UNITED STATES OF AMERICA ME® * • . V FOUNDED 1836 WASHINGTON, D. C. GPO 16—67244-1 ^:~ * iV o + 7923 M #, ■'?■ m//We v/, -^ *# y ^ ±3 r "-iy A TREATISE ON THE PRACTICE OF MEDICINE. IN TWO VOLUMES. BY JOHN EBERLE, M. D. PROFESSOR OP MATERIA MEDICA AND OBSTETRICKS IN JEFFERSON MEDICAL COLLECE ; MEMBER OF THB AMERICAN PHILOSOPHICAL SOCIETY, &C. &C. VOL. I. PitUOfelirfua: JOHN GRIGG, No. 9 NORTH FOURTH STREET. William Brown, Printer. 1830. WE Eih-t IS3o V. I Eastern District of Pennsylvania, to wit: !-^—> j Be it remembered, that on the fourth day of June, in the fifty-fourth T n t year of the Independence of the United States of America, A. D. 1830, ^ b' I John Eberle, M. D. of the said district, has deposited in this office the .—vw ' title of a Book, the right whereof he claims as Author, in the words following, to wit:— " A Treatise on the Practice of Medicine. In Two Volumes. By John Eberle, Professor of Materia Medica and Obstetricks in Jefferson Medical College ; Member of the American Philosophical Society, &c. &c " In conformity to the Act of the Congress of the United States, entitled, " An act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of" such copies, during the times therein mentioned:" and also to an act entitled, " An act supplementary to an act, enti- tled, ' An act for the encouragement of learning, by securing the copies of maps, charts and books, to the authors and proprietors of such copies, during the times therein mentioned;' and extending the benefits thereof to the arts of designing, engravino-, and etching historical and other prints." D. CALDWELL, Clerk of llie Eastern District of Pennsylvania-. TO GEORGE M'CLELLAN, M. D. PROFESSOR OF SURGERY IN JEFFERSON MEDICAL COLLEGE, &C. &C, THIS WORK IS INSCRIBED, AS AN ACKNOWLEDGMENT OF THE HIGH ESTEEM ENTERTAINED FOR HIS TALENTS AND VIRTUES, By his obliged friend, THE AUTHOR. 1 PREFACE. In the composition of this work, an effort has been made to exhibit a distinct view of the essential phenomena and principles pertaining to the various subjects which it em- braces, with an especial endeavour to avoid the extremes of unsatisfactory brevity on the one hand, and of fatiguing prolixity of detail and discussion on the other. With the exception, therefore, of a few instances in the introduc- tory portion of the work, the author has indulged but very little in controversial discussion and general specu- lative disquisition. His object has been, to give a full digest of facts and established principles, rather than of opinions and points of disputation. He has not, however, failed to give an exposition of those pathological and the- rapeutic principles which appeared to him fairly dedu- cible from the particular phenomena brought under con- sideration ; and wherever his own experience and reflec- tions have led him to differ from others, he has freely, though he trusts with becoming deference, stated his sen- timents. It will be perceived, that no general doctrine or system of pathology is exclusively or especially favoured in the following pages. Medicine, as it is now generally culti- vated, is strictly eclectic. The judicious and unprejudiced physician will neither condemn, nor adopt unreservedly any of the leading doctrines advanced in modern times. He will see something to admire and embrace in the sys- tems of Brown, of Cullen, of Darwin, of Broussais—and b vi PREFACE. even of the fanciful Hannemann; although when offered to his acceptance as doctrines of universal application, he may very reasonably refuse his assent. It will be seen also, and perhaps by some regarded as a defect, that no formal classification has been adopted in the arrangement of the work. Nevertheless, the order that has been observed in the succession of the various subjects, is probably as natural as that obtained by any of the modes of systematic arrangement usually pursued in works of this kind. It is now generally, and very justly believed, that the artificial, classific, ordinal, and specific distinctions of nosology have an unfavourable influence on the progress of comprehensive and philosophical views in pathology. The primary elements of disease, like those of matter, are probably but few in number. A few ele- mentary modes of morbid action (if the expression may be used) modified in their general results or phenomena, by different grades of intensity, modes of combination, and the structures implicated, constitute the fundamental morbid conditions, of which the phenomena by which dis- eases are described, are merely the external manifesta- tions. It is here that the unfavourable tendency of noso- logical distinctions mainly exists. Instead of leading the student to contemplate the morbid symptoms as the mere external expressions or signs of disease, modified by various accidental circumstances, and especially by the structures chiefly affected, the artificial divisions of nosology are apt to lead him to regard the groups of symptoms, usually as- sociated, as so many distinct essences, possessing fixed and specific peculiarities of character. To these objections, the arrangements founded on the particular structure primarily implicated in the disease, are not liable. It must be admitted, however, that correct and philosophical as such a classification may appear to be in theory, the attempt to reduce it to practice is attended PREFACE. vu with many very serious difficulties. Nevertheless, should another edition of this treatise be called for, it is the in- tention of the author to arrange its materials upon this plan of classification. It is not improbable that various errors may have escap- ed the author's attention in the course of the work; but he has no apologies to offer for any defects it may be found to possess; and he sends it into the world, in the hope, that with whatever blemishes and deficiencies it may be chargeable, it will be found a useful compilation of facts and principles' in pathology and practice. INDEX. PAGE PAGE Amaurosis, ii. 44 Bronchitis, chronic, i. 287 Symptoms, ii. 46 Diagnosis, i. 290 Diagnosis, ii. 47 Post-mortem appearances, i. ib. Prognosis, ii. 48 Causes, i. 291 Causes, ii. ib. Treatment, i. ib. Treatment, ii. 49 Bronchocele, ii. 467 Amenorrhea, ii. 518 Post-mortem phenomena, ii. 468 Symptoms, ii. ib. Diagnosis, ii. 469 Causes, ii. ib. Etiology, ii. 470 Treatment, ii. 519 Treatment, ii. 475 Angina pectoris, ii. 222 Bubo, ii. 514 Pathology, ii. 223 Causes of fever, i. 22 Treatment, ii. 226 Predisposition and its causes, i. ib. Aorta, aneurism of, ii. 240 Atmospheric heat, t. 24 Apoplexy, ii. 5 Cold, i. 25 " perfect or strong, ii. 6 Of the sources of morbific Apoplexia hydrocephalica, ii. 7 causes, and their general Paralysis, ii. 8 character, i. ib. Diagnosis, ii. ib. Atmospheric temperature Prognosis, ii. 9 and its relations with the Causes, predisposing, ii. 11 animal system, i. 27 Exciting causes, ii. 13 Cold, effects of, i. 28 Pathology, ii. 15 " " on the cutaneous Treatment, ii. 20 exhalents, i. ib. Arachnitis, i. 167 " " heart and arte- Symptoms, i. 169 ries, i. ib. Diagnosis, i. 173 " " sensibility, i. 29 Post-mortem appearances, i. 174 " " digestive organs, i . ib. Causes, i. ib. " " respiratory appa- Treatment, i. 176 ratus, i. ib. Asthma, ii. 183 " " nutrition, i. ib. Causes, ii. 184 " " pulmonary exhala Pathology, ii. 187 tion, i. "ib. Prognosis, ii. 190 « " venereal propen Treatment, ii. 191 sity, i. 50 Asphyxia, ii. 210 " " sexual organs, i. 30 " from drowning, ii. ib. Cold a morbific agent, i. 31 Treatment, ii. 214 Vicissitudes of temperature, i . 32 " from inhalation of irre- Heat, its pathological effects, spirable gases, ii. 218 &c, i. 33 Treatment, ii. 219 Catarrhal ophthalmia, i. 334 *' from electricity, ii. 220 Catalepsy, ii. 78 Treatment, ii. 221 Diagnosis, ii. 81 " from cold, ii. ib. Causes, ii. 82 Bladder, inflammation of, acute, i. 256 Prognosis, ii. 83 " " chronic, i. 263 Treatment, ii. 85 Brain, inflammation of, i. 187 Cerebritis, or softening of the Bronchitis, acute, i. 282 brain, i. 181 Diagnosis, i. 284 Symptoms, i. ib: Post-mortem appearances, i. ib. Treatment, i. 184 Prognosis, i. ib. Chancre, ii. 496 Treatment, i. 285 C Chicken-pox, i. 408 X INDEX. PAGE Chlorosis, ii. 538 Symptoms, ii. ib. Causes, ii. 640 Treatment, ii. 541 Chorea, ii. 85 Causes, ii. 90 Pathology, ii. 91 Prognosis, ii. 92 Treatment, ii. 93 Cholera, ii. 305 Etiology and pathology, ii. 306 Cholera infantum, ii. 308 Etiology, ii. 309 Treatment of cholera,fii. 311 " " cholera infan- tum, ii. 314 Clap, ii. 484 Contagion, i. 46 Two varieties, i. ib. Rules for preventing the spread, i. 50 Convulsions, puerperal, ii. 114 Colic, ii. 320 Diagnosis, ii. 321 Prognosis, ii. ib. Treatment, ii. ib. Colic, bilious, ii. 323 Causes, ii. 324 Treatment, ii. 326 Colica pictonum, ii. 329 Post-mortem examination, ii. 330 Causes and nature, ii. 331 Treatment, ii. 332 Constipation, ii. 341 Causes, ii. 342 Treatment, ii. ib. Cow-pox, i. 395 Croup, i. 310 Symptoms, i. ib. Causes, i. 311 Prognosis, i. 315 Diagnosis, i. ib. Treatment, i. 316 Cystitis, i. 258 Symptoms, i. ib. Suppuration, i. 259 Causes, i. 260 Treatment, i. ib. Cystitis, chronic, i. 262 Treatment, i. 263 Cynanche trachealis, i. 310 Cynanche laryngea, i. 323 Treatment, i. 325 Cynanche tonsillaris, i. 327 Symptoms, i. ib. Causes, i. 328 Treatment, i. ib. Delirium tremens, ii. 174 Pathology, ii. 176 Prognosis, ii. 177 Treatment, ii. 178 Diarrhoea, ii. Causes, ii. Prognosis, ii. Treatment, ii. Diabetes mellitus, ii. Symptoms, ii. Exciting causes, ii. Pathology, ii. Post-mortem appearances, ii. Prognosis, ii. Treatment, ii. Diabetes insipidus, ii. Causes, ii. Prognosis, ii. Treatment, ii. Diseases of the heart, ii. Symptoms, ii. Causes, ii. Diagnosis, ii. Prognosis, ii. Hypertrophy of the heart, ii. Dilatation of the ventricles, ii Aneurism of the aorta, ii. Diagnosis, ii. Treatment of the organic dis eases of the heart, ii. Sympathetic affections, ii. Treatment, ii. Drowning, suffocation from, ii. Dysentery, i. Symptoms, i. Causes, i. Post-mortem appearances, i. Prognosis, i. Treatment, i. Dysmenorrhea, ii. Symptoms, ii. Pathology, ii. Causes, ii. Treatment, ii. Eczema, i. " simplex, i. " rubrum, i. " impetiginodes, i. " chronic, i. Causes, i. Diagnosis, i. Treatment, i. Enteritis, acute peritoneal, i. Symptoms, L Diagnosis, i; Post-mortem appearances, i, Causes, i. Prognosis, i. Treatment, i. Enteritis, chronic, i. Causes, i. Post-mortem appearances, i, _ Treatment, i. Epistaxis, i. Causes, i. PAGT 295 297 299 300 368 370 371 372 374 375 ib. 382 384 ib. 386 229 ib. 231 234 235 237 . 238 240 ib. 241 245 247 210 204 ib. 206 208 209 ib. 524 525 ib. 527 528 485 ib. ib. 486 ib. 487 ib. ib. 195 ib. 196 197 198 ib. ib. 219 220 ib. 221 507 508 INDEX. xi PAGE Prognosis, i. 508 Treatment, i. 509 Epilepsy, ii. 53 Post-mortem appearances, ii. 57 Causes, ii. 58 Prognosis, ii. 62 Treatment,, ii. 63 Erysipelas, i. 445 " phlegmonodes, i. 446 " " biliosum, i. 447 " oedematodes, i. 448 Cause, i. 452 Treatment, i. 454 Erythema, i. 490 Causes, i. 491 Diagnosis, i. ib. Treatment, i. 492 Exanthemata, i. 378 " minor, i. 459 Fever, general pathology of, i. 1 Idiopathic and symptomatic, i. 3 Broussais' doctrine, i. 4 Etiology of, i. 12 Causes, i. 22 General course, type and stages, i. 51 Forming stage, i. ib. Cold stage, i. 53 Hot stage, i. ib. Crisis, i. ib. Stage of declension.i- 54 Definition of type?,i. ib. Fever, intermitting, i. 59 Character, i. ib. Cold stage, i. 60 Hot stage, i. 61 Sweating stage, i. a. Apyrexia, or intermission, i. ib. Fever,inflammatoryintermittents,i. 63 Congestive " i. ib. Gastric " i. 64 Malignant " i. ib. Prognosis, i. 65 Causes, i. 67 Inflammatory variety, i. 72 Ague, congestive and malig- nant, i. ib. Fever, remitting, i. 84 Character, i. ib. Symptoms, i. ib. Hepatic remittents, i. 87 Causes, i. 89 Treatment, i. 90 Fever, yellow, i. 100 Post-mortem appearances, i. 103 Cause, i. • ib. Treatment, i. 105 Fever, continued, in general, i. 109 '•' synocha, i. 110 " synochus, i. Ill " typhus, i. 112 PAGE Fever, synocha, or simple inflam- matory, i. 114 Character, i. ib. Causes, i. 116 Fever, common continued syno- chus, i. 118 Prognosis, i. 124 Treatment, i. ib. Fever, typhus, i. 134 Symptoms, i. ib. Cause, i. 138 Prognosis, i. 143 Treatment, i. 144 Fever, scarlet, i. 423 Gastralgia, ii. 263 Gastritis, acute, i. 184 Symptoms, i. ib. Diagnosis, i. 186 Causes, i. ib. Prognosis, i. 187 Post-mortem appearances, i. ib. Treatment, i. ib. Gastritis, chronic, i. 189 Causes, i. 191 Diagnosis, i. ib. Post-mortem appearances, i. 193 Treatment, i. 194 Glossitis, i. 330 Treatment, i. 331 Gout, i. 363 '* regular, i. 364 " chronic, i. 366 " retrocedent, i. 367 Diagnosis, i. 369 Causes, i. ib. Proximate cause, i. 371 Treatment, i. 372 Goitre, ii. 467 Gonorrhoea, ii. 484 Symptoms, ii. 485 Secondary symptoms, ii. 487 Excoriations, ii. 486 " in women, ii. 487 Treatment, ii. 488 Heart, diseases of, ii. 229 " hypertrophy of, ii. 237 " sympathetic affections of, ii. 245 Heat, a cause of fever, i. 33 Hepatitis, acute, i. 235 Symptoms, i. ib. Diagnosis, i. 237 Gangrene, i. 240 Causes, i. ib. Treatment, i. 242 Hepatitis, chronic, i. 246 Post-mortem appearances, i. 247 Treatment, i. 248 Herpes, i. 459 " Phlyctenodes, i. 460 Diagnosis, i. 461 Causes, i. ib. xii INDEX. PAGE PAGE Herpes zoster, i. 461 Symptoms and course, ii. 269 272 Causes, i. ' 462 Treatment, ii. Prognosis, i. ib. Intestinal worms, ii. 344 Treatment, i. 463 Causes which favour the pro " Circinatus, i. ib. duction, ii. 345 Treatment, i. 464 Species, ii. 346 " Labialis, i. 465 Triocephalus dispar, ii. ib. " Preputalis, i. ib. Ascaris vermicularis, ii. ib. Treatment, i. 466 Ascaris lumbricoides, ii. 347 Hemiplegia, ii. 28 Taenia lata, ii. ib. Hives, (see Croup) i. 310 Taenia solium, ii. ib. Haemorrhages, i. 500 Symptoms, ii. 348 Causes, i. 504 Treatment, ii. ib. Prognosis, i. 506 Of ascarides, ii. 350 Treatment, i. 507 Of tape-worm, ii. 351 Haematuria, i. 514 Alston's method, ii. ib. Treatment, i. 515 Dessault's " ii. ib. Hsematemesis, i. 510 Herrenschwand's method, ii ib. Causes, i. 512 Hufeland's " ii. 352 Prognosis, i. ib. NoufTer's " ii ib. Treatment, i. ib. Schmucker's " ii. 353 Haemoptysis, i. 517 Bremser's " ii . ib. Predisposition, i. 518 Inflammation in general, i. 155 Causes, i. 519 Increased heat, i. ib. Prognosis, i. ib. Swelling, i. 156 Treatment, i. 520 Terminations, i. 158 Haemorrhoids, or Piles, ii. 355 Suppuration, i. 159 Symptoms & consequence, ii 357 Gangrene, i. ib. Local affections, ii. 358 Inflammation of the brain in ge- Contraction of anus, ii. 359 neral; i. 162 Causes, ii. 360 " arachnoid membrane, i. 167 Treatment, ii. 362 " brain, i. 181 Treatment of haemorrhoidal " acute of the stomach, i. 185 discharge, ii. 363 " chronic, « i. 189 Treatment of hjemorrhoidal " peritoneal coat of the tumours, or blind piles, ii. 365 bowels, i. 195 Hysteria, ii. 99 " acute, of the mucous mem " chronic, ii. ib. brane of the intestinal " convulsive, ii. ib. canal, i. 203 Hysteric stupor, ii. 100 " chronic, i. " " 219 Pathology, ii. 101 " peritoneum, acute, i. 223 Causes, ii. 102 " " chronic, i. 230 Diagnosis, ii. 104 " liver acute, i. 235 Treatment, ii. 105 " " chronic, i. 246 Hydrophobia, ii. 134 " spleen, i. 251 Symptoms, ii. 139 " kidneys, i. 253 Post-mortem appearances, ii. 142 " bladder, acute, i. 258 Treatment, ii. 143 " " chronic, i. 262 Hydiocephalus acutus, i. 167 " cavity of the thorax, i. 265 Icterus, (see Jaundice) ii. 281 " bronchia, acute, i. 282 Idio miasmata, i. 40 " chronic, i. £87 Ileus, ii. 316 " trachea, i. 310 Causes, ii. 3j7 " larynx, i, 323 Symptoms, ii. 338 " tonsils, i. 327 Diagnosis, ii. ib. " tongue, i. 230 Prognosis, ii. ib. " eyes, i. 334 Pathology, ii. ib. '* *' catarrhal, i. ib. Treatment, ii. 339 " ,; rheumatic, i. 336 Indigestion, ii. 265 " " purulent, i. 338 Causes, ii. 266 " " scrofulous, i. 342 INDEX. xiii * PAGB Iritis syphilitic, i. 346 Treatment, i. 347 Ischura renalis, ii. 398 Causes, ii. 400 Prognosis, ii. 401 Treatment, ii. >D- Jaundice, ii. 281 Causes, ii. 284 Prognosis, ii. 289 Treatment, ii. ib. Koino miasmata, i. 35 Larynx, inflammation of, i. 323 Laryngitis, (see Cynanche laryn gea,)i. Lichen, i. " Simplex, i. " Agrius, i. Causes, i. Diagnosis, i. Prognosis,!. Treatment, i. Liver, chronic inflammation of, i. " acute " i. Lithiasis, ii. Uurinary deposites, ii. Pulverulent sediments, ii. Crystallized " ii. Solid concretions,rii. Lithic acid diathesis, ii. Amorphous sediments, ii. Yellow, " ii. Red or lateritious " ii. Pink •' ii. Causes which favour the ex- cessive secretion of lithic acid and its compounds, ii. Exciting causes of crystalliz- ed depositions, ii. Phosphatic diathesis, ii. Treatment of lithic acid dia- thesis, ii. Treatmert of phosphatic dia- thesis, ii. Mania-a-potu, (see Delirium tre- mens,) ii. Measles, i. Symptoms, i. Inflammatory variety, Congestive " Typhus " Gastric, '* Sequelx, i. Diagnosis, i. Prognosis, i. Treatment, i. Menorrhagia, i. Causes, i. Treatment, i. Mental derangement, ii. Causes, ii. ib. 481 ib. 482 ib. ib. 484 ib. 246 335 388 ib. ib. ib. ib. S89 ib. ib. 390 ib. ib. 391 392 394 396 174 411 413 416 ib. ib. 417 ib. 418 ib. [419 523 525 527 149 150 PAGB Prognosis, ii. 157 Post mortem phenomena, ii. 160 Medicinal treatment, ii. 169 Miasmata, i. 33 Infection, i. 34 Definition, i. ib. " Ko'mo, i. 35 '• Generation of, i. ib. Heat and moisture, i. ib. Distance diffused, i. 39 " Idio.i. 40 Sphere of influence, i. 41 " Koino and idio, relations of, i. 42 Miliaria, i. 478 Miliary fever, i. ib. Causes, i. 479 Treatment, i. 480 Morbilli, (see Measles,) i. 411 Mumps, (see Parotitis,) i. 332 Nephritis, i. 253 Diagnosis, i. 255 Treatment, i. 256 Nettle-rash, (see Uticaria,) i. 474 Nervous affections, chronic, ii. 1 General observations, ii. 1 Neuralgia, ii. 247 Symptoms, ii. 248 Cause and pathology, ii. 254 Diagnosis, ii. 256 Treatment, ii. ib. Ophthalmia, i. 333 " catarrhal, i. 334 Treatment,i. ib. '* rheumatic, i. 336 Treatment, i. 337 " purulent, i. 338 " Egyptian, i. ib. Treatment, i. 340 " scrofulous, i. 342 Treatment, i. ' 343 Palsy, ii. 26 Hemiphlegia, ii. 28 Paraphlegia, ii. 30 Paralysis partialis, ii 32 Causes, ii. ib. Treatment, ii. 37 Paralysis of the tongue, ii. 43 " partial of the face, ii. 44 Parotitis, i. 332 Treatment, i. 333 Peritonitis, acute, i. 223 Symptoms, ib. Causes, 224 Post-mortem appearances, i. 225 Treatment, i. 226 «• chronic, i. 230 Causes, i. 232 Post-mortem appearances, i. ib. Treatment, i. 233 Pemphigus, i. 466 xiv INDEX. PAGE Pemphigus, symptoms of acute, i. 468 " pompholix solitarius, i. 469 " chronic, i. 470 Cause, i. 471 Diagnosis, i. 472 Prognosis, i. 473 Treatment, i. ib. Peripneumonia notha, i. 282 Phlegmasia dolens, ii. 544 Symptoms, ii. ib. Pathology, ii. 547 Treatment, ii. 548 Phrenitis, or phrensy, i. 163 Character, i. ib. Causes, i. ib. Prognosis, i. 164 Pathology, i. ib. Treatment, i. 165 Phthisis pulmonalis,or pulmonary consumption, i. 297 Tubercular, or scrofulous phthisis, i. 299 Causes, i. 302 Prognosis, i. ib. Laryngeal and tracheal phthisis, i. ib. Tubercular consumption, i. 303 Treatment, i. 304 Piles, (see Haemorrhoids), ii. 355 Pneumonia, or pleurisy, i. 265 Post-mortem appearances, i. 267 Prognosis, i. 268 Peripneumonia, i. ib. Pneumonia biliosa, i. 269 Post-mortem appearances, i. 270 Engorgement, i. ib. Hepatization, i. 271 Gray hepatization, i. ib. Gangrene, i. ib. Diagnosis, i. 272 Prognosis, i. 274 Treatment, i. 275 Puerperal convulsions, ii. 115 Treatment, ii. 117 Purulent ophthalmia, i. 333 Purpura, i. 494 " simple, i. ib. " liaemorrhagica, i. 495 Treatment, i. 497 Quinsy, (see Cynanche tonsil- laris,) i. 327 Retention of urine, ii. 403 Immediate cause, ii. ib. Paral)sis of the bladder, ii. ib. Retention from inflamma- tion, ii. 405 Spasmodic retention, ii. 406 Retention from mechanical obstruction of the urethra or neck of the bladder, ii. 407 Renal retention, ii. 408 Rheumatic ophthalmia, i. Rheumatism acute, i. " bilious, i. Prognosis, i. Metastasis, i. Diagnosis, i. Treatment, i. Rheumatism chronic, i. Treatment, i. Ring worm, (see Herpes circi- natus,) i. Roseola, i. Diagnosis, i. Prognosis, i. Treatment, i. Rubeola, (see Measles,) i. Scarlatina, i. " simplex, i. " anginosa, i. '• maligna, i. Sequela, i. Diagnosis, i. Prognosis, i. Cause, i. Treatment, i. Malignant scarlatina, i. Local treatment, i. Scorbutus, ii. Symptoms, ii. Duration, ii. Dissections, ii. Causes, ii. Prognosis, ii. Treatment, ii. Scurvy, ii. Scrofulous ophthalmia, i. Shingles, (see Herpes zoster,) i. Small-pox, (see Variola,) i. Small-pox modified, i. Symptoms, i. Softening of the brain, i. Splenitis, i. Suppuration, i. Softening, i. Enlargement, i. Treatment, i. Stomach, acute inflammation of, i. " chronic, «« i# Suffocation from drowning, ii. " from the inhalation of irrespirable gases, ii. " from electricity, ii. " from cold, ii. Syphilitic iritis, i. Syphilis, ii. Its origin, ii. Primary ulcers, ii. Venerola superficialis, ii, Venerola vulgaris, ii. Phagadenic ulcer, ii. Syphilitic chancre, ii. PAGE 336 347 348 349 351 352 ib. 359 ib. 463 492 493 ib. ib. 411 423 ib. 425 426 428 429 430 432 433 438 441 478 479 480 ib. 481 482 ib. 478 342 461 380 402 401 181 252 ib. ib. 254 253 184 189 210 218 220 221 346 494 495 496 506 505 507 508 INDEX. xv Sloughing ulcer, ii. 507 Indurated sloughing ulcer, ii. 502 Constitutional symptoms, ii. 498 Treatment of primary symptoms, ii.504 " of constitutional " ii. 509 Tetanus, ii. 119 Causes, ii. 121 Pathology, ii. 123 Treatment, ii. 126 Temperature, atmosphere, and its relation with the animal sys- tem, ii. 27 Tic Douloureux, (see Neuralgia,)ii.247 Tonsils, inflammation of, i. 327 Tongue, •« i. 323 Tubercular consumption, i. 297 Types of fever, definition of, i. 54 Urticaria, i. 474 " febrilis, i. ib. " evanida, i. 475 " tuberosa, i. 479 " sub cutanea, i. ib. Causes, i. ib. Prognosis, i. 477 PAGE Treatment, i. 477 Variola, i. 379 Course and symptoms of the distinct variety, i. 380 Suppuration, i. 382 Confluent small-pox, i. 383 Post-mortem appearances, i. 386 Cause, i. 387 Prognosis, i. 389 Treatment, i. 390 Vaccina, i. 394 Symptoms and progress, i. 396 Diagnosis, i. 398 Varioloid affections, i. 402 Varicella, i. 408 Symptoms, i. 410 St. Vitus' dance, (see Chorea,) ii. 85 Whooping-cough, ii. 196 Prognosis, ii. 198 Cause, ii. 200 Autopsic phenomena, ii. 201 Proximate cause, ii. 202 Treatment, ii. 204 Zona, (see Herpes zoster,) i. 461 A TREATISE ON THE PRACTICE OF MEDICINE. CHAPTER I. FEVER. The history of practical medicine consists of little else than a review of the doctrines which have successively risen and sunk again, concerning the nature and treatment of fever. Whatever other objects of interest or importance within the dominion of medical science may have attracted the attention of physicians, fever has at all times been viewed as presenting the most extensive and inviting field for observation and the exercise of ingenuity. It is in this department that observa- tion and research have been most industrious in accumulating materials, and that hypothesis has luxuriated in her wildest exuberance. When indeed it is considered that the destroying angel has made his most desolating visitations under the form of febrile epidemics; and that in the long list of human maladies fever occurs in perhaps nine cases out of ten, the paramount import- ance of this subject is strongly forced upon our convictions.* * " If we except," says Van Swieten, " those who perish by a violent death, and such as are extinguished by mere old age, and which are in- deed few, almost all the rest die either of fever, or of diseases accompa- nied with fever. We read in Pliny with what fear and trembling the Romans endeavoured to have this universal disease—-fever, appeased by their supplications in the temple of Fanum. And hence perhaps it is that fevers are called diseases by Hesiod, and that Horace calls all dis- eases simply fevers when they rushed out of the box of Pandora— ' Post ignem tetherea domo Subductum, Macies, et nova febrium Terris incubuit cohors.'" Van Swieten->s Com. vol. v. p. 1. 1 2 GENERAL PATHOLOGY OF FEVER. From a retrospective glance at the history of our science, we are forced to acknowledge that there is perhaps no subject which is more eminently calculated to humble the pride of hu- man reason than this one. For, in relation to this subject especially, pathology has been in a continued state of revolu- tion and instability. The human mind has been engaged with this subject for near three thousand years. Theories have risen and sunk again in a continued and rapid series of succession; each has had its hour " to strut upon the stage," and its vo- taries to yield it faith; but the stream of time has hitherto overturned all these insubstantial, though often highly wrought fabrics. Has the mind then made no real advancement in relation to the pathology of fever ? Are we now no nearer correct and rational views concerning this important subject, than were our forefathers ? Has genius always wandered in idle quest, and brought back no substantial trophies from the regions of pathological speculation on this point ? Far from it. Like the asymptotes of the parabola, the human mind is continually verging towards the point of truth, although it may never reach it in relation to the essential nature of fever. There has probably never been any theory or doctrine promul- gated on this subject which did not clear away some old rubbish, or bring to fuller view some of the relations of the phenomena it presumed to elucidate. The dreams of specula- tion have vanished ; but the facts and correct principles which were necessarily mingled with them, remain as so much valu- able treasure saved out of the wrecks of former systems. The mass of solid materials which has been thus gradually accumu- lated, has now in a great measure displaced those vague and hypothetical foundations upon which former doctrines in rela- tion to this subject were constructed. Hypothesis is no longer tolerated in science. Philosophy does not acknowledge her as a legitimate servant. The cyclus of her empire has gone by; and the genius of rational induction is now the only power un- der whose direction the votary of science presses forward to conquest in the fields of knowledge. Like many other things which are at once obvious to the senses, and concerning the existence of which almost every one can decide, fever does not admit of a strictly correct and un- objectionable definition; since there is not a single symptom which is invariably present, and which can be regarded as ab- solutely essential to its existence. Boerhaave collected together, from a great number of au- thors, all the symptoms which had been observed in fevers. He then struck from this list, all those symptoms which do not appear in all, but only in certain particular modifications of fever—retaining such only as by the common consent of au- GENERAL PATHOLOGY OF FEVER. 3 thors and his own observations, were found to be present in every instance of fever. The result was, that only three symp- toms were left standing—namely, a quick and frequent pulse— preternatural heat of the surface of the body—and a sense of cold or chilliness in the commencement. But he might have gone farther, and struck from his list these symptoms also; for it is quite certain that cases of fever do occur in which there is neither preternatural quickness and frequency of the pulse, nor an increased temperature of the surface of the body; nor is a sense of chilliness, though perhaps the most constant of all the febrile symptoms universally present in the initial stage of fever. Notwithstanding the great difficulty, or rather impossibility of giving a strictly unexceptionable scientific definition of fever, yet the train of phenomena whicli this state of disease presents under all its modifications—varying more or less in their con- comitance and succession—offers, upon the whole, a character sufficiently distinct and definite for easy and certain recogni- tion. Pathologists have divided fevers—according to the mode of their development—into idiopathic and sy?nptomatic, and the propriety or impropriety of this division constitutes, at the present day, one of the most important, and warmly contested subjects in pathology. By the former class, are understood those fevers which are developed and sustained by causes, which produce a general morbid state of the system, indepen- dent of a local inflammation or fixed irritation in some part of the system. Those who admit the existence of such fevers, suppose that the remote febric cause produces a deleterious im- pression on the sentient extremities of the part upon which it acts, which deranging function after function, according to the catenation of the organic sympathies, will finally result in a state of general disease, characterized by the ordinary pheno- mena of fever; or, as they presume, the remote cause may gradually change the healthy character of the circulating blood, which, acting as a morbific irritant on the heart and arteries, will give rise to febrile reaction. Many highly eminent pathologists, on the contrary, contend that such fevers can have no existence ; and that all febrile excitement is purely symptomatic, and of course essentially and wholly dependent on a pre-established local irritation or in- flammation. According to these views, the direct influence of the remote causes of fever is limited to the production of the primary local inflammation or irritation, the subsequent py- rexial phenomena being the result solely of this primary local affection; in other words, the secondary and sympathetic ex- citement of the pre-established focus of irritation. At the head of those who advocate the exclusive symptomatic nature of fever is 4 GENERAL PATHOLOGY OF FEVER. Broussais, who, whatever may be thought of his peculiar doc- trines in relation to this subject, has manifested a professional zeal, an activity and acuteness of intellect, which have justly placed him high among the "greater lights" of our profession. Not satisfied however with the adoption and defence of the general doctrine of the universality of symptomatic fever, Broussais contends that the inflammation or irritation whence the febrile sympathies radiate as from a focus, is almost uni- versally located in the mucous membrane of the alimentary canal; and hence gastro-enteritis is with him the fons et origo of febrile phenomena. That fever is a very common result of local inflammation, is unquestionable. So intimately are all the various parts of the animal body connected with each other by the ties of sym- pathy, that no structure or organ can be strongly irritated without causing a sympathetic irritation in other organs or structures. If the primary irritation involve the sanguiferous capillaries, the irritation will be communicated by sympathy to the general vascular system, and fever will be the result; but if the local irritation be purely nervous, it is diffused, and as it were locked up in the general nervous system, and the result will be convulsions, or some other form of general nerv- ous affection. Without doubt too, inflammation of the mucous membrane of the alimentary canal is much more common in febrile diseases than was formerly, and by many is still sup- posed. It is even probable that in many instances of fever, such an inflammation exists as the primary and essential cause of the febrile phenomena. This may be especially the case in those instances of fever which result from the combined agencies of impure and indigestible diet and atmospheric vicissitudes. But although we may admit the correctness of these observa- tions, yet to refer all fevers, remitting, intermitting, and con- tinued, to a gastro-enteritis, as is done by Broussais and his followers, is as remote from truth as it is detrimental in its influence on practice. The advocates of the physiological doctrine, as it is called, endeavour to support their sentiments in relation to this sub- ject, both by the phenomena which are detected on post-mortem examination, and by arguments founded on physiological prin- ciples. It is affirmed that marks of inflammation occur, almost universally, in the mucous membrane of the alimentary canal in subjects that die of febrile affections. The capillary vessels to a greater or less extent, of this membrane, it is said are found injected; and in many instances other and less equivocal traces of previous inflammation are found on dissection. Ad- mitting that such manifestations of inflammation are as uni- versal as they arc asserted to be, is there not reason to con- clude, that very frequently at least, the inflammation thus GENERAL PATHOLOGY OF FEVER. 