalk, the iodide and sub-io- dide, the bromide and sub-bromide, and the nitrate, externally. I have employed several of these, especially the iodides, with results similar to those already mentioned in respect of iodine; but the mercurial iodides require a careful ob- servation of their effects. Mercury with chalk is an excellent alterative, and is often required to correctorto increase the biliary functions. Of all the preparations of mercury, the corrosive sublimate is certainly the most beneficial; but it should be prescribed in very small doses, and generally in conjunction with some preparation of sarza or of cinchona ; and, when thus exhib- ited, I have found it almost equally efficacious with the preparations of iodine. It was much used by Van Swieten, Akenside, and their con- temporaries. I have usually given it with the fluid compound extract, or sirup of sarsaparilla, or in the compound tincture or decoction of cin- chona. In the more obstinate cases, a course of the sublimate may be alternated with a course of one of the iodides ; and when the bones are at all implicated, this plan will generally prove efficacious, especially when aided by an appro- priate diet and regimen. 176. D. Preparations of Iron. — Most of the preparations of iron maybe given advantageous- ly in scrofula, especially after morbid secretions and faecal accumulations have been evacuated. The preparations which I have preferred are, the ammonio-tartrate, the potassio-tartrate, the ammonio-chloride, the saccharine carbonate, the io- dide, and the compound mixture of iron. Mention has already been made ofthe iodide ($ 172). The compound mixture of iron is one of the most efficacious, and 1 have usually prescribed it with an additional quantity of the carbonate of pot- ash, or with solution of potash, with extract of conium and liquorice. The sulphate and muriate of iron were generally preferred by Thilenius, Thomann, and Hufeland ; and when the for- mer can be, taken in a pill, and when the latter is given in the form of the tincture of the ses- quichloride, either of these is very beneficial. These preparations are most serviceable where there is any tendency to anaemia or chlorosis, and not less so when scrofula is associated with hysteria or disorder of the catamenia in any form. 177. E. Chlorides.—(a) Chloride of Barium — Dr. Adair Crawford first contended for the an- ti-scrofulous operation of the muriate of baryta, and in this he was supported by Ferriar, Tho- mann, Pearson, Bucholtz, Westrumb, Hufe- land, Pinel, Armstrong, Wkndelstadt, Ver- dier, &c. But Chapman, Portal, Jadelot, and others have not fully confirmed the opinions which were formerly entertained respecting it. The muriate of baryta had fallen into neglect for some time, its use having been superseded by medicines which were found more efficacious and less irritating to the stomach, when Dr. Pirondi advised a more active employment of it. He prescribed six grains of the medicine in four ounces of water, and directed a table- spoonful to be taken every hour, excepting the hours before and after a meal. He increased the dose by six grains every day, until a drachm was given ; and the patient was restricted to a vegetable diet and water. Having had some SGROFULA AND TUBERCLES—Treatment of. 833 acquaintance with Dr. Pirondi, I was induced to make a partial trial of this plan in a few cases, but I could not succeed in giving more than ten or twelve grains in the twenty-four hours, and then it was given more diluted than he advises. Its irritating effects on the stomach frequently prevented me from prescribing more than six or seven grains in the twenty-four hours. It appeared to be more efficacious when given in moderate doses, either soon after or with the meals, than when taken in larger doses in the intervals. According to Dr. Glover, who makes a very favourable mention of the chloride of barium in scrofula, the bromide and iodide of ba- rium has the same physiological action with the chloride, the iodide, moreover, acting energetic- ally on the uterine system. 178. (b) Chloride of calcium was formerly much employed against scrofulous swellings and sores, and in similar states of solution to those ia which the chloride of barium was pre- scribed. Beddoes, Odier, Frank, and Hufe- land have made favourable mention of this substance. The last-named of these writers, however, considered it more irritating than the ehloride of barium, and that it, therefore, should be used more cautiously. Dr. Simmons stated it to be inefficacious, and Mr. Phillips seems to be of a nearly similar opinion. " Fourcroy and the Dutch physicians had much confidence in its power over scrofula. Biett for many y^ears made much use of this medicine in the treat- ment of the scrofulous patients of St. Louis, without observing those inconveniences which are frequently attendant upon the use of baryta in full doses. It is the base of the anti-scrofu- lous nostrum of Niemann. I have frequently used it in the following form : a drachm of this chloride to twenty drachms of distilled water, of which a tea-spoonful was taken in milk two or three times a day. I have carried the dose up to two tea-spoonfuls, but not exceeded that dose. I am not satisfied that it has any evident action upon scrofulous glands, but it is more generally tolerated than the chloride of bari- um."—(Phillips, Op. cit., p. 282.) [Beneke has shown that the phosphate of lime in man, as well as vegetables and the inferior animals, is absolutely essential for the forma- tion of cells, and he considers that many path- ological states of the system may depend on a deficiency of this salt, such as ulcerations de- pending on a general dyscrasia, infantile atro- phy, scrofula, and tuberculous diseases. Dr. Stone, of New Orleans, has, in consequence of these views, employed the phosphate of lime, in conjunction with cod-liver oil, in such cases, with very beneficial results, and we have no doubt it will prove one of our most valuable remedies in such cases. It is used in doses of from six to eight grains, three times a day] 179. (c) There are other chlorides, as the chlo- ride of potassium, the chloride of zinc, &c, which, if judiciously employed, may act beneficially in scrofulous swellings and sores, The chlorate of potass has been very frequently prescribed by me in this and in other cachectic diseases since 1819, and I can recommend it as one of the substances most deserving adoption in scrof- ulous affections. Dr. Glover remarks that his experiments prove the chloride of/potassium to be much more energetic than the corresponding compound of sodium, although not so powerful III. 53 as the iodide of potassium. " There is scarcely a doubt but that the chlorides, bromides, and iodides of the same bases produce effects iden- tically similar in kind, differing only in degree. The bromide of potassium is more powerful than the chloride, less active than the iodide. Not being so apt to occasion nausea as the latter substance, it may be used in cases where this might disagree." 180. F. Solutions of chlorine—aqua chlorinei —and chlorinated solutions of the alkalies have considerable influence in the more cachectic states of scrofula. Dr. Glover observes that the strongest analogy, in physiological and me- dicinal properties, exists between chlorine, bro- mine, and iodine ; and that any one of these bodies is capable of producing the effects which can be obtained from another ; but that the dif- ferent forms in which we must use them give rise to differences in action. " Thus the very slight solubility of iodine almost precludes its use in watery solution, and the convenience with which solutions of bromine can be prepared ren- ders this body peculiarly adapted to form lotions for external application." Mr. Potter and Dr. Glover have proved the utility of bromine used externally, eight or twelve minims of bromine being added to a pint or half a pint of water. I have directed one drachm of bromine to eight ounces of distilled water; and from five to twelve drops of this solution to be taken in any suitable vehicle internally ; and from one to two drachms of the solution to eight ounces of wa- ter for external use. 181. G. Alkalies have long had a great repu- tation for the cure of tuberculosis and scrofula. They are much praised by Hamilton, Blank- ard, Kirkland and Fodere, especially the car- bonates and the solution of potass. These are, however, much less efficacious than Brandish's alkaline solution, which owes much of its effi- cacy to the lime which it contains. The alka- lies should generally be conjoined with tonic or bitter infusions or decoctions, with chalybeates, as in the mistura ferri composita, or with deob- struent extracts, as taraxacum, guaiacum, sar- za, &c.; or they may be given in the form of common or medicated soap, in conjunction with these extracts, or with ammoniacum, myrrh, &c. I have frequently combined either of the carbonates, or the solution of potash, with the iodide of potassium, with marked advantage. The aerated alkaline waters may be made the vehicle for several other medicines in the form of tincture; and, when the bowels are lax or irritable, or discharges from any of the mucous canals are troublesome, then lime-water, or the aerated lime-water taken either alone, or with milk, or with other medicines, which the circumstances of the case will indicate, will be of great service. 182. H. Acids have rarely been found of serv- ice in scrofulous swellings, although they have often been given in certain states of tubercu- losis, especially when affecting the lungs, and sometimes with benefit. I have found, how- ever, the nitro-hydrochloric acids used internally or externally, or in both ways, of great service ; and they may be employed either as the chief means, or in aid of other remedies. They are most beneficial when the functions of the liver are imperfectly performed, when the circulation is languid and weak, especially in the extremi- 834 SCROFULA AND TUBERCLES—Treatment or. ties, and when the hands or feet are cold. The | hydrochloric acid was recommended by Ferriar and Joerdens, and I have prescribed it in scrof- ulous affections in the decoction or infusion of cinchona with much advantage. The nitro-hy- drochloric acids may be taken either alone, or in bitter or tonic infusions. 183. J. Tonics of various kinds have been very generally recommended for external scrof- ulous affections, but not so frequently for in- ternal tuberculosis as rational views of the nature of this malady might have suggested. The preparations of cinchona were much em- ployed by Whytt, Fothergill, Northcote, and Fordyce ; and various bitter extracts and vegetable tonics by Grossmann, Hufeland, and others. The connexion of scrofulous af- fections with debility, and with imperfect di- gestion and assimilation, indicates the necessi- ty of having recourse to this class of medicines either as the principal means of cure, or as ad- juvants, or as the vehicles of other more spe- cific remedies. A solution of pepsin has been recommended as a tonic and promoter of diges- tion by Dr. Tyler Smith. He gives it a quar- ter of an hour after every solid meal, and in larger quantity after dinner than at any other time. 184. K. Cod-liver oil and the oil from the liv- ers of other species of the same genus have been recently much employed in the treatment of all forms of scrofula and tuberculosis. I have pre- scribed it since its use was revived; and I have had numerous occasions of observing its bene- ficial effects, especially when aided by such means as the peculiarities of the case should suggest. Its operation is not merely that of a nutrient, but it is also alterative, and it certainly produces more or less of a healing influence on ulcerated cavities or surfaces; these effects be- ing the more manifest, the more recent the oil, and the less it is subjected to clarification and other chemical manipulations. I have usually found it most beneficial when taken on the sur- face of diluted lemon-juice, or on lemonade, or on the surface of the infusion of orange-peel, with or without a few drops of the solution of potash, or of Brandish's solution ; or on water containing a few drops of the nitro-hydrochlo- ric acids, or of the muriated tincture of iron. When there is much cachexy, or inaction of the liver, or more or less anaemia, these modes of exhibition should be preferred. 185. L. Burned sponge had once considerable reputation for the cure of scrofula, and to this it was chiefly indebted to Arnault de Ville- neuve, Astruc, Lane, Ring, Fodere, and Hufe- land. I have had no experience of its effects ; but that it was entirely without effect I cannot believe, although the quantity of iodine it con- tains is very minute. The animal charcoal which was thus formed might not have been entirely inefficacious, especially in correcting the contents ofthe alimentary canal; for which, indeed, powdered charcoal is extremely effica- cious. Lettsom, a sagacious practitioner, often had recourse to burned sponge, and sometimes gave it with calomel. 186. M. Various substances have been em- ployed more or less empirically, or without any clear ideas as to their operation, or as to the amount of effect which may be ascribed to them. —(a) Of the benefit which may be derived from emetics and stomachic aperients, as advised By Schmidt, Weikard, and others, there can be no doubt, when prescribed at the commencement of the treatment, and when circumstances in- dicating their use are present. Several other substances were also much employed at differ- ent periods, and were probably not altogether without benefit, particularly as alteratives and restoratives, thereby improving the constitu- tional powers. Among these guaiacum, sassa- fras, the decoction of walnut-leaves, willow-bark, hops, taraxacum, tussilago, cantharides, asafati- da, 6cc-, held the most conspicuous places. Ri- vbrius prescribed gum ammoniaatm, both in- ternally and externally ; and I have seen much benefit derived from the balsam of Peru; and, in other instances, from capsicum taken intern- ally, and from the external application of a weak infusion of it to scrofulous sores. Dr. Tyler Smith has recently recommended the exhibition of pepsin in order to promote the functions of the stomach. 187. (b) Digitalis was formerly much employ- ed internally against scrofulous and tubercular diseases- M. Bayle (Biblioth. Therapeutique, t. iii.) states that it was first prescribed by Van Helmont ; and subsequently by Haller and Darwin, the latter of whom gave the powder in as large doses as five or six grains thrice daily. This substance was used also externally, either in the form of the infusion, or powder of the leaves, and the internal and external uses were conjoined. I have no experience ofthe remedy in scrofula, and I believe that it is more likely to prove injurious than beneficial. The walnut- leaves have lately been much recommended by M. Negrier ; but I agree with Dr. Gloter in considering them as only slightly beneficial as a tonie, when the preparations of these leaves are used internally, and as an astringent when ap- plied externally, and as inferior to several other tonics and alteratives usually adopted. 188 (c) At the commencement ofthe last cen- tury tar-water was very much vaunted for the cure of every form of scrofula and tuberculosis, and some years ago I prescribed it largely, both internally and externally, in a stronger form, as a wash to scrofulous sores ; and, from my ex- perience of its effects, I consider it one ofthe most efficacious means which we possess, when aided by a suitable diet and regimen. I also gave the pure Norwegian tar in the form of pill by means of liquorice powder. Tar may be given more largely when made into pills with magne- sia, but in this combination the pills often pass through the bowels without being dissolved. In the more indolent states of scrofulous sores, creasote may be substituted for tar-water, but my experience leads me to prefer the latter. The tar may likewise be made into pills with powdered charcoal or other substances, or be taken in gelatine capsules. This medicine is often very efficacious in the chronic cutaneous eruptions which occur in the scrofulous taint, or associated with any ofthe forms of scrofula or tuberculosis. 189. (d) During the 16th and I7th centuries, and more recently, a medicine was much in vogue as an alterative and restorative, not only in scrofula, but also in many other maladies, under the appellation of the infusion of a thou- sand flowers. This Consisted of an infusion, either warm or cold, ofthe recent dung of cows SCROFULA AND TUBERCLES—Treatment of 835 and bullocks feeding in open pastures. The only effect which this medicine could produce must be referred to the proportion of bile which it contained. That ox-gall is possessed of much efficacy, either alone or properly combined, I have shown in various parts of this work, espe- cially in promoting the -digestive and assimila- ting processes. It is readily procured in the states of inspissation and extract. I have pre- scribed it in the form of pill since 1820, and it is now kept by most of the chemists in this city. It is most beneficially used as an adjunct to oth- er appropriate means, especially in the states of inaction of the liver, and when the bowels are weak and irritable. 190. (e) Since the work of Stoerck on conium appeared, this substance has had great reputa- tion for the cure of scrofula ; and, although it has received the commendations of Quarin, Rutty, and many others, I am at a loss to rec- ognise its virtues. The same remark applies to digitalis, which has been prescribed by Menz, Darwin, and Hufeland. Sulphur in various states of combination is more deserving atten- tion. I have often prescribed it in scrofulous affections, in conjunction with magnesia, pow- dered cascarilla, or aromatics and warm carmin- atives, with the view of promoting the cutane- ous functions, which are often imperfectly per- formed (and this object it attains more perma- nently than most other means), and in order to promote the intestinal evacuations. Camphor was recommended internally by Copland, Lett- som, and Fodere, and externally dissolved in olive oil; and in this form it may be applied with gentle friction or more permanently. Sul- phate of zinc was praised by White, but it is much inferior to the sulphate, or other prepara- tions of iron. 191. (/) Electricity was long since recom- mended by Sigaud la Fond for scrofulous swell- ings, and its use has been recently revived ; but in whatever manner this agent may be employ- ed, either as electro-galvanism, or as electro- magnetism, or as shocks from the Leyden jar, or as sparks from the parts affected, it is appro- priate only to the more indolent and atonic states, and when the parts furnish no signs of acute inflammatory action. 192. N. Change of air to the sea-side, in con- nexion with sea-bathing, &c., has frequently a beneficial influence, and a considerable share of the benefit has been imputed to the sea-air. The amount of benefit has most probably been exaggerated, but I cannot think that it is with- out influence, especially when the body is duly protected from cold. Mr. Phillips thinks that change to the sea-coast exercises no greater in- fluence on scrofula than change to any inland situation where the air is pure and dry. For young persons and scrofulous children change of air is always beneficial, and when this can be conjoined with the use of sea-water and sea- bathing, I believe the benefit to be augmented ; and, for this purpose, especially to residents in the metropolis or other large towns, there are no places more salubrious, during the months of June, July, August, and September, than Lowes- toft and its vicinity, and the Isle of Thanet. 193 (a) Sea and mineral waters have always had a great reputation in the treatment of scrof- ulous and tubercular affections. Sea-water has been strongly recommended by Russell, Kirk- land, Tolberg, and many others, both internal- ly and externally ; and of all waters it is cer- tainly most generally appropriate and effica- cious, if its use be judiciously directed. When it can be retained on the stomach, even in small quantity, it will generally be taken internally with benefit; and when the bowels are sluggish it is one ofthe best aperients that can be given. As a warm, tepid, shower, or cold bath, or used in washing or sponging the surface, it is also an excellent remedy. But when sea-bathing is adopted, especially for children, the period of immersion should be brief—short in proportion to their youth and the amount of debility ; and, if alarm be caused by it, the shock should be avoided by substituting effusion on the surface by a sponge, or even by less alarming modes of employing salt-water. In some cases artificial sea-water may be used, or a solution of bay-salt, or this salt may be added to sea-water. Reac- tion should follow cold bathing; and when this is not manifested, either the period of immer- sion has been too protracted, or the means is too severe for the constitutional powers of the pa- tient, and should not be persisted in. 194. (b) Several mineral waters axe used with great benefit, both internally and externally, for scrofulous affections; but they should be pre- scribed with strict reference to the states of nu- trition, circulation, and assimilation, otherwise but little advantage will be derived from them. Where the assimilative functions are much im- paired, and more or less of anaemia exists, the chalybeate mineral waters of this country should be preferred ; and these may not only be taken internally, but also used externally as baths, as advised by Lentin and others. The several al- kaline and sulphureous waters, as those of Bath, Harrowgate, Leamington, &c, are generally of service, especially when a deobstruent and al- terative effect is required. Dr. Glover remarks that the mineral waters of Shap and Shotley, in the north of England, appear to be the best suit- ed for scrofula, oh account of the large quantity of alkaline and earthy muriates which they con- tain. Besides these, the mineral springs and the factitious waters of Carlsbad, Ems, Fachingen, Homberg, Kissingen, Seltzer, and of Bareges, Bonnes, Cauterets, Enghien, &c, have several- ly been recommended in scrofulous affections, and are more or less beneficial when judicious- ly employed, and aided by suitable medicines, diet, and regimen.* 195. 0. Medicated baths of various kinds have been recommended for external scrofula. Those containing the iodide of iron, or iodide of potas- sium with the sub-carbonate of potass, or small quantities of the sulphuret of potash, are the most beneficial. I have prescribed baths with the sub-carbonate of potash alone, and believed them to have been of service. It is manifest that these can be viewed merely as aids of in- ternal remedies. 196. P. The local treatment of scrofula requires * [Our country furnishes a vast variety of mineral wa- ters, of which the carbonated saline and ferruginous springs of Saratoga, the sulphur waters of Avon, Richfield, and Sharon, New York, and the White, Red, and Salt Sul- phur Springs of Virginia, are the most celebrated. These are all well adapted to different forms of scrofula, in some of its stages, but the advice of a physician will be needed to indicate their respective adaptations to particular cases. Much of the benefit, however, is to be attributed to change of air and habits.] 836 SCROFULA AND TUBERCLES—Treatment of. merely a few remarks; for, if scrofulous gland- i ular swellings receive an early attention, the in- ternal or constitutional means described above, more especially the administration ofthe prep- arations and combinations of iodine, appropri- ately to the circumstances of the case, should be chiefly confided in. The treatment of scrof- ulous swellings should depend chiefly on the ab- sence or presence of increased heat and redness. If either or both be present, very different means from those which are indicated when they are absent are required. As long as the tumour continues devoid of redness, of increased heat, or much tenderness, gentle frictions, with fresh olive oil, to which small proportions of spirits of turpentine and camphor are added, with or without a little soap, will generally be of serv- ice. The preparations of iodine, especially oint- ments, lotions, and tinctures of iodine, have been much employed to the affected parts. But these should be sufficiently mild not to irritate the skin; for when they are too strong, the irritation ofthe surface caused by them will extend to the parts underneath, and superinduce an inflamma- tion which might not otherwise have occurred. The iodine ointment of the Pharmacopoeia is much too strong, and contains too large a pro- portion of iodine as respects that ofthe iodide of potassium and that of lard. I have much preferred the ointments prescribed in the Ap- pendix (see Form. 766-770); and even they should be cautiously applied, so as to avoid ir- ritation and pain. If the swelling be painful, or if it be irritated by the friction, the compound tincture of iodine may be applied, more or less diluted, to the surface, or the lotions prescribed in the Appendix may be employed (see Form. 671-673); but the stronger of these should be very much diluted. 197. When inflammatory action appears, ei- ther in the surface ofthe swelling or in the sub- jacent parts, the more common applications for sthenic inflammation are seldom of service, but, on the contrary, are often prejudicial. The ex- istence of pain in the swollen part should not be viewed as always indicative of inflammation, for where the former is most severe the latter may not be present. In these cases, the ungu- entum iodinii plumbi and the unguentum iodinii opiatum, in the Appendix (Form. 768, 770), are the most serviceable. I have also found the unguentum calomelanos cum camphord (Form. 757) of use. These ointments should be rubbed gently over the surface, without exciting irrita- tion. If increased heat and redness continue nevertheless, warm and anodyne applications are frequently more beneficial. In these cases, either of the deobstruent ointments in the Ap- pendix (Form. 761, 762) may be tried, as there prescribed or more or less diluted. 198. If the inflamed part goes on to suppura- tion, an early outlet should be given to the mat- ter, as its retention contaminates the tissues which surround it, and, extending in more than one direction, often gives rise to sinuses. The ulceration consequent on scrofulous suppuration generally requires not only much attention to the general health, by the means above de- scribed, but also a pure air, and suitable diet and regimen. In addition to these, gently stim- ulating applications, consisting either of very weak ioduretted ointments or lotions—of oint- ments containing either the balsam of Peru or a small proportion of the iodide of zinc—of lo- tions containing a few drops ofthe tincture of capsicum, or of one of the chlorides—will be used with benefit. The solutions of iodine rec- ommended by Lugol to scrofulous ulcers are the following: ------------------1 No. 1. | No- »• I No75~ Todih'eT........ 2 grs. 3 grs. 4 grs. Iodide of Potass. 4 grs. 6 grs. 8 grs. Distilled water.. | 1 pound. 1 pound. 1 pound. These, commencing with the weakest, may be used frequently, either as washes or lotions, or be injected into scrofulous sinuses. 199. Q. The diet and regimen of scrofulous and tubercular subjects, whether infants, children, or adults, axe in every respect the same as above recommended (v 148-153) for the prevention and the hygeienic treatment of scrofula and tubercu- losis. The chief of these means are animal warmth and suitable food during infancy; a pure, dry, moderately warm and uncontamina- ted atmosphere ; due ventilation of the apart- ments, especially of bed-rooms ; change of air, sea-air, and voyaging; a due regulation and subjugation of the passions, desires, and imag- ination ; a light, digestible, and nutritious diet, avoiding stimulants or heating beverages ; and regular exercise in the open air; due exposure to light and sunshine ; early and regular hours for sleeping and waking, and for meals; and attention to the states of all the secretions and excretions—the cutaneous, intestinal, and urin- ary—are the most conducive, not merely to the prevention of scrofula and tuberculosis, but also to the recovery of health in all the forms in which these states of disease manifest them- selves. [With Drs. Stokes, Warren, and others, we hold that there is nothing specific in the char- acter of scrofula, or reducible to the supposi- tion of a virus existing in the system ; but that its essence consists essentially in a slow irrita- tion of the lymphatic system, occurring in per- sons who have a preponderance of white fluids and white tissues. This may be hereditary (congenital) or acquired, and when acquired, it is superinduced by the causes pointed out so fully by our author ; all of which tend to diminish the proportion of the red tissue, to give a pre- ponderance to the lymphatic system, and lower the vitality of the system. The scrofulous di- athesis implies an arrest of development, an ex- cess of the white, and diminution of the red tissues, and not in any specific virus, as many suppose, which is to be eradicated also by spe- cifics. The blood is albuminous, the proportion of fibrin and red globules small, the muscles, consequently, weak and flabby, and all the symptoms indicate a weakened state ofthe vi- tal forces. The indications then point to such curative means as tend to invigorate the sys- tem and add to the existing sum of vitality. The extractum carnis, as recommended by Liebig, will be found, as it has hitherto proved, well adapted to the treatment of scrofula and tuberculosis. The manner of preparing it is to take one pound of lean beef, free from fat, chop it fine, as for mince-meat; mix uniformly with it its own weight of cold water; heat slowly to boiling ; after boiling about two minutes, strain through linen. Salt may be added, or other con- diments, to suit the taste. Prepared thus.it is SCROFULA AND TUBERCLES—Bibliography and References. 837 admirably adapted to cases of scrofula, phthisis, &c , especially where there are derangements of the digestive organs, such as ulcerations, dyspepsia, tubercular deposits in the intestinal .glands, &c, as well as to the early and later periods of typhus, sloughing of the cellular tis- sue, and copious suppuration. One ounce of the " extractum carnis," thus prepared, is equal to 32 ounces of meat, and, being in a state of fine solution, may be readily assimilated, with- out much exertion of the digestive organs. The remedial properties of alimentary substances deserve more attention from the profession, as they are often far more efficient agents in combating disease than strictly pharmaceutical agents, which may stimulate languid organs, but do not renovate, by supplying new materi- al. We would not advocate the doctrine that no substances should be used as remedies, in this or other diseases, except such as help to constitute in health the solids and fluids of the body; but we do hold that in such diseases as scrofula, tuberculosis, general cachexy, &c, where there is a vitiated and impoverished state ofthe blood, and corresponding affection ofthe solid tissues, the true indication is to supply a more nutritive material by way of aliment, and in such form as will be most easily assimilated. Quinine, iron, iodine, and other agents, which act dynamically or chemically, are to be used only as adjuncts, and With due regard to the state of vital force and organic nervous power. M. Negrier, of Angers, found a strong infu- sion of walnut-leaves, taken internally and ap- plied as a wash to scrofulous sores, very effica- cious in the treatment of the disease. Twelve out of seventeen scrofulous children, nine of whom had osseous enlargement with caries, seven ulcerated glands, and one several swol- len cervical glands, with scrofulous ophthalmia of both eyes, were cured by the above remedy after a course of six months' treatment, so that M. Negrier considers that the walnut-leaves are superior to all other anti-scrofulous remedies. —Brit, and For. Rev., Oct., 1841. A new remedy has lately been introduced into some of the French hospitals, called extract of blood, which promises to be of service in scrof- ulous and endemic subjects. It is prepared from fresh beef's blood, allowing it to coagu- late, depurating the serum through a filter, and drying the clot by evaporation until it can be readily reduced to a powder; of which from 10 to 20 grains are given three or four times a day. This, as will be perceived, is only another form of the " extractum carnis" of Liebig ; whether it will prove a perfect substitute remains to be proved. With regard to iodine in scrofulous affec- tions, we have used it very extensively in dis- pensary and private practice for many years, and think we have seen the most marked and unequivocal benefits from its employment. We have generally employed the sirup of iodide of iron, which will be found to suit a majority of cases belter than any other preparation. It must be continued, however, for a considerable period, in conjunction with cutaneous friction and cold sponging, and a nutritive diet of ani- mal food ; these, with abundance of active ex- ercise in the open air, will usually produce de- cided amendment. Some of our ablest physi- cians, however, are somewhat skeptical with regard to iodine in this affection. Dr. J. C.War- ren remarks, for example, that " after many years' trial ofthe preparations of iodine in vari- ous forms of scrofulous affection, I have rarely seen any very distinct advantages from it. I have employed it in large and small doses, in hospital practice and private, externally and in- ternally ; nor, in truth, ought we to allow our- selves to expect the results which have been promised. Scrofula is a constitutional disease. If there be any remedy for such a disease, it must be found in agents which influence the in- timate structure ofthe body more generally and intimately than iodine, or any medicinal sub- stance can do. Such agents are food ; a heal- thy state ofthe excretory apparatus ; a pure at- mosphere; and an exercise of the muscular sys- tem, suited to the constitution of the patient. I do not wish to dissuade from the use of so con- venient a medicine as iodine ; but would advise it to be employed in such a way as not to dis- turb the functions which remain healthy ; and that it never should be used to the exclusion of those restorative means to which reason and experience have given their sanction."—Surg. Observations on Tumours, p. 164. Cod-liver oil has now been sufficiently tried in diseases of a cachectic character to have its value properly determined. Our experience with the article more than 20 years ago in dis- pensary practice, fully satisfied us of its im- portant remedial influence in scrofula, &c, al- though, from carelessness in its preparation, it was too nauseous to be borne well in a very large proportion of cases. But where it was retained, and did not derange the appetite, it produced the most marked benefit. Such is the expe- rience of a large majority of those who have employed it. Dr. Gerhard states that it has proved of great service in the Pennsylvania Hospital, that the tuberculous patients to whom it was administered increased in flesh, weight, and strength under its use ; that the cough and expectoration diminished, andi in some cases the hectic and rigours wholly disappeared, and the patients resumed their usual occupations. The improvement ofthe physical signs was not coincident with that of the general symptoms ; and, where the disease terminated fatally, the appetite, nutrition, and strength appeared for a time to be decidedly increased—life appeared for a time to be temporarily protracted; but for a few weeks preceding dissolution the remedy seemed to have lost its value. It was also found necessary to continue its use for some time after the most striking symptoms of the disease had disappeared. It was generally tak- en before meals, in milk or porter, sometimes clear, and where it produced nausea, the pale oil was substituted for the brown, and it was giv- en after eating. For a large array of testimony in favour of cod-liver oil in scrofula, rickets, tuberculous cachexy, see "New Remedies," by Prof. Dunglison, ed. 1851, p. 552-4.] Bibliog. and Refeb---Hippocrates, Ilept AStvuv. Opera, p. 970— Celsus, 1. v., ch. 28. — Galen, Tie Tumori- bus, c. 10, 15. Methodus Medendi, 1. xiv., c. 11. — Oriba- sius, Synopsis, 1. vii., ch. 29.—Avicenna, Canon, 1. iv., fen. iii., tr. 2, c. 9.— W. Tooker, Explicatio totius Qusestionis, de Mirabilium Sanitatum gratia, in qua praecipue agitatur de solenni et sacra Curatione Strumas, cui Reges Anglite Divinitus Medicati sunt, 4to. Lond., 1597.— W. Clowes, A Right fructful and approved Treatise for the Cure of Struma or Evill cured by Kinges and Queenes of England, 4to. Lond., 1602. — A. Laurentius, De Mirabili Strumas 838 SCROFULA AND TUBERCLES—Bibliography and References. sanandi vi solis Galliee Regibus concessa, 8vo. Paris, 1609. —J. Barbier, Les Miracufeus Effets de la Main des Rois de France, 12mo. Lion., 1618.—Riverius, Cant, i., obs. 76; ii., 54; iv., 18. — Anon., Traite de la Guferison des Ecrou- elles par l'Attouchement des Septenaires. Aix, 1643.—F. Tomlinson, Of Scrofula, &c, in Chirurgical Treatises, fol. Lond., 1676. — Wiseman, Several Chirurgical Treatises, 1. iv.—J. Brown, Adenochoiradelogia; or, a Treatise of Glan- dules and Strumals, or King's Evil Swellings, 8vo. Lond. 1684. — T. Mayerne, Praxis, p. 162.— T. Fern, A perfect Cure for the King's Evil, 8vo. Lond., 1709.— W. Vickers, A brief Account of a specific Remedy for curing the King's Evil, 3d ed., Svo. Lond., 1710. — J. Gibbs, Observations of various eminent Cures of Scrofulous Disorders, 8vo. Lond., 1712.—Morton, Phthisiologia, 1. i., c. 9.—ii. Boulton, Account of the Gout, King's Evil, &c . 8vo. Lond., 1715. —F. Gherli, Centuria de rare Osservazioni, &c, 8vo. Ve- nezia, 1719. (Recommends a Liniment consisting of Ox- gall, Oil, and Salt.) — W. Beckett, Two Letters as a free Inquiry into the Antiquity and Efficacy of touching for the King's Evil, 8vo. Lond., 1122.—Petit, Traite des Mai. Chi- rurg., t i, p. 209. (SaU applied in Bags locally.)—R. Black- more, Discourses on the Gout, Rheumatism, and King's Evil, 8vo. Lond., 1726.— P. V. Dubois, Traite Nouveau des Scrofules, ]2mo. Paris, 1726.—R. Willan, Essay on the King's Evil, 8vo. Lond., 1746. — J. Badger, Cases of Cures of the King's Evil perfected by the Royal Touch, Bvo. Lond., 1748.—R. Russell, De Fabe Glandulari, 8vo. Oxon., 1750.—J. B. Charmetton, Essai th6oretique et pra- tique sur les Ecrouelles, 12mo. Avign., 1752. — W. Scott, Dissertation on the Scrofula or King's Evil, 8vo. Lond., 1759.—Anon., Essay on the Nature and Cure of the King's Evil, by a Gentleman of Halsted, in Essex, 8vo. Lond., 1760.—Durant, A Treatise on the King's Evil, 8vo. Lond., 1762.—Murel, Essay on the Nature and Cure of the King's Evil, 8vo. Lond., 1760.—J. Morley, Essay on the NatuVe and Cure of Scrofulous Disorders, 8vo. Lond., 1767.—Af. Renard, Essai sur les Ecrouelles, 8va Paris, 1769.— Blankard, Collect. Med. Physica, Cent i., n. 41, 42.—Kirk- land, On the present State of Surgery, vol. ii.— Anon., Observations on the Effects of Sea-water on the Scurvy and Scrofula, 8vo. Lond., 1770. — M. Chappot, Systeme de la Nature sur le Virus Ecrouelleux, 8vo. Toul., 1779. —P. de Lalonette, Traite des Scrofules vulgairement ap- pellfis Ecrouelles, 12mo. Paris, 1780.—Rutty, In Med. Ob- servat. and Inquiries, vol. iii., art 23.—Astruc, Traite des Tumeurs, t. ii.—J. Swainson. Hints to Families on the in- creasing Prevalence of Scrofula, 8vo. Lond., 1787.—Lett- som. In Memoirs of the Med. Society of London, vol. iii., n. 29.—Lang, In Ibid., vpl. i., art. 14.—Anon., The Ceremo- nies for the Healing of them that be Diseased with the King's Evil, used in the time of King Henry the VII., 8vo. Lond., 1789. —J. Rymer, A short Account of the Method of treating Scrofula, &c, 8vo. Lond., 1790.—R. Hamilton, Observations on Scrofulous Affections, 8vo. Lond., 1791. —Thomann, Annales Wurceb., t ii., p. 163. — D. Roberts, Remarks on the King's Evil, with an Account of a Speci- fic, &c, 8vo. Lond., 1792. — G. Mossman, An Essay to elucidate the Nature, Origin, &c, of Scrofula and Glandu- lar Consumption, 8vo. Bradford, 1792.—Assalini, Ueber die Krankheiten des Lymphatischcn Systems, 8vo. Dres- den, p. 56. — F. A. Weber, Von der Skrophein, eine Epi- demische Krankheit vieler Provinzen Europens, 8vo. Salz., 1793.— W. Nisbett, An Inquiry into the History, See., of Scrofula, &c, 8vo. Lond., 1795. — Ferriar, Medical Histories, vol. iii., ch. 3.— White, A Treatise on the Struma, or Scrofula, commonly called the King's Evil, 2d edit, 8vo. Lond., 1794.—S. T. Soemmering, De Morbis Vasorum absorbentium, 8vo. Traj., 1795.— Crawford, In Medical Communications, &c, vol. ii., n. 25.—C. Brown, A Trent. iee on Scrofulous Diseases, showing the good Effects of Factitious Airs, 8vo. 1798. — White, Observations on the Willow-Bark, 8vo. Lond., 1798. — J. Burns, Dissert, on Inflammations, 8vo. Glasg., 1800, ch. vi. — Beddoes, On Consumption, Digitalis, and Scrofula, 8vo. Lond., 1801. — A Pujol, OSuvres, t — Copland, In Edin. Med. Com- ment, voL xv., p. 92.—J. A. Capelle, Essai sur la Nature, &.c, des Affections Scrofuleuses, 8vo. Paris, 1802. — J. Merdman, Dissertation on White Swellings, &c, Svo. Edin., 1802. — F. Hebreard, Essai sur les Tumeurs Scrof- uleuses, f Berlin, 1819. —Begin, Diet des Sciences M6dicales, t L, p. 278. — E. Lloyd, A Treatise on the Nature and Treatment of Scrof- ula, 8vo. Lond., 1821.—M. Macher, Ueber die Ursachen, &c, der Skrofelkrankheit 8vo. Wien, 1821. — W. Farr, Treatise on the Nature of Scrofula, 8vo. Lond., 1822.— J. Baron, An Inquiry into the Nature of Tuberculated Ac- cretions of Serous Membranes, and the Origin of Tuber- cles and Tumours, &c, 8vo. Lond., 1819; and niustra- trons of the Inquiry respecting Tuberculous Diseases, &c, 8vo. Lond., 1822. — J. F. Coindet, Observations of the Remarkable Effects of Iodine in Bronchocele and Scrof- ula, 2d edit, 8vo. Lond., 1824.—Andral, In Revue Medi- cale, t iv., 1825, p. 405.—Guersent, In Diet de MGdecine, art. ScrofuU, t xix.. 8vo. Paris, 1827.—F. M. J. Siebold, Die Englische Krankheit, 4to. Wurzb., 1827. — C. Van Mont, Consider, sur les Scrofules et le Rachitisme, 8vo. Brux., 1829.—J. G. A. Lugol, Memoire sur l'Emploi de l'lode dans les Maladies Scrofuleuses, 8vo. Paris, 1829.