5 detected, supervened during the course of the disease, as a consequence of the fever, rather than that the inflammation was pre-established, and became the immediate exciting cause of the febrile phenomena ? We frequently see inflammations supervene in parts exposed to observation many days after general fever has been fully established. Indeed, when it is considered that in all febrile affections, the secretions which are poured into the intestinal tube are unnatural and vitiated— that the process of digestion is suspended, atid consequently that fermentation and decomposition of the contents of the stomach and bowels are especially favoured—is there any cause to wonder that we should so often meet with traces of inflammation in the digestive organs in those who die of febrile affections ? The Broussaian mode of treating fevers, although especially meant to obviate such inflammations, appears to me, in one respect, well calculated to favour their occurrence. The almost total proscription of purgatives from the list of our re- mediate means for the treatment of fever, so far from lessening the tendency to gastro-enteritis, tends, I conceive, in general, to an opposite result. In a recent work by Bouillaud, there are upwards of sixty cases of fever reported, in not a single in- stanceof which was there a purgative medicine administered by the mouth. In all of these cases however marks of inflamma- tion, and in the majority ulcerations were detected in some portion of the mucous membrane of the bowels. That this should have been observed, will not appear strange, when it is considered that in all these cases, most of which continued from three to four weeks, all the acrid and vitiated contents of the intestines were suffered to remain, undisturbed, to act on their delicate lining membrane. Nothing but the blind zeal which usually characterizes the disciples of a new doctrine could, one should suppose, induce any one to withhold a laxative under the apprehension of its causing injurious irritation, and yet suffer, without any such fears, the most irritating substances to lie quietly in the bowels. It is true, laxative lavements were repeatedly resorted to in these cases, but that these did not disturb or remove the acrid materials which were enclosed in the bowels, is abundantly manifest from what Mr. Bouillaud himself has stated. After having gravely told us that in all the cases he describes, the traces of mucous inflammation in the bowels were tres prononce, he states that, "in general the stomach and small intestines were filed with a yellowish or greenish bile, and that the resi- due of the alimentary substances which were found in the small and large intestines, invariably exhaled an intolerably fetid smelly and frequently exhibited the consistence of mustard* This residue, mixed with various fluids secreted in the intes- tines, appeared to have undergone a complete process of putre- 6 GENERAL PATHOLOGY OF FEVER. factive decomposition, as was evident from the extreme offen* siveness of the smell, and the fetid gas which distended the bowels.'-* Can it be reasonably supposed that the transient and mode- rate irritation of a purgative in these cases would have been more injurious than the constant impressions of the acrid and irritating substances which were so long left in immediate con- tact with the bowels ? It is thus, it can hardly be doubted, that many instances of gastro-enteritis, so abundant in the practice and dissections of the Brotissaian school, are developed. Were laxatives employed with due moderation, it is pro- bable, that the so much dreaded gastro-enterile would in some instances at least, perhaps in many, be prevented, and the world deprived of a large proportion of those triumphant demonstrations which are continually brought out in formidable array against the unbelievers of the physiological doctrine. As a further offset to the evidence adduced from post mortem examination, it must be observed, that so far as the mere red- ness or injected state of the mucous membrane is concerned, we can draw no certain inference as to the previous existence of inflammation in this structure. That these phenomena are frequently the result of changes effected in articulo mortis, or post mortem, is fully demonstrated by the observations of Mr. Yellowly and of Mr. Seeds, f * Traite Clinique et Eperimental des Fievres. Par J. Bouillaud, Paris, 1826. t" It must have happened to every one," says the former of these writers, " accustomed to the examination of dead bodies, to see appear- ances of vascular injection in the villous coat of the stomach. Such appearances have very frequently been referred to inflammation, but they have probably been but little studied. I have several times been present at the examination of bodies, where the vascularity of the villous coat of the stomach was so considerable as even to give rise to suspi- cions that the appearance had been produced by something deleterious. I was therefore induced to embrace frequent opportunities of viewing the state of the inner surface of the stomach, and I so often found in it the appearances alluded to, as to induce me to imagine, that the opinion which is commonly entertained of their being marks of disease, is not well founded. In persons suddenly destroyed, when apparently in per- fect health, he found the mucous membrane of the stomach highly in- jected." Mr. Seeds too found that in animals bled to death, the membra- neous structures frequently exhibit a state of injection which might, at first sight, be readily mistaken for inflammation. It is well known that the arterial tubes possess a power of contract- ing to a considerable extent, by what Bichat calls the contractility of texture, and that this power is not limited to the period of life, but con- tinues some time after death. It is equally ascertained that the capilla- ries are endowed during life with a peculiar degree of sensibility, which causes them to resist the intromission of such fluids as they are not de- stined to convey in the performance of their natural functions. This peculiar sensibility, by virtue of which the serous capillaries refuse, or contract against the intromission of red blood, would seem to depend on GENERAL PATHOLOGY OF FEVER. 7 Broussais and his followers are indeed fully sensible of the observation of Celsus: Neque quicquam esse stultius qaam quale quid vivo homine est, tale existimare esse moriente imo jam mortuo ; for where they fail in detecting a red and inject- ed state of the mucous membrane of the bowels, they account for its absence by ascribing it to & post mortem change; thus availing themselves of this fact when it affords an argument in their favour; whilst they manifest an utter unwillingness to allow any importance to it when it is adduced against their doctrine. It cannot indeed be presumed that the injected state of the mucous membrane of the intestinal tube, so often discovered in those who die from fevers, is always, or even generally, to he ascribed to a mere post mortem change; hut that such changes do sometimes, nay often occur, and that they have been assum- ed as evidences of previous inflammation, there can exist but little doubt. The first obvious effect of the remote febrific causes, consists almost universally in a diminution of the nervous energy, and consequently of the action of the heart and arteries ; as is mani- the regular influx -of the nervous influence. That this is the case ap- pears highly probable, if not certain, from the different results arising from the forcible injection of fluids into the arteries in living and dead animals. " Push into the aorta of a living animal, by means of a sy- ringe, different fine fluids, and you will never see them fill the capillary system, or issue by the exhalentsj" when however the same experiment is performed on an animal soon after death, the fluid will be found to pass readily into the serous capillaries, and pass out by the exhalents, excretory ducts, &c. (Bichat.) Mr. Buniva's experiments, quoted by Bichat, with injections upon dead and living animals, illustrate this fact in a very striking manner. He fixed the pipe of a syringe into an ar- tery of a living animal, and on endeavouring to force the fluid into the vessel he found very great resistance, the piston passing down very slowly, and only with the application of much force. On causing the animal to be suddenly killed by dividing the spinal marrow just below the occiput, the fluid passed rapidly out of the syringe into the artery, although but little force was applied. While the capillaries retained their full portion of vitality, they resisted the introduction of the fluid; but as soon as they had lost their sensibility in the death of the animal, they yielded like passive tubes to the fluid forced upon them by the vis d tergo. The application of these facts to the post mortem production of a red and injected state of the membraneous structures, especially the more vascu- lar ones, is easily to be understood. So long as the serous capillaries retain their vitality, they resist the entrance into them of red blood. As soon however as their vital properties cease to exist, they lose the power of resisting the intromission of red blood—becoming in fact mere passive and yielding tubes. But as the arteries continue to contract on their contents some hours after the extinction of life, they must neces- sarily force the blood forward into the relaxed and unresisting capillary system, into which it will therefore be driven as into a sponge, and give to the more vascular structures the red and injected state so often found on post mortem examination, where no previous inflammation whatever existed. S GENERAL PATHOLOGY OF FEVER. fested by the weak and contracted pulse, the general langour and lassitude, the diminished temperature and the sense of chil- liness which usher in all febrile affections. These initial phe- nomena of fever are especially conspicuous in intermittents, remittents, and in catarrhal affections. There is nothing in the character of these symptoms which can justify the inference that they arc dependent on inflammation. " Inflammation, ' says Dr. Armstrong, "cannot exist in the cold stage of fevers, all the phenomena of which arc directly opposed to inflamma- tion." The course and phenomena of intermitting fevers pre- sent us indeed with insurmountable objections to the "physiolo- gical doctrine." The periodicity of these fevers is strongly opposed to the idea of their immediate dependence on gastro- enteritis. It is indeed true that some affections of an inflam- matory character have been known to recur in a strictly peri- odical manner; but such cases must be viewed as anomalies, and altogether contrary to the almost universal course and character of phlegmasial diseases. An inflammation which observes aperlVct periodicity in its attacks, must be suigeneris. If intermitting fever depend on inflammation of the mucous membrane of the aliamentary canal, then must this inflamma- tion be periodical, and therefore esssentially distinct from the inflammation which produces remitting fever ; for in this ma- lady it must be continuous. These two forms of fever are however produced by the same remote cause; and we are there- fore ibrced to admit, by the assumption of this doctrine, that the same remote cause is capable of producing two kinds of inflammation essentially distinct from each other. The cha- racter of the remedies too which have been found most effectual in arresting intermitting fever, is directly opposed to the idea that gastro-enteritis constitutes its proximate cause. Who can believe that quinine, arsenic, black pepper, and other remedies of a similar character are peculiarly calculated to cure inflam- mation of the mucous membrane of the alimentary canal? In- deed these very articles appear to be particularly dreaded by the disciples of this doctrine, on account of their tendency to create gastro-enteric irritation, and yet all experience goes to prove that they are decidedly the most prompt and valuable means for the cure of intermitting fever. M. Broussais' theory of the mode in which the remote causes of febrile affections produce gastro-enteritis is gratuitous, and but little calculated to satisfy the understanding. "Every irritation," he says, " which is capable of producing a percep- tion in the brain, passes back by the nerves to be repeated in the mucous membranes." Thus if a person be innoculated with small-pox virus, the irritation of the primary pustule, or of the innoculated point, is conveyed to the brain, whence it is reflected by the nerves upon the mucous membranes of the GENERAL PATHOLOGY OF FEVER. 9 alimentary canal, in which it establishes an inflammation. This intestinal inflammation constitutes the essential cause of eruptive fever, and the eruption itself is only a metatastic dis- order of the cutaneous system. The assumption then, " that every irritation which is capable of producing a perception in the brain, is reflected by this organ to be repeated in the mu- cous membranes of the alimentary canal, forms the main prin- ciple in the Broussaian doctrine of the etiology of fever. That the mucous membranes of the intestinal tube possess a very wide sphere of sympathetic relations, is a fact indeed as unde- niable as it is important in a pathological point of view. But that this structure constitutes a subordinate sensorium commune, to which all morbific impressions are especially conveyed, after having been perceived by the brain, is a position which all the zeal and ingenuity of its advocates have as yet failed, and I apprehend will ever fail to place upon that firm basis which it ought to have for a foundation of our pathological faith. I do not mean to object to the general fact, that all impres- sions capable of ultimately exciting fever are in the first place communicated to the sensorium commune, and thence reflected throughout the system, and sometimes upon some particular organ or structure; but this reflected impression does not, it may be justly maintained, necessarily establish a focus of irri- tation, or always, nor even generally, fall especially upon the intestinal mucous membrane. If the impressions of morbific causes are always transferred to the mucous membrane of the alimentary canal, the impres- sions of all agents, remedial as well as others, must of course be referred to the same structure. This, however, does not accord with the results of observations. When mercury is rubbed on the skin, the salivary glands, the gums, and the mucous membrane of the mouth receive the chief impressions excited by this agent. Will it be contended that a gastro- enteritis must be established before salivation can be produced? If opium be applied to any part of the body, the impressions are concentrated in the nervous centre. When cantharides are applied to the surface, the irritation is conveyed to the neck of the bladder, and not to the mucous membrane of the bowels, and yet fever will be the result. From these and many other similar facts that might be adduced, it is manifest that the supposed law of the animal economy, by which, as is alleged, all febrific impressions are reflected from the brain and repeat' ed in the mucous membranes of the bowels, is gratuitous, or to say the least, highly improbable. The fallacy of those doctrines which confine the primary inflammation to some one structure exclusively, is strikingly illustrated by the circumstance that different writers have fixed on different structures, as the parts primarily affected in fevers. 2 10 GENERAL PATHOLOGY OF FEVER. Thus Clutterbuck maintains, with Broussais, that fever is always a purely symptomatic affection depending on a local inflammation pre-established by the febrific cause. He asserts that this primary inflammation is invariably located in the brain and its membranes, and adduces the phenomena dis- covered on post mortem examination, in testimony of the cor- rectness of his doctrine. Broussais, on the other hand, asserts that the primary inflammation is not in the brain, but in the mucous membrane of the bowels, and appeals with equal con- fidence to the appearances exhibited on dissection for confirma- tion of his doctrine. This discrepancy is in itself sufficient to show the weak foundation on which -these two doctrines rest; for if the evi- dence afforded by autopsic inspection in relation to this subject were not extremely ambiguous, it would one may suppose, be impossible to draw from it conclusions so very discrepant, and yet so nearly equal in point of plausibility. The advocates of the gastro-entcritic pathology of fever, place no inconsiderable reliance for support to their doctrine on, what they are pleased to assert, their superior success in the remediate management of fevers. Leeches, and an almost total abstinence from food, with cooling, acidulated, mucila- ginous drinks, constitute nearly the whole of their remediate applications; and they claim for this mode of treatment, a greater success than that which they allow to others who pur- sue a more active course of treatment in fevers. It does not appear however that the golden age of medical success, so confidently promised by Broussais, on the introduction of his doctrine has as yet arrived ;* nor do the statements which have been published in France, in reference to the comparative mortality under the Broussaian, and the other modes of treat- ment, give any confirmation to the claims of superior success set up for the former. We might however admit the excellence of the Broussaian mode of treating fevers, without yielding our assent to the correctness of the doctrine which alleges that the gastro-enteritis is primary where it does exist. There exists but little doubt in my mind, that in continued and remitting fevers, active purgation is not unfrequently carried to an in- jurious extent; for although we may, and, as I conceive, ought * In 1821, Broussais asserted " that the tables of mortality declare in favour of the new doctrine, and that its influence upon population would be more favourable than that of the introduction of vaccination." Unfortu nately, however, this happy influence of the nouvelle doctrine, remains vet to be realized;* and the advocates of the doctrine may console themselves for the tardiness of this influence, with the certain prospect of not beine very soon deprived of the opportunity of publishing their ordinary quan- tum of post mortem examinations. H * Refutation de la Doctrine dc M. L. Doct. Broussais, Par. L. Castcl. GENERAL PATHOLOGY OF FETER. 11 to reject the opinion that such fevers depend essentially on gastro-enteritis, yet it is beyond all doubt, that a very con- siderable degree of irritation, amounting in many instances to inflammation does often supervene during the progress of the disease as an epiphenomenon, and unconnected with the origi- nation of the fever. In cases where such a condition of the mucous membrane of the intestinal canal occurs during the course of the disease, the soothing treatment recommended by Broussais, would no doubt be much more salutary than tho vigorous purgative plan so commonly pursued in this country and in England. Unquestionably intestinal irritation and inflammation perform an important part in febrile diseases. These conditions often arise as consequences of the general febrile action ; and frequently, no doubt, also in consequence of harsh and and repeated purgation, and the use of other irri- tating remediate agents. But it is equally probable that gas- tro-enteritis is often the result of the remora in the intestinal tube, of acrid and vitiated secretions, and other offensive mate- rials, in consequence of withholding suitable laxatives, in the commencement and during the progress of the malady. Brous- sais has done much good, by awakening the attention of the profession to these pathological conditions; and thus added another proof of the fact, that new doctrines, though funda- mentally erroneous, seldom fail to do some good, by directing the views of physicians to important circumstances which were previously overlooked or too much neglected. In leaving this subject, I deem it right to observe, that how- ever widely we may differ from Broussais in relation to the pathology of fever, all must admit that he has just and high claims to the respect and gratitude of the profession for the light which he has thrown on the nature, symptoms, and treat- ment of mucous intestinal inflammation, as well as on the physiological and morbid sympathies of the animal system. Broussais is unquestionably one of the most enlightened and ingenious pathologists of the present day. His is now the only general doctrine which especially occupies the attention of the profession. Like all the preceding great doctrines in medicine, it is destined, perhaps, to culminate for a while in the firma- ment of our science, and to attract its host of worshippers; but, assuredly, sooner or later it must sink again, and add another to the long list of once highly favoured, but now exploded and neglected doctrines. That the Broussaian system contains much that is valuable, it would be unjust to deny; but to these con- cessions in its favour, there are, unless the majority of compe* tent judges greatly err, offsets of no small moment. In rela- tion to this doctrine, as indeed of every one else, it behoves us 12 ETIOLOGY OF FEVER. to embrace the useful and reject the false; in short, to adopt the good advice of Lucretius, doctrinam acri Judicio perpende; et si tibi vera videtur Dede manus—aut si falsa est, accingere contra. The positions, which appear to me susceptible of firm sup- port, in relation to the general character and etiology of fever, are embraced in the following propositions:— I. Fever consists in an irritated excitement of the sanguife- rous system; and is essentially connected with a deranged state of the vital properties of this system. II. This irritated excitement may be the result of irritating causes acting immediately on the internal surface of the sanguiferous system ; or of irritating impressions, con- veyed sympathetically to this system from a primary focus of irritation. With regard to the first of these positions, namely, that fever consists in an irritated action of the sanguiferous system, it is scarcely necessary to offer any arguments in support of its cor- rectness ; the morbid action of the heart and arteries; the altered state of the secretions ; the immediate products of vascular ac- tion ; the elevated temperature of the body; the morbid changes which are detected on post-mortem examination ; all show, in- contestibly, that the essential location of febrile action is in the vascular system. The vascular excitement which constitutes fever is an irri- tated condition, and not a mere increased action, of the heart and arteries. There exists a wide difference between irritated and merely increased excitement. The former is the result of stimuli acting either directly or indirectly through the medium of the nervous system, upon a part, or system, whose vital powers are in a deranged or morbid state. This result, is not simply a greater degree of the natural or healthy action, but an action or excitement which is essentially morbid or distinct in quality from healthy action. The latter, namely, mere increas- ed excitement is the result of stimuli acting either directly or indirectly on an organ or system whose vital properties are in a healthy or underanged condition. Thus a few ounces of al- cohol will cause a high degree of arterial action in an indivi- dual not accustomed to this stimulus. The same effect will be produced by any sudden and violent bodily exertions, as run- ning, or rapid walking. Here, then, there will be increased ac- tion of the heart and arteries, and an augmented state of the animal temperature, but fever, notwithstanding, will not be present; because the vital properties remain in a natural con- dition, in consequence of which, the organs thus inordinately ETIOLOGY OF FEVER. 13 excited, will return to their regular grade of healthy action, as soon as the exciting cause has expended its force. As, how- ever, all excessive action tends to weaken, and finally to de- range, the vital properties of the over-excited part, so, when these stimuli are very protracted in their influence, they at last derange these properties, and fever is the immediate re- sult. Fever is, therefore, essentially connected with an altered or morbid condition of the organic sensibility and irritability of the heart, arteries, and capillary system ; for, without such a condition, all irritants or stimuli can produce only increased, but no morbid action in the capillary and general sanguiferous system. So long as the vital properties retain their healthy condition, every excitation can only produce a greater degree of normal action—the various secretions can only be augment- ed, but not depraved, or morbidly diminished. So soon, how- ever, as these properties have undergone a change from their natural state, every stimulus, whether natural or morbific, must necessarily excite a morbid action. Hence, it may be concluded, that every cause which produces fever, in whatever way its influence may be conveyed to the heart and arteries, must necessarily derange their vital properties, either directly, or indirectly, before that general irritated vascular action, which constitutes fever, can be established. The second proposition, laid down above, involves the much agitated question: whether fever can possibly exist independent of a fixed local irritation or inflammation ; in other words, can fever arise and continue as an idiopathic affection? If by an idiopathic fever, be meant one which arises from the direct ac- tion of the febrific cause on the heart and arteries, and which is not a mere sympathetic vascular excitement, dependent on some remote local inflammation, or focus of irritation—the possibility of which is denied by the Broussaians ; the affirma- tive appears to me susceptible of the strongest support. It must, indeed, be admitted that fever is always ab initio essentially attended with local irritation, passing sometimes into actual inflammation; yet this admission does not favour the views of Broussais, since it is predicated, in part, on the demonstrable position that this local irritation is often located in the lining membrane of the blood-vessels themselves, and produced by external irritating agents admitted into the circu- lation, or retained recrementitious elements acting directly upon the internal surface of the sanguiferous system.* It ap- pears to me, indeed, that there is no pathological fact which is more susceptible of rational support, than that fever is fre- » M. Bouillaud, whose work I have already mentioned, advocates this view of the etiology of certain varieties of fever. Upon this subject he hat introduced many very interesting and ingenious observations. 14 ETIOLOGY OF FEVER. quently produced by causes acting directly on the sanguiferous system, and establishing an irritation to a greater or less ex- tent, in its internal lining membrane. Without denying the all-pervading influence of that princi- ple of the living system, called sympathy—or still more com- prehensively, without denying that all the phenomena of life, whether of health or disease, are but so many manifestations of the action of the living solids, it is a truth equally undenia- ble, that the blood may and docs frequently serve as the me- dium through which deleterious agents act immediately on the heart and arteries, and thus give rise to febrile phenomena. '•The veinous system," says Bichat, " may be regarded as a ge- neral reservoir, into which are poured all the materials which are to be thrown out of the body, and all those which are to enter it. In this last respect, this system of vessels performs an essential part in the production and support of diseases. The deleterious substances may be introduced into the blood- vessels with the chyle, and produce ravages in the system in circulating with the fluids. There can he no doubt, moreover, that besides the principles which convert the veinous into arte- terial blood, there often passes through the lungs into the cir- culation deleterious miasmata, which produce diseases, as my experiments on aspliyxia have proved. The intestines, the lungs, and the skin, are the three avenues through which the morbific agents may gain admission into the circulation."* That foreign substances are readily taken up by the absor- bents and veins, and conveyed into the circulation in an unas- similated stale, is now no longer a subject of doubt or dispute. It appears to me highly probable, that miasmatic agents act upon the animal system, in part at least, by being admitted through the lungs, into the current of the circulation. Some contend that these aerial morbific causes act primarily on the stomach. It is asserted, that the miasm, becoming entangled in the saliva, and swallowed with this fluid into the stomach, establishes a primary morbid impression in its delicate mucous membrane. It is alleged, in confirmation of this opinion, that the stomach, possessing a very extensive circle of sympathetic relations, and being highly sensitive to impressions, is pecu- liarly calculated to become the primary focus of morbid excite- ment from external morbific causes. It is affirmed, moreover, that the initial symptoms of fever point out the primary influ- ence of the febrific cause on the stomach. The depressed or abolished appetite, the nausea and vomiting, and the peculiar sense of uneasiness in the epigastrium, are considered as afford- ing strong evidence of the correctness of this opinion. It is as- serted, finally, that the lungs are endowed with an inferior de- * Anatom. Gener. vol. I p. 284. ETIOLOGY OF FEVER. 15 gree of sensibility, and that their sympathetic relations are by no means very extensive, and that, therefore, they are but im- perfectly adapted for receiving and propagating morbid im- pressions from external causes. In reply to these arguments, it must be observed that it does not seem probable that a sufficient quantity of miasmata could gain admission into the stomach to produce disease. As to the evidence drawn from the character of the premonitory symp- toms, it cannot afford any available support to this doctrine. A severe wound, or contusion, will give rise to nausea, vomit- ing, and immediate loss of appetite. Such phenomena, only show that the stomach readily sympathizes with impressions made on every part of the body, when of sufficient degree of in- tensity. With regard to the alleged insensibility of the lungs, or its limited sphere of sympathy, we might admit its just- ness without being reduced to the necessity of adopting the opinion that miasmata act primarily on the stomach. It is not presumed that aerial morbific agents act simply on the nervous extremities of the respiratory passages, and thus give rise to a chain of sympathetic morbid actions. It is contended, that agents of this kind pass through the lungs into the current of the circulation, or effect certain morbid alterations of the blood, in consequence of which, the lining membrane of the heart, arteries, and capillary system, is irritated, and the vas- cular system thrown into a state of febrile excitement. That agents of this kind are absorbed into the circulation, and act upon the system through the medium of the blood, may be in- ferred from anumber of familiar facts in relation to the inhala- tion of odoriferous effluvia. The inhalation of the fumes of turpentine, of garlic, and of various other substances, of a similar character, is speedily followed by the manifestation of these odours in the urine. How are we to account for the ex- traordinary effects which arise from the inhalation of nitrous oxyd, and of the vapour of sulphuric ether? It does not seem probable that these effects are produced by the mere impres- sions of these causes on the pulmonary nerves; for when these substances are taken into the stomach, the nerves of which are so highly sensitive, no such consequences ensue. These facts go to show, that substances capable of affecting the animal economy, will, when admitted into the lungs in a gaseous form, promptly and powerfully exert their peculiar influence upon the system. There are no good grounds, therefore, for denying that miasmata and contagious effluvia, may pro- duce their deleterious effects through the same avenue. The bronchial tubes and cells, expose a very extensive surface to the impressions or intromission of such agents, a circumstance, which, it may be presumed, is well calculated to favour their morbific influence on the system. The experiments of Magen- 16 ETIOLOGY OF FEVER. die, in relation to the effects of putrid effluvia, afford, more- over, strong evidence in favour of this opinion. On exposing animals to the inhalation of putrid effluvia, some were found to suffer no apparent injury, whilst others, became rapidly ema- ciated, and died, at different periods, within twenty days. When, however, the putrid substances from which these effluvia emanated were received into the stomach, no inconveniences were experienced by the animals.* To these facts we may add, that small-pox virus, when swallowed into the stomach, will not infect the system, whereas, every one knows, how readily the disease is contracted by inhaling the effluvia which arise from persons labouring under this disease. It is, therefore, evident that aeriform morbific agents act upon the system through the medium of the lungs, and it is ex- tremely probable that they pass into the current of the circula- tion, and act immediately on the internal surface of the heart and blood-vessels, and perhaps primarily on some portion of the capillary system. It cannot, indeed, be justly maintained that this class of agents acts exclusively through the medium of the blood; any part which exposes a sensitive surface to such causes, may enable them to operate injuriously on the system. All that is here contended for is, that morbific agents of every kind, but espe- cially gaseous substances, do often gain admission into the cir- culation, and that becoming thus mixed with the blood, and carried along with it throughout the whole organization, they act directly on the nervous extremities of the lining membrane of the vascular system, and thus excite febrile action in the system without any distant local focus of irritation, and conse- quently, that fevers are not always merely symptomatic of a pre-established local inflammation.f Besides the source of direct vascular irritation already men- tioned, there is another one perhaps still more common and extensive in its influence—namely, retained excrementitious elements, in consequence of accidental glandular torpor or in- activity. " If one organ is impeded in its office of ridding the economy of certain noxious materials, and not vicariously sup- plied by any other, such materials must therefore accumulate in the blood, and become a source of irritation throughout the system; but more especially to the organ whose function it is to eliminate them. Thus, if from certain causes, the elements entering into the composition of bile abound in the system, a * Journal de Physiologie, Janvier, 1823. J Dr. James Johnson, the very able editor of the Medico-Chirurgical Review, observes: " It has always been our opinion that febrific causes made their first impressions on the nervous system; but this, we think, does not disprove that absorption first takes place; still less that absorp- tion is not necessary at all."—M. C. R. ETIOLOGY OF FEVER. 17 Bource of disorder or of irritation is present in the blood. This irritating cause must act upon those parts which are sensible to its impressions, and to which it is incessantly and immediate- ly applied. Derangement of the whole vascular system becomes the consequence of such irritation offered to the nerves, rami- fied upon the heart and blood-vessels, but more especially in the organ destined to combine and to secrete, under new forms, the materials now so abundantly presented to it."* Thus too, if the cutaneous exhalation be arrested in consequence of the sudden influence of cold, a large portion of the recrementitious perspirable matter will be retained in the circulation. If this be not removed out of the system by the vicarious functions of some other organ, the whole mass of the blood will become sur- charged with substances which the welfare of the economy re- quires to be cast off, and which must necessarily impart a mor- bific, or irritating quality to the blood. This circumstance, therefore, with the internal congestions which usually attend torpor of the cutaneous exhalents, becomes a direct source of irritation to the heart and arteries, and consequently of febrile excitement. With all the evidence which we possess, therefore, that the blood frequently becomes charged with substances of an irri- tating or deleterious character, there can surely exist no rea- sonable doubt that fever must sometimes be the result of a direct and primary irritation of the heart and arteries ; for it will, most assuredly, not be denied that agents which are ca- pable of causing morbid impressions on the nerves of the skin, the alimentary canal, or of any other organ, will be equally capable of producing irritation in the heart and arteries, when they are brought in immediate contact with their internal sur- face ; and no one certainly will undertake to maintain, that irritating impressions made upon the whole internal surface of the vascular system, will not be as likely to excite that morbid vascular action which constitutes fever, as when the irritation is conveyed to this system sympathetically from some remote local inflammation. Although reason and observation lead us to the conviction that fever is often excited by & primary irritation of the vas- cular system ; it is equally true that this form of disease is also frequently the consequence of a sympathetic irritation of this system, derived from a local inflammation or irrita- tion, pre-established in some part of the system. It is pro- bable, however, that the primary local cause of symptomatic fever consists much more frequently in mere irritation, or functional disorder, than in actual inflammation. I presume that those causes which do not produce fever, by making their * London Medical Repository, No. 102, p. 509. S 18 ETIOLOGY OF FEVER. deleterious impressions directly on the heart and arteries, cause in the first place an irritation and consequent functional de- rangement in one or more important organs of the system. In consequence of this, the balance of excitement and of the circu- lation is destroyed; the vital properties deranged; and the heart and arteries drawn into sympathetic morbid excite- ment. But although the organs which sustain the primary irritation, and from which the febrile phenomena are diffused as from a centre, are probably not at first in a state of actual inflammation, yet as they are" already morbidly irritable and irritated, they will readily pass into a state of complete in- flammation, soon after the febrile reaction of the. heart and arteries is established, and an increased momentum thus given to the blood. It is perhaps this, almost inevitable speedy supervention of inflammation in the structures primarily irritated after the fe- brile excitement has been developed, that has given rise to the belief, with some pathologists, that the inflammation is pri- mary ; whereas it is probably in many cases wholly the conse- quence of the increased momentum of the circulation, and the established predisposition to inflammation in the part which receives the primary influence of the remote febrific cause. Fever, perhaps, always commences by a local irritation. Even when it is the result of causes which act immediately on the internal surface of the vascular system, the irritation is probably at first confined to a comparatively small portion of this system—namely the heart, or the capillaries of some par- ticular organ or structure, according to the nature of the re- mote cause. Observation has taught us that almost every agent, whether medicinal or deleterious, has a tendency, in its ulterior operation, to affect particular organs or structures in preference to others. On whatever part of the system the im- pression is made, the excitement produced is chiefly conveyed to some particular organ or structure, according to the pecu- liar character of the primary impression. Thus ergot, whe- ther introduced into the stomach, or injected into the rec- tum, produces an excitement which is especially conveyed to the gravid uterus; and thus too jalap, tartar emetic, and various other similar agents, will manifest their peculiar influence upon the alimentary canal, when introduced into the circulation. That this should be the case, might indeed be inferred from physiological principles, independent of the evi- dence of experience. That each organ or structure in the animal economy possesses a peculiar modification of the vital properties, may be considered as an established fact in physio- logy. In this physiological circumstance, then, we perceive the cause why different agents manifest peculiar tendencies to act on different parts of the system. It cannot be doubted that ETIOLOGY OF-FEVER. 19 when an impression is made on the system, it will be most felt by that structure whose specific or peculiar vital properties are most in relation with it. When an impression is made on the nervous extremities of any part of the body, the excitement which it produces is conveyed to the brain, and reflected thence, throughout the whole nervous system. But as the va- rious parts of the body are endowed with peculiar modifications of sensibility, there will be some that are insensible, whilst others are more or less sensible to the reflected impression, and consequently there will be some parts in which a new ex- citement will be produced by the reflected excitement, and others in which no effect will be manifested. Thus, if tartar emetic be kept in contact with the external region of the sto- mach, the impression which it causes will be conveyed to the brain, which in its turn will reflect the impression throughout the whole nervous system, but as the stomach alone is endow- ed with a mode of feeling capable of receiving this peculiar impression, it will be in this organ that its effects will be con- spicuous. Let us suppose, then, that an agent capable of producing fever makes its primary impression upon the nerves of the sto- mach, or of the skin, or of any other part of the body. This impression will then be conveyed to the sensorium commune, whence it will be reflected throughout the whole nervous system. As the different organs of the body are however endowed, each with its own or peculiar modification of sensibility, there must be some that are insusceptible, whilst others are- peculiarly susceptible of receiving and responding to the reflected mor- bific impression; and these latter, it is reasonable to presume, will be irritated and functionally deranged. From the organs, or organ thus primarily irritated, the morbid excitement passes from organ to organ, or tissue to tissue, according to their various degrees of sympathy with the part primarily affected and with each other, until the whole system is involved in morbid excitement. That in fevers which are the result of a series of sympathetic actions, the primary irritation is almost universally established in the mucous membrane of the alimentary canal as is asserted by Broussais, appears to me as far from the truth, as that all fevers are purely symptomatic. Almost every organ or struc- ture of the body may, I conceive, be the first to suffer irritation, and consequent functional derangement from external morbific impressions. The lungs, or the liver, or the brain, or the skin, &c. may sometimes receive the reflected impressions of such causes, and become the focus whence the febrile actions emanate. Nor does it seem probable, that the irritation thus produced by a reflected excitement from the brain, amounts often to the grade of inflammation. Deranged or irritated 20 ETIOLOGY OF FEVER. action of an organ, thus produced, may be sufficient to esta- blish a train of morbid excitement which must ultimately ter- minate in febrile reaction. Thus a draught of cold water, while the body is in a state of free perspiration, may in its ultimate consequences establish fever. In this case the impressions of the cold water on the nerves of the stomach, pass through the medium of the sensorium commune to the cutaneous capillaries. These are thereby thrown into a state of torpor or functional derangement, and, as it would seem, the sensibility of the sub- cutaneous nerves becomes altered, in consequence of which a sense of chilliness is experienced. These, then, are the first sympathetic phenomena of the remote or exciting cause; and from these morbid conditions other proceed, in regular sequence, until the fever is fully developed. Thus from the sudden torpor of the cutaneous exhalents, and diminished circulation in the external capillary system, three pathological conditions must necessarily arise, which tend especially to evolve febrile ex- citement. In the first place, a large portion of the recremen- titious substances which are destined to be cast off by the skin, will be retained in the blood; secondly, the heart and large internal vessels will become greatly engorged with blood ; and thirdly, the action of the liver will be diminished, in conse- quence of its direct sympathy with the cutaneous exhalents.* A fever thus produced—namely, by a cause acting primarily on the stomach, as in the example just assumed, probably often becomes early connected with more or less inflammation of the mucous membrane of this organ. For, having in the first place sustained the injurious impressions of the cause, and conse- quently at once been brought into a state of morbid excitement and debility, it can hardly fail passing into a state of inflam- mation as soon as the general momentum of the circulation is considerably augmented by the development of the fever. It must be remembered that inflammation consists not only in congestion of the inflamed capillaries, but also in an altered or morbid condition of their vital properties ; and hence when an organ is already in a state of morbid irritation, inflamma- tion will very readily ensue, when, by a general increased mo- mentum of the circulation, the blood is urged into the debili- tated and morbid capillaries. It is on this account that we so often find inflammation to supervene in the stomach and intes- tinal canal in fevers. The mucous membrane of these organs is so readily and so generally deranged in the commencement of fevers, that the increased momentum of the circulation which occurs as soon as fevers are developed, must very frequently • Vide Johnson on the Diseases of Tropical Climates. Of the cor- rectness of his sentiments in relation to the influence of the cutaneo- hepatic sympathy, I entertain no doubt. ETIOLOGY OF FEVER. 21 cause more or less of inflammation in this delicate structure, in almost every variety of fever. These inflammations are nevertheless purely secondary, and can by no means be re- garded as the cause of the febrile phenomena, although their influence in increasing the violence and duration of these phe- nomena cannot be doubted. If the foregoing observations and reasoning be well founded, we may lay down the following corollaries in relation to this subject. I. Fever is essentially located in the sanguiferous system, and consists of an irritated action of this system. II. This irritated action of the sanguiferous system results from the combined influence of a deranged state of its vital properties, and of irritating impressions made upon this system. III. The irritating impressions may be the result of mor- bific agents acting directly upon the internal surface of the heart, arteries, and capillary system, by being admitted into the circulation ; or of an excitement conveyed sympathetically to the vascular system from some pre-established local irrita- tion or inflammation. IV. Those general causes of fever which do not act directly upon the sanguiferous system through the medium of the blood, produce fever by causing some important functional derange- ment or organic irritation, which successively draws other organs within the sphere of morbid irritation, until the heart and arteries are thrown into a state of irritated excitement. Inflammation is rarely the primary consequence of their in- fluence. V. Although the fevers which are the result of a series of sympathetic actions, do not often depend on a primary local inflammation, but rather on some important functional lesion (the immediate result of the remote cause,) yet inflammation is very apt to supervene in the structures or organs thus pri- marily deranged, when the general momentum of the circula- tion is augmented in the development of the fever. VI. The mucous membrane of the alimentary canal is par- ticularly subject to more or less inflammation during the course of a fever, both from the circumstance mentioned in the pre- ceding paragraph, and from the irritation caused by the viti- ated and exciting secretions and products of decomposition, generated in the intestinal tube. 22 CAUSES OF FEVER. CHAPTER II. OF THE CAUSES OF FEVER. The causes of fever are generally divided by pathologists into two varieties, the predisposing and the exciting. The for- mer are all those external and internal causes, which tend to lessen the power of vital resistance to the influence of morbific agents. The latter are those causes which excite actual disease by the deleterious or irritating impressions which they make on the animal system. There exists, however, no absolute diffe- rence in the nature or character of these two varieties of morbific causes. The same agent, or circumstance, may manifest its influence on the animal economy, either as & predisposing or an exciting cause of fever, according to the degree of intensity with which it acts, or the previous condition of the system. Predisposition, and its causes.—Predisposition to disease is either natural, or accidental, or hereditary. As the human system is continually under the influence of causes which have a tendency to interrupt and terminate its actions, life would be but ephemeral in its duration, and ha- rassed by constant disease, if the animal organization were not endowed with the inherent power of resisting, to a degree, the influence of injurious causes. It is by the aid of this vital re- sistance, that man is enabled to live through a long series of years, amidst a multiplicity of causes, which conspire unceas- ingly to his destruction. In relation to the degree in which this power of resisting injurious influences is possessed by dif- ferent individuals, there exists very great diversity; and hence the various degrees of constitutional or natural predispo- sition to fever, which obtains among different individuals. Thus, the prick of a needle will, in one individual, cause great pain and constitutional irritation ; in another, syncope • in a third, convulsions or tetanus ; and in a fifth, scarcely any perceptible consequences at all.* There exists, therefore a na- tural or constitutional predisposition to disease in some indi- viduals, wholly independent of accidental causes, or mere casual debility ; and this constitutional aptitute to disease depends probably on the peculiar organization of the animal system. Under the head of natural, or constitutional predispositions * Surledifferens Degrees de Resistance vitale dans les Maladies &c Par M. L. Martinet, M. D.—Revue Meduale, Octr. 1824. ' CAUSES OF FEVER. 23 must be ranked those specific predispositions which render the system susceptible of certain specific diseases, and which are wholly lost by the actual occurrence of these maladies. Thes^ specific predispositions are especially incomprehensible and mysterious. Neither temperament, nor constitutional vigour, nor debility, nor any circumstance connected with the health of the individual, appears to have any relation with, or influence upon them. With regard to accidental or acquired predisposition, obser- vation has not left us so entirely in the dark. According to the late Dr. Rush, general or local debility, accompanied by an increased excitability, constitutes the state of predisposition to fever. Without doubt, general debility, with increased ex- citability, must render the system more liable to the action of irritating or exciting causes; yet it does not appear that this condition of the system can, with propriety, be considered as constituting the essential state of the organization which pre- disposes to fever. It is well known that the most robust and healthy individuals are generally the first and most certain victims of febrile epidemics. The vigorous and the healthy are often prostrated under the devastating dominion of pestilence, and even under the less ruthless sway of the milder paludal fevers, whilst the feeble and the valitudinarian pass along un- touched. It may, moreover, be observed, that in the feebleness of convalescence from bilious, typhus, and other forms of fever, fresh attacks, or relapses, are by no means so common as one would expect, if mere debility constituted febrile predis- position. When we wish to obviate fever, after a surgical ope- ration, we reduce the system by low diet, purgation, and per- haps blood-letting.* In a general way, every cause capable of deranging the health of the animal economy, may, when acting with moderate force, produce such a change in one or more organs as will pre- dispose the system to fever, and which requires only some fur- ther exciting cause to evolve actual febrile disease. Predispo- sition, produced by the influence of accidental causes, consists probably always in more or less functional derangement of one or at most a few structures or organs. I have already stated some reasons which render it highly probable that the impres- sions of every morbific cause, on whatever part of the system primarily made, is in the first place reflected upon some parti- cular organ, according to the nature of the impression, and the organic sensibility of the various parts of the system. If this be correct, it is manifest that if the morbific impression, thus reflected upon an organ or structure, be too weak to establish a sufficient degree of irritation to excite general derangement, * Richter's Specielle Therapie. vol. I. p. 36. 24 CAUSES OF FEVER. or febrile reaction, the result will be only a slight degree of in- sulated functional derangement, or irritation, which, though not manifested by any feelings or appearances of ill-health, is still an incipient link of disease, and wants only some addition- al morbific influences to enable it to put in motion the latent train of morbid sympathies. How greatly mere functional de- rangement of an important organ aids the causes of fever in developing disease, is often conspicuously illustrated by the influence of digestive derangement in the production of fever. Let but this citadel of the animal system languish, and the ene- mies of human health will speedily attack the outposts, and make an easy conquest of the whole. Hence, of all the precautions which those who visit insalubrious climates may be required to adopt, the avoidance of every thing which is calculated to derange the digestive functions, is perhaps the most important. By a well-known law of the animal economy, every agent, however deleterious, gradually diminishes, and finally almost destroys the susceptibility of the system to its influence, by long continued or very repeated action. Hence every agent will, cseteris paribus, manifest its operation with a promptitude and intensi- ty proportionate to the degree of previous immunity from its influence. It is this circumstance, which causes the difference of predisposition to endemial fevers between the acclimated na- tives of insalubrious regions, and strangers arriving from northern latitudes. This variety of predisposition depends in no degree on a want of constitutional vigour or general health. The robust and healthy, are, in general, as much if not more under its influence, as the weak and infirm. By a gradual or protracted exposure to morbific agents, the animal economy loses, insensibly, its natural susceptibility to their influence. When such a change is effected by the combined operation of climate and endemial morbific agents, the system is said to be acclimated or seasoned, and the individual, thus seasoned, enjoys a comparative immunity from the diseases of the cli- mate. Besides the foregoing source of predisposition to disease, from causes peculiar to hot climates, there is another and per- haps not less powerful one—namely, atmospheric heat. High atmospheric temperature, is, strictly speaking, rather a pre- disposing than a morbific agent in relation to its influence on the human system.* In this respect it exercises a very power- ful influence in the production of diseases. Long continued ex- posure to an elevated degree of solar heat tends very consider- ably to increase the general irritability of the system, and to lessen the power of vital resistance. Hence, the frequency of tetanus in hot climates from injuries, or from the influence o£ * Dr. James Johnson on Tropical Climates, &c. CAUSES OF FEVER. 