— M6moire sur l'Emploi des Bains lodures dans les Mai Scrofuleuses, 8vo. Paris, 1830.—Troisieme Memoire sur l'Emploi de l'lode, 8vo. Paris, 1831. — Recherches et Ob- servations sur les Causes des Mai. Scrofuleuses, 8ro. Paris, 1844. — Jahn, In Journ. Complement du Diet des Sc. M6d, t xxxv., p. 18. — S. Deygullieres, Theorie nou- velle de la Maladie Scrofuleuse, 8vo. Paris, 1829, p. 73, Sec.—Tonnelle, Journ. Hebdomad, de Med., t iv, p. 567; t v., p. 187.—Le Peltetier, Traite complet de la Mai. Scrof- uleuse, p. 22.—J. R, Von Vering, Heilart der Scrofelkrank- heiten, 8vo. Wien., 1829.—Papavoine, Journ. des Progres des Sc. Med., 2d ser., t ii, p. 84.— W. B. OShavghntssy, Essay on the Effects of Iodine in Scrofulous Diseases. Translated from Lugol, with an Appendix, 8vo. Lond, 1831.—C. Cumin, art Scrofula, in Cyclop, of Pract Med, vol. iv., p. 701.—Fischer, Ueber Ursache, Wesen u. Heilart der Scropheln, &c. Leipz, 1832, t. 33.—J. A. W. Hedmus, Die Heilung der Scrofeln durch Konigshand, 8vo. Dread, 1833.^J. Clark, A Treatise on Pulmonary Consumption, comprehending an Inquiry into the Causes, Nature, Pre- vention, and Treatment of Tuberculous and Scrofulous Diseases in general, 8vo. Lond, 1835.—J. FurniraU, On Consumption and Scrofulous Diseases, 8vo. Lond, 1838. —Harrel, In Archives Gener. de Medecine, t xxi, p. 444. —Godier, In Ibid, t. xxi, p. 596. (ClorinatcdSoda.)—Lt- grand, In Ibid, t xxi, p. 622. (Preparations of Gold far Scrofula.) — W. Alison, In Transactions of Med. and Chi- rurg. Society of Edinburgh, vol. i, p. 365; vol. iii, p. 273. — J. Abercrombie, In Ibid, vol. i, p. 682. — Lombard, In Edinburgh Medical and Surgical Journal, vol. xxix, p. 210.—J. A. Disse, Die Skrofelkrankheit nach ibrem Wesen. Berlin, ltMO, s. 19.—Henle, Pathologische Untersuchungen, Svo. Berlin, 1840, p. 153. — Gruby, Observat Microscop. ad Morpholog. Pathol. Vindob, 1840, p. 27.— J. Vogel, Anleitung z. Gebrauche des Mikrosk, 8vo. Leipz, 1841, s. 457.— Vetter, In Schmidt's Encyclop, b. vi, s. 248.— Mandl, In Archives Gener. de Med. Oct and March, 1840 ; Febr, 1841. — Sehonlein. Allgeraeine und Spec. Pa- thologie und Therapie. St Gallen, 1841; t iii, s. 71.— L'Heritier, Chimie Pathologique. Paris, 1842, p. 23.— W. Alison, Outlines of Pathology and Practice of Medicine, 8vo. Edin, 1844 ; vol. i, p. 187.— C. F. Heusinger, Re- cherches de Pathologie Comparee. Cassel. 1844, p. 131. — W. Holland, Medical Notes and Reflections, &c, Svo. Lond, p. 32.—Canstatt, Specielle Pathologie u. Therapie. Erlung, 1843; b. i, s. 222. — Bredow, Ueber die Scrofel- sucht Berlin, 1843. — J. J. Scherer, Chemische u. Mikro- skopische Untersuchungen zur Pathologie, 8vo. Heidelb, 1843, s. 199.- W. Tyler Smith, Scrofula: its Nature, Causes, and Treatment; and on the Prevention and Eradication ofthe Strumous Diathesis, &c, 8vo. Lond, 1844. — N. Lebert. Physiologie Pathologique, ou Recherches CM- niques, Experimentales et Microscopiques, sur rinflamma- tion. la Tuberculisation, &c, 2 tomes, 8vo. Paris, 1845; t. i, p. 351, et seq.—Barthez et Rilliet, Des Mai. des Enfans, t, iii, p. 3, et pluries.—J. H. Bennett, In Edin. Med. and Surg. Journal, April, 1845. — T. Addison, In Guy's Hospital Re- ports, April, 1845. — B. PkUlips, Scrofula: ito Nature, its Causes, its Prevalence, and the Principles of Treatment, 8vo. Lond, 1846. — R. M. Glover, On the Pathology and Treatment of Scrofula; being the Fothergillian Prize Es- say for 1846, 8vo. Lond, 1846.—7\ Hughes Bennett, Treat- ise on the Oleum Jecoris Aselh, as a therapeutic agent in certain forms of Gout, Rheumatism, and Scrofula Pvo. Edin, 1648.— W. Addison, On Healthy and Diseased Struc- ture; and the true Principles of Treatment for the Cure SCURVY—Historical Smtch or. 839 •f Disease, especially Consumption and Scrofula, Sea., 8vo. Lond, 1849, p. 47. — G. C. Holland, Nature and Cure of Consumption, Indigestion, Scrofula, and Nervous Affec- tions, 8vo. Lond, 1850. [Am. Biblioo. and Refer. —Few if any Monographs have been written on Scrofula in this country.—See John C. Warren, Surg. Observ. on Tumours, with Cases and Observations, 8vo. Boston, 1837.—L. Shattuck, Report of the Sanitary Commission of Massachusetts, 8vo. Bost, 1850. — Levick, on Cod-liver Oil, and its uses in Tubercu- lar Disease. Am. Journ. Med. Sci, Jan, 1851, p. 21.— T. M. Markoe, In New York Med. Gazette, Feb. 9, 1842. —C. L. Payne, Case of Scrofula, successfully treated by Iodine, in vol. vi. Am Journ. Med. Sci.—Shattuck, In Am. Journ. Med. Sci, vol, xliv, p. 80, 85.—C. A. Lee, Review of Lugol, in New York Med. and Phys. Journ, 1829.] SCURVY.—Synon.—Scorbutus, Sauvages, Vo- gel, Cullen, &c.— Scorbutus Nauticus, Young. Porphyra Nautica, Good. Scharbock, Skorbut, Germ. Skiorbug, Dan. Scorbut, Fr. Scor- buto, Ital. Scorb, Searbock, Skorbut, Scorbie, &c, Saxon ; hence Scorbutus, Scurvy. Classif.—ith Class, Cachectic Diseases. 3d Order, Impetiginous Affections (Cul- len). 3d Class, Sanguineous Diseases. 4/A Order, Cachexies (Good).—Class IV., Order IV. (Author in Preface). 1. Defin.—Lassitude, debility, lowness of spir- its, fator ofthe breath and sponginess ofthe gums, followed by livid sub-cutaneous patches and spots, especially on the lower extremities and roots of the hair; and, lastly, by spontaneous hamorrhages from mucous canals, by contractions and pains of the limbs, and superficial ulcers, cf-c, the disease proceeding from an alteration of the blood, caused by the nature of the food, and chiefly by the priva- tion of fresh vegetables and fruit. 2.1. Historical Sketch.—Some writers have supposed, with Sennertus, Mead, and Milman, that scurvy was known to the ancients, while others have believed, with Friend, that there is nothing to be found in their writings to warrant this supposition. Hippocrates, in mentioning enlargement of the spleen—cmteiv fieyac—no- tices but one symptom which is applicable to scurvy, and that is ulceration of the legs; and, in describing Convolvulus Sanguineus—ElXebc aluarirnc—he adduces the dark discoloration of the skin, the eruption of ulcers on the legs, and the difficulty of walking, as more particularly distinguishing it; but these remarks are insuffi- cient to show that he was actually acquainted with true scurvy. It has been supposed that the disease, with which Pliny states the army of CiESAR Germanicus to have been afflicted after a long encampment in Germany beyond the Rhine, near the sea-coast, and which was as- cribed to the water which was drank, was that now under consideration. He states that" the teeth dropped out, and the knees became para- lytic. The physicians called the malady Stom- acace and Scetetyrbe. They discovered a reme- dy against it, viz., Herba Britannica." What this plant, of which Pliny adds a very short and im- perfect description, actually was has not been shown by his commentators. Subsequent an- cient writers, not even the Arabians, have fur- nished any thing in addition to what I have now adduced. , . . t . 3 The earliest account of scurvy is that given by the Sieur Joinville, as it appeared in 1260, in the army of Louis IX. in Egypt, owing to the nature and scarcity of the food, and the scarcity of water The next notice taken of it is by Fabricics who states that it was very prevalent and fatal in Misnia during 1846. As soon as long voyages were nndertaken, scurvy appear- ed in an unmistakable form. During the voy- age of Vasco de Gama, who first made the pas- sage to the East Indies by the Cape of Good Hope, more than 100 of his men out of 160 died Of this malady. The History of Portuguese dis- coveries, by W. Lopes de Castennada, contains the relation of this voyage which furnished the first account of this disease as it occurred at sea. 4. That scurvy was not then, nor for some time afterward, known, is evident from the ac- count given by Cartier of his second voyage to Newfoundland in 1535. After mentioning the characteristic symptoms, he adds that, " about the middle of February, of a hundred and ten people there were not ten whole." "Eight were already dead, and more than fifty sick, seeming- ly past all hopes of recovery. This malady be- ing unknown to us, the body of one of our men was opened, to see if by any means possible the occasion of it might be discovered, and the rest of us preserved. But in such sort did the ca- lamity increase, that there were not now above three sound men left. Twenty-five of our best men died, and all the rest were so ill that we thought they would never recover again, when it pleased God to send us the knowledge of a remedy for our health and recovery." The rem- edy was a decoction of the leaves and bark of a tree, which was called by the natives ameda or hamuda, and which has been considered to have been a species of spruce-fir. 5. Dr. Lind states that the name of this dis- ease is said to be mentioned in the history of Saxony, by Albert Kruntz ; and if so, he will be found the first author now extant who calls it the scurvy. It is next taken notice of by Euritios Cordos in his Botanologicon, published in 1534, where it is observed that the herb cheli- donium minus is called by the Saxons Schorbock rout, being an excellent remedy for that disease. In the year 1539, it is mentioned by J. Agricola in his Medicina Herbaria. Olaus Magnus, in his history of the northern nations, published in 1555, observing what diseases are peculiar to them, gives a long description of scurvy, men- tioning that it is vulgarly called Schoerbuck, which is synonymous with the cachexy of the Greeks. He refers it chiefly to the nature of the food, and mentions that the habitual use of absinthiated beverages is had recourse to in or- der to prevent and to cure it. About this peri- od, four treatises on the disease were published by Ronsseus, Ecthius, Wierus, and Langius. Forestus states that the description by Ecthius was contained in an epistle sent in 1541 to Bli- enburchius, a physician in Utrecht. The first book published expressly on scurvy was by Ronsseus, who remarks, in a reprint, that if he had first seen the accurate description by Wib- rus, his own should not have heen published. 6. Wierus states that scurvy had been long pe- culiar to the inhabitants ofthe countries near the North Seas, and that he had never met with it in Spain, France, or Italy, nor in Asia or Africa. There can be no doubt ofthe existence of scur- vy in the northern countries of Europe from the earliest ages, although no account of it had ap- peared previously to the appearance ofthe work* now mentioned ; and it is equally manifest that years of scarcity, wars, sieges, &c, must have rendered it more or less endemic, or even epi- demic, in various places and localities. During 840 SCURVY—Historical Sketch or. severe winters and early spring, the food of the inhabitants of these countries, the dried and im- perfectly-cured meats and fish, and the want of sueculent and other vegetables, particularly in the countries adjoining I he Baltic, and the North- ern and German Oceans, must have occasioned a remarkable prevalence of this malady, even although nature had provided them with the best preventives and means of cure in the spruce-fir, and numerous other antiscorbutic plants and herbs with which they abound. The compara- tively recent culture of succulent vegetables, and more especially ofthe potato, in these coun- tries, accounts not only for the rarer appearance of this malady in these parts in recent times, but also for the prevalence of it during earlier ages. 7. Ofthe four ships which sailed from England the beginning of April, 1609, for the establish- ment of the East India Company, three were so severely visited by scurvy as to have lost near- ly one fourth of their crews when they arrived at the Cape of Good Hope. The commodore's ship was not attacked. This immunity arose from three table-spoonfuls of lemon-juice having been served daily to each of his men. Notwith- standing this evidence of the success of lemon- juice in preventing scurvy—evidence the most conclusive—this valuable remedy and preven- tive was altogether slighted for 150 years after- ward, although scurvy destroyed often one half or three fourths ofthe crews of our fleets, and was even more destructive to our armies than either battles or sieges, independently ofthe deaths it occasioned, both on land and at sea, in trading vessels. Sir R. Hawkins states, in his observations on his voyage to the South Sea in 1593, that upward of ten thousand mariners had died of scurvy under his own observation alone, during the twenty years that he had been at sea.—(Purchas's Collect, of Voyages, vol. i. and iv.) Admiral Hosier, who sailed in April, 1728, with seven ships ofthe line to the West Indies, buried his crews twice, and died broken- hearted in consequence. Lord Anson's expedi- tion, at the end of two years from its leaving England in 1740, had lost from this disease more than four fifths ofthe number that sailed in it. The voyages of Drake, Cavendish, Dampier, Byron, and of numerous other navigators, fur- nish similar details, and show how recklessly the lives of sailors were sacrificed. 8. But it was not only in fleets and single ships that scurvy was so destructive, but also in towns, fortifications, camps, and armies, and wherever the population was subjected to the causes which occasioned it in fleets. That scur- vy was endemic, and also epidemic, in northern European countries, has been stated to be man- ifest from the early works on the disease, and from the nature ofthe food upon which their inhabitants subsisted. Owing to the difficulty of procuring fresh, succulent vegetables, and from their ignorance of the disease and of its several preventives and cures, the early fre- quenters of Hudson's Bay, of Newfoundland, and the coast of Labrador, were frequently al- most altogether destroyed; and the early French settlers in Canada experienced so severe losses in winter and early spring from this disease, as almost to induce them to abandon the settle- ment. 9. While sporadic cases of scurvy were of frequent occurrence, the ravages of the disease were often great in winter and spring, especial- ly in years of scarcity, and in besieged towns or fortifications, and in armies. Vander Mye states that, during the siege of Breda by the Spaniards in 1625, the garrison and inhabitants were greiviously affected by this disease, 1608 soldiers having been attacked up to the fourth month of the siege, the numbers having in- creased daily until the place surrendered in June, after a siege of eight months. Backstrom has recorded that, in 1703, when Thorn, in Prus- sia, was besieged by the Swedes, 5000 of the garrison, besides many of the inhabitants, were carried off by scurvy during the five month's siege; the besiegers being altogether exempt from it. During the war between the Austri- ans and Turks in 1720, "when the imperial army wintered in Hungary, many thousands of the common soldiers, but not one officer, were cut off by scurvy. Dr. Kramer, physician to the army, being unacquainted with a remedy for it, requested a consultation of the College of Physicians at Vienna. Their advice was. how- ever, of no avail; the disease, which broke out at the end of winter, continued until, at the ap- proach of summer, the earth became covered with greens and vegetables." Backstrom (Ob- servat. circa Scorbutum, &c, 1734) states, that both in the siege of Thorn and in the imperial army, as soon as the former was raised, and vegetables and greens from the country were admitted into the town, and when the latter procured the same articles of food, the disease entirely disappeared. From these and other facts, he concludes that an abstinence from re- cent vegetables is altogether and solely the cause ofthe distemper, and so these alone are its effectual remedies. 10. Dr. Nitzsch, in 1747, gave a detailed ac- count of the prevalence of scurvy in the Rus- sian armies, especially at Wiburgh, and during the siege of Asoph, in 1736. At these and other places, the mortality was great during winter and spring, and was, as on most other occa- sions, ascribed to the unwholesome nature of the food, and the want of fresh succulent vege- tables. In the spring of 1760, the British troops, forming the garrison of Quebec after its capture from the French, suffered so severely from cold, and the want of vegetables, that, before the end of April, 1000 of them were dead of scurvy, and more than twice that number unfit for service. M. Fodere states that scurvy was remarkably prevalent in the French army of the Alps in 1795; and Larrey says that, in 1801, during the siege of Alexandria, which was commenced in May, and ended with August, 3500 scorbutic patients were received into the military hos- pitals ofthe city. During the war in Siam and Ava, the native and British troops suffered most severely from scurvy and scorbutic dysentery,* owing to causes which will be referred to in the sequel. In 1836, the troops in the province of Adelaide, near the Cape of Good Hope, also suf- fered severely from scurvy, although abundantly supplied with good fresh meat; but they had been long without fresh vegetables and fruit. Scur- * During 1827, the directors ofthe East India Company allowed me to inspect the regimental and other returns preserved in the India House, respecting the Causes, Na- ture, and Treatment of this disease as it occurred in the expedition to Ava, and of the cholera then prevalent in India. SCURVY—Description of. 841 vy was seldom or never seen in Great Britain since the end of the last century, up to 1847, excepting in jails and penitentiaries. In 1823 it appeared in the form of scorbutic dysentery in the Millbank penitentiary, owing to a poor and watery diet, without fresh or succulent veg- etables ; and, in 1836, 1837, and 1838, it oc- curred in several jails, owing to the same causes, more especially to the privation of fresh succulent vegetables. During the early months of 1847, 1848, and 1849, scurvy has appeared in various parts of England, Scotland, and Ireland, owing chiefly to the potato-blight. The Lit- erary History of this disease will more fully ap- pear from the Bibliography and References appended to this article. [It would seem that scurvy has almost inva- riably attacked the early colonists of northern latitudes, while those within or near the tropics have, from the abundance of fruits and vege- tables, escaped. The early Massachusetts col- onists, especially those who came in the May- flower, and landed at Plymouth, Massachusetts, were dreadfully afflicted, more than half hav- ing died the first season. This disease has oc- casionally appeared in the United States army and navy; but more frequently among our merchant whaling vessels, which continue for many months at sea—-in which there is little regard paid to personal cleanliness, and which are often excessively filthy and offensive. Not- withstanding, there is no instance on record, so far as we know, where the disease has pre- vailed on board of any vessel which had a good supply of .fresh potatoes. In 1809, the scurvy proved very fatal among the United States troops on the lower Mississippi, 600 men having fallen victims to it. From 1819 to 1839, it pre- vailed occasionally in the United States army, sometimes proving quite fatal, as at Council Bluffs and St. Peter's, in 1820, when there were 503 cases and 168 deaths. It also was observed to some extent during the Florida war, in 1837 and 1838 (Fovry), and also among the Ameri- can troops during the late Mexican war. Dr. Faltz, surgeon, has described the disease as it existed on board the United States squadron in the Gulf of Mexico, in the summer of 1846 (Am. Jour. Med. Sci., vol. xv., N. S.); and with- in the last two years it has committed extensive ravages among the early colonists, especially the miners, in California.] 11. II. Description.—i. Ofthe symptoms of scurvy, the earliest are observed in the coun- tenance. The face, as well as the rest ofthe surface, is pale and bloated. The carunculae of the eyes and lips have a dirty or greenish hue. The expression of the features is de- pressed. The gums are swollen, spongy, soft, livid, and bleed on the slightest friction. The odour of the breath is offensive. The patient complains of lassitude and debility, frequently of pains in the lower extremities, resembling rheumatism. He is averse from any kind of exertion ; and when he attempts to exert him- self he complains of stiffness of the joints, feebleness of the limbs, of panting or breath- Iessness, and of extreme fatigue. The skin is dry and harsh, and it generally continues dry throughout the course of the malady. Some- times it is rough, resembling the goose-skin appearance ; but it is more frequently shining, with patches, streaks, or spots of a reddish- brown, bluish, greenish, black, or livid hue, re- sembling those following a severe bruise. The size of these patches varies from a small point to that of a handbreadth, and it generally in- creases with the progress ofthe malady. The patches are first observed, and are most numer- ous on the legs and thighs ; but they soon ap- pear on the arms and trunk, and on the scalp; very rarely on the face, which, however, as- sumes a more dingy and bloated hue. The ankles swell, and the legs and feet become oedematous. In addition to these, the patient often complains of shifting pains; and, if the disease have supervened upon rheumatism or ague, these pains are more or less severe, and are referred to the bones, to the back, thorax, or joints. When the disease follows ague, ob- scure or irregular remissions or intermissions of febrile symptoms are observable, and more or less enlargement, with pain in the region of the spleen, is often detected. The above may be considered as the first or early stage of the distemper. [As described by our naval surgeons, "lassi- tude and debility" are not usually among the symptoms which usher in this disease ; on the contrary, there is generally great activity, and not unfrequently cheerfulness, good appetite, and sound sleep at night, for weeks after the teeth were loosened, the gums ulcerated, the limbs cedematous and discoloured. The nerv- ous symptom was commonly the last to be in- vaded, and then it was not an indisposition to corporeal exertion, but an actual disability. The countenance became pale, languid, cadav- erous, the respiration oppressed and irregular, and the pulse feeble, fluttering, intermittent, simultaneous with this muscular prostration. Slight efforts to turn, sit up, or move about, were followed by tremours and syncope ; and these symptoms usually indicated an early fatal result.] 12. These symptoms may continue a longer or a shorter time, or may be removed quickly by an appropriate treatment; but otherwise they may remain stationary; or, if the cause continues, they increase in severity. The gums become more tumid, more livid, and bleed from the slightest touch, and the breath remarkably offensive; the patches on the surface of the body enlarge, increase in number, and present a deeper and darker ecchymosed appearance. The pains are more severe, and are accom- panied with swellings ofthe hams, stiffness and contractions of the knee-joints and ankles, and often with a brawny feel of the parts, owing to effusion of lymph between the integuments and aponeuroses, preventing the motion ofthe skin over the swollen parts. With the exudation of lymph, red globules, &c, into the tissues, chiefly into the connecting cellular tissue and perios- teum, exudations of blood take place, giving rise to more or less marked hamorrhage from mucous canals, especially from the nostrils, mouth, and bowels, and from the vagina ; much more rarely from the bronchi, urinary organs, and stomach. The tendency to haemorrhage increases with the progress ofthe malady, and the loss of blood is often so great as to rapidly Bink the vital powers of the patient. In this ad- vanced stage, the livid patches are generally as sociated with hard and painful swellings in va rious parts, particularly in the lower extremi- 842 SCURVY—Dkscription of. ties, and in the calves of the legs; and these often pass into superficial fungous ulcers. Old cicatrices frequently open afresh, and become the seats of foul scorbutic sores. The teeth fall out; the gums present foul, livid, spongy ulcers. The respiration becomes remarkably short and hurried on the least exertion, and de- liquium or faintness is apt to supervene. The contractions ofthe joints, the cedema, indura- tion, and pain of swollen parts, the discolora- tion of the patches, and the number of the ul- cers, are all more and more developed, and the debility and vital depression greater. 13. From the commencement of the disease the alvine evacuations axe more or less disorder- ed. The stools are morbid; but at first they are not so remarkably so as to attract atten- tion, and costiveness is then often experienced ; but, as the disease advances, they are not only much disordered, but are much more frequent, and very offensive. Diarrhcea and colicky pains often supervene, and, with more or less attend- ant haemorrhage, rapidly sink the patient at this stage. Under certain circumstances, the dis- ease passes into a state of scorbutic dysentery, or dysentery and scorbutus supervene upon each other, and thus become associated, as shown when treating of Dysentery (see that art., § 39, etseq.). The urine is scanty and high- coloured (see t) 20). 14. The pulse is often little affected at an early stage, but is more generally slower and feebler than in health ; but in more advanced cases, or when the malady is associated with some degree of asthenic or sub-inflammation in the seats of effusion, the pulse is often remark- ably frequent, as well as small or weak. When the pulse is slow and feeble, the patient is often chilly, the surface cool, and the temperature of the body lower than natural. This state of the disease was called the cold scurvy by the earlier writers. When much swelling and hardness, with pain, is occasioned by effusion in the con- necting cellular tissue, or even below the peri- osteum, the pulse is generally frequent, varying from 100 to 120 in a minute, probably owing to some degree of inflammatory irritation pro- duced by the effused matters in these situations, as indicated by the great tenderness which al- ways is present. This state of febrile action gave rise to the distinction of hot scurvy, accord- ing to various authors. 15. The tongue is generally clean and pale, but commonly broad, flabby, and indented at its edges by the teeth. The insides of the cheeks and lips are pallid, and contrast remarkably with the appearance ofthe gums. Thirst is not much complained of, unless in the more fehrile state of the disease, or when the supply of fluids is scanty. The appetite is not impaired. It may be even greater than in health ; and digestion is not very manifestly impaired. Sleep is not deficient, unless at a far advanced stage, when wakefulness or disturbed sleep is experienced. The mental faculties are not impaired, although the spirits are generally more or less deject- ed and anxious ; but towards a fatal issue the patient becomes indifferent and torpid. The memory is generally unimpaired, but the eye- sight is occasionally weakened.* * [Nyctalopia, or moon-blindness, is a symptom which is not uncommon as a precursor or attendant on scurvy, and has been particularly noticed by Dr. Co ale in his account 16. As the disease approaches an unfavour- able issue the breathing becomes remarkably frequent, and the dyspnaa extreme. The pa- tient coughs, and expectorates a frothy mucus, sometimes tinged with dark blood. The chest was generally every where resonant on percus- sion ; the respiratory murmur was loud and dis- tinct ; and the sounds of the heart were loud and extensive, but unaccompanied by any mor- bid bruit in six cases examined by Dr. Budd. In the most advanced states of scurvy, not only may ulcers, and injuries or wounds which have healed up for many years, break out afresh, but old and well-united fractures may become dis- united. The tendency to swoon in the most se- vere cases is sometimes so great that the slight- est motion, or the erect posture, or even any trifling exertion, may be followed by fatal syn- cope. It is stated in the account of Lord An- son's voyage, that many of the men, although confined to their hammocks, eat and drank heartily, were cheerful, and talked with much seeming vigour, and in a strong tone of voice; and yet, on their being the least moved, al- though it was only from one part of the ship to another, and that in their hammocks, they have immediately expired; and others, who have con- fided in their seeming strength, and have re- solved to get out of their hammocks, have died before they could reach the deck. And it was no uncommon thing for those who could do some kind of duty, and walk the deck, to drop down dead in an instant, on any endeavour to act with their utmost vigour. 17. Emaciation is not necessarily a phenom- enon of the disease, unless there has actually been considerable privation of food; but it is occasionally observed, and anaemia is not infre- quent. Dr. Budd observes that, although there is a remarkable tendency to the breaking out of old ulcers or wounds long previously healed, yet there is very little disposition to the occur- rence of bed-sores from pressure. The separa- tion of the epiphyses from bones has been men- tioned by some writers as having occurred in children attacked by this malady, but it has not been often observed in adults, or, if observed, not mentioned by many writers. 18. Scorbutic ulcers exude a thin, fetid, sani- ous fluid, instead of pus. Their edges are of a livid colour, and, as if puffed rip, a coagulum soon forms on their surfaces, which is separa- ted or wiped away with difficulty. The parts underneath it are soft, spongy, or putrid. When this coagulum is removed, the same change again occurs after a few hours, forming a soft, bloody fungus, resembling boiled bullock's liver. of the disease as it existed on board the United States frigate Columbia in 1843, and also by Dr. Foltz, U. S. N. The blindness is represented as coming on soon after sun- down, the conjunctiva becoming injected, when the blind- ness was so perfect as to prevent vision, even at a few inches distance. Dr. Foltz, in his history of the disease, as it appeared on board the United States frigate Raritan, remarks as follows: " Nyctalopia occurred in five, and hemarolopia in two cases. One case of the latter was so bad that the patient could not move about the even decks, with which he was perfectly familiar, without the greatest difficulty. There were other affections of the eyes, owing obviously to this scorbutic diathesis, such as inflammation of the conjunctiva, induration, and irritation of the cilia?, accompanied with a copious acrimonious discharge. The usual collyria were used without any benefit, and the eyes improved or became worse in proportion to the arrest or progress of the scurvy; and ultimately, as the disease was eradicated, the ophthalmic affections permanently disap- peared."— Loc. eU.] r SCURVY—Description of. 843 This fungus exudation, Dr. Lind states, some- times rises in a night's time to a great size, and, although cut off, in which case a plenti- ful haemorrhage generally ensues, at the next dressing is as large as ever.* 19. ii. The Chemical Analyses of the Blood and Urine in scurvy have been few, and even these unsatisfactory. It is manifest that the states ofthe blood and of the excretions in this disease will depend much upon the treatment adopted, and upon the time during which the treatment has preceded the analysis.— A. Si- mon's "Animal Chemistry" furnishes no inform- ation as to the blood in scurvy; but Dr. Day, in his additions to the work, states that Mr. Busk, in three well-marked cases of scurvy, found the composition of the blood as follows, comparing the scorbutic blood with the healthy, according to his analysis ofthe latter : IstCase. 2d Case. 3d Case. 4th. Healthy Blood. (Busk.) 849-9 1501 6-5 840 47-8 9-5 835-9 164-1 45 76-6 72-3 11-5 846-2 153-8 '5-9 742 60-7 109 788-8 211-2 3-3 67-2 133-7 6-8 Solid constituents. Blood-corpuscles . Although the fibrin appears to be increased, its vital cohesion is evidently impaired ; and the al- bumen is certainly altered in quality, although the alteration is not shown by chemical analy- sis. * [Dr. Foltz, United States navy, maintains that the Land Scurvy (Morbus maculosus, Werlhofii) is a " total- ly different" disease from Sea Scurvy. " In their symp- toms there is, in the early stages, a slight assimilation; but, as they progress, in their pathological character they are perfectly dissimilar. Among the troops employed in Flor- ida during the Seminole war, the morbus maculosus com- mitted extensive ravages. Nyctalopia was a common symptom; some thirty cases of the disease occurring among the marine corps, co-operating with the army, were transferred from the field to the Marine Hospital at Wash- ington, then under our charge. These cases, as well as a number we witnessed at Point Isabel, in May, in the forces engaged under General Tayxob, were totally distinct from the scurvy as it occurs on board ships at sea. Purpura cedema, the cadaverous and fetid effluvium which follows the extreme emaciation, the fainting upon the slightest ex- ertion, and the extent of disease in the respiratory and cir- culatory systems, which always occur in the scurvy on board ships, are never met with in the land scurvy. In the latter we have sponginess of the gums, ulceration, which terminates in dysenteries and fevers, the first in- duced by a cachectic diathesis, but never involving that complete anaemia of the blood, which amounts to a uni- versal septic tendency." Is not this difference in the phenomena of the disease owing solely to the fact that on board of vessels at sea men are compelled to breathe a confined, vitiated, and Impure air, while upon land this cause of deterioration of the blood is removed 1 It is much to be regretted that the internal arrangements, with the accommodations for officers and crew, on board many of even our large public vessels are so defective — the hold being small, badly arranged, and imperfectly venti- lated, while the berth-deck is low, with very small air- ports, which are only opened in port, or at anchor, and in the best weather; while the apartments for the officers are small, dark, and contracted. The ventilation is imper- fect below, because the hatches leading to the berth-deck are so arranged that wind-sails cannot pass in a perpen- dicular line from the spar-deck to the berth-deck or hold ; while the sick-bay in the bows of the ship, on the berth- deck, and the cockpit, are without light and air, with a temperature sometimes of between 80 and 90° for weeks together, and no hatch for the admission of a wind-sail. When to these we add the low dismal wardroom, poorly lighted and ventilated; and the coldness, and dampness in winter, incident to daily washing and wetting, the daily use of salt beef and pork, long preserved, and consequent- ly innutritious; the daily spirit-ration and personal un- cleanliness, we need not be surprised at the occasional appearance of scrofula, in its most malignant form, in the United States navy.] 20. B. The urine in scurvy is commonly of a dark reddish brown, and sometimes of an al- most black colour. Although it is slightly acid as it is evacuated, it very soon becomes alka- line, and emits a strong and disagreeable am- moniacal odour. Blood is often discharged with the urine, and the urine then assumes a dark reddish-brown colour, in consequence of the presence of haematoglobulin ; in this case it de- velops hydrosulphate of ammonia, and soon be- comes putrid. Dr. Simon examined the urine in three cases of scurvy in SchSnlein's clinical wards-^two men and one woman. The urine was very similar in these three cases in its phys- ical characters. It was scanty, and of a deep dark-brown colour ; after standing a few hours, it emitted a disagreeable ammoniacal odour. The three specimens resembled each other, and were found to approximate the chemical characters of the urine in typhus. The urea was less than in healthy urine, not exceeding 25-30ths of the solid residue. The fixed salts were diminished in the two male cases, being 14-18ths of the solid residue ; but in the fe- male they were 27, or a little above the normal average (25). The uric acid was slightly above the healthy standard in all, being from 1 to 3 of the solid residue. 21. iii. Appearances on Dissection.—Scur- vy at the present day seldom proves fatal, un- less in ships or in besieged towns, where op- portunities of minutely examining the bodies after death are rarely enjoyed ; and the observ- ations of early writers on this subject are gen- erally devoid of precision, and the necessary de- tails. The best account of the appearances aft- er death has been furnished by Dr. Budd, from the cases which were brought to the Dread- nought Hospital Ship. He states, " The general inferences to be drawn from preceding facts are, that, in the inspection of the bodies of per- sons who die of scurvy, the chief indications of that disease are met with in the colour of the skin, in the state of the gums, and in the pres- ence of fibrinous effusions, and of ecchymoses, or effusions of blood. These effusions occur most frequently in the skin, in the subcutane- ous cellular tissue, and between the muscles of the lower extremities, between the periosteum and bones of the lower extremities and of the jaws; and in the peritoneal coat, and in the muscular and mucous coats of the intestinal canal. The numerous traces of haemorrhage observed in the coats of the intestines are in accordance with the frequency with which scor- butic persons pass blood by stool." 22. The slight effusions of blood between the periosteum and bone do not destroy the muscu- lar connexions between these parts, so that the latter does not generally present farther altera- tion. Beyond a paleness of tissue, there is no change characteristic of scurvy observable in the brain. The organs of respiration, the heart and large blood-vessels, the glandular system and the bones, presented no remarkable changes in the cases inspected by Dr. Budd. His ob- servations furnished him with no direct inform- ation respecting the blood, except that it is de- ficient in red particles ; that it does not impart a stain to the lining membrane of the heart or vessels ; and that it has not lost the property of coagulating. The change observed in the skin and in the complexion is to be ascribed to 844 SCURVY—Diagnosis. the alteration of the blood, and the haemor- rhages doubtless proceed, at least in part, also from this alteration. Former writers have no- ticed more or less of a fluid or dissolved condi- tion of the blood, and a soft, flabby state of the heart; this latter change accounting for the swooning and fatal deliquium sometimes oc- curring in the more extreme cases. The liver has been found pale, or of a pale buff colour, or of a nutmeg appearance ; and the bile in the gall-bladder of a pale or yellowish colour. The spleen is generally soft, of a plum colour, and often more or less enlarged. The lungs axe sometimes oedematous, especially in their more depending parts. The kidneys and urinary pas- sages seldom present any change in the uncom- plicated states ofthe disease. 23. According to the descriptions of Poupart, Lind, and others, the blood discharged from the mucous canals during life, as well as that found in the cavities of the heart and vessels after death, was remarkably altered, fluid, broken down, and presented more or less of a green- ish-black hue. The spleen was generally much enlarged, and so soft as to break down on being handled. Adhesions often existed between the costal and pulmonic pleura, and sometimes dir- ty serous effusions were found in the pleural cavities. Black, corrupted blood was general- ly effused between the muscles, or infiltrated between their fasciculi, and under the skin and periosteum ; and the auricles were remarkably distended by coagulated blood, in those who died suddenly. In young subjects the epiphy- ses were loosened from the shafts of the long bones, and the ribs had separated from their cartilages. In some the glands of the mesen- tery were more or less enlarged. The kidneys were occasionally altered. The alterations found in the bones, especially those now men- tioned, most probably arose from the effusion of blood between the periosteum and osseous structure, and from the consequent destruction of the vessels of the former, which nourish the latter. 24. iv. Complications, &c.—Much of the di- versity observed in the symptoms and progress of scurvy, as well as in the appearances after death, depends upon the nature of the food, or ofthe privations causing the malady, and upon antecedent, concurrent, or intercurrent disease ; for, as will be shown in the sequel, although the privation of fresh vegetables and fruit is mainly productive of it, still much is owing to the food upon which the patient has been living up to the time of his attack and during its progress. The diseases which commonly precede and fa- vour the appearance of scurvy are agues and remittent fevers, enlargement of the spleen or liver, rheumatism, dysentery, or chronic diar- rhcea ; and either of these may complicate, in a more or less evident manner, the scorbutic state, especially in its more chronic form, or may ap- pear as an intercurrent malady. These com- plications are most apt to occur in warm or tem- perate climates, and wherever malaria is pres- ent ; and probably the association with rheuma- tism is most common in colder regions and sea- sons. When they do appear, they are readily recognised when the physician is alive to the probability of their association, and when the causes on which they chiefly depend are ob- served to be in operation. The supervention of scurvy upon ague, or upon enlargements of the spleen, or upon affections of the bowels, is not infrequent, especially in the winter and spring months, when fresh vegetables and fruits have become scarce, and when cold, humidity, and these diseases have predisposed the frame to this malady; and it was certainly much more common in former ages, before potatoes came into general use. 25. The complication of scurvy with dysentery was the most prevalent and fatal disease dur- ing the Burmese war, and was entirely owing to the nature ofthe food in connexion with malaria and bad water. But it is unnecessary to add, at this place, to what I have stated when treat- ing of the forms and complications o/Dysentery (see Y 39, et seq). Although rheumatism is un- doubtedly in some cases, and at certain seasons, occasionally associated with scurvy, still the pains, which are most commonly attendant upon the latter, are rather to be imputed to the infil- trations of blood which take place between the muscular fasciculi and under the periosteum, than to any rheumatic complication. A moder- ate attention to the matter will be sufficient to distinguish the nature of the case, as well as the existence of enlargement ofthe spleen, and the connexion ofthe disease with ague. 26. Persons labouring under scurvy are very liable, when exposed to cold and humidity, to experience severe attacks of pleurisy, or of peri- carditis, or of peripneumonia, or of bronchitis, which may carry off the patient in a short time, without materially influencing the symptoms of scurvy. In these cases, the dyspnoea, cough, and difficulty of expectorating become urgent; the expectoration, varying with the state of pec- toral disease, from a slight mucous, frothy mat- ter, to a dirty brown, or dark red, or sanious substance. Effusion into the pleural cavities, or effusion into the air-cells and small bronchi, and splenification of the substance of the lung, ultimately hasten or occasion a fatal issue. In rarer instances changes in the kidneys, which I have ascribed to cachectic inflammation of the secreting structure of these organs (see art. Kidneys, § 80, et seq.), supervene, and, by em- barrassing the functions of these organs, super- induce dropsy upon the scorbutic disease, and thereby occasion or accelerate an unfavourable termination. 