25 the cool and damp night air; and hence too the greater liability to this, and other irritative affections, during the hot seasons of our own climate than in the cold months. Atmospheric heat tends, moreover, to predispose to fever, and other affections, by the profuse and continued perspiration it causes, as well as the redundent secretion of bile it is apt to excite. By these over-exciteed actions of two important organs the general sys- tem is exhausted, whilst the organs themselves are rendered more susceptible of the injurious impressions of one of the most common and powerful exciting causes of disease—name- ly, cold. In relation to those predispositions to disease which are transmitted from parent to offspring, it may be sufficient to ob- serve, in this place, that they depend, no doubt, on a peculiar physical condition, or intimate state of the organization, which we may presume is as apt to be imparted by the parent to the offspring, as the contour of the countenance or of the general structure of the body. Of the sou\ces of morbific causes, and their general character. When we take a general surveyof the source of all the pos- sible causes of fever, we find that in relation to their origin, they range themselves under the following four general heads, viz.* I. Recrementitious substances, which in health are separated and thrown out of the system, but being retained in the circulation, or reabsorbed, become a source of irritation to the sanguiferous system, and, therefore, of irritative fever. These morbific causes are always secondary, being themselves the consequences of an anterior injuri- ous cause or impression. Thus, the retention of the perspirable matter can occur only in consequence of the influence of some previous cause, adequate to disturb or arrest the action of the cutaneous exhalents. The recrementitious fluids which appear to be.most injurious to the animal economy when retained in the circulation, even in their elementary forms, are the perspirable mat- ter, the bile, and the urine; and of these the first is perhaps the most frequently concerned in the produc- tion of fever. The influence of causes of this kind in the development of fever, is probably much more exten- sive than is generally admitted in etiological inquiries. In all that extensive class of febrile affections which * Richter's Specielle Therapie. vol. I. 4 26 CAUSES OF FEVER. arise from the influence of cold, retained perspirable matter performs, probably, a principal part in their development. . . . Checked perspiration, or, more correctly speaking, inactivi- ty of the cutaneous exhalents, constitutes the primary link in, perphaps, three-fourths of our febrile diseases. Let it not be imagined, that, as the recrementitious substances which are retained in the circulation are in a simple or elementary state, they cannot possess powers sufficiently irritating or active to excite morbid vascular action. In whatever form these sub- stances may exist in the blood, they are still recrementitious, and it is not to be presumed, that materials of this character, could be long retained without an injurious influence on the animal economy. The accidental torpor of one emunctory, is often vicariously supplied by the increased activity of another, and disease thus prevented. Thus if, after the cutaneous exha- lents have been rendered torpid by the sudden influence of cold, the flow of urine becomes unusually copious, disease will rarely ensue. Indeed, the all-wise and benevolent Creator has provided against the injurious consequences which must have resulted from the constant changes to which the function of the skin is necessarily exposed from the ever-varying Condition of the atmosphere, by placing in the interior an organ, whose functions may, in a great degree, supply any accidental defi- ciency in the action of the former. II. Irritating substances, generated within the body, but wholly independent of any organic actions. These causes of disease, are usually generated in the primse vise, and consist of worms, acids, mucous, and various other irritating substances, resulting from the fermen- tative or putrefactive processes. Worms have been, and by some are still considered as inno- cent inmates of the human body. This, however, is most cer- tainly an erroneous sentiment. Without doubt, a few, or even a considerable number of worms in the alimentary canal, may not be able to disturb the general system when it is in a state of good health and constitutional vigour; but when the body is debilitated and irritable, as it commonly is during the period of dentition, the presence of worms in the intestinal tube will frequently give rise to the most alarming affections. Worms tend, moreover, to sustain and protract fevers produced by other exciting causes; an inattention to which frequently ren- ders the progress of ordinary diseases peculiarly perplexing and unmanageable. It is not uncommon to meet with cases of slight febrile disease in children from cold, which continue in spite of our remediate efforts, and gradually assume the form of a slow remitting fever, with a foul tongue, and gastric dis- CAUSES OF FEVER. 27 turbances, and at last suddenly change for the better, on the expulsion of a few large lumbrici. The agency of causes of this kind in the production of fever, was, however, formerly considered much more extensive than it appears in reality to be. Verminous epidemic fevers are described by some of the older writers, and saburral fevers were supposed, as it would appear, very common. Without ascribing so great an importance to these causes us originators of fever, it is nevertheless, unquestionable, that they do, at times, give rise to febrile affections,, independent of all other febrile irritants. Their morbific tendency is, however, much more frequently manifested by the support, or additional violence, which they give to fevers originating from other causes, than by their power of producing them by their own immediate influence. III. Morbific agents, generated out of the animal body, con- sisting either of deleterious substances floating in the air, or of the sensible properties of the atmosphere, or, finally, mechanical causes—namely, miasmata, noxious gases, heat, cold, electricity, humidity, and mechanical injuries. IV. The fourth and last class of morbific agents, compre- hends those causes which are generated by a morbid organic action of the living system, constituting the various contagions. The principal causes which are embraced under the two last heads are so extensive in their influence on the human system, and so interesting and important, both in a medical and sci- entific point of view, that a separate and full exposition of their respective modes of origin, and physical as well as morbific characters, will not, it is presumed, be deemed inappropriate in a work of this kind. § Atmospheric temperature, and its relations with the animal system. A certain quantity of heat is indispensable to life, throughout the whole range of organized beings. Every animated being possesses an inherent power to gene- rate heat, and to resist to a certain extent the physical law of the distribution of heat; and consequently to maintain its pe- culiar or specific temperature, when placed in a medium either many degrees below or above its own temperature. The con- stant and rapid reproduction of heat by the vital powers, keeps up the natural temperature of the animal body although sur- rounded by a medium which abstracts its heat with great ra- pidity. Such indeed is the evolution of heat by the human body, that an atmosphere of the temperature of 98° is generally 28 CAUSES OF FEVER. very oppressive and unpleasant by the feeling of warmth which it causes, although at this temperature of the air, no heat can be communicated by the surrounding atmosphere to the body. The temperature most grateful and invigorating to the human system, ranges from about 60° to 65°. "This temperature of the air appears to abstract the heat of the body in about the same proportion in which it is generated in the healthy state of the system; and this degree of the temperature is therefore the most congenial, for it neither exhausts the vital powers, nor gives rise to unpleasant sensations." There exists, however, considerable diversity in the human constitution, in relation to the power of supporting the ex- tremes of temperature. This depends not only on the original vigour of the constitution, but also greatly on the influence of habit and modes of living. A person endowed with a vigorous constitution, and with habitual good health, will bear a degree of cold without any unpleasant feelings, which to one of a feeble and exhausted system will be a source of painful sensations and indisposition. Habit in relation to previous exposure, has a powerful influence in varying the effects of temperature on the animal system. The same temperature will cause feelings of severe cold or great warmth, according as the body has been previously exposed to a high or low temperature. Whenever the surrounding medium abstracts the heat of the body more rapidly than it is generated by the regular actions of the ani- mal economy, the sensation of cold will be produced, and the intensity of this sensation will always be proportionate to the rapidity with which the heat is abstracted, and the feebleness of the heat-generating power of the system. Physiological effects of cold.—1. Diminution of the action of the cutaneous exhalents, and external capillary system; hence the pale, shrunken, and_dry state of the skin, when the sensation of cold is experienced. 2. Diminished action of the heart and arteries—manifested by the smallness, the weakness, and the diminished frequency of the pulse. Upon this latter point, however, namely, the frequency of the pulse, there exists some discrepancy of opinion among physiologists. From the experiments of Drs. Stock, Spooner, and M'Donne], it would seem that although the strength and size of the pulse is dimi- nished by cold, yet its frequency is considerably increased. Against these experiments may be advanced the results of those performed by Currie, Rush, and Klapp ;* and my own * That Dr. Stock and the other experimenters observed what they record upon this point, cannot be doubted. We can readily admit that when the body is suddenly plunged into cold water, the mode adopted by them, the pulse will at first be accelerated. It must be observed that when the body is suddenly immersed in cold water, the blood is violently driven in upon the heart and larger vessels, and the respiration is per- CAUSES OF FEVER. 29 experience has led me to a different conclusion, having invaria- bly found the pulse diminished both in frequency and in volume, when cold was applied to any particular portion of the body.* 3. Diminished sensibility of the external part, passing by degrees throughout the whole system. Hence the benumbed state of hands, fingers, and other external parts, on protracted exposure to severe cold ; as well as the torpor of the sensorial functions, and the sluggishness and feebleness of muscular action. It is in this way, too, that the almost irresistible incli- nation to sleep occurs, when the cold is very intense. Artificial somnolency has been produced in certain animals by exposing them to a very low degree of temperature.f 4. When mode- rately applied, cold increases the powers of the digestive organs. Hence the aphorism of Hippocrates, Hieme ventres calidiores sunt. The appetite increases, and the process of digestion is performed more rapidly in moderately cold and dry, than in warm weather. We are informed by Xenophon that the Greek soldiers on their return from Asia, were exceedingly harassed by the most severe sensations of hunger, while passing the snow covered mountains of Armenia. When cold becomes very in- tense and protracted, however, the digestive as well as all the other organs of the system become inactive. 5. The sudden application of cold causes a hurried and irregular action of the respiratory apparatus; and when intense, it always checks or impedes " the ordinary efforts to dilate the chest," and these effects increase pari passu with the increased influence of the cold, until the respiration is performed so imperfectly, as to prevent the due decarbonization of the blood, and the whole organization, from the consequent want of nervous influence, sinks into a state of torpor and insensibility. 6. Moderate cold is favourable to nutrition. Si Man and all animals are fatter in winter than in summer; and in the north than in the south." When the cold is applied in an intense grade, and prolonged in its influence, the process of nutrition is disturbed and interrupted. 7. The pulmonary exhalation, and the se- cretion of urine are increased by cold ; and supply, in a de- gree, the checked exhalation by the skin from the same cause. Stringuntur tubuli pellis, coguntur et intus Tot variis pellenda viis excreta, Sfc. formed in a hurried and imperfect manner, in consequence of which the heart is excited into a temporary exertion to overcome the load which oppresses it; and the pulse consequently at first accelerated. * Vide Coxe's Medical Museum for the year 1809. ■f The pulse of the inhabitants of northern climates is habitually slower than its ordinary standard of frequency in the middle latitudes. Amongst the Greenlanders it is by no means uncommon to find the pulse as slow as 40 and 45 in a minute.—Beauprt on the Effects and Properties of Cold, p. 50. 30 CAUSES OF FEVER. 8. Cold, when prolonged in its influence, diminishes the vene- real propensity, (Montesquieu, Esp. des loix B. 14. C. 2,) but it does not appear to repress the function of generation; for although the venereal appetite be less constant and urgent in cold than in warm climates, yet the power of procreation would seem to be even greater in the former than in the latter. " In Sweden it is not uncommon to see women have twenty or thirty children ; and in Russia marriages are followed by a numerous progeny."* 9. Cold retards the development of the sexual organs, and the period of pubescence, more especially in the female sex. Cold is therefore a sedative agent, for although when mode- rately and transiently applied, it is generally followed by phenomena which manifest a stimulating influence; yet these effects are not, strictly speaking, the immediate consequence of the low temperature, but of the reaction of the vital energies after the temporary reduction of their activity by the cold. When an agreeable glow, and an augmentation of general vigour is experienced after leaving a cold bath, it arises pro- bably not from the direct stimulus of the cold, but from its reducing the excitement of the surface, and augmenting its susceptibility to the action of stimuli; in consequence of which, the ordinary influence of the atmosphere, the warmth of the clothing, and even the stimulus of the blood, as well as exer- cise, and other usual exciting influences, will cause a greater degree of excitement, more especially in the cutaneous capil- lary system. That the phenomena of increased activity and vigour which sometimes ensue, are solely the consequence of a reaction in the system, after the cold has temporarily dimi- nished excitement, and thereby increased the susceptibility to subsequent excitation, is fully demonstrated by the fact, that unless the system be endowed with a considerable degree of energy and activity, no such favourable effects will follow the application of cold. If cold produced these effects by its sti- mulating powers, it would, one may reasonably believe, pro- duce them when the system is in a state of feebleness, because mere weakness can never annul the operation of a stimulus provided the excitability be not exhausted. That cold must necessarily diminish the actions of the system, is evident from its being in fact nothing else than a comparatively diminished grade of temperature. For if heat be a stimulus, it is manifest * Beaupre", on the Effects of Cold, &c. p. 88. " In the coldest regions approaching the poles, excessive cold retards the generative flame and we may say extinguishes the lamp of physical love. Beyond the 65th degree of latitude, population continues to decrease, and ends at Spitz- bergen and Nova-Zembla. Lapland and Iceland females are said to menstruate but little; they are apathetic in love, and know but little of the bitter feelings of jealousy, or the vehemence of sexual attachment." CAUSES OF FEVER. 31 that this stimulus must be lessened in its powers, just in the ratio in which its intensity is decreased. Thus if 80° produce a certain degree of excitation, 60° {cseteris paribus) must pro- duce a less degree, and 40° still less, and so on. Correctly speaking, every agent capable of affecting the animal economy is a stimulus; but when we speak of cold and its effects, it is to be always understood in a relative sense; for when it is said that cold is a sedative, it can mean nothing else than that it is less stimulating than a higher degree of temperature. It is to be observed, however, that although it unquestiona- bly tends to diminish the actions of the system, cold, when applied suddenly, manifests a very conspicuous exciting agency on the nervous or sensitive system. Thus a few drops of cold water sprinkled on the face of a person in a state of syncope, or approaching to this state, will generally produce immediate excitation and return of consciousness. In asphyxia from car- bonic acid, too, I have known a quart of cold water thrown on the face and breast, to cause immediate respiration, and other manifestations of returning life. In cases of this kind the sud- den sensation which the cold produces acts probably as the exciting cause. Cold as a morbific agent.—-Cold is perhaps the most common and frequent of all the remote causes of disease. Its injurious tendency appears to be much enhanced by being conjoined with humidity; for a very dry and cold air is far less capable of abstracting the animal temperature, than low temperature united with humidity. But the most important circumstances which render the impressions of low temperature prejudicial to the animal economy, relate to the previous condition of the system itself, in reference to the degree of cutaneous transpira- tion, and the antecedent exposure to high temperature. The morbific influence of cold is always efficient in proportion as the body has been previously exposed to an elevated tempera- ture, and more especially in proportion as the perspiration is more or less copious. The most powerful of all the predispos- ing conditions of the animal system to the injurious effects of cold, is a state of free perspiration from fatiguing and exhaust- ing exercise or labour, under the influence of high solar heat. In this state of the body, and scarcely in any other, the sudden application of cold to ft large extent of the surface, or to the stomach, in the form df ice or cold water, will often produce the most alarming and suddenly fatal consequences.* Expe- rience has shown that where the heat is steadily retained, and before it is rapidly carried off by a free perspiration, and the system is not exhausted by fatigue, cold can never give rise to such violent and dangerous consequences. The dangerous * Rush's Medical Inquiries. Currie's Medical Reports. 32 CAUSES OF FEVER. effects here alluded to, as the immediate consequences of the impressions of cold, while the body is in a state ot copious perspiration from fatiguing exercise and atmospheric heat, are of a nervous or spasmodic character, manifested generally by a sudden prostration and effacement of the vital energies oi the system. As nfebrific cause, cold plays a very important part in the production of disease. It is not however merely as cold, that low temperature is so influential as a febrific agent; vicis- situdes of temperature, sudden changes from warm to cola, or from cold to warm weather, are the sources whence febrile disease is so abundantly derived ; and these changes are always injurious in proportion to the suddenness of the transition, and the greatness of the change. A very gradual change of atmos- pheric temperature rarely produces disease, except in such as are peculiarly predisposed to influences of this kind. The mode in which fever is produced by cold has already been ex- plained. The first effect is torpor of the cutaneous exhalents, and a retreat of the blood from the surface to the internal or- gans. The recrementitious perspirable matter is therefore retained; and the blood thereby rendered more irritating. In consequence of these secondary conditions, the heart will be excited into increased action ; by which the blood is again pro- pelled into the external capillary system, without however overcoming the torpor of the exhalents. If any portion of the capillary vessels be predisposed by previous debility to mor- bid excitement, the irritation will be particularly increased in this part, and probably to the extent of producing a local in- flammation. Should the mucous membrane of the respiratory passages be in a state of predisposition to irritation, catarrhal or pneumonic affections will be the consequence. If the ali- mentary canal be in a state of accidental or habitual irritation, dysentery or enteritis will probably occur. In short, whatever part of the system may be in a condition peculiarly predisposed to disease, inflammation or a state of high irritation will most likely be developed in it, by the general momentum of the cir- culation, and the immediate local impressions of the recremen- titious elements retrained in the circulation.* When the degree of cold is excessive, or very prolonged in its action on the animal system, it gradually abstracts the ani- mal temperature to a degree incompatible with vital action, ' and asphyxia, gangrene, or death, ensues. The tendency which very lowr temperature has to produce these effects, is greatly controlled by the degree of constitutional energy, as well as the degree of corporeal exercise, of those who are ex- posed to its prolonged influence. A person of a vigorous and * Dr. James Johnson, passim. CAUSES OF FEVER. 33 healthy habit of body, will readily bear a degree of cold with- out particular injury, which would soon destroy an individual of a weak and infirm state of the system. In all instances, where cold is applied in a degree capable of gradually reducing and finally arresting the vital actions, an indomitable inclina- tion to sleep supervenes just before the fatal torpor comes on. When this oppressive somnolency ensues, all feelings of pain or suffering cease—if it be not resisted, death is inevitable. Heat.—High atmospheric temperature acts much more fre- quently as a predisposing than an exciting cause of disease. "Solar heat," says Dr. James Johnson, "produces only the predisposition, while terrestrial exhalations and cold, call into action the principal diseases of hot climates. The mode in which solar heat contributes to the production of disease, ap- pears to be either by augmenting the general irritability of the system, or, more generally, by exciting inordinate functional action of the skin and the liver, and thereby rendering them more susceptible of the paralyzing impression of cold. Be- tween the skin and the liver there exists a close and powerful sympathy, in consequence of which, whatever excites the func- tions of the former, produces, perhaps, an equal increase of the functions of the latter organ."* Hence, high atmospheric heat very generally produces an increased secretion of bile, by its influence upon the liver through the medium of the skin, whose functions it is so peculiarly adapted to augment. It is manifest that an inordinate activity of these two functions from the in- fluence of heat, must render them extremely obnoxious to tor- por or inactivity from the sudden application of cold; and it is equally obvious, that a sudden torpor of these two important emunctories cannot occur without an immediate injurious con- sequence upon the whole system. Solar heat is, moreover, ex- tensively concerned as an indirect cause of febrile affections, by favouring the production of marsh miasmata. By its ex- pansive and exciting influence, it sometimes gives rise to sud- den and dangerous local determinations, particularly to the head. CHAPTER III. MIASMATA. The term miasmata is here used, as designating a highly important class of febrific agents of a gaseous form, and which act on the animal system through the medium of the atmos- * Dr. James Johnson, on the Influence of Tropical Climates, Sfc. 5 34 MIASMATA. phere. This class of agents consists of two orders: namely, 1. Infection, comprehending, those febrific effluvia which are generated by the decomposition of vegetable and animal matter; and, 2. Aeriform contagions generated by the animal system in a state of disease. . Infection; or that variety of febrific agents which is produced by decomposition out of the animal system, consists of two genera; namely, 1. Those which result from the humid decomposition of vegetable and animal substances contained in the public filth of cities, in marshes, and in other soils and public situations furnishing these materials. This genus is usually designated by the term marsh-miasm, but from the common or public source of these morbific effluvia, it has been proposed, and by some adopted, with much propriety. I con- ceive, to distinguish them by the compound term koino-miasma. And 2. Those febrific effluvia which are generated by the de- composition of the natural exhalations and excretions of the human body, accumulated and confined in crowded and ill-ven- tilated habitations. These deleterious effluvia, originating from the decomposition of matter derived from the human body, have, with equal propriety, been designated by the terms idio- miasma, expressive of the persoftal or private character of their source.* Before treating of these febrific agents in an etiological point of view, it will be proper to describe, more circumstantially, the manner and condition in which they are generated, as well as their physical characters, so far as these are objects of cognizance. * These distinctive terms were originally proposed and adopted by the late Dr. Edward Miller, of New-York, in the year 1804. He observed that there were two species of miasmata; the one consisting of fe- brific exhalations from marshes and other soils, and the other of effluvia generated by the decomposition of personal and domestic filth. " In order to distinguish these two varieties of miasmatic agents, and, at the same time, duly to fix in the mind the impression of the origin and production of them, it is judged expedient to designate each by terms which will invariably, express the process of nature in their formation. As the Greek language has been generally resorted to in the framing of scien- tific nomenclature, I shall employ the adjective koinos, common or public, to denote one species of miasma, and 1A102, personal or private, to denote the other. The application of these terms will readily be under- tood. That portion of the air charged with miasmata, exhaled by solar heat, from the surface of swampy ground, or from masses of filth over- spreading the open area of cities, according to this distinction, is denomi- nated Atmosphera koino-miasmatica. And that other small portions of air, contaminated by miasmata, emitted from and surrounding the b^dy, clothes, bedding, and furniture, of persons immersed in the filth of their own excretions, and of those associated in the same family with them accumulated, long retained, and acted upon by animal heat, is denomi- nated Atmosphera idio-miasmatica."—Attempt to deduce a Nomenclature and Med. Repository. New-York, 1804. MIASMATA. 