27. III. Diagnosis.—Of the numerous writers who preceded Lind, very few pointed out with due accuracy the diagnostic characters of scur- vy, or distinguished sufficiently between this disease and malignant or putrid fevers. In many circumstances, and on many occasions, some of which I have myself witnessed, it is difficult to determine as to the presence of scurvy or of putrid fever, at first sight, or until a more pa- tient and close observation has shown the dif- ference, so insensibly or gradually, in such cir- cumstances, some of which I observed in Ger- many and France after the last war, does the one malady approach the characters of the oth- er. In Ireland, in 1847, owing to the failure of the potato-crop, and general misery, scurvy was intimately associated with putro-adynamic fe- ver, and it was most difficult to distinguish be- tween them, or to say which was the primary malady. The same observations equally apply to purpura, which often arises from similar causes to those producing scurvy, and is more SCURVY—Prognosis—Causes of. 845 or less closely allied to, although generally distinguished from, scurvy, the more extreme points of difference between the two having been laid hold of as diagnostic characters, while the closest resemblances have been kept out of view. It will be more just, more conducive, moreover, to accurate pathological views, and certainly tend more to the adoption of sound indications and means of cure, to look closely at diseases as they occur in practice, to con- sider both alliances and differences, and to pro- ceed in our treatment on the comprehensive basis thereby furnished us. • 28. Circumstances have occurred, and may occur again, in which certain of the causes of malignant fever, as a confined impure air, crowd- ing of numbers into a small and ill-ventilated space, &c, have come into operation, in con- nexion with the causes of scurvy, especially a deficiency or want of fresh vegetables and fruit, and have given rise either to the petechial or putro-adynamic form of fever, or to a state of febrile scurvy, or to a disease in which the symptoms of either the one or the other pre- dominated, according as the causes of either prevailed. In attempting to distinguish between these diseases, or to determine the existence of either, the discriminating physician will be guided by the slow and gradual, or the rapid accession of the symptoms; by the states of the skin, of the gums, and of the teeth ; of the general surface, and particularly of the lower extremities; by the discoloration and other changes there observed ; by the presence or ab- sence of complete prostration and of other fe- brile phenomena ; by the acuteness or intensi- ty and duration of the malady; by the appetite and function of digestion ; by the inability or capability of leaving the bed ; and by the pres- ence or absence of contractions of the lower extremities, or of hardness, swelling, and livid patches or ulcers in these situations. 29. In distinguishing, also, between scurvy and purpura, the presence or absence of the majori- ty of the above symptoms, and more especially the states ofthe gums and teeth, the swellings, indurations, livid blotches, cedema of, or the fungous ulcers on, the extremities ; the con- tractions of the joints ; and various associated phenomena, will guide the physician to a cor- rect diagnosis, and while they indicate with due precision the existence of either the one or the other, will at the same time point out the close alliance between both as to their causes and their natures. (See Purpura, v 23.) 30. IV. The Prognosis of Scurvy.—Before the disease is advanced so far as to present con- tractions, indurated swellings, or fungous ul- cers on the extremities ; or haemorrhages from mucous canals; or swoonings upon assuming the erect posture, or on slight exertion, a speedy recovery will generally follow the use of the means about to be recommended ; but when the malady is thus far advaneed, although the same means will often save the patient, they may also fail; and this unfavourable result is the more likely to ensue if, with these symp- toms, the patient complains of dyspnoea, and oppression at the chest; if his respiration and pulse be very frequent ; if there be any pulmo- nary, pleuritic, or dysenteric complication ; if dropsical effusions or albuminous urine super- vene ; if the spleen be much enlarged ; and if haemorrhages from the bowels be copious, then great danger may be apprehended, and with still greater reason, if the. adoption of a suit- able diet and remedies is not soon followed by any amendment. 31. In cases which present not the extreme symptoms characteristic of scurvy, and are nevertheless unamenable to the usual scorbutic remedies, some complication should be looked for and ascertained, as this most probably either retards or prevents the efficacy of such means, or the disease partakes, owing to the causes above noticed (v 28), more or less of the char- acters of putro-adynamic or petechial fever— possesses the intermediate form already men- tioned (y 27), and requires an appropriate meth- od of treatment. I am persuaded that the in- stances of scurvy which have been adduced of the failure of these remedies have either been the severer, or pulmonic, pleuritic, pericardiac, dysenteric, or dropsical complications of the dis- temper, or those intermediate states of disease now alluded to. 32. V. Causes of Scurvy.—The causes of scurvy were only partially known until a com- paratively recent period; for the disease was often ascribed to one only of the causes, and that a predisposing cause ; and even now, when the chief causes have been duly recognised, oth- ers which either predispose the frame to their operation, or concur with them, and aid or de- termine their effects, are too generally over- looked, and their influence in modifying the malady, or in delaying or preventing the bene- ficial operation of the means employed, is al- together neglected, or even unknown. It has been fully ascertained that several of the causes to which scurvy was formerly imputed are not really the exciting or efficient causes of this malady; but their influence as predisposing, concurring, or determining causes should not be denied, although they cannot take the high- est rank in causation, or because they have been pushed from the position formerly assign- ed them, by others of much greater influence. 33. i. Predisposing Causes. — Several of these causes were formerly believed to have had the chief share in the production of scur- vy ; but they are now more clearly proved to perform a less important part; but this part they fill in the causation not only of this malady, but also of dysentery, putro-dynamic fever, purpu- ra, and probably of other diseases.—A. Much importance was attached formerly to living on salt provisions; and as this disease most fre- quently and certainly appeared in ships provi- sioned with salt meats chiefly, so it was infer- red that these were the causes of its occurrence. That salted meats are not more productive of scurvy than fresh meats, or at least not much more so, is shown by the prevalence of the mal- ady, in the spring of 1720, in an army which Kramer stated to have enjoyed an abundance of fresh meat at a low price ; in the Russian armies, in 1736, which were similarly circum- stanced ; in the French prisoners, at the mid- dle of last century, who had no salt provisions; and in the regiments at the Cape, in 1836, that enjoyed an abundance of fresh meat. 34. From these and other facts, it may be inferred that scurvy may appear even among those who have a sufficient supply of fresh meats, if there be a prolonged deficiency at the 846 SCURVY—Causes of. same time of succulent vegetables and fruits. Nevertheless, the question remains, Are salted meats more favourable to the supervention of scurvy than fresh meats 1 I believe, after hav- ing paid some attention to the matter, that re- cently-salted or uninjured salt meats, if they have been of a good and healthy description, and quite fresh when salted, are not materially more productive of scurvy than fresh meats; but while the quality of the latter is generally manifest, that of the former is not always so evident. The salted provisions supplied to ships have frequently been long cured, even before they are received on board, and are so often of the most inferior and unwholesome character, as to account in great measure for the appear- ance of cachectic maladies in those who live upon them. It was notorious, during Queen Anne's wars, that, owing chiefly to collusion between the heads ofthe commissariat or others in power and the contractors, and even in more recent times, that the salted provisions supplied to the navy and army often consisted not only of long or imperfectly cured meats, but also of the flesh of animals which had, died of disease ; that horse-flesh was often placed in casks of beef; and that similar villainous acts were not confined to salted provisions, but extended also to the flour and biscuits supplied to these serv- ices, both of these having been adulterated, and the latter mouldy, and swarming in maggots and weevils. Owing to this cause, as shown by some medical writers of the day, a much greater number of human lives were lost from scurvy, scorbutic dysentery, and putro-adynam- ic fever—by diseases caused by the unwhole- someness of the provisions—than from all other diseases, and from naval and military actions, sieges, and other causes combined.* 35. Not only were both salted and farina- ceous provisions frequently deleterious, but the supply also was insufficient to both army and navy, up to the mutiny at the Nore, the causes of which were generally misrepresented by those in power, and misunderstood or glazed over by historians. In times more recent, acts similar to the above have been perpetrated in more places than one. The returns made to the Medi- cal Boards in India by the medical officers, and which are preserved at the India House, are full of complaints as to the unwholesome na- ture of the provisions supplied to the army in the Burmese war; even the rice having been either unripe or damaged. The remarkable prevalence of scorbutic dysentery, and low fe- ver among the troops in that war, was ascribed chiefly to this cause ; the mortality continuing great until more wholesome provisions were procured. But it was not only in the public serv- ices—in fleets, armies, and transport vessels— that these enormities were practiced ; trading- vessels, emigrant ships, &c, were sometimes, and are occasionally up to the present day, sup- plied with the cheaper kinds of Irish provisions', which are frequently of a similar kind to that * From a tolerably extensive field of observation in va- rious parts of Europe and within the tropics, between the years 1815 and 1819 inclusive, I can state, that, of the va- rious kinds of unwholesome cured meats, pork is perhaps the most injurious, especially when it has been imper- fectly salted or too long kept; and, more particularly, if it have been coarsely ted, or diseased, or not cured im- mediately upon being killed: scorbutic and other forms of dysentery generally resulting. above described; and to this circumstance in part, and to others about to be noticed, should be ascribed the scurvy and fever so frequently breaking out in ships after their provisions have been used sufficiently long to produce their ef- fects. To the unwholesomeness and nature of the food, and to the state of the water, even independently of therwant of fresh vegetables and fruit, the diversity of characters presented by scurvy and fever in ships, armies, prisons, &c, is in great measure to be imputed, as well as the want of success in treating these diseases by the more usual remedies, or by those more generally found efficacious under other circum- stances—the same causes not merely predis- posing to these forms of disease, but actually producing them, and giving them their distinct- ive features.* 36. Much of the mischief observed in those who had lived long on salt provisions was for- merly, and still is by many imputed to the salt by which these are cured, or at least to the state ofthe provisions ; and by others to the supposi- tion that salted meats are not so nutritious as fresh. But when these provisions have been from the first wholesome and good, have been salted while quite fresh, and have not been aft- erward kept so long as to produce any sensible or unpleasant change, they may then be consid- ered as having had no farther share in the pro- duction of scurvy, even although it should have appeared during the use of such provisions, than that they have constituted the chief or only food, to the neglect of other articles requisite to cor- rect the effects of so exclusive a diet, such as fresh vegetables and fruits. On this subject Dr. Budd justly remarks, that " the circumstan- ces showing that scurvy may prevail to a fright- ful extent among persons living solely on fresh meat; that persons who, from the nature of their occupations, are continually absorbing sa- line particles, are exempt from scurvy; that scurvy is not brought on by the use of sea-wa- * [In the United States navy, the salt beef and pork, which constitute a great portion of the daily ration of the seamen, are very generally deteriorated by age, and often unwholesome and innutritious; and, as the navy is sup- plied with these articles by contract, they are generally long kept, and nearly spoiled before they are served out The salt, moreover, which is used in curing them is fre- quently of an inferior quality. As Dr. Foltz has stated, when new beef and pork are delivered to the government in a sound and wholesome state, they are carefully stow- ed away until the old stock on hand is consumed, by which time the new has reached the same condition as that which was nearly in a state to be condemned, if sur- veyed. Dr. Goale (United States navy) states that "the best beef that could be procured" (on board the United States frigate Columbia, previous to the appearance of the scur- vy), "had been salted so long that all characteristics as an article of food seemed to be lost, and its odour, when boiled, was scarce supportable. The biscuit was very dark, required generally a hammer to break it, and the fracture mostly resembled a vitreous lustre." — (Am. Journ. Med. Sci., Jan., 1842.) The daily rations supplied to the United States seamen are as follows: Bread, fourteen ounces ; whiskey (at option), half a pint daily; and in addition, on Sunday, suet, quarter of a pound; beef, quarter of a pound; flour, half a pound. Monday, pork, one pound; beans, half a pint Tuesday, cheese, two ounces; beef, one pound. Wednesday, pork, one pound; rice, half a pint. Thursday, suet, quarter of a pound; beef, one pound and a quarter; flour, half a pound. Friday, cheese, four ounces; butter, two ounces; rice, half a pint; molasses, half a pint. Saturday, pork, one pound; beans, half a pint; vinegar, half a pint. It would doubtless conduce very much to the health of our sailors if potatoes could enter somewhat largely into the dietaries of our vessels, and form part ofthe daily rations.] SCURVY—Causes of. 847 ter, which may be drunk with impunity, even by scorbutic people ; and that the disease may be prevented for any length of time in persons who subsist on salt provisions, and can be readily cured, even in those who continue the use of them, are sufficient to justify the conclusion that salt has no share whatever in producing it" (p. 65). To this statement I would merely add, that the salt conceals, and partly corrects, the sensibly noxious properties of previously taint- ed, diseased, or otherwise unwholesome meats ; and hence meats of this description, when salt- ed, are more readily, and perhaps less injuri- ously, partaken of, and, moreover, have not their injurious nature made so manifest, or even sus- pected, as if an attempt to use them in their fresh state were made. 37. B. Next to the state of meat provisions, that offarinaceous food supplied to ships, armies, &c., as predisposing to, or even as producing scurvy, may be noticed. In various countries in the East, where little or no animal provision is used, scurvy has nevertheless appeared, and has been ascribed, with sufficient reason, not so much to deficiency ofthe amount as to the un- wholesome nature ofthe food, whether rice, In- dian corn, &c, which often have been damaged, unripe, mouldy, Or too long kept. The flour, biscuits, and other farinaceous articles, supplied by contract or otherwise to the public services, and to trading vessels, were formerly, on many occasions, similarly damaged and unwholesome, or became so after having been kept for some time, and contributed their share towards the production of scurvy, fevers, and even to vis- ceral disease. That these articles of food have actually been productive of these maladies, was demonstrated by the occurrences in the Bur- mese war; native Indian regiments subsisting entirely on rice and other farinaceous articles, which in that war was more or less damaged and unwholesome, having been universally at- tacked with scurvy and scorbutic dysentery. 38. C. The water, also, with which ships of war and trading vessels were supplied for long voy- ages, having been kept in wooden casks, the use of iron tanks for this purpose being of re- cent date, the water became offensive and un- wholesome, on many occasions so much so as to be nauseous, and to require the addition of spirits to prevent its more immediate ill effects. The effects of marsh water in causing bowel complaints and enlargements of the spleen and liver, are well known to many who have pos- sessed powers of observation in connexion with the requisite opportunities. But I can say from personal observation, that water, long kept in wooden casks, however well these casks may have been charred, as they sometimes are on their insides, becomes even more deleterious to health, and much more offensive to the senses, than any water taken from marsh-grounds or land-tanks, much, however, depending upon the state of the water when filled into the casks. The greater attention now paid to the supply, state, and preservation of water in the public services, and in trading vessels, is one of the chief causes of the less frequent appearance of disease in them, and more especially of scurvy and allied maladies. 39. D. Cold and humidity have long been con- sidered as very influential in favouring the oc- currence of scurvy. That these causes are of some importance, I can assert, although Dr. Budd strongly doubts their influence. But he has not viewed them in a proper light. He re- marks, that " the merchant seamen who enter the port of London, affected with scurvy, come almost exclusively from Mauritius, India, Cey- lon, or China; and have consequently been in no higher latitude than that of the Cape." But he overlooks the circumstance that those voy- ages are long, and that the men have been living long upon cured meats, without a due supply of fresh fruits and vegetables ; while most other vessels arriving at the port of London have had short voyages, they coming from much nearer countries, and consequently a sufficient period for the development of scurvy in them has not elapsed. It is not, however, the cold and moist- ure depending upon climate, or even upon weath- er, that are so influential in favouring the devel- opment of scurvy, as the cold and humidity aris- ing from daily, and even twice daily, washing and scruhbing the decks, formerly and even still so much in use, to the neglect of dry-scrubbing and cleansing. The evaporation from the wet decks during day and night, consequent upon frequent washings during fine and dry weather, and the wet and humidity of body-clothes, bed- clothes, and hammocks, produced by these wash- ings, and during foul or stormy weather, are the forms of cold and humidity which, on ship-board, predispose to scurvy, and more directly produce the several forms of rheumatism, chiefly by sup- pressing the cutaneous functions, by reducing nervous power, and thereby causing the accu- mulation of those excrementitious matters, the retention of which occasions these maladies. All the most experienced writers on scurvy have remarked the suppression ofthe cutaneous functions previously to the appearance of, and during the progress of scurvy, and I have no doubt of the fact from my more limited observ- ation. 40. E. Impure air has been considered by some writers as predisposing, more or less, to the appearance of scurvy. The testimony of Lind, Trotter, and Blane, most experienced physicians, is opposed to the opinion that it has any influence either in the production or on the course of this malady. That the influence is not very remarkable, may be admitted; but that this cause is not altogether without effect can- not be denied, especially in modifying or alto- gether changing the characters of the disease, when conjoined with those causes which more directly and commonly produce scurvy. It was observed in the American squadron, in 1846, that scurvy was most severe in vessels which were the worst ventilated.* 41, F. Several other diseases predispose the frame to the appearance of scurvy; and al- though the predisposing influence has been at- tributed to the debility produced by those dis- eases, yet I believe that it is not the debility * [In every instance where scurvy has broken out on board any of our United States public vessels, as the Rar- itan, the Potomac, the Falmouth, &c., it could be traced di- rectly to the unwholesome and indigestible character of the meats, beef and pork, owing to long keeping, and the inferior quality of the salt used in curing them. In con- nexion with this was long absence from land, the total want of fresh provisions, breathing a vitiated atmosphere from imperfect ventilation, bad water, or a diminished supply; and, in some cases, despondency and disappoint- ment from being kept on board after the expiration ofthe period for which the crew had shipped.] 848 SCURVY—Causes of. alone which predisposes, but more especially the nature of the malady. Agues, remittent fevers, enlargement of the spleen, and rheuma- tism, and previous disorder of the digestive or- gans, especially the former, have been generally considered by medical writers as more or less influential in the production of scurvy. The previously impaired assimilation and nutrition, and the consequent state of the blood, in con- nexion with exhausted organic nervous energy, readily account for the readiness with which scurvy supervenes upon those maladies when its causes are in operation. 42. G. The state ofthe mind is influential both in predisposing to and warding off scurvy; the depressing passions favouring the appearance, and the exciting emotions preventing or delay- ing the occurrence ofthe malady. Disappointed expectations; anxiety; hope deferred; longings to return to more desired scenes; prolonged confinement; a want of exciting, amusing, and exhilarating occupations; breathing the same kind of air in the same locality ; a monotonous and unexciting course of existence ; losses of relations and friends, and extinction of those hopes or expectations which render privations endurable—all have their influence in predis- posing the body to scurvy or its allied states of cachexy. 43. H. The seasons have no small influence on the appearance of scurvy, but mainly in con- sequence of the privation of fresh vegetahles and fruits, which is experienced chiefly during winter and spring; so that in armies, as well as in fleets in, or departing from, cold or tem- perate countries, a deficient supply of those di- etetic means of prevention is more likely to be experienced at those seasons than at any other. Suppressed perspiration, produced by the cold and humidity of these seasons, may also not be altogether uninfluential, as shown above (§ 39), in favouring the evolution of this malady. In northern countries, where the inhabitants, the seamen, and the soldiers, live chiefly upon cured meat provisions, as salted and smoked meats, and dried fish, during winter and spring, and un- til the commencement of summer, when vege- tables and fruits begin to appear, their consti- tutions have made considerable progress to the scorbutic diathesis ; so that, when these pre- ventive articles of diet cannot be obtained at this latter season, owing either to states of siege, and to the provisioning and other circum- stances of armies or fleets, scurvy is then much more apt to break out in spring, and even in summer, than at other seasons. 44. I. The early writers on scurvy were in- clined to ascribe a contagious influence to this disease, chiefly from the number attacked with it in the same place and circumstances ; but it was clearly shown that contagion had no share in producing it, by Lind and others, who wrote about the middle and end of the last century, the causes inducing the malady being common to all affected by it in the same locality. But, although the disease is actually uncontagious, it is by no means unreasonable to infer that the putrid emanations from a number of persons in an advanced stage of the disease, confined oft- en in very limited spaces, either on board of ships, in the crowded hospitals of a besieged town, or in crowded prisons, are not altogether innocuous, or are not without some influence in predisposing the body to this or some allied malady, arising from the contamination of the circulating fluids, and from the depression of vital or organic nervous power, by the accumu- lation of these emanations in the air which is respired for a longer or shorter time. Nor would it be improbable that the emanations arising from a number of scorbutic patients, in places insufficiently ventilated, may convert the scor- butic malady into putrid, maculated, or putro- adynamic fever, or into scorbutic dysentery, or even may more directly develop these diseases. 45. K. Age and Sex have probably out little influence on the production of scurvy, for it is observed at all ages, and in both sexes ; but there is no doubt that it occurs much more fre- quently in adults, or from early puberty until far advanced age, than in children, and in males than in females, chiefly in consequence of the greater exposure of adult males to the causes, owing to the circumstances in which they are liable to be placed. 46. ii. The exciting Causes of Scurvy may be briefly stated to be the use, for a longer or shorter period, of all kinds of animal meats, too long or imperfectly cured or preserved; of dried, or smoked, or tainted meats or fish ; or mouldy, old, damaged, diseased, or unripe farinaceous articles of food, to the exclusion of, or without possessing the advantages of, fresh or succulent vegetables and fruits, or of other preventive ar- ticles of diet, or of medicine ; more especially when the use of the former kinds of food, and the want of the latter, are aided by one or more of the predisposing or concurring causes already considered. That the want or neglect of those vegetable productions which have been found so beneficial, both in preventing and in curing scurvy, has a greater influence in the produc- tion ofthe malady, than even the prolonged use of the several kinds of animal food, however cured or preserved, has been proved on various occasions. But it cannot be denied that dam- aged, tainted, or too-long-cured substances- pork, the viscera and blood of the animals gen- erally used for food—the flesh of animals which have died of disease, &c, are much more likely to occasion scurvy, and its various complica- tions, than fresh and wholesome meats; al- though even these last may be followed by the disease, when too long or exclusively used, and when fresh vegetables and fruits cannot be ob- tained. 47. Although I cannot admit that scurvy is to be ascribed entirely and always to the absence or want of fresh succulent vegetables and fruits, as articles of diet, as contended for by Dr. Budd, yet I will not deny that such a privation is the most common and exciting cause of the malady, especially when no suitable means are employ- ed—none ofthe numerous preventives about to be noticed (c> 54, et seq.) is had recourse to, in order to supply the deficiency, or to counteract the effects resulting from the nature or state of the aliments. In this, as well as in other dis- eases, we cannot with propriety ascribe the sole agency to one cause; generally more than one, frequently several, although of diversified amount of power, are concerned in developing the result, whether that result be simple, defi- nite, or specific, or whether it be complicated more or less, or contingently associated. 48. iii. The chief causes insisted on by writers SCURVY—Causes of. 849 en this disease were often approaches only to the truth, but these approaches were some- times so near as to lead to judicious means of prevention and cure, although certain subordin- ate agencies were often overlooked. Ecthius, one of the earliest writers on scurvy, assigns as causes, " gross, unwholesome food of salt, dried, or semi-putrid flesh and fish, pork, spoiled bread, stinking water," &c. Ronsseus ascribed the frequency of scurvy in Holland to the diet and air, to eating quantities of water-fowl, but chiefly to living on flesh first salted, then smoked and dried, and to the season and weather. Wierus, who probably viewed cases of pso- riasis as modifications of scurvy, and in this agreed with many who both preceded and fol- lowed him, more justly, remarked the not infre- quent connexion of scurvy with ague and ma- lignant forms of fever ; and, with sufficient rea- son, ascribes this distemper "to unwholesome air, and chiefly to such bad or corrupt food as was used in northern countries, and by their shipping, viz., stinking pork, smoked rancid ba- con, mouldy bread, thick, feculent ale, bad wa- ter, melancholy and grief of mind, preceding fevers, the stoppage of usual evacuations," &c DoDON-aaus imputed the scurvy in Brabant, in 1556, to the use of corrupted rye during a sea- son of scarcity. Rostock„ in a treatise publish- ed in 1589, remarks, that impure water and bad air aid unwholesome food in producing scurvy, and states that the disease is endemic in sev- eral northern countries, and that scorbutic moth- ers often there bear scorbutic children, and oft- en miscarry, or bring forth dead foetuses. Brun- ner insists upon the influence of damp, marshy localities, and other sources of malaria, in pro- ducing scurvy, and ascribes more to the nature ofthe bread used by the inhabitants of those lo- calities than previous writers. Horstius like- wise insists upon the influence of malaria, and the use of new ale, without hops or any other bitter, in causing scurvy in various places in the north of Germany. Vander Mye notices, more particularly than any previous writer, the influ- ence ofthe emotions and passions ofthe mind in causing and in preventing scurvy, and addu- ces the effects of occurrences which took place during the siege of Breda in support of his views. In this siege he attributed the disease chiefly to the general use of old, spoiled, or mus- ty rye, and to humidity ; but other causes, both physical and moral, were also in operation. He adds, that " the distemper proved most fatal to the English soldiers, as they very early began to feed on dog's flesh, were in want of their be- loved tobacco, and lay in the most wet or damp barracks. It was much less frequent among the Walloons and Flemings, they being more careful and delicate in their diet, and having much wholesomer quarters. Among the French it was more rarely met with, owing to their be- ing stationed in the driest part ofthe town, and to their more sprightly dispositions." 49 J Hartmann takes notice of the influence of mercury, and of mercurial courses, in predis- posing to scurvy. In 1645, the medical faculty of Copenhagen published a consultation on the causes, prevention, and cure of the distemper for the benefit of the poor of the country; and in this meritorious production, the influence of cold humidity, malaria, and of unwholesome water and beverages, is insisted upon, as aid- III- 54 ing the effects produced by food such as that already mentioned. Martin Lister, and many of preceding and contemporary writers, and sub- sequently COCKBURN, PlTCAIRN, BOERHAAVE, and others down to the appearance of Bachstrom's work, in 1734, agree in ascribing scurvy to the use of unwholesome food and water, or to those causes chiefly which had been mentioned by their predecessors. But the last-named author was the first to demonstrate that, however much the food and water used were concerned in occasioning.scurvy, abstinence from recent veg- etables was the chief cause of the malady, and the use of these the chief prevention and cure. Not- withstanding this very decided opinion, and the very conclusive evidence Bachstrom furnished of its truth, the disease has been imputed by writers, down almost to the present day, rather to the prolonged use of cured provisions, than to the want of fresh vegetables and fruit. But it is unnecessary to pursue this part ofthe sub- ject any farther. 50. Dr. Lind states that scurvy most com- monly occurred on land in persons who subsist- ed chiefly on dried, or smoked, or salted flesh or fish, and the unfermented farines ; or upon bread made of peas, or a composition of peas and oatmeal. Kramer states that, in his time, this distemper appeared most frequently among those who lived altogether on boiled pulses, without any green vegetables or summer fruits. The occurrence ofthe disease among the Rus- sian troops, whose chief food was rye bread and meal, has been already noticed. Scurvy appeared among the inmates of a lunatic asy- lum in India, whose food consisted chiefly of rice and split peas; and Mr. Macolmson men- tions the occurrence of the distemper in the same country among prisoners kept om bread and water. That various kinds of bread, espe- cially when long kept, will occasion scurvy, or at least not prevent it, I believe, when they are not accompanied with succulent vegetables or fruits. But something is also owing to insuffi- ciency, as well as sameness of diet, to living in a state of confinement, to breathing the air of the same place or habitation, and to the du- ration of this state of confinement; for it has always been remarked that, when this latter cause has been concerned in producing the dis- ease, the first cases have been those longest confined. It may also be noticed that the influ- ence of farinaceous food in occasioning scurvy is great in proportion to the length of time the articles have been kept previously, or subse- quent to their usual modes of preparation, and to their healthy, or ripe, or untainted condition when prepared. And it should be recollected that flour, if sound and fresh, is more likely to prove beneficial when baked or otherwise pre- pared, shortly before it is used, than when it has been made into bread or biscuits a long time previously. 51. The prevalence of scurvy during 1847 and 1848, in Ireland, Scotland, and some parts of England, was very generally ascribed to the failure of the potato crop. But in some places in Scotland, Dr. Christison imputed the disease to the privation of milk—an opinion which has been negatived by numerous observations ofthe prevalence of scurvy where the supply of milk was abundant* * [In the Perth general prisop where scurvy was very 850 SCURVY—Nature and Prevention of. 52. VI. The Nature of Scurvy may be in- ferred with tolerable accuracy, especially as re- spects every practical purpose, from what has been adduced. But it is obvious that the nu- merous occurrences of the distemper, both on land and at sea, as described at least by the majority of the writers referred to in the Bibli- ography, were associated with the appearance of one or more of those maladies, of which I have pointed out the relations with scurvy ($ 27, et seq.); and that, with many cases of scurvy, both simple and complicated, others of a dif- ferent nature, as psoriasis, and various chronic eruptions, also appeared. To these circum- stances—to the extended signification thus im- parted to the name, as well as to the complica- tions it actually manifested—are to be ascribed the diversity of description, and the numerous and complicated subdivisions of the malady, contained in works upon it during the 17th and 18th centuries. Opinions as to the nature or proximate cause of scurvy were no less divers- ified, and even numerous. Without attempting to adduce these opinions in full, or to connect them with their authors, it may be briefly re- marked, that they generally agreed with the pathological doctrines ofthe day in which they respectively appeared, and were assigned by their authors, without any satisfactory proofs— were mere suppositions, or, at best, inferences from loosely-observed phenomena. While some writers imputed scurvy to an acid state of the blood, others ascribed it to an alkaline condi- tion of this fluid, and some even, to make more sure of the fact, considered that acidity in cer- tain cases, and alkalinity in others, were its act- ual causes, the predominance of either condi- tion giving rise to the different forms of the malady. These views not proving satisfacto- ry, especially to those who had opinions of their own to propose, the existence of a predomi- nant saline condition of the blood was supposed and accredited by many. But the particular salt was never shown, some considering it to be an acrid salt, others a rancid salt, and so on. Then came a viscid state of the blood to be as- serted, then a vitiated as well as a viscid condi- prevalent, Dr. Christison states that the prisoners were constantly employed; that they were not exposed to damp ; that the ventilation of .the cells was tolerably good ; that the victuals of all kinds were excellent in quality; that there were no salt provisions; that fre9h succulent vegetables, though not abundant, were not wanting; that milk has recently been withdrawn, and treacle substituted in its place. Hence he concludes that the sole cause of the disease was the absence of milk; for he states that the restoration ofthe milk arrested the spread ofthe disease. But meat was also given three times a week, which no doubt contributed to check the disease. That the absence of milk alone will not cause scurvy, is demonstrated in all our penitentiaries, alms-houses, jails, Sic., in which milk is rarely, if ever, used, and yet the disease is almost un- known. The want of potatoes, meat, and milk in the Perth prison, with imperfect ventilation, was amply suP ficient to produce the disease. So we have observed the disease, in former years, to prevail pretty generally among the New York pauper children, confined in crowd- ed apartments at the Long Island Farms, and kept on too innutritious food, scanty in quantity, and miserable in qual- ity, which disappeared on supplying them with meat, and a more generous diet. Any diet whatever, which will de- teriorate the blood, lessening the globuline and its plastic qualities, will produce scurvy ; and where persons sub- jected to such diet breathe an atmosphere deficient in ox- ygen, the blood becomes still more rapidly vitiated, and the disease assumes a more severe and malignant form. The Indians of our western prairies live for weeks on the flesh of the buffalo, without fresh vegetables, and yet we never hear of their being attacked with scurvy.] tion, and even the existence of a putrid ferment in the blood to be inferred. More recent writ- ers considered that a simple dyscrasis of the blood only existed ; others, not content with the simplicity of this view, thought it necessary to impart to it some special property or chemi- cal quality, and contended that the dyscrasy was acid; and some were positive as to the dyscrasy being alkaline. Lastly, we find the distemper referred to the existence of a dys- crasis produced by the evolution of an acid fer- ment in the blood ; the chief reason for the ex- istence of this ferment being that an alkaline ferment could not exist; but the particular acid was not shown. 