35 I. Koino-miasmata, usually designated by the the terms marsh-miasmata, or malaria. This morbific agent, was not unknown to the ancient Greek physicians. They personified this aeriform poison under the emblem of a many-headed mon- ster, whose pestiferous influence was so severely exercised over the luxuriant fields of Argolis, that it was made one of the la- bours of the potent son of Alcmcnus to rid the country of this dreaded source of pestilence. Hercules, accordingly drained the extensive Lernean marshes, and thus dried up this abundant source of pestiferous emanations. Heat and moisture are indispensable to the generation of koino-miasmata; without these, no decomposition can take place, and without decomposition no deleterious agents can be generated from dead vegetable and animal substances. In those latitudes, where the atmospheric temperature seldom rises above 60°, the diseases which arise from this agent occur but extremely seldom, and perhaps never, in an epidemic manner. The Lithuanian marshes of Russia do not render the surround- ing districts insalubrious. It would seem, indeed, from a long series of observations, that koino-miasmata are seldom evolved to a degree sufficiently copious or active to create extensive disease, so long as the temperature of the air does not rise above 80° of Fahrenheit. It is, however, not necessary that moisture should be present in great abundance for the produc- tion of miasmata. Indeed, grounds completely covered with water, send forth but very little of this deleterious effluvium, however favourable the temperature, and other necessary cir- cumstances may be. Hence, copious and continued rains,by inundating marshy soils, render such localities comparatively salubrious. (Dalzille, Ferguson.) Ferguson was led to infer, from his observations on this point, that miasmata were extri- cated wholly independent of the humid decay or decomposition of vegetable and animal matter, and apparently without the agency of humidity. He asserts that this aeriform poison is never extricated, in any considerable quantity, until the mois- ture of the soil is so far dissipated as to leave the ground in the last stage of the drying process. This, however, is decidedly contradicted by almost universal experience. In proof of his opinion, he states: " In the months of June and July our army marched through the singularly dry, rocky, and elevated country on the confines of Portugal, the weather having been previously so hot, for several weeks, as to dry up the mountain streams. In some of the hilly ravines, that had lately been water-courses, several regiments took up their bivouac, for the sake of being near the stagnant pools of water that were still left among the rocks. Many men were seized with intermitting fever." From this, and similar facts, he thinks himself warranted to conclude, that the humid decay of vegetable and animal matter has no immediate agency in the production of miasmata, and 36 MIASMATA. that moisture, particularly, is not essential. But " half dried ravines, and stagnant pools of water," are surely no evidence of a want of humidity, and present, one should think, precisely the conditions most favourable to the emission of miasmata from vegetable and animal decomposition. Dr. James Johnson observes, that we will "scarcely find a spot of this earth's sur- face that is not covered or imbued with both vegetable and ani- mal remains in a state of decomposition, and ready to afford pabulum for the sun's rays, with or without humidity to extri- cate the injurious principle in question." It may be observed, that in every instance which is adduced by Dr. Ferguson, in proof of his opinion, that the extrication of miasmata docs not depend on the humid decay of vegetable and animal matter, the soil from which the miasmata was emitted had been previously thoroughly saturated with water during the rainy season, and, therefore, moisture must have existed in abundance, a short distance under the surface of the soil, however parched this latter may have been. Under such circumstances, miasmata might be abundantly sent forth with- out any obvious humidity and vegetable decomposition on the surface; for the vegetable and animal remains, collected during the rainy season, must have been gradually decomposed during the drying process, and left, in part, at least, mingled with the portions of the soil on the surface. In this state, then, the slow evaporation of the humidity under the surface, in passing up into the air, would dissolve the putrid but dry par- ticles of animal and vegetable remains, and convey them in the form of an effluvium into the circumambient atmosphere. That a considerable degree of humidity is especially favour- able, and even essential, to the evolution of miasmata, is evi- dent from the circumstance that marshes, stagnant pools, and the oozy shores of rivers, have, in all ages, and in all countries, been found the most insalubrious portions of the earth during the hot seasons. As to the variety of soil most favourable to the production of miasmata, we possess no very definite or certain informa- tion. It has been asserted, that an argillaceous soil is the best calulated for the extrication of this effluvium ; but its tendency in this way appears to depend solely on its greater compact- ness, by which it not only retains humidity much longer than other soils, but is, moreover, especially suited to maintain standing pools of water, and to favour the formation of marshes. A mixture of fresh and salt water in marshes, appears to en- hance the copiousness and virulence of miasmata to a very ob- vious degree. It is a singular fact, that the water of the sea, is much more apt to enter into putrefactive decomposition than fresh water; and this, no doubt, depends on the great quantity of organic matter which it contains. M. Monfalcon, mentions MIASMATA. 37 some interesting examples illustrative of this fact.* The ex- tensive pool of Valdec, in the south of France, is quite saline. Not more than a few rods from it is a large pool of fresh water, call Engrenier. When the waters of these two pools rise, and run into each other, much sickness soon occurs throughout the adjoining parts. In the vicinity of Lukes, on the south of the Ligurian Appennines, there is a large marshy plain accessible to the high tides of the ocean. The neighbouring districts were almost uninhabitable from the pestilential effluvia which ema- nated from this marsh, until the waters of the sea were sepa- rated from the sweet water of the marsh by means of sluices and hydraulic works, when it became healthy, and the popula- tion increased rapidly. Of the nature of koino-miasmata we possess, as yet. no cer- tain knowledge. Examined, chemically, the air of the most pestiferous marshes is found to differ, in nothing, from the purest and most salubrious air. According to the experiments of Professor Julia, of Lyons, it would appear that:— 1. The deleterious influence of koino-miasmata, depends on particles of putrid animal or vegetable matter dissolved and suspended in aqueous vapour. 2. The air of marshes does not differ from atmospheric air in any of the principles which chemical analysis can detect. 3. None of the gases, disengaged from bodies in a state of putrefaction, exhibit themselves in a sensible quantity. 4. The disorders caused by koino-miasmata, are not, in any degree, dependent on the predominance of azote, of carbureted hydrogen, of ammonia, of nitrous oxyd, &c. in the air. That koino-miasmata consists very probably in particles of putrid vegetable and animal matter, dissolved in aqueous va- pour, receives considerable support from the experiments of Gaspard and Majendie on the effects of putrid exhalations on animals, and which have already been cited in a former part of this volume. Majendie found that on exposing different animals to the exhalations of putrid animal matter, affections were produced analogous to those which are known to occur in man from the influence of pestilential miasmata. It is not im- probable, therefore, that such putrid materials, suspended in vapour, constitute the deleterious principle of miasmata of this kind; and it may be reasonably presumed that the different modifications of disease produced by this agent, in different lo- calities, depend, in a great degree, on the different degrees of concentration, as well as on the particular character and pro- portion of the substances from whose decomposition the putrid miasmal particles are derived. It can hardly be doubted, * Histoire Medicale des Marais. Paris, 1828. 38 MIASMATA. that the relative proportions of animal and vegetable matter which may enter into miasmal exhalations, will determine the violence of their influence, and modify its results on the sys- tem. Plausible as these sentiments may be, it should not he forgotten that they are founded on no certain data, and, that we may, after all, be as yet remote from the truth in rela- tion to this subject. Whatever may be our views in reference to the essential na- ture of koino-miasma, observation has made us acquainted with certain of its physical qualities, as well as with its general effects on the human system, and which is perhaps all that it imports us, in a practical relation, especially to know. Koino-miasmata possess a specific gravity greater than atmospheric air, (De Lisle.) They cannot, consequently, ascend into the air without being attached to and carried up by lighter bodies ; and these vehicles consist, without doubt, of aqueous vapours. Hence persons sleeping in elevated cham- bers, are much less apt to contract miasmal diseases than such as are lodged on the ground floor, (Hunter, on the diseases of Jamaica, Blane, Lempriere,* De Lisle.) And hence, too, the greater salubrity of hills, and very elevated parts, than the ad- joining low grounds. It is true, that some very remarkable exceptions have occurred to this fact; Bancroft mentions the great mortality which has repeatedly been observed on the top of Monte-fortune, at St. Lucie; and on the Hospital and Richmond hills, at Grenada, while the surrounding low situa- tions were comparatively salubrious. Dr. ITHallaran, in his account of the yellow fever of the south and east coasts of Spain, mentions similar examples of the great prevalence of miasmal diseases on very elevated situations, whilst the sur- rounding marshy grounds were but little infected with this de- leterious effluvium. He refers particularly to Monjui, a hill 700 feet high, overlooking Barcelona, the air of which, he says, is so deleterious in its qualities, that it was found necessary to relieve the stationary guard every eight or ten days ; and, he adds, that the injurious influence of the exhalations arising from the swamps below, manifested itself more conspicuously upon the summit of the hill than in the subjacent parts. Dr. Blane, who mentions similar facts, explains them by supposing that the vapours formed on the low and swampy grounds ascend, and, with the miasmata which they hold in solution, pass over the lower situations and impinge and settle on the neighbour- ing hills. It is, indeed, by no means uncommon to see fogs, * Drs. Blane and Lempriere, in their report to the Secretary of War, concerning the Walcheren fever, observe: "On no account should ground floors be used to sleep on; the more lofty the buildings the bet- ter; for the tenants of the upper stories not only enjoy the best health, but, when taken ill, have the disease in the mildest form."—Bancroft on Marsh Exhalations. MIASMATA. 39 which rise out of the low grounds, ascend and hover over the tops of the nighbouring mountains. Considerable difference of opinion exists as to the distance to which koino-miasmata may be diffused from their source in a state o( sufficient concentration to produce fever. This distance would seem to he much smaller than what has been generally supposed. Bancroft thinks it rarely extends beyond a quarter of a mile, and he adduces several facts which would seem to demonstrate his opinion very conclusively. It is ob- vious, however, that this distance must be much under the con- trol of various physical causes, such as the face of the ground, the volocity and constancy of currents of air, the degree of at- mospheric humidity, &c. Koino miasmata is abundantly pre- cipitated to the surface of the earth during the night, and more especially during the first hours after the setting, and shortly before the rising of the sun. Hence, in part, the greater lia- bility of contracting miasmatic diseases from exposure between the setting and the rising of the sun, than-after the sun is con- siderably above the horizon, (De Lisle, Bancroft, Sir James Fellows, Johnson.) The most dangerous period in the twenty- four hours of the day, is "that which accompanies the setting and that which immediately precedes the rising of the sun, and the least critical time is when the sun is at its highest point above the horizon," (De Lisle.) In these facts we have a strong evidence of the correctness of an observation already made—namely, that the miasma is united with and suspended in the air by aqueous vapour, which, falling in the form of dew, carries down along with it the deleterious miasmatic particles. Koino-miasmata may be arrested in its progress or passage from its source to other parts by whatever is capable of imped- ing and intercepting the progress of aqueous vapour. Thus the interposition of a dense forest, of a high wall, or fence, of a chain of elevated hills, in short, of any mechanical obstacle of this kind, has been known to protect the inhabitants of vil- lages, of camps, of convents, and of single habitations, from the pestiferous influence of neighbouring marshes. De Lisle relates several very remarkable facts illustrative of this obser- vation, (Monfalcon, Bancroft.) A convent, situated on Mount Argental, near the village of St. Stephano, was, for a long time, remarkable for its salubrity, until the trees by which it was surrounded were cut down, when it became extremely sickly. By currents of wind passing over marshes, koino-miasmata are often carried to a considerable distance in a state of con- centration sufficient to manifest its full deleterious powers. The account of the thirty Roman noblemen mentioned by Lan- cisci, is an interesting and striking illustration of this fact. They were sailing near the mouth of the Tyber, on a party of 40 MIASMATA. pleasure. Suddenly the wind shifted and blew over the putrid marshes. Twenty-nine out of the thirty wore soon seized with intermitting fever. The effects, often truly frightful, of the harmattan, after becoming loaded with the pestilential effluvia of the swamps of Benin, afford also a strong illustration of this fact. Violent storms, and copious showers of rain, tend powerful- ly to free the atmosphere from koino-miasmata. The former violently disperses them, and the latter sweeps or washes them down to the surface of the earth. Nothing is more common than to find miasmatic epidemics to remit immediately after copious floods of rain or violent storms, (Rush, Bancroft, Mon- falcon.) A humid air is a much better vehicle for the transportation of miasmatic exhalations than a dry one. The particles of the miasmatic poison attach themselves to the humidity of the air, and are thereby carried along by currents of wind. It is to be remarked, however, that although atmospheric humidity ap- pears to favour the dissemination and action of miasmata, yet observation would seem to show that when these effluvia pass over a surface of water they become absorbed, or in some way lost. This circumstance may, in part, account for the short distance assigned by Bancroft to the dissemination of mias- mata from their source ; for in all the examples which he ad- duces in support of this judgment, the miasmata were conveyed over bodies of water, (Bancroft, De Lisle.) II. Idto-miasmata.—This variety of miasmata is generated by the decomposition of the matter of perspiration, and the other excretions of the animal body; and hence it most frequently occurs in the confined and crowded hovels of the poor, in crowded jails, ships, hospitals, and wherever many individuals are confined in apartments not duly ventilated. From an in- ability to procure separate dwellings, the poor are generally obliged to take up with small apartments, into which two or three families are often crowded; and in order to save fuel, and indeed frequently from the total want of fuel, every access of the external cold air is carefully cut off. Add to this the filth and want of proper changes of clothing almost insepara- ble from extreme poverty, and you have a combination of cir- cumstances peculiarly calculated to generate a miasma from the putrefactive decomposition of the animal exhalations with which the air and every article of clothing in such apartments must be saturated. It is chiefly during the cold season of win- ter that this variety of miasmata is generated. When the wea- ther is warm, the air of crowded and filthy apartments is MIASMATA. 41 constantly renewed by the doors and windows being kept open, and the accumulation and stagnation of the animal exhalations thereby prevented. Dr. Smith observes, that this miasm is especially generated in the apartments of the sick, particularly " of those who are labouring under the typhus state of fever."* It does not appear, however, that those exhalations which ema- nate from the body in a state of disease, and which possess the power of producing the same disease as that under whose in- fluence they are evolved, can, with strict propriety, be ranked with the present class of miasmal poisons. They belong to the contagions. I would restrict the term idio-miasma, to those morbific effluvia which are generated by decomposition of the animal secretions, whether formed in a state of health or dis- ease, and to the ordinary exhalations from the body, when ac- cumulated in such a manner as to deteriorate the atmosphere of confined rooms, if these be really capable in themselves, and without decomposition, of exciting fevers. Idio-miasmata are always quite limited in the sphere of their influence. Beyond the room or habitation in which they are generated their operation cannot extend, unless indeed they are absorbed or adhere to articles of clothing, and are conveyed abroad in a state of sufficient activity to act on the human sys- tem. Whenever fever is found to spread from a source of idio- miasmata, it is in consequence, I presume, of the generation of a new contagious miasm by the disease, produced in the first instance by the idio-miasmatic poison. I am well aware that tlus opinion involves what has been declared a manifest incon- sistency—namely, the origination of a contagious disease by a common or general exciting cause. All such objections, founded merely on speculative inferences, maybe met by facts, which must stand good, however irreconcilable they may ap- pear to be with the dogmas of philosophy, or with admitted principles. It is a. fact, for instance, that typhus may be ori- ginated by the miasma produced from the exhalations of a number of even healthy individuals crowded and confined a long time in narrow and unventilated apartments. And, that although not necessarily a contagious malady, typhus may, under peculiar circumstances, generate a specific virus which is capable of exciting the same disease in others, is a fact sup- ported by a mass of testimony which cannot be reasonably re- jected. " There are few physicians," says one of the most eminent medical writers of the present day,f " who believe that epidemic or endemic fevers arise from specific contagion, though facts daily teach us that typhus, yellow-fever, dysen- » Elements of the Etiology and Philosophy of Epidemics, p. 52. f Dr. James Johnson: Med. Chir. Rev. vol. VII. 1825,) p. 65. 6 42 MIASMATA. tery, &c. occasionally, and under particular circumstances, give out a something, (call it what you please) which produces a similar disease in the healthy stander-by, who happens to come within its range. If we may venture to prognosticate, we would anticipate that this will be, as it assuredly now is, the more general opinion among practitioners." From the circumstance of this variety of miasmatic poison " becoming innoxious when diffused in the atmosphere, even a few feet beyond the apartments in which it is generated," none of the forms of disease, which it is capable of producing, are apt to occur epidemically. Typhus, nevertheless, has been known to occur in a manner well entitled to the name of epidemic. The late widely spread epidemic of Ireland was surely strong- ly characterized in its progress and extent of diffusion by every feature which can give to diseases the character of an epidemic. Though engendered and nursed in the lap of wretchedness and poverty, it did not, in its desolating sway, fall exclusively upon those who were suffering under the distressing privations of pe- nury. Its fatal visitations were abundantly made to the ample and airy habitations of plenty and comfort; and almost— -------aequo pulsat pede pauperum tabernas Regumque turres. The question here occurs: If "idio-miasmata becomes in- noxious by being diffused in the atmosphere even a few feet be- yond the apartments in which it is engendered," how can typhus, which is manifestly originated by this effluvium, be- come epidemic, or be produced in large and well ventilated dwellings remote from the usual sources of this miasm? Is it by the idio-miasmata attaching itself to the clothes of individuals, or to other substances by which it may be conveyed from one to another place? If this be admitted, then idio-miasma must possess the character of a contagion. Is it not more probable that in the majority of instances of this kind, the disease is pro- pagated by a specific virus, generated by morbid secretion, and conveyed as other contagions of an aeriform character are con- veyed. It does not seem probable that idio-miasmata can be dis- seminated by fomites. If it can be so disseminated, it must pos- sess all the characteristics of a veritable contagion. Having given an account of the physical character, and thecon- ditions under which the two infectious effluvia, koino and idio- miasmata, are evolved, I proceed to the consideration of their relations, as morbific agents, with the human system, as well as with each other. Upon this subject I stand largely indebted to the ingenious and truly philosophical work of Professor Smith, MIASMATA. 45 of New-York ; for although I have long since entertained simi- lar views in relation to the combined agency of these miasmal poisons in the production of fevers, yet the enlarged, systema- tic, and precise views taken of this subject by Dr. Smith, have afforded me many new and interesting insights into the etiology of fevers. Koino-miasmata produce a class of fevers very distinct in their general character, and we may presume in their intimate natures from those which are the result of the influence of idio- miasmata. The former give rise to intermittent and remittent fevers, and to bilious fevers; and the latter miasma is the source of typhus, and the low nervous fevers of former writers. The deleterious nature of koino-miasmata is manifested not only by the violent and fatal fevers which they are known to produce so abundantly, but also in an equal degree by the more slow inroads they make on the physical and moral condition of those unfortunate beings who are habitually exposed to their influence. The indigenous inhabitants of marshy districts in warm climates present an aspect of suffering and wretchedness from this cause, which is well calculated to draw forth the commiseration of those who are more fortunately located. Continually exposed to the deleterious influence of these bane- ful exhalations, man, in such situations, exhibits a state of feebleness and early decrepitude strongly indicative of a broken down constitution, " and deep and irremediable chronic disease." But while such chronic and constitutional effects are wrought by the habitual endurance of koino-miasmata, the system loses its susceptibility of being excited into those violent commotions of febrile action which this agent is so apt to produce in those who are less accustomed to its impressions. The natives of marshy districts are comparatively much more seldom affected with the highest grades of miasmal fevers than such as are only occasionally brought within the sphere of its influence. In the former the agency of this poison proceeds as4t were by a slow and concealed combustion, whilst in those who are not accustomed to its influence its effects burst out in a raging and rapidly consuming flame. There can be but little doubt that koino-miasmata varies in its powers, and often very considerably, according to various circumstances in point of locality and the relative proportions of the animal and vegetable matter which supply the materials for its composition. Dr. James Johnson, whose authority I am always disposed to respect, has expressed his belief in the occurrence of such diversities in the peculiar morbific powers of this agent. " The fever of Batavia," he observes, " differs from the fever of Walcheren—the fever of Antigua, from the fevers of the Ganges—and all these differ materially from the 44 MIASMATA. plague of the Levant.0 Professor Smith also expresses the same sentiment. " Different countries, and different localities in the same country, probably furnish varieties of koino-mias- mata."* It cannot be presumed that the relative proportions of animal and vegetable matter should be the same in different localities, and equally improbable is it that the same kinds of these materials should be present in the different situations where miasmata are generated. There must be a great diver- sity in both these respects ; and a corresponding diversity in the essential morbific qualities of the miasmata evolved from them. I have already mentioned the experiments of Majendie in relation to the effects of putrid animal substances on the animal system. From these it appears that ''different kinds of flesh, when in a putrid state, produce different effects on the animal economy,"! and it is, therefore, quite reasonable to con- clude that miasmata will differ in their powers not only ac- cording to the greater or less proportion, but also to the kind of animal matter concerned in their production. The influence of koino-miasmata on the human system, like that of other general causes of disease, is much under the con- trol of the physiological state of the animal economy, of idio- syncracy, of temperament, predisposition, and of accidental external causes. Thus of a number of individuals exposed for a certain time to the same miasm, some may become affected with intermitting fever, others with mild remittent fever, some with malignant bilious fever, some with bilious colic, some with dysentery, and others perhaps will escape the disease en- tirely. The class of diseases produced by koino-miasmata, if we take into view their various modifications, is by no means limited in its range. The most simple form of disease arising from this cause is the intermittent fever. In proportion as this febrific effluvium increases in potency, so does it produce fevers of a higher and more violent grade. The range of activity of this miasma extends from the simple tertian of the temperate latitudes to the malignant and fatal plague of the east, or the scarcely less fatal bilious fever of Batavia. The period which intervenes between the reception of koino- miasmata and the first manifestation of its influence on the human body, is extremely various. Of many persons exposed to it at the same time, some may be immediately affected, others in a few days, some not until several weeks have passed, whilst others may remain free from its effects a still longer time. ° As the powers of koino-miasmata most probably vary consi- * On the Etiology of Epidemics, p. 74. t Journal de Physiologie; Janvier, 1823. MIASMATA. 45 derably in different countries and localities, it may be inferred, a priori, that the fevers which they produce are impressed with a corresponding diversity in their character; and obser- vation would seem to confirm this inference. Dr. Smith thinks, that whatever external or general diversities may occur in fe- vers produced by this miasma, "their pathology or essential nature is every where the same." This is highly probable; for the diversities in question would seem to depend more on the mere grade of violence and general course of these fevers, than on any radical difference in their essential pathological conditions. Upon this point, however, it becomes us to speak with diffidence, as this question is not to be solved by mere closet inferences and reasonings, but by close observation and careful experience, in relation to these fevers as they occur in various countries, climates, and localities. How far a mixture, or the combined agency of koino and idio-miasmata, may operate in producing novel or anomalous varieties of fever, it is impossible to say ; but that such a com- bination does sometimes occur, and give rise to fevers of a peculiar or mixed character, will scarcely he doubted by any one who has given due attention to this interesting subject. Professor Smith, to whose work I have already so frequently referred, has given this subject a comprehensive and minute consideration, and to whom indeed the whole credit is due for introducing this interesting point of etiology to the notice of the profession. " Let us suppose," says Dr. Smith, " the cir- cumstances in which typhus originates to occur in summer, such as the crowding of individuals into small apartments, badly ventilated, and rendered offensive by personal and do- mestic filth. These causes would obviously produce typhus in its ordinary form. But suppose there exist at the same time those exhalations which occasion plague and yellow fever, or intermittent and remittent fevers. Under such circumstances,* we should not expect to see any one of those diseases fully and distinctly formed, but a disease of a novel or modified charac- ter." There exists no doubt in my mind, of the correctness of Dr. Smith's observation, that the late Banker street fever in New-York, as well as the peculiar fever which prevailed among the blacks in this city a few years ago, were engender- ed by the united influence of these two miasmal poisons. I once had a striking illustration of the anomalous and fatal cha- racter which the united action of koino and idio-miasmata are apt to impart to fever. During the fall of 1814, while attend- ing in the capacity of regimental surgeon in the encampment at Baltimore, ten men affected with mild remitting fever, were lodged in a room of confined dimensions, and as the weather was cold, the room was kept pretty warm by fire, and the doors and windows as little opened as was admissible. The 46 MIASMATA. adjoining room was exceedingly crowded with invalids, and but little attention was paid to cleanliness and ventilation. In a short time several cases of fatal typhus occurred in this room. Soon after this, the patients who were affected with intermitting fever in the next room, manifested new and more alarming symptoms; blood began to ooze from their gums ; extreme tenderness of the epigastrium occurred; the intellect was but little disturbed ; the eyes were dull, watery, and staring ; the temperature of the skin and the pulse nearly na- tural; the animal powers so little prostrated, that one of the men died a few minutes after he had been sitting up with his back leaned against the wall of the room. They were all im- mediately removed to the Baltimore Hospital, and all except one died'in a few days. There can be no doubt, that this pe- culiar modification of febrile disease was the result of the im- pressions of idio-miasmata (engendered in the house,) made on systems already under the morbific influence of koino- miasmata. CHAPTER IV. CONTAGION. By a contagion is understood a deleterious agent secreted by the animal body in a state of disease, which, when brought to acton a healthy individual, will produce a disease specifi- cally similar to the one from which it derives its origin. Con- tagions occur under two distinct forms; and may therefore he divided into two varieties: viz. I. Those which consist of a palpable matter or virus; and, II. Those which consist of an imperceptible effluvium. The chronic contagious maladies are propagated exclusively by a palpable virus, and consequently always by actual contact. Those acute contagious diseases which are not attended by a specific local affection, or an exan- theme, are, on the other hand, exclusively propagated by a morbific contagious effluvium, and, by consequence, solely through the medium of the atmosphere. Those acute diseases, which are essentially connected with a specific local affection, or an cxantheme, are communicated both by a palpable virus, and by an imperceptible effluvium, and consequently both by actual contact and through the medium of the atmosphere. We perceive, therefore, that of the extremes of a purely local, and a purely general malady, there is, on the one hand, com- munication of the disease solely by a palpable matter, and, on the other, by effluvia only; and that where the local and CONTAGION. 