53. The chemical pathologists ofthe present day have not thrown much more light upon this part of the subject than their predecessors, each of whom considered his opinion as good as the former believed their own to have been. Dr. Christison supposes that scurvy arises from the want of vegetable albumen or animal case- in in the food; and Dr. Garrod believes that the malady is caused by the absence of potash, and that potatoes and other antiscorbutics owe their virtues to the potash they contain. Dr. Aldridge contends for the influence which should be ascribed to a deficiency of phospho- rus, sulphur, lime, and the alkalies, in occasion- ing scurvy. That something may be owing—a part merely—to the causes contended for by Dr. Aldridge, is not improbable. But it is unne- cessary to pursue this subject any farther than very briefly to state that one of the most evi- dent changes from the healthy condition is seat- ed in the blood ; but that this change is proba- bly not the earliest in the procession of morbid phenomena, as it most certainly is not the only or the most advanced. That the change of the blood is manifested by the sensible or physical properties, as well as by the chemical constitu- tion of this fluid, will readily be admitted; and that, in consequence of this change, the several solids ofthe body are more or less affected, will also be conceded ; but I contend that these are not the only alterations ; for the vital qualities of the blood itself are more or less altered, or rather impaired—those vital qualities which the blood derives from the organic nervous system, through the medium chiefly of the vessels in which it circulates. That the organic nervous system is early affected, either primarily, oi through the medium of the blood, or in both modes, is shown, not merely by the functions, but also by the vital cohesion and organization, of the viscera and tissues which this system supplies and vitally actuates. But it is imma- terial whether this system or the blood be the part primarily affected ; for there can be no doubt that morbid states of the chyle, occasion- ed either by the nature and quality of the ali- ments, or by the defect of certain elements con- sequent upon the want of the requisite vege- table productions, or by both causes conjoined, will affect the assimilating functions, both by impairing organic nervous power and by alter- ing the constitution of the blood, the slow and gradual progress of these changes giving rise to all the structural as well as functional altera- tions characterizing the advanced stages ofthe malady. 54. VII. The Prevention of Sourvy___A. The efficacy of limes, lemons, shaddocks, oranges, scurvy—: and pomegranates, in preventing scurvy, was known to several of the earlier writers on the disease, one of whom is quoted by Lind, in proof of the use thus made of these fruits by the Dutch seamen. Rousseus, Albertus, and other writers in the 16th century, make partic- ular mention of lemons and oranges for the pre- vention and cure of scurvy. Although partic- ular and convincing proofs of the efficacy of these were thus early furnished, not only by the Dutch, but also by some of our own early navigators, and subsequently by Admiral Wa- ger, and others, insufficient attention was paid to the use of these fruits until the appearance of Dr. Lino's celebrated work on scurvy, at the middle of the last century. Notwithstanding the evidence so conclusively adduced by this able writer, these means of preventing scurvy were nevertheless more or less neglected, or were left to the caprice or choice of command- ers and others, until the efforts of Blane, Blair, and Trotter, towards the end of that century, succeeded in procuring the adoption of lime- juice for the naval service. The lemon and lime juice now supplied to the navy is preserv- ed by the addition of one part of strong brandy to ten ofthe juice. But when the fruit can be procured, it is generally preferred, and is used, especially when it is actually required, with much pleasure and relish. 55. B. Other fruits, particularly those of an acid nature, and even the sweet fruits before they are ripe, are more or less efficacious in the prevention and cure of scurvy. Dr. Trotter states that, having remarked that scorbutic slaves threw away ripe guavas, while they used the green fruit, he resolved to try the effects of such. He selected nine negroes, equally affect- ed with scurvy. To three of those he gave limes, to three green guavas, and to three ripe guavas. They were served by himself; and, at the end of a week, those who were restricted to the ripe fruit were nearly as before the ex- periment, while the others were Almost well. M. Fodere states that the good effects of un- ripe grapes were very apparent in the scorbutic cases of the French army of the Alps, in 1795 Sir J. Pringle recommended apples as a pre- ventive in 1776; and Dr. Trotter remarks that, " when Lord Bridport's fleet arrived at Spit- head, in September, 1795, almost every man in the fleet was more or less affected with scurvy. Large supplies of vegetables were provided; and lemon-juice being scarce, in consequence of the previous great consumption, fifty baskets of unripe apples were procured for the use of the fleet. The Royal Sovereign, in particular, derived great benefit from them ;" and the cure of the disease was every where most speedy. Tamarinds, and most of the acidulous fruits of warm and hot climates, are more or less anti- scorbutic. When scurvy was prevalent among the troops at Rangoon, during the Burmese war of 1824, the Phyllanthus emblica, or anola, which has a rich, acid taste, was employed as an anti- scorbutic with much benefit. 56 When Bachstrom asserted, in 1734, that scurvy was the result of a more or less pro- tracted privation of fresh vegetables and fruits, he stated at the same time both its prevention and its cure,; and, although certain vegetables and fruits accomplished these purposes more quickly and fully than others, all those which VENTION OF. ggl are edible possess more or less of these bene- ficial properties The writers of the 16th cen- tury have generally noticed the popular use of scurvy-grass, brook-lime, water-cresses, &c., for the prevention and cure of this distemper. AH succulent vegetables and plants comprised in the order Crucifera are more or less effica- cious, especially the radish, horseradish, turnip, carrot, cabbage, &c. ; and even sueh of these as are commonly only used when boiled are most efficacious when taken raw and fresh from the ground. Dr. Lind very justly insists upon this circumstance, and remarks that herbs in form of salads are more efficacious than when boiled; and that their antiscorbutic properties are de- stroyed by drying, as shown by Kramer, and by the results observed from the antiscorbutic herbs sent from Vienna to the army in Hun- gary. Onions, garlic, leeks, and potatoes are all very decidedly antiscorbutic, and as these may be preserved for some time, they are most ben- eficial for the provisioning of ships or armies. The very general use of potatoes in modern times partly accounts for the remarkably less prevalence of scurvy at the present day than formerly. 57. Most of the articles which are antiscor- butic may be preserved by pickling, especially by the pyroligneous acid or vinegar, and retain in a great degree their virtues. The immunity of Dutch vessels from scurvy has been ascribed by Dr. Kerr and others to the use of sour kroute; and the health of the crew of the Centurion, during Captain Cook's voyage, was considered to have been dwing to a liberal supply of this antiscorbutic* The quantity usually allowed of this substance was two pounds' weight to each man per week, besides a pound and a half, or two pounds, with every gallon of peas, for making soup. 58. There is no northern country where scur- vy is generally endemic during winter, spring, and the early part of summer, that does not furnish a supply of antiscorbutics, if duly rec- ognized and preserved for these seasons. In Norway, Greenland, Iceland, and Lapland, they employ scurvy-grass, sorrel, and various other warm and acid herbs. Sir E. Parry, in his first polar expedition, experienced the advantage of sorrel in the cases which occurred among his crews. He states that sorrel was preferred by the Esquimaux to scurvy-grass. He adopted, also, the advice of Bachstrom and Lind, and raised small quantities of mustard and cress in his cabin, in small, shallow boxes, filled with mould, and placed along the stove-pipe ; and as much of these were thus produced, although etiolated from want of light, as to prove bene- ficial to the scorbutic cases. 59. C. There is, perhaps, not any vegetable production more remarkably antiscorbutic than the tribe of firs, especially the spruce-fir and * Dr. Kerb, in his able treatise on scurvy, remarks, that " Sour kroute or croute (sauer-kraul, Germ.) is pre- pared by slicing the soundest and most solid cabbages in the way cucumbers are used in this country. In this state they are put into a barrel in layers, hand high, and over each is strewed a handful of salt and caraway seeds : in this manner it is rammed down, stratum supra stratum, till the barrel is full, when a cover is put over it, and it is pressed down with a heavy weight After standing for some time in this state, it begins to ferment; and it is not until the fermentation has entirely subsided that the head is fitted to it, and the barrel is finally shut up and prepar- ed for use."—Cyclop, of Pract. Med., vol. iii., p. 691. Prevention of. 852 SCURVY—I common fir, and mountain pine. Moellenbroek states, that when the Swedish army, at war with the Muscovites, were attacked with scurvy, Dr. Erbenius prescribed a decoction of fir-tops, by which the most deplorable cases were cured, and the rest of the troops protected from the distemper. Two squadrons of ships fitted out by Russia in 1736, were obliged to winter in Siberia, and their crews became affected with scurvy. After attempts to discover a remedy, the pines which grew plentifully on the adjoin- ing mountains were hit upon ; and by these all the men recovered in a few days.—(Gmelin, Flor. Siber., p. 181.) Dr. Lind remarks, that pines and firs, as well as the shrub called the black spruce, have all analogous medicinal vir- tues, and great efficacy in the prevention and cure of this disease. " A simple decoction of the tops, cones, leaves, or even green bark and wood of these trees, is an excellent antiscor- butic ; but it becomes much more so when fer- mented, as in making spruce-beer, where the molasses contributes, by its diaphoretic quality, to make it a more suitable medicine. By car- rying a few bags of spruce to sea, this whole- some drink may be prepared at any time. But when it cannot be had, the common fir-tops should be first boiled in water, and the decoc- tion afterward fermented with molasses, in the common method of making spruce-beer, to which a small quantity of wormwood and horseradish root (which it is easy to preserve fresh at sea) may be added." 60. Tar-water was formerly strongly recom- mended as an antiscorbutic; but the extrava- gant praises bestowed upon it at the commence- ment ofthe last century greatly injured its just reputation. Dr. Lind still continued to uphold it; and many years ago, I had occasion to have recourse to it as a preventive, when placed in circumstances most likely to occasion this dis- temper, and when no other means could be ob- tained.* There are many reasons to believe that all the terebinthinates axe antiscorbutic ; and that, when the disease is attended by haemor- rhage, there is no substance so efficacious as the spirit of turpentine, when taken in small and repeated doses, in arresting the haemor- rhage, in restoring the tone of the extreme ves- sels, and removing the contractions of the joints. With this impression, I recommended Sir E. Parry to have a supply of this medicine in his last polar expedition ; and he adopted the rec- ommendation. The anuda-tree, to which Car- * The author of this work, in the winter of 1817 and 1818, was a passenger to England in a vessel which was detained by bad weather at sea during thirteen weeks and four days, and which was provisioned and watered for seven or eight weeks only. He fortunately had laid in a small stock of articles for his own use ; but, nevertheless, it was found necessary, after Gome time, to place every one on an abridged allowance of food and water. The meat provisions were altogether long salted, and were chiefly pork; the biscuit was coarse and mouldy. The water ultimately, also, was short in quantity, turbid, bluish, and most offensive. There fortunately was a very mod- erate supply of potatoes. During thirteen weeks no land had been seen, nor any other vessel communicated with. In this predicament—which, however, was not the only or the most dangerous one—the author caused a small quan- tity of tar to be put into the water before it was used for drinking, and a little spirit was added. To these means, aided by a very moderate supply of potatoes, he attributed the preservation of the crew from scurvy and scorbutic dysentery, every person arriving in the Downs in good health, notwithstanding the unwholesome supply of food and water, and the unfavourable season. tier attributed the remarkably quick recovery of his crew, is considered by Lind to have been the leaves and tops of the American spruce ; and it, as well as the other pines and firs, evi- dently owed much of its virtues to the terebin- thinate principles it contained. 61. D. Molasses has been considered by Lind and others as antiscorbutic; and Sir G. Blane states, that the ship in which it was first tried was the only one in the squadron that was free from scurvy, which prevailed so much in the other ships, that, on their return to Portsmouth in August, 1780, 2400 men were sent to the hospital with this disease. Subsequently, mo- lasses was served with rice to the men who were scorbutic, or threatened with scurvy, in Lord Howe's fleet; and the benefit derived from it was so great that it was made for some time a regular article in the victualling of ships. Nevertheless, the malady was not entirely pre- vented ; and in some vessels well supplied with it, scurvy prevailed to a great extent. Dr. Budd believes that the antiscorbutic properties of sug- ar-cane are greater than those of molasses, and that they are much impaired by the process em- ployed in the manufacture of sugar. I consider this opinion to be correct, from what I have ob- served in warm climates. 62. An anonymous work on scurvy, published in 1767, recommended the use of wort, or an infusion of malt, as an antiscorbutic; and this substance was afterward favourably noticed by Dr. Badenoch. Captain Cook employed it in the Centurion, and spoke highly of its efficacy. He took with him a large supply of malt, with which tp make wort; of this from one to three pints were given daily to each man. Sir G. Blane states that the fleet in the West Indies was supplied with the essence of malt; that it proved of service, but that its antiscorbutic prop- erties were inconsiderable. The process of ex- tracting the essence very probably impaired the properties possessed by the infusion. 63. E. Various fermented liquors have been used as antiscorbutics, some of them from times immemorial, in northern countries. In Norway, in-the Feroe and Shetland Isles, the inhabitants have, from the earliest ages, used, as their com- mon beverages or drink, two kinds of ferment- ed liquors ; the one consisting ofthe fermented serum of butter-milk, or of fermented butter- milk, the caseous matter being removed as the fermentation proceeds ; the other being an in- fusion of the bran or husks of oats and barley, that is fermented after the chief part of the fari- naceous deposit from the infusion is removed. This deposit takes place from the infusion after this latter is poured off, or otherwise separated from the bran or husks. The infusion is then allowed to ferment, and the farinaceous deposit is removed, and used as an article of diet. These are very agreeable beverages, especially during the advanced stages of their fermenta- tion, and constitute the common drink of the in- habitants. They are the chief means of avert- ing scurvy in these parts, where fresh vegeta- bles are either scarce, or hot to be obtained, during a great part of the year, and where fruits are almost altogether wanting. / 64. In all the continental countries border- ing on the Baltic, and Northern and German Oceans, spruce-beer is the most generally and most efficaciously used as a preventive of scur- SCURVY—Prevention of. 853 vy; vessels from Denmark, Sweden, Holland, Riga, Dantzic, &c, being generally provided either with it or with the essence of spruce, for their antiscorbutic properties. Spruce-beer is beneficial, not only for the prevention and cure of scurvy, but also in the treatment of most fevers of a low type, and of several cachectic diseases; in all of which I have, since the com- mencement of my practice, frequently prescribed it. As shown above ($ 59), it may be readily prepared from the materials which are easily procured, and as easily carried about. Cider and perry axe among the most decided antiscor- butic beverages in use in this country, and were long ago shown to be very serviceable by Sir J. Pringle and Dr. Lind. Small-beer, in a state of brisk fermentation, is also antiscorbutic, es- pecially when a sufficient quantity of hops, or of a vegetable bitter, has been added. Sir G. Blane and others have made a favourable men- tion of malt liquors, and I have seen them used with advantage, especially porter, when bottled and well preserved. 65. The several kinds of wine axe more or less antiscorbutic; and they are rendered still more so by the addition of vegetable bitters and aromatics, more particularly absinthium, calum- ba, cascarilla, ginger, orange and lemon peel, &c. It has been observed that scurvy was rare in French ships of war in which the wines of their country were served out to the crews. Sir G. Blane, Dr. Lind, and Dr. Bryson, agree in reprobating the use of spirituous liquors. There can be no doubt of the injurious tendency of these when taken in excess, or habitually, or undiluted; but used in small quantity, largely diluted, and added to the more common anti- scorbutic beverages, or to bitter vegetable infu- sions, they are decidedly beneficial, both in the prevention and cure of the distemper. There are various contingencies which occur to voy- agers, requiring a cautious and moderate re- coarse to one or other of these liquors; and, in circumstances threatening the outbreak of scurvy, the addition of a small quantity of either of them to the means of prevention in common use has a very beneficial influence upon the spirits and constitution of those who thus ab- stemiously use them, and promotes the good ef- fects of the more efficacious antiscorbutics, es- pecially during exposures to cold and humidity. 66. Vinegar was early employed as an anti- scorbutic, and our fleets were generally sup- plied with it during the last century. Dr. Lind, Sir G. Blane, Dr. Trotter, and others, have shown that the distemper prevailed in ships which were well supplied with this article. Much, however, depends upon the kind of vin- egar employed. The pyroligneous acetic acid certainly possesses considerable antiscorbutic properties, much apparently depending upon the source and the preparation of this article. Dr. Budd remarks, that he has observed scurvy in ships well supplied with vinegar ; but the dis- ease, in its most aggravated form, has appeared among those crews which had no regular allow- ance of this article. [The expressed juice of the Agave Americana (American aloe, or maguey, as it is termed in Mexico) has lately been used with great suc- cess in the American army in Texas for scor- butus Dr. Perin, U. S. A., reports several cases cured very promptly by the maguey, which go to show it to be greatly superior to most other remedies in this disease. The leaves are cut off close to the root, placed in hot ashes until thoroughly cooked, when they are removed, and the juice expressed from them. The expressed juice is then strained, and given in doses of from ?ij. to jiij., three times a day. It is not disagreeable to take, and sits well on the stom- ach. After the leaves have been cooked, the cortical portion near the root may be removed, and the white internal portion may be eaten. It appears to be a wholesome and nutritious food— (New York Jour. Med., Sept., 1851.) The wild pepper-grass (Lepidium Virginicum) was found very useful in the treatment of scur- vy in Florida during the Seminole war. The wild onion (Allium angulosum), a small bulbous plant growing on the Upper Missouri and the Western prairies, has also proved very benefi- cial in arresting the disease] 67. F. The mineral acids have been found but little influential in the prevention and cure of scurvy. Dr. Lind took twelve patients on board ofthe Salisbury at sea ; their cases were quite similar. They lay in one place, and the diet was the same for all of them. Two of them were ordered a quart of cider daily ; two others took twenty-five drops of elixir of vitriol three times a. day ; two had two spoonfuls of vinegar thrice a day, and their food well acidu- lated with it ; two were put on a course of sea- water, about half a pint having been given ev- ery day ; two had each two oranges and one lemon daily; and two had the size of a nutmeg, three times a day, of an electuary made of gar- lic, mustard-seed, rad. raphan., balsam of Peru, and myrrh; using barley-water, acidulated with tamarinds, for drink. The oranges and lemons were the most speedily beneficial; next to those the cider : those who took the other medicines were, at the end of a fortnight, much in the same state as those who had taken only leni- tive electuary and cream of tartar as an aperi- ent. 68. G. There are numerous medicines besides those already mentioned which are more or less useful in preventing as well as in curing scur- vy. Most of the more succulent and acidulous vegetables, plants, and fruits, especially when fresh, or preserved by pyroligneous vinegar, are beneficial; but many of them lose their anti- scorbutic virtues when dried, and others when boiled. Ofthe medicines which may be used, and which are certainly occasionally service- able, even when other means have failed, I may mention the chlorate of potash, nitrate of potash, camphor, the chlorides, lime-water and the chlo- ride of lime, chlorine, chlorinated water and chlo- rinated soda, sarsaparilla, serpentaria, sassafras, capsicum, taraxacum, guaiacum, mezereon, sene- ga, elm-bark, dulcamara, the several balsams, &c.; but these are severally only of use for certain modifications and complications of the malady. 