47 the general affections meet in the same disease, as essential concomitants, (in the exanthemata) there the two modes of propagation also obtain.* It must be observed, however, that though in a practical point of view we may properly adopt these distinctions be- tween contagions communicated by contact, and through the medium of the atmosphere, yet, in reality, an actual contact must, by necessity, always occur between the contagion and the individual before it can possibly produce disease, whether the contagion be a palpable matter or an imperceptible miasm. The only essential difference exists in the mode in which this contact is effected. One of the most remarkable peculiarities of contagious dis- eases, is their inherent and undeviating tendency to preserve their essential individuality, under whatever circumstances of age, sex, constitution, temperament, modes of living, climate, and place they may occur. Thus the small-pox of the present day differs in no essential circumstance from the same disease as it was observed and described by Rhazes more than eight centu- ries ago ; and the itch has changed in nothing since the time of Galen. Any certain contagion can, so far as we know, pro- duce only one disease, and if the system has become insuscep- tible of such disease, its peculiar cause is no longer a morbific agent in relation to that system. The laws of the acute contagious diseases differ entirely from those which govern the rise, progress, and declension of the chronic contagious affections. The former observe the ut- most regularity in all these respects. The rise, advancement, and decline, in short, the whole series of essential phenomena, are governed by laws as steadfast as those which regulate the motions of the planets. The latter class of diseases, on the contrary, are extremely irregular in their course, having no definite period of duration, nor established duration of the successive phenomena of their progress. The power which the acute contagious diseases have of de- stroying the susceptibility of the human system to the sub- sequent influence of their specific causes, constitutes one of the most remarkable and mysterious characteristics of this class of maladies. In this respect they differ as far from the chronic affections of this kind, as they do from the febrile diseases produced by general and other non-contagious causes. In consequence of this law of acute contagious diseases, no ma- * This arrangement is adopted from Dr. Hosack's very lucid classifi- cation of contagions and their peculiar diseases. There is no writer of the present day, whose views upon the character and arrangement of this class of maladies, deserve higher respect and attention than those which have been so lucidly and cogently promulgated by Dr. Hosack. 48 CONTAGION. lady of this kind can ever relapse during the period of conva- lescence. Considerable diversity of sentiment has been expressed in relation to the distance to which contagious miasmata may he dispersed from their source, in a state of sufficient activity to generate disease. That their sphere of activity is very limited, however, has been abundantly demonstrated, both by experi- ment and observation. The experiments of Dr. O. Ryan, professor of physic in the college of Lyons, prove that the con- tagious miasm of small-pox does not extend more than a few feet beyond its source.* The most malignant contagions are rendered inert and harmless by being diffused in the atmo- sphere, and even by diffusion in the air of a well ventilated apartment. Ventilation diminishes the activity of contagious effluvia, simply by diffusing the miasm in a large portion of at- mospheric air, in consequence of which, those who become ex- posed to it receive it in weak and inefficient doses. Contagions are perpetuated and conveyed to great distances from their source, by becoming absorbed by and attached to various substances, such as clothing, furniture, bedding, &c, with which they are often transported even across the ocean. Animal substances, such as wool, hair, and articles manufac- tured from them, are said to retain contagious matter with the greatest tenacity. The more the substances which have become saturated with contagion are kept from the access of the open air, the more virulent and active will be its powers when it is broughl to act upon the human system. Thus, arti- cles of clothing, after having been impregnated with contagious virus, will retain the power of infecting much longer, and in much greater intensity, if they are kept confined in close rooms, or locked up in chests or closets, than when they are freely exposed to the open air. It is by articles of this kind, locked up in trunks, that the small-pox and other contagious maladies have been conveyed to distant parts of the world in ships, although no person on board may have been sick with the disease during the voyage. The articles which are thus imbued with contagious virus, are called fomites. It was the opinion of Cullen, that contagions are more powerful when they are thus lodged in fomites than when they arise imme- diately from the human body, or when in a separate state. The same opinion is expressed by Dr. Lind. The influence which peculiar atmospheric constitutions have on the activity of contagions and on their tendency to disse- mination, is a subject as interesting as it is inscrutable. The most careless observation is sufficient to convince any one that there exists in the varying constitutional, or perhaps accidental * Rees's Cyclopedia, article Contagion. CONTAGION. 49 conditions of the atmosphere, a powerful modifying principle in relation to the powers of contagious agents. At times, it would seem impossible for a contagious disease to extend its sphere of influence; for, although sporadic cases may occur here and there, yet no neglect in relation to proper seclusion, will enable the disease to assume an epidemic or endemic cha- racter. During other periods, on the contrary, the accidental importation of fomites, or the occurrence of a case of conta- gious disease, acts like a spark of fire thrown among combus- tible materials, and speedily spreads disease extensively among the people. The same powerful influence of atmospheric peculiarity shows itself in the diversity of character, in rela- tion to the grade of violence, malignity, and general diathesis, which the same malady is observed to assume at different pe- riods of its prevalence. That these tilings depend on some modifying agency of the atmosphere, there can exist but little doubt. Wrhat this condition of the atmosphere consists in, it seems impossible to ascertain ; it is probable, however, that it has no immediate connexion with either the temperature or the hygrometrical state of the air, for with the exception of typhus, which is manifestly favoured by cold weather, the contagious diseases of every kind prevail equally during the heat of the sum- mer and the cold of the winter. The mode in which contagions are either favoured or retarded in their progress by atmo- spheric constitutions, consists probably not in any influence which they may exert immediately on the powers of the conta- gion, but rather, perhaps, in their tendency to modify the human constitution, so as at one time to render it peculiarly susceptible of the influence of the contagion, and at another to diminish, or for a time to annul the natural predisposition to its operation. Of the primary source of contagion we know but very little. It is probable that each contagious disease was at first deve- loped independent of contagion, by the accidental concurrence of various circumstances, which, in the infinite series of such contingencies, may not again occur for many centuries. That a disease may be originated by the concurrence of general causes, without the agency of a contagion, and which may afterwards communicate itself to others by a specifie virus of its own elaboration, we have a familiar example both in typhus fever and in itch. There is reason to believe, indeed, that various contagions have been thus produced, which have long since passed away from the face of the earth ;* and it is not * The sudor anglicanus, so accurately described by Caius, appears to have been a highly contagious disease. It visited England five times in the period of seven years, and swept offa vast number of victims to its fatal violence. In many instances, those who were affected with it died within an hour, and few who sunk under its malignity suffered longer 7 50 CONTAGION. an idle conjecture to say, that new contagions may hereafter arise, which, after having exhausted their power on mankind, may again disappear for ever, or until a similar concurrence of causes occurs which at first evolved the contagion. It is an interesting fact, that contagious diseases sometimes originate in the lower orders of animals, and are afterwards communicated to the human species. Hydrophobia and the vaccine disease are familiar examples of this kind. Professor Remur has published some observations which go to show that other diseases, such as the virulent coryza of horses, the plica of long-haired animals, and the gangrenous inflammation of the spleen which occurs in cows, may be communicated by im- mediate contact to man. The following rules have been recommended for preventing the spread of contagious maladies to those who are obliged to approach patients labouring under diseases of this kind. (Hay garth.) 1. " The chamber in which the patient lies, must be kept clean and freely ventilated. No bed curtains must be allow- ed to be drawn around the patient." 2. " Dirty cloths, utensils, &c. should be often changed, and immediately immersed in cold water; and wash- ed clean when taken out." 3. "The discharges from the patient must be instantly re- moved; and the floor around the patient should be rubbed clean once a day with a wet cloth." 4. "Avoid the current of the patient's breath, as well as the effluvia which ascend from his body, and from the eva- cuations." 5. "Visitors ought not to go into the patient's chamber with an empty stomach; and in doubtful circum- stances, on coming out they should blow from the nose and spit from the mouth any contagious poison which may adhere to these passages." Although it is quite certain that contagions will adhere to, and imbue various substances, especially clothing, so as after- wards to reproduce the same disease at a distance from their source, and often a long time after they had been generated • yet it seems to be well ascertained, that such substances' (clothing) can rarely be sufficiently imbued with contagion by a slight and transient exposure to the poison, as to be capable afterwards of producing disease in the healthy. The clothes of transient visitors, for instance, will scarcely ever imbibe sufficient contagion to communicate the disease to others. than four or five hours. It has not been known to occur for several cen- turies past; its contagion having long since become wholly extinct. CONTAGION. 51 "Dr. Clark affirms, that in eighteen years of medical prac- tice, he never communicated the contagion of small-pox nor of scarlet fever to any one, although he had frequently, on the same day, visited many patients sick with these diseases, and in their most malignant forms." Mere ventilation is inadequate to destroy the contagion de- posited in fomites. To effect this important object, a great variety of means, such as exposing them to various vapours and fumes, have been devised. Without enumerating the dif- ferent disinfecting agents which have been successively brought forward and again rejected, it will be sufficient to mention those, which experience has shown to possess active powers in this respect, and which are now relied on as unquestionable disinfecting agents. The nitrous acid vapours have been much employed for disinfecting ships and houses, in which contagion has been found to exist. Such was the evidence brought for- ward of the efficacy of the nitrous acid fumes in purifying in- fected places and fomites, that the British parliament voted a national donation of five thousand pounds to Dr. Carmichael Smith for the discovery. This vapour is readily obtained by mixing with powdered nitre, in a cup, a little of sulphuric acid, and applying gentle heat with a lamp. CHAPTER V. OF THE GENERAL COURSE, TYPE, AND STAGES OF FEVER. The series of phenomena which intervene between the com- mencement of a fever and its termination in convalescence, constitutes what is technically called its course. The course of a fever is either intermitting, remitting, or continued, accord- ing as its phenomena intermit, or remit, or are continuous. The series of phenomena which constitute the course of a fever, may be divided into six periods or stages; viz. the forming, the cold, the hot, the critical, the declining, and the convalescing periods. 1. The forming stage—the stadium prodromorum includes the period which intervenes between the first impressions of the febrific cause, and the actual commencement of the essen- tial febrile phenomena. This period is characterized by a va- riety of feelings or sensations, which, though manifesting a deviation from the healthy condition of the system, do not constitute any definite state of disease. These constitute the premonitory symptoms. Their duration is very various ; and in some instances, though very rarely, they are entirely ab- 52 GENERAL COURSE, &c. OF FEVER. sent—the disease making its attack at once, without any pre- vious manifestations of its approach. This is most apt to occur in fevers of very vigorous reaction, and in such as are of a malignant character. The longer or shorter duration of the premonitory stage depends, however, probably as much on the different powers of vital resistance, as on a difference in the degree of concentration or activity of the remote febrific cause. The whole train of premonitory symptoms may be regarded as the result of the struggle between the vital powers and the febrific cause. If the cause be feeble and the vital resistance great, its first impressions may give rise to some unusual or unpleasant sensations, until the system finally triumphs over its influence, and disease be obviated. When the relative pow- ers of the cause and the vital resistance are more nearly ba- lanced, the struggle between them may be prolonged, until the latter yield and disease be developed ; and where the system resists feebly, whilst the febrific cause acts with energy, the contest will probably be short, and the fever occur suddenly with violent symptoms. There exists nevertheless in almost every febrific cause, a natural tendency to produce some pecu- liar premonitory symptoms, although the general and most conspicuous of these phenomena are pretty nearly the same in almost every form of febrile disease. In general, those fevers which are apt to run through a protracted course, have a much longer train of premonitory symptoms than such as are violent and of short duration. Thus, the premonitory period is almost uniformly much more protracted in typhus and typhoid, than in the synocal fevers. The following are among the most common symptoms of this initial period of febrile affections: loss of appetite; dis- turbed sleep; yawning, stretching, lassitude, wrandering pains in the limbs and back ; an unpleasant sensation in the sto- mach ; a harsh and dry skin ; irregularity of the bowels; a general feeling of mal-aise; nausea; eructations; interrup- tions of the ordinary habits and appetites ; fretfulness ; dis- content ; slight headach ; slight creeping sensations of cold ; the drying up of old sores; tremours of the extremities; changed expression of the countenance ; giddiness ; and per- haps some other slight deviations from a state of perfect health, or the ordinary habits and feelings of the individual. If we examine the symptoms of this stage in the usual order in which they occur, we will perceive that the nervous system is the first that suffers : this is manifested by the lassitude, langour, and slight transient pains which usher in this stage. Next the digestive organs are brought into a state of slight suffering; and finally the skin. The heart and arteries appear to be the last organs which are brought into morbid action in the development of fever. GENERAL COURSE, &c. OF FEVER. 53 2. The cold stage.—Nearly all fevers commence with a greater or less sensation of chilliness. The feeling of cold is not always attended with an actual subduclion of sensible tem- perature ; for, in some instances, the skin of the patient will feel quite warm to the touch, whilst he is shivering under the severest sensations of cold. It is manifest, therefore, that in such instances, the feeling of cold experienced by the patient depends in reality on an altered or morbid condition of the sensibility of the skin, in consequence of which its power of perceiving (if I may use the expression) the ordinary degree of animal temperature is diminished. In most instances of febrile chills, however, there occurs an actual reduction of the tempe- rature of the surface, especially of the hands and feet. Not unfrequently these latter parts will feel quite cold to the touch of a healthy person, whilst the surface of the trunk and the forehead will be found of the natural temperature, and some- times apparently even higher, although the sensation of chilli- ness experienced by the patient will be diffused throughout his whole system. The chills are attended with a pale, contracted, and dry state of the surface; the volume of the body is dimi- nished ; the respiration confined, irregular, anxious, and op- pressed, attended frequently with a short dry cough ; the head feels confused ; the tongue is dry, attended sometimes with great thirst; the pulse becomes extremely small, frequent, and feeble; nausea often occurs, and sometimes vomiting. Gene- rally the sense of chilliness is diffused over the whole body ; but in some instances it is partial, and occasionally limited to a small part of the body. In general, the more violent the chills are, the more vigorous will be the subsequent arterial reaction. As the cold stage gradually subsides, the arterial reaction regularly rises until chilliness has wholly gone off, and the disease has entered into the— 3. Third, or hot stage.—This stage is characterized by what maybe termed the essential phenomena of fever: viz. augmented heat and a return of the natural fulness and colour of the surface; flushed countenance; a full, quick, frequent, and vigorous, or a small, tense, quick, and frequent pulse; throbbing pain in the head ; eyes prominent and sensible to the light; a dry and hot skin; urine scanty and high-co- loured ; continued wakefulness, &c. These symptoms, with more or less intensity, continue for a longer or shorter period, until the acme of the febrile condition has arrived, and the period of— 4. Crisis supervenes. By the crisis, is understood, in the most general acceptation of the term, that period in the course of a fever at which it has arrived at its highest point, and a determination either to a fatal or a favourable issue takes place; and by which therefore the fate of the patient is deter- 54 GENERAL COURSE, &c. OF FEVER. mined. The period during which this decision occurs, is ne- cessarily always short; and is almost universally attended with some evacuation. The most common critical evacuation of a simple febrile paroxysm, consists of a very greatly in- creased flow of perspiration, and hence the subsequent period during which this evacuation is continued, is called the sweat- ing stage, but which I would call— 5. The stage of declension—stadium decrementi morbi.— This stage may be considered as commencing immediately after the favourable crisis has taken place. In the rapid, continued fevers, and in a single paroxysm of an intermittent, one crisis only occurs ; but in by far the greater number of protracted, and especially in remitting fevers, the crises continue to recur through the whole period of declension at every tertian ex- acerbation, until the disease is finally subdued. The duration of this stage is extremely various. In general, the period of declension will be pretty nearly in proportion to the period occupied in the progress of the fever to its acme. The space of time which is occupied by one paroxysm of a fever and its succeeding intermission, or which intervenes be- tween the regular periodical exacerbations of fevers not pa- roxysmal, is called the revolution of a fever. The revolutions of fevers are various in point of duration; some fevers com- pleting theirs in 24 hours, others in 48, whilst others require 74 hours. The form which a fever assumes, in this respect, is called its type; so that a fever which occupies 24 hours from the commencement of one paroxysm to another, is said to be of the quotidian type ; whilst one which revolves every 48 hours, is of the tertian type ; and when this period is extended to 74 hours, the fever is of the quartan type. The quotidian, the tertian, and the quartan types, constitute the three principal and primary tyes of fevers ; all of which are, however, subject to modifications, which may readily mislead the careless ob- server, so as to confound them, or mistake one for the other, especially the quotidian and the tertian. It has been observed, that in fevers of the quotidian type, the paroxysms generally come on in the morning—a circum- stance which has been almost invariably verified in my own experience, and which is indeed so constant, that Cullen was induced to notice it in his definition of a quotidian. Tertians commonly come on towards noon ; but they are much less regular in this respect than the fevers of the pre- ceding type. Two simple tertians sometimes go on contempo- raneously in the same patient; so that instead of the paroxysms recurring only every other day, they occur daily as in a quo- tidian. These cases are called double tertians; and are dis- tinguished from quotidians by the paroxysms of the alternate days being similar in relation to the precise time of their oc- GENERAL COURSE, Sec. OF FEVER. 55 currence, grade of violence, duration, and other circumstances. Thus the paroxysms on the odd days will perhaps recur at 9 o'clock in the forenoon, whilst those which happen on the even days will come on at 2 or 3 o'clock in the afternoon, so that, although each day has its paroxysm, the fever cannot be pro- perly considered as a quotidian, but the contemporaneous pro- gress of two simple tertians, the one having commenced a day sooner than the other. Fevers, however, rarely assume the double tertian type from their commencement. They almost invariably begin and continue for some time in the simple ter- tian type—the duplication occurring afterwards; and when the type thus becomes doubled, the new or accessory paroxysms will generally be considerably milder than those of the original or simple tertian. It is asserted, that a double tertian seldom terminates without first reassuming the single tertian type— the accessory or weaker paroxysm usually disappearing first.* There are other varieties of double tertians mentioned by the older writers, such as the tertiana duplicata, in which two paroxysms occur every second day, and none on the intervening one; the hsemitritxus of the ancients, in which a paroxysm occurs daily, the intermissions or remissions between the first and second, the third and fourth, being much more prolonged than those which occur between the second and third, the fourth and fifth, &c. Authors also mention a triple tertian—tertiana triplex. The quartan type, also, has been known to assume similar modifications. Double and triple quartans are mentioned in the books, and other anomalous varieties of this affection. Before I proceed to the consideration of the particular forms of fever, it will be proper to say something concerning crisis or critical days—a subject which, though but little regarded at the present day, appears to me entirely worthy of attention. It may, I think, be assumed as a safe principle, that doctrines or sentiments, concerning facts which are objects of mere ob- servation and experience, cannot be wholly erroneous or illu- sory, after having obtained the entire confidence, through a series of more than twenty centuries, of a vast number of as accurate and devoted observers of nature as have ever adorned our profession. Without professing a belief in the correctness of the doctrine of crisis, as it was taught by the ancients, and by many of the moderns, we may yet admit, on good grounds, it is conceived, that there exists a natural tendency in the ope- rations of the animal economy, whether in a state of health or disease, to certain periodical fluctuations, which, under particu- lar circumstances, manifest themselves in a way sufficiently conspicuous to exhibit an obvious revolution in the increase and declension of the morbid actions of the animal system. It was *Richter's Specielle Therapie. vol. I. 56 GENERAL COURSE, &c. OF FEVER. early observed that there are certain regular periods in the course of many febrile affections at which prominent changes are wont to occur, preceded generally by a manifest aggrava- tion of the symptoms, and followed or attended by certain evacuations. These evacuations, from their being almost al- ways followed by an obvious abatement in the symptoms, were called critical, and were thought to consist of noxious or febri- fic matters, which were thus thrust out of the system by the sana- tive powers of nature. Fever was supposed to be nothing else than an effort of nature to prepare and cast out of the system the morbific materials which disturbed the regular actions of the animal economy, and that the amendment which ensued was the immediate consequence of such eliminations of morbi- fic matter. At the present day it is, however, more correctly maintained that these critical discharges are the effects, and not the causes of the melioration which occur about the periods at which they take place ; and that they are to be viewed rather as the first manifestations of a favourable change in the condition of the system, than as the immediate causes of such a change. That this is the correct view in relation to the nature of such discharges there can, indeed, exist no doubt; but this view of the subject does not deprive it of its importance, and directs our attention rather to the periodical exacerbations and inherent tendencies in these maladies to terminate their course at one period in preference to another, than merely to the evacuations which are apt to supervene at such times. In no forms of fever, perhaps, are these tendencies to terminate at a certain fixed period more frequently manifested than in intermittcnts. There appears in these fevers a septenary revo- lution, which I have often seen verified in the most unequivo- cal manner. If an ague of the quotidian type be suffered to run on until it terminates spontaneously, the termination will almost universally occur, if it occurs at all, either after the seventh, fourteenth, or twenty-first paroxysms ; and I have repeatedly found that febrifuge remedies exhibited immediately after these septenary periods will arrest it with more certainty, and with much less liability to relapse, than when employed during any of the intervening intermissions. From the same inherent tendency, the relapses which are so common in this disease, will, in a vast majority of instances, occur about the septenary periods from the time of the last paroxysm, and most commonly about the eighth or fourteenth, and sometimes for several periods about the twentieth day—{Jackson,* Spren- gl*A Observation has shown that the crises of fevers happen al- * On the Diseases of Jamaica. t Handbuch der Pathologie; Band. II. p. 171. GENERAL COURSE, $c. OF FEVER. 