69. It has been frequently supposed, and the supposition too often acted upon, that fresh meat is of itself sufficient to prevent or to cure scur- vy when it breaks out in ships, and this opin- ion may supersede the opportunity of procuring fresh vegetables and fruits. Dr. Budd states, that, during the year in which he wrote on this disease, "the captain of a vessel trading to the Mauritius furnished his men, while they stayed 854 SCURVY—Treatment or. at the island, with a plentiful supply of fresh beef, procured at considerable expense, but neglected to provide them with vegetables and limes, which abound in the island. The conse- quence was, that scurvy broke out soon after they set sail, and before the ship arrived in this country one half the men before the mast had died of it, and the rest were disabled" (p. 77). 70. H. It is not alone requisite to use the above means of prevention, as they may sev- erally be possessed by individuals or communi- ties, under circumstances which render the ap- pearance of scurvy either probable or certain ; but all the predisposing and exciting causes (y 33, et seq.) ought to be carefully avoided, as far as this can be effected. I believe that no mean cause of the prevalence of scurvy in the navy, as well as in trading ships, was the habit, morning and evening, of washing the decks, thereby keeping in a constant state of humidity and evaporation, and the air either cold and humid, or close and humid, according to concomitant circumstan- ces. This evil is partly abated by adopting dry scrubbing and similar means ; but it still should be kept in recollection, as the adoption of it de- pends upon the knowledge or caprice of the captain, who in this, as well as in other matters connected with naval service, may thus occa- sion an unhealthy state of air, an artificial ma- laria, the humidity favouring the concentration of emanation from the hold and other parts of the ship, and from the individuals confined dur- ing the night in a limited space and in a close air. Harassing duties, fatigue, and whatever lowers the general standard of health, or de- presses the vital powers, ought also to be avoided. 71. I. Much, as will be seen from the above, depends upon the victualling of ships, especially those which proceed upon long voyages. The sailors should have a sufficient supply of cocoa, tea, coffee, fresh lemon-juice, sugar, or molas- ses ; and while spirituous liquors are allowed in very moderate quantity, and only when wet or fatigued, they should either be withheld, or al- lowed in very small quantity only, when these exigencies do not exist. In circumstances tend- ing to depress the mind, endeavours should be used to amuse and to excite it, in such ways as may the least tend to be followed by depres- sion. In these respects, as well as in others, the means adopted by Sir E. Parry deserves both praise and adoption, as far as the latter is possible.* * [Potato or corn starch, which is now extensively manufactured, ought to enter largely into the dietaries of seamen, especially since it is so prepared and put up that there is no danger of deterioration by age or climate. An abundant supply of potatoes, sliced and dried, was taken out in the late United States Exploring Expedition in search of Sir John Franklin, and answered an admirable purpose in preventing scurvy. Dried apples and peaches should also be supplied in liberal quantities to the navy, and more frequent supplies of fresh meat and vegetables should be furnished, by a more frequent resort to ports where they can be procured. More attention is also need- ed, in our mercantile and public vessels, to ventilation, the quality of stores, personal cleanliness, and to the abolition of the spirit-ration, which is a constant source of both moral and physical evil. The forecastle on board our merchantmen is either cold, wet, and uncomfortable, or hot, suffocating, and filthy, with all manner of offensive smells, and no ventilation whatever. Since the recent en- actments by Congress in regard to the regulation of emi- grant vessels and packet ships, many of the abuses which formerly existed have been done away with; still there is great neglect in enforcing the law; and the consequence is, that typhus fever, dysentery, &c., often prove very fatal 72. VIII. Treatment of Scurvy.—What has already been stated with reference to the pre- vention of scurvy applies equally to the treatment of it, especially in its early stages, and less com- plicated or less severe states. But it is occa- sionally observed that, owing either to the con- tinued influence of certain causes which are overlooked, or cannot be removed, or to the presence of some complication, the disease re- sists the usual means of cure, and even those remedies which have generally been efficacious in the most severe cases. Lime-juice, and es- pecially fresh lemons and limes, have been found the most efficacious means of cure in pure scur- vy ; but instances have been recorded very re- cently in which lime-juice has failed. These in- stances of failure have, however, been adduced in too general terms, and without a sufficient and precise record ofthe several circumstances in which the failure occurred, or ofthe particu- lars in which the disease varied in its charac- ter from that usually observed. The distemper has commonly been stated to have been scurvy arising out of the usual causes; and lime-juice has been said to have been given without ben- efit ; but no particulars are adduced as to the existence or non-existence of one or more of those predisposing and concurring causes de- scribed above (Y 33, et seq.), as not merely con- tributing to the production of the malady, but also actually perpetuating, modifying, or aggra- vating it, if they are allowed to continue in op- eration during the treatment. When lemons, limes, shaddocks, and oranges can be procured, they are preferable to other means ; but other- wise the preserved lime-juice or crystallized citric acid should be substituted. In respect of the preserved juice, we have no adequate information as to the time it will retain its anti- scorbutic properties; for it is not unreason- able to infer—indeed it has been proved—that, when this juice has been kept two or three years, as is not infrequently the case, it may have lost much of its virtues, the failure of it under such circumstances being sufficiently evi- dent, without looking for the cause of failure in the nature ofthe disease itself, or in the in- efficacy of the remedy. 73. One of our oldest English writers on scur- vy, John Woodall, in his meritorious work, en- titled the " Surgeon's Mate"—a name too vul- gar to be noticed by doctors of modern manu- facture— observes that " we have many good things that heale the scurvy well on land, but the sea chirurgeon shall do little good at sea with them, neither will they endure. The use of the juyce of lemmons is a precious medicine, and well tried ; being sound and good, let it have the chiefe place, for it well deserves it; the use •whereof is : it is to be taken each morning, two or three spoonfuls, and fast after it two hours ; and if you add one spoonful of aqua vita there- to, to a cold stomach, it is the better. Also, if you take a little thereof at night, it is good to mixe therewith sugar, or to take of the syrup thereof is not amisse." This good advice was given in 1636, and farther insisted upon subse- quently by Martin Lister, Dellon, and many on board these vessels. Were the regulations, however, fully carried out with regard to the number of passen- gers, the quality and quantity of food, ventilation, and cleanliness, these diseases would rarely be observed on board, if, indeed, they ever appeared, except sporadically .J SCURVY—Treatment of. 855 others ; and yet, when Lord Anson proceeded on his circumnavigation, no provision of the kind was made against scurvy ; the prevention and cure of disease, and rewards for those who devote themselves to those laudable undertak- ings, never having been considered of any im- portance by British governments, or, at least, of very minor importance only ; the aggrand- izement of party and family connexions always absorbing and utterly annihilating considera- tions of public justice and patriotism. 74. Since the works of Lind, Trotter, and Blane established the reputation of lemon-juice and acidulous fruits for the cure of scurvy, these, with the use of fresh succulent vegetables, have been generally adopted. Nevertheless, other means have been resorted to, owing either to the failure of the lemon-juice, or to the form of, and circumstances attending, the malady. The other vegetable acids, and the mineral acids, have been found very remarkably inferior to the citric in the treatment of scurvy ; but the amount of benefit which various kinds of salts, and the alkaline carbonates, are capable of af- fording, has not been ascertained, excepting in the single instance of nitre. Mr. Patterson, a naval surgeon, writing in 1794, showed the good effects of a solution of nitrate of potash in vinegar. He advised four ounces of nitre to be dissolved in a quart of vinegar, and gave half an ounce of this solution twice or thrice daily, and bathed the local sores with it as often. He states, that" some patients cannot bear the so- lution without the addition of water, while oth- ers, without the least inconvenience, bear it un- diluted. The discharges by stool, or the pres- ence of gripes or nausea, guide me with respect to increasing or diminishing the dose ; but, at the same time, it is not a slight degree of nau- sea, colic, or diarrhcea that renders an altera- tion in the quantity of the medicine necessary. To a great number of scorbutic patients, eight ounces of this strong solution, containing one ounce of nitre, have, in the course of the day, as long as such a quantity was necessary, been administered to each with the greatest success. Also, large and frequently-repeated doses of this medicine have been given in cases ofscorbutic dysentery, and, instead of increasing, I have al- ways found it remove the disease." 75. Mr. Cameron, another experienced naval surgeon, states, that having on several occa- sions observed the excellent effects of a solu- tion of nitre, as recommended by Mr. Patter- son, in scurvy, he was induced to employ it when the disease broke out among the prison- ers on board of a convict-ship proceeding to Sydney in December, 1829, under his care. As soon as he commenced the use of this solution, many almost hopeless cases began to improve rapidly, and, before one third of the voyage was accomplished, the health of the sick improved so fast under the new treatment, that he did not think it necessary to go into any port; and the general health of the prisoners (216), when they arrived at Sydney, was much better than when they embarked in Ireland. Some of the cases manifested a severe pulmonary complica- tion, but these also recovered. Mr. Cameron's preparation consisted of eight ounces of nitre, dissolved in sixty ounces of vinegar. Some- times equal parts of vinegar and lime-juice were used: a little sugar was generally added, to ren- der it more palatable, and a few drops of oil of peppermint, and a little alcohol. An ounce of this solution was a dose ; and from three to eight doses, according to the stage and severity of the disease, were given at equal intervals, from six in the morning until eight at night. 76. It has been contended by Dr. Stephens that the state of the blood in scurvy indicates the exhibition of the non-purgative salts, and not of acids. His own experience appears not to have furnished him with sufficient evidence in this matter. But I may mention that, in states of disease closely allied to scurvy, I have given, from an early period of my practice, the chlorate of potash, as well as the carbonates of soda and potash, with very marked benefit. In obstinate or complicated cases, or when the above means fail, a combination of these salts —of the nitrate and chlorate ofpotash, and the carbonate of soda or potash—may be tried ; or the chlorinated solutions of lime or of soda. When diarrhoea is present, lime-water with milk, or small and frequent doses of the chloride of lime, ox of creasote, in any demulcent vehicle, may be of use; and when haemorrhages are pres- ent, small or moderate doses of the terebinthi- nates, or of the spirits of turpentine* (y 68, 69), should be exhibited in any suitable form, or on the surface of spruce-beer, when that beverage can be procured. 77. When the disease is complicated with pleu- risy or with congestive pneumonia, the nitre, with lime-juice and camphor, will be found benefi- cial ; and epithems or embrocations applied to the chest or over the seat of pain, consisting of the compound camphor and turpentine lini- ments, will prove of essential service. When the disease is associated with disease of the spleen, as often occurs when it follows inter- mittent ox remittent fevers, the preparations of cinchona or quinine, of serpentaria, guaiacum, &c, have frequently been found of service. In these, as well as in complications with ague, the remedies just mentioned should be exhibit- ed in decided or sufficient doses; or various chalybeate preparations may be substituted, or given as circumstances may suggest. If the functions of the liver be torpid, or if congestions of this organ or of the spleen be indicated, the nitro-hydrochloric acids may be taken in weak solution, as the common drink, and the surface of the trunk, or the lower extremities, sponged or bathed with the tepid or warm solution of these acids. In many circumstances of the dis- ease, the compound decoction of sarsaparilla, ox other preparations of this medicine, will be taken with advantage ; and several of the sub- stances mentioned above (y 68, et seq.) will be beneficially conjoined with others, according as circumstances arise. 78. During the course of scurvy, whether sim- ple or complicated, the bowels axe often more or less disordered. When costiveness occurs, it should be removed by the less irritating but ef- ficient means. The most appropriate and the * Very recently the spirits of turpentine has been rec- ommended for haemorrhages, as a new medicine for this class of diseases. I may mention that, in a memoir, with experiments on the use of this remedy in disease, publish- ed by me in 1821, in the London Medical and Physical Journal, it was strongly advised to be prescribed for all hsemorrhagic affections; and the same advice has been given for these affections, as well as for numerous others, in this work. 856 SCURVY—Bibliography and References. most successful is a solution either of the cit- rate of magnesia or of the phosphate of soda; or a sufficient quantity of magnesia, taken shortly before exhibiting the lemon-juice or the solu- tion of citric acid. In order to keep the bowels sufficiently open, and to procure a return ofthe functions of the skin, magnesia may be taken conjoined with the precipitated sulphur and a little powdered ginger, in repeated doses. If diarrhaa ox dysentery supervene, the means al- ready mentioned, or those advised in another place (see Dysentery, Scorbutic), should be employed. If the evacuations be very offensive as well as frequent, lime-water with milk, or the chloride of lime, or powdered charcoal, or tar-water, or creasote, will be found very ben- eficial ; and to either of these the calamus aro- malicus, or other similar substances, may be added. M. Brachet states that he has cured several cases of scurvy with powdered carbon alone. 79. As the disease approaches to, or assumes the characters of putro-adynamic or maculated fever, as observed sometimes under circum- stances favouring this occurrence, the remedies advised above (y 68) for the complication ofthe distemper with ague ; and various antiseptics, especially those recommended for the treatment of putro-adynamic or typhoid fevers (s^Fevers, y 585, et seq.), should be prescribed with due de- cision, and appropriately to the features of in- dividual cases. In all the states or complica- tions of scurvy, as in low states of fever, ap- proaching in character to those of scurvy, an expectant practice is not only a most dangerous, but a fatal one. The medical journals of the day —the middle ofthe 19th century —teem with the histories of cases of low fever, in which the practice was either expectant or in- appropriate, as far as the treatment is recorded ; the post-mortem changes revealing the results, which, by the experienced and observing phy- sician, may have generally been anticipated. 80. The diet and regimen during the course of the malady constitute the chief part of the treatment, and, as such, have been sufficiently noticed, in respect both of the prevention and cure of the malady. A warm, dry, and pure air (avoiding exposure to cold and wet), and mod- erate mental excitement, amusement, &c, will contribute very remarkably to the removal, as well as to prevention of scurvy. [The facts stated by our arfthor with regard to the causes and successful treatment of scur- vy may perhaps be so generalized, by careful induction, as to lead to a knowledge ofthe prin- ciples involved. It is very evident that the ele- ments of healthy secretion and excretion must be found in sufficient quantity in the food or that the fluids will deteriorate, and the health suffer. Every part of the body, the bones, the nervous matter, the muscles, the cellular tis- sue &c, each must have those elements sup- plied m the food, which belong to its normal constitution, as lime, phosphorus, sulphur pot- ash, &c, or disease will be the consequence. In all cases where scurvy has existed, some of these elements have probably been wanting There must be sufficient protein, oxygen nitro- gen, hydrogen, and carbon for the soft tissues, as well as phosphate of lime for the bones, phos- phorus for the brain and nerves, sodium and sulphur for the bile, and iron for the blood in order for the due performance of the animal functions. By a process of oxygenation, the various solids and fluids are being constantly thrown off in various forms, as urea, lithic acid, lactic acid, bile, sweat, &c, and they must as constantly be supplied, though the relative quan- tity may vary with the age and the circumstan- ces in which an individual is placed ; more lime and iron, for example, being required in the early periods of life. But the food must supply elements equal to the waste. Now ani- mal food, as well as vegetable seeds, furnish nitrogen in that form which is most easily as- similated ; while succulent roots supply the in- organic elements, the alkalies,lime, sulphur, and phosphorus-; while the carbonaceous element of the farinaceous substances serves for com- bustion, and the production of animal heat. Now, under favourable circumstances, it is pos- sible that some of these elements may be want- ing in the food, and still the health not appear to suffer; but where other causes co-operate with this, scurvy or some analogous affeetion is very sure to occur. The constituent want- ing may be organic or inorganic. Dr. Garrod has attempted to show that in all scorbutic di- ets potash exists in much smaller quantities than in those which are capable of maintaining health ; that all antiscorbutics contain a large amount of potash ; that in scurvy the blood as well as urine is deficient in potash ; and, lastly, that the disease is effectually cured by the same agent, without making any change in the diet. It is certain that in salt beef and pork, owing to the action ofthe soda, there is a gradual ex- osmosis of the potash, and loss of this element; while in milk, fish, potatoes, and in most vege- table juices and fruits, it is very abundant. It also abounds in wine, cider, spruce-beer, wort, the pine, juniper, and spruce, the vegetable acids, and, in fact, in all antiscorbutic articles of food. The nitrate of potash, as well as the bitartrate and the oxalate, have also proved valuable rem- edies in the disease. The rapidity of the cure will generally be proportioned to the nutritious quality of the food, together with the variety; but in all cases, fresh vegetables, which abound with the salts of potash, are the most beneficial] Bibliog and Refer. — Hippocrates, De intern. Affec- hombus edit. Foesii, p. 557.—Celsus, lib. ii., cap. 7.—Pliny, Histor. Natural, lib. xxv„ cap. 3.- Olaus Magnus, Hist! SeptNat.lib. ix, cap. 38. —J. Carlier's Second Voyage, &c, in Hakluu's Collection of Voyages, vol. iii p 225 — Collection of Voyages and Travels, compiled from'the Li- brary of Lord Oxford, vol. iii., p. 808. - J. Ecthius, De Scorbuto vel Scorbutica Passione Epitome. 1541 —B. Rousstus De: magnis Hippocratis Lienibus, Pliniique Stom- acace ac Sceletyrbe, seu vulgd dicto Scorbuto Commenta- rius, &c„ 12mo Antw., 1564.-JT. Wierus, MedicarumOb- servauonum lib. i, De Scorbuto, &c„ 4to. 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