57 most uniformly on the odd days, reckoning from the com- mencement of the malady. According to the observations of Hippocrates, the crises occur in conformity to the tertian type, until the fifth crisis, or the eleventh day of the fever, after which they observe the quartan type, occurring only every fourth day. It must be observed, however, that these evacuations do not occur exclusively on the days just indicated, for they are some- times, though rarely, found to happen on the intervening days. Galen supposed that when the crisis falls on any other than a critical day, the fever is diverted from its natural tendency by the occurrence of an accidental irritation in some part of the system. Galen divided the critical days into the perfect, the secondary, and the intercurrent. The perfect are those which happen on the seventh, fourteenth, twenty-first, and twenty* eighth days. The secondary, or less perfect, occur on the in- termediate day between each perfect or septenary crisis ; name- ly, the fourth, eleventh, eighteenth, twenty-fifth, &c. days. If, for example, it was observed that a slight deposit in the urine, or a moderate flow of sweat took place on the eleventh day, it was regarded as an indication of a more perfect crisis on the fourteenth day. The intercurrent crises occur on the remain- ing odd days—that is, on the fifth, ninth, thirteenth, &c. Such are the principal points in the doctrine of crisis, as it was taught by the ancients, and more especially by Hippocrates, and his commentator Galen. No one at the present day, however, pre- tends to have observed the many minute distinctions and phe- nomena which are embraced in the ancient doctrine on this subject; indeed there are very few who regard it as at all worth any attention ; and the profession seem long since to have thrown it into the common mass of error and misconception which has been formed out of the wrecks of former systems and doctrines. However antiquated it may appear, at the present advanced stage of our science, to profess some faith in the ge- neral correctness of this doctrine, I cannot, at the risk even of being set down as a cherisher of obsolete and exploded sen- timents, divest myself of the conviction that among much that is erroneous and absurd in this doctrine, there are important and fundamental truths which ought not to he carelessly re- jected. In order to understand the nature of crisis, every fever must be considered as having a tendency to some one of the princi- pal types mentioned above. A simple tertian intermittent may be regarded as the elementary type of fever. In fevers of this type, an exacerbation or paroxysm and a crisis will occur on every odd day ; and if we consider a continued fever as made up of tertian paroxysms prolonged and running into each other, or as possessing a natural, though countervailed tendency to the elementary or tertian type, there will, in like manner, occur 8 58 GENERAL COURSE, &c. OF FEVER. more or less considerable tertian exacerbations, with their ac- companying discharges. From what has already been said concerning the manifest septenary movements of intermittents, the tendency of continued fevers to terminate on the fourteenth or twenty-first days, which can scarcely be denied, would seem to be in conformity to an original law of the animal economy under a state of febrile excitement. The evacuations which usually accompany the crisis of fever are, 1. haemorrhages : 2. a flow of sweat; 3. an increase or changed character of urine; and 4. diarrhoea. Critical haemorrhages are generally attended with an increased action of the heart and arteries, and often with a manifest determina- tion to, and congestion in the part from which the discharge occurs. They must be regarded as mere manifestations of a previous change in the system, and hence this kind of critical evacuation cannot be substituted by an artificial abstraction of the blood; since, although blood maybe abstracted, the peculiar condition of the action of the solids, which constitutes the actual crisis, or change to a favourable tendency, cannot be thus pro- duced. Crisis, by haemorrhage, is generally confined to in- flammatory fever; or, more correctly speaking, to fevers at- tended with an increased activity and action of the heart and arteries. Critical haemorrhages most commonly proceed from the nose, and according to the observations of many of the older writers, are frequently preceded by the dicrotus pulse, in which two distinct wave-like heats occur during each dyastole of the artery. Immediately before the irruption of the blood the carotids beat strongly ; the face becomes flushed ; sparks appear before the eyes; the eyes are red and suffused with tears; and, in some instances, frequent sneezing, and a thin watery discharge from the nostrils occurs just before the haemorrhage appears. Critical sanguineous discharges have also been known to occur from the uterus, the rectum, and sometimes, though very rarely, from the stomach, and even from external parts. Crisis, by an increased flow of perspiration, is by no means uncommon. Catarrhal and rheumatic forms of fever are more apt to terminate by this mode of crisis than any other forms of febrile affection. This discharge is not, however, to be re- garded as indicative of a favourable change in the malady, un- less it be generally diffused over the whole surface, and espe- cially unless it be attended ivilh a turbid slate of the urine, or a copious sediment in this latter evacuation. The surface should, moreover, be soft, and of a natural temperature__that is, not cold and clammy. Crisis by urine, independent of perspiration, is a very un- common mode of termination in febrile complaints. A critical urine derives its favourable character not so much from the GENERAL COURSE, &c. OF FEVER. 59 mere quantity of the evacuation, as from its appearances and the materials with which it is impregnated or mixed. For in- spection, the urine which is evacuated at the termination of a paroxysm, or in the morning, ought to be chosen. In a truly critical urine there may be seen at first a cloud floating in the upper part of the vessel, then a globular body of mucous about the middle, and a sediment at the bottom.* So universal is the concurrence of a critical urine, and a general moisture of the skin, that these two evacuations may be considered as essential- ly connected. A critical discharge from the bowels is less common than those I have already mentioned. It occurs most frequently in bilious fevers, and in such febrile affections as are attended with some visceral disease within the abdomen. These dis- charges do not, however, occur as the others do, in the acme or exacerbations of the fever, but during the periods of re- mission. They are generally very copious. The signs of an approaching crisis by diarrhoea, are a peculiar trembling of the under lip ; stammering speech ; a full and wave-like pulse; pain and rumbling noise in the bowels; discharge of wind; a moist tongue; itching in the nose; paucity of urine, &c. {Richter.) CHAPTER VI. OF INTERMITTING FEVER. Character.—A succession of periodical paroxysms of fever, each paroxysm commencing with chills and terminating in free perspiration, with protracted intervals of perfect freedom from fever. Intermitting fevers occur under the three primary types mentioned in the preceding chapter, and occasionally under the various complications which these types are liable to as- sume. According to the type which they assume, therefore, they are divided into quotidians, tertians, and quartans. The fit or paroxysm of an intermitting fever consists of three distinct periods, all of which are characterized by a series of peculiar phenomena, each succeeding period being the im- mediate consequence of the one which precedes it. * Vogel, Richter, Hufeland. I have frequently noticed these ap- pearances in the urine evacuated after a paroxysm of intermitting fever; and I am well satisfied that it is a common occurrence in the urine dis- charged soon after fevers have commenced to decline. 60 INTERMITTING FEVER. The symptoms which characterize the forming stage of an intermittent paroxysm, do not differ from those which usually precede the development of other forms of fever. A sense of great lassitude, frequent yawning and stretching, a feeling of uncomfortable weariness of the whole body, and slight aching pains in the loins and extremities, constitute the first manifesta- tions of the approach of an intermittent fever. Cold stage.—After the foregoing symptoms have continued for an indefinite time, the patient begins to experience slight and transient sensations of cold along the back ; the fingers and feet also lose their natural temperature and feel slightly benumbed ; the patient becomes restless, and soon tired of the same position; his ideas pass with unusual rapidity through his mind, and he finds himself incapable of fixing his attention upon any particular object. The sensation of chilliness, with more or less rapidity, extends itself from the extremities over the whole body ; the skin becomes universally pale, con- tracted, and rough; the pulse loses its activity and size, be- coming small, contracted, frequent, and firm. When the sense of chilliness has passed from the extremities to the body, a slight trembling of the muscles begins, generally, at first, in the jaws, and extending thence quickly over the whole frame. This trembling is sometimes so severe as to agitate the patient as if he were in a paroxysm of convulsions, and sometimes ex- hausts him so much as to leave him scarcely able to move his limbs after their subsidence. These tremours are technically called rigors. During the chills the sensibility of the surface is benumbed, and the whole body becomes diminished in volume, so that rings which were previously tight drop from the fingers. The breathing also is hurried, anxious, and op- pressed, and frequently attended with a short dry cough, deep sighing, and a sense of weight and tightness in the chest. Along with these symptoms there occurs usually much dejec- tion and confusion of the mind, and, in some instances, a slight degree of delirium. In very debilitated persons a violent fit of rigors often induces a complete state of stupor or coma, more especially when feebleness of body is attended with general plethora. In many instances, frequent and distressing vomit- ing occurs, particularly about the period of its subsidence, and the ejections are generally bilious, though occasionally ropy, transparent, and insipid. The thirst is always urgent in this stage, and the mouth and fauces are dry and clammy. The urine is clear, colourless, without sediment, and often copious. Generally the chills are universally diffused over the body; but in some cases they occur partially, remaining confined to one or more parts of the body ; and instances have been re- corded, in which a single extremity only was affected with the chills. In some cases of intermitting fever, the cold stage is INTERMITTING FEVER. 61 attended with but a very slight sensation of chilliness creeping along the back and over the extremities; and I have known this stage to commence with violent vomiting, and to terminate speedily in stupor and partial insensibility. The duration of the cold stage is very various, ranging from a few minutes to four or five hours. Sooner or later, however, the chills begin to abate; transient flushes of heat pass over the face and body; the chilliness now recedes rapidly, and the heat encroaches paripassu, until it has obtained an entire ascendency. At this time the nausea and vomiting are usually most severe—both of which often continue until the hot stage is completely deve- loped. The hot stage is characterized by a full and flushed counte- nance ; an intensely hot and dry state of the surface of the body; great thirst and dryness of the mouth ; great acuteness of the sensorial powers ; a full, strong, and frequent pulse ; a more free and regular respiration than in the preceding stage, though still more oppressed and hurried than natural; great pain in the forehead ; pain in the back and extremities; some- times slight delirium just before the commencement of the succeeding stage ; a scanty and deep-coloured urine without sediment. This stage is as various in its duration in different cases as the preceding one. It continues, however, almost al- ways much longer than the cold stage. The temperature of the skin is always very considerably augmented. Fordyce observed it as high as 105° of Fahrenheit. This stage termi- nates in the last, or— The sweating stage.—When the perspiration begins to ap- pear, an obvious abatement of all the febrile symptoms occurs. The sweat appears at first about the head and breast, and thence gradually extends over the whole surface of the body. On the appearance of this evacuation, the pulse loses its hardness and frequency, but still retains its fulness. The breathing at the same time becomes free and natural; thefebrile heat sub- sides rapidly; and the urine, though still very high-coloured, deposits a lateritious or pale-red sediment. This gradual me- lioration of the febrile symptoms, continues under the free flow of the perspiration, until the paroxysm terminates in a state of perfect convalescence or apyrexia. The apyrexia, or intermission, though entirely free from fe- brile phenomena, cannot, however, be regarded as a state of health ; for during this interval, the patient usually feels some degree of langour ; becomes easily fatigued ; complains often of a want of appetite, and an indisposition to bodily or mental exertion. He possesses, moreover, an unusual degree of sensibi- lity to the impressions of cold air; and his countenance ex- hibits a pale and sickly aspect. In some, though compara- tively speaking few instances, the appetite is good, and the 62 INTERMITTING FEVER. patient experiences no feelings of indisposition whatever dur- ing the intermission. The more conspicuous the symptoms of imperfect health are during the intermissions, the more dif- ficult, in general, will it be to prevent its recurrence; or, the more readily will it relapse after it has been suspended. Intermittents do not, however, always pursue the regular course that has just been described. In some instances, anom- alies of a remarkable character occur, both in relation to the phenomena, and the succession of the stages of the disease. I have known a case, in which the two first paroxysms occurred, in a perfectly regular manner; but after employing arsenic, un- successfully, during the second intermission, the paroxysms returned without a cold stage, the patient having experienced, instead of it, a peculiar feeling of numbness on the top of the head, with great dulness of hearing, for about forty or fifty minutes, before the supervention of the hot stage. There are instances on record, of the inversion of the natural order of the cold, hot, and sweating stages ; several distinct instances of which occurred under my observation in the fall of 1828. Cases have been noticed, in which the perspiration, in the third stage, was substituted by diarrhoea; and Cleghorn states, that he saw tertians, which terminated by an increased flow of urine, with scarcely any sweat. A variety of other anomalous oc- currences are related in the hooks, concerning the phenomena and progress of this disease, which it would be altogether useless to repeat in this place. There are certain affections, not of unfrequent occurrence, which, from their strict periodicity, as well as from their ap- parent origination from the same causes that give rise to inter- mittents, are termed masked agues, febres intermittentes lar- vatx. Thus, baemicrania, tooth-ach, cramp in the stomach, dysentery, cholera, hiccough, mania, and acute pains in other parts of the body,* have been known to recur in a manner strictly periodical, and to have yielded readily to the same remedies which are found to arrest the course of an ague. These affections, when thus perfectly periodical, generally manifest their alliance to intermitting fever, by being almost always preceded by a very slight sensation of chilliness, and by being attended with a moist skin and a turbid urine at the termina- tion of the paroxysm. (Richler.) In infants, the paroxysms of intermitting fever are sometimes ushered in by convulsions ; but the convulsions are most apt to occur at the commencement of the hot stage. Indeed, the cold stage of very young children is seldom marked by dis- * Jour. Gen. de Med. No. 291, foot-note. See also Gazette de Sante, No. 17. INTERMITTING FEVER. 63 tinct rigors. A pale and shrunken countenance, with an obvi- ous reduction of the temperature of the surface, yawning, and stretching, usually manifest the presence of this stage in infants. Intermittents of every type are subject to certain prominent modifications in relation to their general character, which as they have important practical bearings, deserve particular at- tention. We meet with intermittents, for instance, which are attended with unequivocal manifestations of an inflammatory character; others occur, in which symptoms of great inter- nal venous congestions are equally conspicuous ; a third varie- ty of intermittents will exhibit strong symptoms of biliary and gastric irritation ; and a fourth variety will be charac- terized by phenomena indicative of a more or less malignant character. According to these circumstances, intermittents may, therefore, be divided into the four following varieties: viz. 1, the inflammatory; 2, the congestive; 3, the gastric; and 4, the malignant intermittents. 1. Inflammatory intermittents occur most frequently during winter and in spring. Quotidians are more apt to assume this character than tertians ; and tertians, more apt than quartans, (Richter.) In young, robust, and plethoric subjects, vernal quotidians, are especially prone to manifest inflammatory symptoms. Intermittents of this character, generally begin with strong rigors. In the hot stage, the temperature of the surface is very intense, and the pulse is peculiarly strong, hard, and full. The most characteristic marks of inflammato- ry intermittents, occur however during the intermission. How- ever profuse the perspiration in the last stage, the apyrexia does not become complete. The pulse remains quick, some- what tense and accelerated; the thirst is still considerable, and the skin dry and warmer than natural; the whole system is irritable; the temper is fretful or discontented ; slight head- ach is experienced; and transient pains are often felt in the extremities and the back. In many instances a short and dry cough occurs, with some oppression in the chest, or other pec- toral affections. Richter observes, that inflammatory intermit- tents are very rarely attended with symptoms of gastric dis- turbance from vitiated secretions, bile, &c. The intermissions in agues of this kind are usually short. (Richter.) 2. Congestive intermittents occur seldom. They happen generally in persons of exhausted and debilitated habits; and in such as are of an irritable and nervous temperament, con- nected with habitual or accidental debility. They are charac- terized by a very protracted cold stage, deep-seated pain in the head, vertigo, fainting, a sense of weight or oppression in the breast, coma, a small and weak pulse ; the hot stage com- ing on very slowly, and developing itself very imperfectly, so 64 INTERMITTING FEVER. that instead of hot skin, flushed countenance, and a full and vigorous pulse, the system continues to be oppressed, the skin scarcely warm, the countenance pale and contracted, the breathing confined and anxious, and the pulse frequent, small, and tense, with an internal sensation of heat. 3. Gastric intermittents are characterized by prominent symptoms of gastric and intestinal irritation, redundancy of biliary secretion, and other saburral matters lodged in the ali- mentary canal. The ordinary intermittents of the temperate climates, occurring in autumn, are usually of this kind. Inter- mittents of this modification, are attended with a foul and bit- ter tongue; much nausea and bilious vomiting; great pain in the forehead ; diarrhoea, an icteric hue of the skin and albugi- nea ; urine loaded with bilious matter ; thirst for acid drinks, and sensation of weight or fulness in the right bypochondrium. Intermittents of this kind are apt to produce visceral disorders, more especially indurations of the spleen and liver ; and final- ly a cachectic condition of the system which it is often extreme- ly difficult to remove. (Richter.') 4. Malignant intermittents are of frequent occurrence in hot climates, and are always of the most dangerous character. They are characterized by a very copious and fetid perspira- tion in the third stage, together with colliquative haemorrhages from various parts of the body, sometimes petechia, and other marks of malignity. They run their course with great rapidity, death usually taking place in the third paroxysm. (Jllibert.) Intermittents are sometimes complicated with other affec- tions, such as dysentery, cholera, jaundice, and visceral inflam- mations. The vernal intermittents are most apt to become complicated with inflammatory affections; and those which oc- cur in autumn are most frequently combined with disorders of the alimentary canal. Many of the concurrent and adventitious affections which happen in intermittents, are produced by the remote febrific cause; whilst others, such as jaundice, scirrhous, and dropsy, are evidently the result of the fever itself. Broussais affirms that of all causes, intermittents are most apt to produce aneu- rismal enlargements of the cavities of the heart and large in- ternal vascular trunks. (Hist, des Phlegmas. vol. I. p. 149.) But if intermitting fever has a tendency to produce other af- fections, it has been found also to remove various diseases of a chronic and obstinate character. Celsus observes, that in- termitting fever is often remedial of itself. (Lib. II. cap. 8. p. 70.) The tendency of quartans to cure epilepsy, is mention- ed by Hippocrates; (Epidem. 1.) and we are told that the ce- lebrated mathematician De la Hire, was permanently relieved of an habitual and most violent palpitation of the heart, by an attack of ague of the quartan type, (Academ. des Sciences, INTERMITTING FEVER. «3 PAn. 1718. Hist. p. 110.) Fordyce states that rheumatism, cutaneous eruptions, hysteria, and indigestion, have been effec- tually removed by attacks of intermitting fever; and Vogel 6tates that he has known asthma and hypochondriasis cured by this disease. Almost all writers, however, attribute much more sanative power in this respect to quartans, than to either of the other two types. Intermittents, when suffered to pursue their course without being controlled or embarrassed by external influences, appear to have a natural tendency to terminate spontaneously, after a certain number of paroxysms have been passed through. Quo- tidians, for instance, if they are simple and regular, will tend to terminate their course on the seventh day, and tertians on the fourteenth. Quartans will generally run on to the sixth week. Of the natural tendency of the two former types to terminate at about the periods just indicated, I have the strongest con- viction from my own observations. The disease may not ge- nerally terminate spontaneously at these periods, but its ten- dency to do so will be such, that if assisted by a proper febri- fuge, it will not only most certainly be arrested, but a relapse will scarcely ever occur, unless the remote cause continues to act on the system. Every one who has had considerable ex- perience in the treatment of intermittents, must have been struck with the great frequency of relapses, even where the patient has been removed out of the sphere of the influence of the remote cause. From what I have observed in relation to this subject, I will venture to say, that if the usual febrifuges were withheld until after the seventh paroxysm, such an occur- rence would, under all circumstances, be comparatively very rare. I have already adverted to the tendency of intermitting fevers to relapse at stated intervals; and although I cannot undertake to reconcile the apparent opposition in these state- ments, namely, that fevers of this kind tend naturally to ter- minate, and also to relapse at the septenary periods; yet of the truth of the observation I entertain the strongest convic- tion. Prognosis.—The intermittents of the temperate climates are among the least dangerous of febrile affections. In hot lati- tudes, however, they often assume a highly malignant and fatal character. Death from a simple and mild intermittent does nevertheless sometimes occur; and when this happens, it is nearly always jn the cold stage, and under symptoms of apo- plexy. I have met with two fatal instances of this kind. The violent internal congestions which occur during the cold stage, are well calculated to produce cerebral oppression and apo- plexy, particularly in persons who are naturally predisposed to this malady. In general, much less danger is to be appre- hended from this disease in the young, robust, and vigorous, 9 ft« INTERMITTING FEVER. than when it occurs in persons of feeble, nervous, and deprav- ed habits of body. In individuals of this latter habit, there is sometimes not sufficient vital energy to react and develope the hot stage, and they occasionally sink into a state of lethargy or fatal apoplexy. The more irregular an intermittent is, in relation to its type and particular phenomena, the more diffi- cult in general it is to effect a permanent cure. Postponing agues are more favourable than such as anticipate their pa- roxysms. The latter tend to the continued form. A scabby and humid eruption about the mouth and nostrils is a favour- able sign. When hahital discharges, whether natural or morbid, re-appear after having been suppressed by the ague, perfect convalescence generally soon follows. The state of the digestive functions has an important bearing on the prognosis of intermittents. So long as digestion is performed with con- siderable activity, and there are no decided marks of gastric irritation, very little difficulty in general will be experienced in removing the disease. But when these functions are pro- minently deranged, and there are marks of much debility of the stomach, we may calculate on meeting with considerable difficulty in preventing the return of the paroxysms; for even should a temporary stop be put to the progress of the disease, the liability to relapse in this state of the digestive apparatus, is such as to render the best directed treatment often abortive. Delirium seldom occurs in intermittents, and when it does, it must he viewed as unfavourable; and even more so than mere coma. In malignant intermittents delirium is common, indeed it may be regarded as almost peculiar to the worst va- rieties of this disease. Difficult and oppressed breathing, at- tended with hiccough and frequent deep sighing, is a bad sign. Sydenham observes, that a tumid and hard abdomen, with swelling of the tonsils, is in general indicative of a fatal ter- mination. One of the most unfavourable signs is a profuse and prolonged colliquative and offensive diarrhoea. Bloody urine also is very unfavourable. These latter symptoms are almost exclusively confined to the violent intermittents of hot climates. When, during the intermission the patient remains very much debilitated and oppressed, and the feet and legs are (edematous, considerable danger may be justly apprehended. Tertians are in general more readily removed than quotidi- ans, and quotidians than quartans. Intermittents not unfre- quently change into the remittent form, and this conversion is of course always an unfavourable occurrence. When such a change is about to happen, the paroxysms of the intermittents are progressively prolonged until they run into each other. Simple tertians always reduplicate their type before they can assume the remitting form. The conversion of intermittents into £Ju« rsmittent form, is particularly favoured by whatever is est- INTERMITTING FEVER. 67 pable of causing or augmenting the general phlogistic con- dition of the system, and especially by the accidental superven- tion of some internal inflammation. The unseasonable em- ployment of tonics and stimulants is frequently productive of such changes in the form of the fever. Causes.—The only general cause of intermitting fever is koino-miasmata. Intermittents are the simplest, and in ge- neral the least dangerous of all the febrile diseases produced by this variety of miasmata. In the vicinity of marshes, wc may often trace the various grades of miasmatic fevers from the most violent and fatal to the simplest and mildest varieties, as we progressively remove from the focus of the deleterious exhalations towards the circumference of its influence. On the borders of the soil, whence the miasmata emanate, if they be very copiously engendered, continued and highly fatal cases of bilious fever will prevail; at a greater or less distance from this point, mild remittents will predominate; and at a still more remote situation, intermittents will be most common. From the same circumstance, the first diseases which occur in miasmatic districts are generally intermitting fevers; as the season advances, remittents occur and finally prevail with great violence; as the cold weather approaches, and the extri- cation of miasmata begins to diminish, intermittents again be- come more common, and the remitting fevers gradually disappear. The tendency of koino-miasmata to produce intermittents, is much enhanced by sudden changes of atmospheric temperature. Intermittents are never more prevalent than when the days are very warm, and the evenings and mornings cool and damp. In some instances, several weeks elapse between the reception or impressions of the miasm, and the occurrence of the fever. I have repeatedly known persons to be attacked with intermit- ting fever in this city, several weeks after they had been ex- posed to koino-miasmata in the country. Persons who have been exposed to miasmata, ought to be careful to avoid every thing capable of debilitating the system, and particularly the digestive organs, for at least two weeks after. Although koino-miasmata may be regarded as the universal cause of intermitting fever, yet various other causes may, un- der favourable circumstances, give rise to this form of fever. Richter observes, that worms and other causes of intestinal irritation have been known to produce intermitting fever. He mentions also suppressed catamenia, and haemorrhoidal dis- charge, as well as the drying up of old ulcers, as occasional causes of intermitting fever. I have seen one instance, in a delicate child, where a distinctly formed ague was manifestly produced by intestinal irritation from too free an indulgence in irritating articles of food. An interesting case is related by 68 INTERMITTING FEVER. Mr. Earle,* in which a regular intermittent was produced by the irritation of a small piece of dead bone in an old wound, and which was at once arrested on removing the irritating substance. Proximate cause.—In relation to the proximate cause of this form of fever and of its periodicity, we may at once con- fess our entire ignorance; for all that has hitherto been ad- vanced in relation to these mysterious subjects, amounts to nothing more at best than some exhibitions of ingenious con- jectures and hypothetical speculations, with a great deal of crude and absurd reasoning and idle suppositions. As to the sentiments of Broussais, which place the proximate cause of this and all other fevers in an inflammation of the mucous membrane of the alimentary canal, it can neither be profitable nor interesting to repeat again what I have already advanced in refutation of its correctness. Treatment.—The treatment of intermittents must be con- sidered under two distinct heads: namely, that which is proper during the paroxysm ; and that which is to be employed during the intermissions, and upon which the radical cure of the dis- ease depends. In the ordinary regular intermittents of the temperate lati- tudes, remediate interference during the paroxysm of the dis- ease is extremely uncommon, and is indeed very generally altogether unnecessary. Nevertheless, where the febrile ex- citement becomes very violent in the hot stage; or where the system is so enfeebled that dangerous congestions and oppres- sion occur during the cold stage, medicinal aid is not only proper, but sometimes absolutely essential to the safety of the patient. During the cold stage of an intermittent, the patient ought to be kept moderately warm ; and as the thirst is gene- rally very urgent, bland and warm drinks should be freely allowed. In general, however, stimulating drinks, and the application of much artificial heat, with the view of moderat- ing the distressing sense of cold, are improper; since they ve- ry rarely lessen the feeling of chilliness, and tend often con- siderably to increase the violence of the succeeding hot stage. These observations apply to the regular disease occurring in individuals of sufficient vital energy to develope the hot stage without any artificial support. When the patient is feeble, nervous, or exhausted, it will generally be beneficial to aid the vital powers during the cold stage, both by external and inter- nal exciting agents, more especially by the applications of ex- ternal heat. Without such aid, the cold stage will probably be greatly prolonged, and the system so oppressed by internal congestions, as to prevent the regular development of the sub- sequent stages. * Medico-Chir. Review, January, 1827. INTERMITTING FEVER. 69 Various means have been adopted for the purpose of curtail- ing the cold stage; of these, emetics and opium appear to be the most efficient. An emetic administered at the beginning of this stage will frequently put a speedy termination to its pro- gress ; and a full dose of opium taken a short time before the expected occurrence of the chills, will generally have the same good effect. This latter remedy was particularly recommended by Dr. Trotter; and other eminent physicians have given their testimony in its favour. In debilitated and relaxed habits, the exhibition of a grain or two of this narcotic, just before the accession of the chills, will generally prove decidedly be- neficial. I have frequently resorted to it in cases of this kind, with obvious advantage. In persons of a full and vigorous habit of body, however, it will rarely do any siood, and may readily do mischief by increasing the violence of the reaction, and of the determination to the brain in the hot stage. Com- pression with the tourniquet, also, was some years ago strong- ly recommended to the profession, as a means for arresting the cold stage of intermittents, by Dr. Kellie.* I have known it to be employed in four cases, and although the effects of it were by no means equal to those which Dr. Kellie ascribes to it, there was nevertheless a manifest impression made in the violence and progress of the chilis. Dr. Kellie asserts, that by obstructing the circulation in this way in an upper and in a lower extremity, by means of a tourniquet, we may in ge- neral stop the cold stage in three minutes ; and that if the compression be made immediately previous to the accession of the cold stage, it will be entirely prevented. The limited ex- perience which I have had in relation to this practice, does not confirm this very favourable account of its effects; although some, and occasionally perhaps considerable advantage may, no doubti be obtained from it. I should apprehend, however, that in vigorous and plethoric subjects, considerable danger must attend this practice, from the tendency which it must have to favour vascular turgescence of the brain; and thereby dan- gerous oppression or apoplexy. ... . , Within the last two years, Dr. Mackintosh has published some highly interesting observations on the utility of blood- letting in the cold stage of agues, which, although contrary to the sentiments universally entertained concerning the charac- ter of this condition or stage of febrile development, and the known tendency of blood-letting, are nevertheless too strongly confirmed by well attested facts to admit of being rejected with- out being duly tested. "There are few things," says a late writer, " more repugnant to the imagination of a medical man ♦Medical Commentaries for the years 1794-1797, by Dr. Duncan of Edinburgh. 70 INTERMITTING FEVER. than that of venesection in the cold stage of intermittents. Books and lectures all inculcate a diametrically opposite prac- tice. We see the face and the surface of the body pale and cold; the pulse feeble and quick; the teeth chattering; the whole body shivering; and the suffering patient huddling him- self up in all the clothes he can find to keep the spark of life from being extinguished! The very idea of abstracting the vital fluid, which seems almost entirely to have vanished, is horrible. But yet, when we come to reflect that the blood has only shifted its place from the circumference to the centre, and that the internal vessels and organs must now be gorged with this fluid, and as it were in a state of suffocation, there is no- thing very incongruous in the attempt to relieve the suffering organs, by abstracting a portion of blood from the general cir- culation." Moreover, when we advert to the circumstance that blood-letting has been strongly recommended and suc- cessfully employed, to remove the internal congestions which occur in typhus fevers, where there is generally an actual de- ficiency or impairment of the vital energies, it does not appear so very extraordinary, that the same means should be adequate to restore the equilibrium of the circulation, or to remove the internal congestion in an ague, where the vital powers are not impairedbut only oppressed. Dr. Mackintosh states, " that he has seen men in the most severe sufferings from the chills, re- lieved after the abstraction of six, eight, and ten ounces of blood ; and he has known three ounces to suffice. The relief, which is the most perfect relief that can be conceived, is so sudden, when a good orifice is made, that it has surprised and delighted every one who has seen this practice." Dr. M. had this practice tried on himself in 1810; and, although bark and other remedies had entirely failed, he found that before twelve ounces of blood were drawn, " the rigors ceased with all their unpleasant accompaniments," and neither the hot nor the sweating stage ensued. " A pleasant sense of heat succeeded the painful one of cold ; and, instead of weakness, he was sen- sible of an acquisition of strength." He afterwards bled many other patients in the cold stage of this malady, and uniformly with the same favourable results. This practice was put in operation in the Royal Ordinance Hospital, of Edinburgh, in the presence of many medical gentlemen, and must, therefore, be regarded as amply attested.* In a single instance I have drawn blood in the cold stage of this disease ; and, in this case it moderated the violence of the chills and curtailed their dura- tion in a manifest degree. I have not since had a favourable opportunity of repeating this practice, but from the result of * Ed. Med. and Surg. Jour. April, 1827; and Medico-Chir. Rev. 1827, page 186. INTERMITTING FEVER. 71 this case, and the strong testimony of Dr. Mackintosh, I feel entirely inclined to give it a further trial whenever an oppor- tunity of doing so shall present itself. Dr. M. thinks, that " this practice may be advantageously adopted in the first stage of all fevers, and probably will be found useful in concussion of the brain." In the hot stage, it sometimes becomes necessary to moderate the violence of the febrile excitement, especially when delirium or alarming local determinations take place. Blood-letting is of course the most direct and efficient means for this purpose, and where the indications for antiphlogistic measures arc strong, it ought to be promptly employed. In agues of a de- cidedly phlogistic diathesis, blood-letting during the hot stage will often contribute considerably to the successful employment of the bark in the intermission. I have sometimes known the bark promptly efficient in arresting the disease after a copious blood-letting during the paroxysm, although it had previously failed entirely. In all cases where the skin is very hot and dry, and the pulse vigorous, cool, bland, and acidulated drinks are both grateful and salutary. A draught of cold water, so long as the skin remains dry, will often speedily subduct the febrile heat, and predispose to perspiration. It may also be proper in some instances of very high general febrile excitement, to ex- hibit some of the refrigerent diaphoretics—such as nitre—anti- mony—the saline effervescing mixture. So soon, however, as the skin begins to be moist, cold drinks must be withheld. Dur- ing the last or sweating stage, we may allow tepid drinks of a bland character freely. When the stomach is extremely irritable—giving rise to fre- quent and violent vomiting in the cold or hot stage, tepid dilu- ents should be given until there is reason to think that the bile is discharged,—opium is perhaps our best remedy for checking excessive vomiting in this disease. This article does not often aggravate the violence of the reaction, when given in the hot stage, as might be expected. Indeed, Dr. Lind zealously ad- vocates the propriety of exhibiting a full dose of opium soon after the hot stage is developed, as a general practice. He as- serts, that it takes off the burning heat of the fever, hastens the accession of the sweating stage, and often produces a soft and refreshing sleep, from which the patient awakes free from all complaints and in full perspiration. He thinks, moreover, that the use of opium in the hot stage, tends to obviate dropsy and jaundice. I have given opium in the hot stage to check vomiting, and have always found it to answer this purpose very promptly and completely, without any unpleasant conse- quences. I cannot, however, think that opium is a proper re- medy in the hot stage of ague, unless it be in broken down consti- tutions, or in such as are feeble and exhausted by previous inju- 72 INTERMITTING FEVER. rious influences—or unless it be employed to remove some accidental affection of a distressing or dangerous character. In cases where the reaction of the heart and arteries is incom- plete, and in which much internal congestion continues through this stage, opium is, without doubt, a valuable remedy. To put a stop to excessive vomiting in this, as well as in other diseases, not connected with phlogosis of the mucous mem- brane of the stomach, I know of no medicine which is so promptly and certainly effectual as a solution of camphor in the sulphuric aether, in the proportion of two scruples of the former to an ounce of the latter, of which 20 or SO drops may be given with about ten grains of calcined magnesia every half hour until the vomiting is arrested. I have rarely found the second dose necessary. Whatever advantages may result from remediate treatment during the paroxysm, however, universal opinion concurs in regarding the intermission as the proper period for the safe and certain radical treatment of intermitting fevers. In pre- scribing for the radical cure of intermittents, it is of no small consequence to attend to the particular character of the disease in relation to the four modifications or varieties mentioned above; for each of these requires some peculiar modifications of treatment. 1. The inflammatory variety, as has already been stated, is marked by symptoms during the intermission, which indicate an irritated and phlogistic condition of the system incompatible with the salutary influence of bark and of the other febrifuge remedies of this kind. In cases of this modification, a strictly antiphlogistic treatment must precede the employment of the tonics usually resorted to for the cure of the disease. The pa- tient must be put under an antiphlogistic regimen ; one or two cathartics, composed of calomel and jalap—or calomel suc- ceeded in a few hours by an ounce of Epsom or Glauber's salts, will be proper; and where the inflammatory diathesis is very conspicuous, blood-letting, nitre, antimonials, &c. are often indispensable. In cases of this character, the blood-letting will, in general, be most efficient in reducing the phlogistic habit when it is practised pretty copiously during the hot stage. In some cases of vernal intermittents, in which the bark or qui- nine had failed in consequence of the general irritated and phlo- gistic condition of the system, I succeeded perfectly with these febrifuges after the patient had taken one of the following pow- ders* every two hours during an intermission, and a small bleeding in the hot stage of the succeeding paroxysm. In the congestive and malignant varieties of ague, it will * R. Pulv. nitrat. potassae 3iss. pulv. doveri gr. vj. calom. gr. vj. M. In chart. No. vj. dividend. INTERMITTING FEVKR. 73 seldom be proper to lose much time in preparing the system for febrifuge tonics. In such cases the powers of the system must be economised, and tonics early and liberally resorted to. In the gastric modification, which is the one generally met with in the temperate latitudes, there exist obvious indications of gastric impurities and disorder—such as nausea ; bilious vomiting and purging; foul tongue; loss of appetite; pains in the stomach and bowels; bitter or depraved taste, &c. In intermittents of this character, much advantage will in general result from a pre- vious attention to the state of the alimentary canal, before the bark or other remedies of this kind are resorted to. Mild mer- curial purgatives are generally decidedly beneficial. In some instances, it may be necessary to repeat them several times before the bowels are brought to a proper state for the employ- ment of febrifuges. Emetics, too, will often contribute much to the success of the bark or quinine. In intermittents of a well-formed inflammatory character, there are seldom any un- equivocal manifestations of gastric impurities, and hence these evacuants are much less useful or important in them than in the variety I have termed gastric. Among the various articles which have been recommended for the cure of intermittents, the Peruvian bark and its prepa- rations, is, unquestionably, by far the most important. With- in the last ten years, the sulphate of quinine has, in a great measure, taken place of the bark in substance, and in many respects, this preparation possesses important advantages over the crude material. It has indeed been said, that the bark it- self will sometimes remove the disease where the quinine has failed; but the converse may be said with equal correctness; for I have, in several instances, succeeded with the latter after the former had been used in large doses without success. Mr. Valpes, of Naples, in a recent communication to the French Royal Academy of Medicine, states as the result of his inqui- ries, that the sulphate of quinine is preferable to the cinchona, in intermitting fevers, whilst the latter is preferable in the fevers formerly denominated putrid,* and which are produced by idio-miasmata.f From my own experience, I have not been * Revue Medicale, Mai, 1828, p. 306. t In March 1825, the number of lunatics brought to the Maison d'Aversa in the kingdom of Naples was so great, that it was found ne- cessary to lodge tbem in a convent, which was not properly prepared to receive them. The most filthy of these unfortunate beings were put into a small dormitory which was in a state of extreme filthiness. A fever soon broke out among tbem, which was at first regarded as a petechial fever, and was treated by antiphlogistics. The disease made a rapid progress, and became unusually fatal. The sulphate of quinine was final- ly employed, but this appeared rather to aggravate the symptoms, than to afford any advantage. At last, the bark in substance was given, and immediately resulted in the happiest effects.—Revue Medicale, 1828. Mai, 306. 10 74 INTERMITTING FEVER. led to think that there exists any essential difference in the fe- brifuge virtues of these two remedies; hut as the quinine is much less nauseous, and can be given in sufficient doses in a very small bulk, I should, from these advantages, always pre- fer it to the bark in substance, unless some idiosyncracy exist against its remediate influence, which can be ascertained only from experience. Much difference of opinion has been expressed, both in rela- tion to the period of the disease, and the particular time of the intermission, at which the bark may be most effectually admi- nistered in this form of fever. It has been contended, that it will generally be much better to suffer several paroxysms to take place, before any attempt is made to arrest their recur- rence. Recamier has recently advocated this practice, as both the most effectual and the safest to the future health of the in- dividual. I do not at all doubt the correctness of this mode of management. Unquestionably, a great majority of our or- dinary agues may be immediately arrested by giving the bark, during the first or second intermission, with perfect safety; but where this is generally done, relapses are much more common than where the disease has been suffered to run on to the fifth or seventh paroxysm. I have found agues which were arrested after the first or second paroxysm, relapse again and again, until they were suffered to run on to the fifth or seventh day, when a few doses of quinine put a permanent stop to their progress. For five or six years past, whenever I have met with a case of ague which, though arrested by bark, always relapsed again, (which generally occurs about the seventh or fourteenth day,)* I have suffered the disease to run on for at least five paroxysms, and in a few instances, over the seventh, before any attempt was made to check it; and I have invaria- bly found this plan permanently successful. In cases which require preparation, especially in inflammatory intermittents, delay is of course essential, before the bark can be employed with propriety. I would not, however, lay it down as a ge- neral rule, that the disease should be suffered to run on through five or seven paroxysms; for where the apyrexia is very com- plete, and the patient experiences no feelings of illness during the intermissions, the bark may almost always be given with complete success, as soon as the bowels are evacuated by a suitable catharticf In instances of an opposite character, or such as have shown a tendency to return after a week or * Pringle says, that tertians are apt to relapse after the seventh, and quotidians after the fourteenth day. Hanbuch der Pathologie, Band II. p. 171. According to the observations of Jackson, the relapses usually occur on the even days—particularly on the 8th, 12th, 14th, and 20tb.— See his work on the Fevers of Jamaica. f R. Pulv. jalap.. . Calomel aa. gr. x. M. INTERMITTING FEVER. 75 two, it will almost be in vain to expect to put a final stop to the paroxysms, if the febrifuge be employed during the first or second intermission. A case came under my notice during the preceding autumn which had already relapsed four times, and always punctually on the seventh day. After each relapse, the patient took quinine in full doses, which always immediately arrested it for the short period mentioned. When he applied to me, I advised him to suffer his disease to go on for some time, without any other medicine than a mild purge every other day. He did so; and on the ninth day, the disease left him sponta- neously and permanently. The foregoing observations apply, of course, to the regular intermittents of the temperate latitudes; for, in that rapid and fatal variety which is termed malignant, no time ought to be lost by preparatory measures, but immediate recourse had to large and frequent doses of the bark as soon as a favoura- ble intermission occurs. The same rule applies to those cases which occur in very feeble, nervous, and exhausted subjects; for, unless the disease be speedily removed, the system may sink under the repeated shocks of the paroxysms. With regard to the particular period during the intermission at which the bark may be most successfully given to arrest the succeeding paroxysm, a diversity of sentiments have been ex- pressed by writers. Some have advised its employment in large doses immediately after the sweating stage has passed off; whilst others recommend it to be given largely, " as near to the time of the expected paroxysm as the condition of the patient's stomach will allow," (Cullen.) There are others, again, who think it best to exhibit the bark in divided and frequent doses throughout the whole period of the intermission, (Fordyce.) A few years ago, Dr. Ridgway published some cases which go to show that one large dose of cinchona given as near as possible to the commencement of the approaching paroxysm will as certainly avert the paroxysm, as if it be given in repeated doses throughout the intermission.* Since Dr. Ridgway's publication, Dr. Brown, of Boston, has published a small work, in which he adduces testimony of a similar pur- port.! According to Dr. Brown's experience, two or three grains of the quinine taken just as the first symptoms of the approaching paroxysm are experienced, will, when followed up at intervals with a second, third, aud sometimes a fourth dose, almost invariably put a stop to the disease. When given just as the cold stage commences, " its influence over the rising symptoms becomes manifest in a few minutes; the pulse becomes * London Medical and Physical Journal for April, 1825. t A Treatise on repelling the Paroxysm of Intermitting Fevers. Bos- ton, 1826. 76 INTERMITTING FEVER. more full and distinct; the respiration more easy ; the skin ac- quires its natural temperature ;" and, in eleven minutes, in his own case, " not one unpleasant symptom remained." This state, however, generally continues but a short time, and it becomes necessary to repeat the dose, sometimes three and even four times before* the paroxysm is subdued. Dr. Ridgway gave an ounce of the bark at once, as soon as the premonitory symptoms of the paroxysm were felt, and always found it to prevent the attack. There can be no doubt that the disease may be speedily arrested in this way ; but it may be reasonably ques- tioned, whether it possesses any real advantages over the plan of exhibiting this febrifuge in efficient doses during the latter period of the intermission. For the last three years I have gene- ral ly prescribed the quinine in two grain doses every hour, com- mencing about six hours before the beginning of the approach- ing paroxysm ; and I have had no cause to be dissatisfied with the consequences. Indeed, 1 have reason to apprehend that a large dose of quinine given during the chills, is calculated to produce some very disagreeable effects. In two instances,one a delicate married lady, and the other a lad about twelve years old, a most singular and raving species of maniacal affection ensued, apparently from taking large doses of this medicine after the chills had commenced. In both instances this alarm- ing mental disturbance continued for several hours. I may be wrong in ascribing it to the causes here assigned, but the cir- cumstances strongly favoured the suspicion. Whatever views we may adopt, however, with regard to the time at which it may be best to begin with the bark or quinine, there can be no doubt concerning the propriety of giving large doses,* in such a manner as to make a decisive impression on the system in the latter periods of the intermission. I am well satisfied that two or three large doses—three grains of the qui- nine, given two or three hours before the paroxysm, will do more towards averting it than a larger quantity exhibited in small doses throughout the whole interval of the apyrexia. In relation to the propriety of employing emetics and cathartics as preparatory measures for the use of the bark, authors express contradictory opinions. Unquestionably, where the signs of gastric impurities are conspicuous, and there exists no urgent necessity from the nature of the case to arrest the disease promptly, it will be proper to evacuate the alimentary canal previous to the employment of the bark. These evacuants will also be useful in cases where the inflammatory habit is so * If the bark in substance be employed, not less than two drachms ought to be administered at each dose. Such doses taken at inter- vals of an hour or an hour and a half, within the last five hours of the intermission, will, perhaps, do all that can be effected by bark in this disease. INTERMITTING FEVER. 77 strong as to prevent a complete apyrexia. Nevertheless, in the ordinary cases of the disease, where there are no signs of a loaded state of the bowels, and the apyrexia is very complete, the bark may be successfully employed without either previous purgation or emesis. Upon the whole, however, I should in all instances of this disease not attended by malignity or great prostration, prefer one or two mild cathartics, before the bark is taken, for the reasons already mentioned. The Peruvian bark has been frequently accused of having a tendency to produce visceral indurations and other unpleasant consequences, such as rheumatism, dropsy, &c. This accusa- tion is, however, wholly unfounded. No doubt, indeed, can exist that these and other injurious consequences may be produced by the injudicious employment of this remedy. When given, for instance, in agues, attended with strong marks of an inflamma- tory condition of the system, without proper antiphlogistic pre- paratory measures, we can readily conceive that the bark would favour the natural tendency of such cases to terminate in these disorders. In this respect, however, the bark does not differ from other tonic and stimulating remedies ; for it is not by any thing peculiar in the bark that these effects are produced, but simply by the power it possesses, in common with the majority of febrifuge remedies, of favouring the phlogistic diathesis, and the progress of obscure inflammations. The bark is now generally given by itself. Formerly it was customary to give it in conjunction with various other reme- diate articles which were thought to augment its febrifuge powers. It is extremely doubtful, however, whether any com- binations can materially improve its virtues ; and unless some particular circumstance be present which may render the use of other remedies proper, or unless the bark by itself produce unpleasant or injurious effects on the alimentary canal, it will probably be best to employ it singly. When it causes much constipation, it may be usefully given as follows: R. Pulv. cinchon. condam. ig. ----rhei 3ss. ----muriat. ammoniac 3j. Misce. In chart. No. iv. dividendse. One to be taken every hour or two. When the bark purges, it should be given with small portions of Dover's, powder; or opium. The former especially acts beneficially in such instances, five grains of which may be given at each dose. Alkaline remedies become necessary in cases where there are signs of much acid in the stomach. The sub- carbonate of potash is an excellent adjuvant to the bark in cases of this kind. From ten to twenty grains of the alkali may be given with each dose of the bark ; and to prevent this from acting on the bowels, which it is apt to do, it is generally 78 INTERMITTING FEVER. necessary to make a triple compound—viz. bark, subcarbonate of potash, and opium, or what is better, confectio opii. When the stomach is irritable, the bark will generally be speedily rejected. In this case we may sometimes cause it to be retained by uniting it with some aromatic substance, such as serpenta- ria, or cloves, or nutmeg, or the calamus aromaticus. The serpen- taria is, perhaps, the best aromatic adjuvant to bark, where the stomach is too weak to retain it singly. I have, however, al- ways found small doses of opium to answer better than any other remedy for this purpose. The addition of powdered black pepper answers extremely well in cases where the vomiting arises simply from gastric debility. Where, however, this oc- currence depends on a highly irritated condition of the mu- cous membrane, neither this nor any other aromatic can be proper. In this condition, indeed, the bark itself cannot be employed until the gastric irritation is subdued by leeches, blisters, or cupping over the epigastrium. The employment of the quinine is much less apt to produce the inconveniences just mentioned than the bark in substance; but even this preparation will sometimes produce violent purg- ing or vomiting—several very violent instances of each of which I have encountered in my practice. Formerly it was customary to employ the decoction, or the tincture, or what is better, both in union with each other, where the bark in sub- stance could not be conveniently administered, or where the stomach rejected it. Since the introduction of the quinine into practice, however, this mode of exhibiting the cinchona has been but little employed ; nor does it appear probable that any circumstances can occur which may not be as well met with this very convenient and concentrated preparation, than with either the decoction or the tincture of the bark. The most con- venient and elegant formula for exhibiting the quinine, is, per- haps, the following: R. Sulphatis quinse gr. xvj. Elixr. vitriol gtt. xvj. Syrup, limonis fj. M. Dose—a tea- spoonful every hour or two for an adult. As this mixture, though a very neat and concentrated one, is sometimes much objected to on account of its bitterness, espe- cially by children, 1 have generally prescribed it according to the following formula, by which almost all the bitterness is wholly removed: R. Sulphat. quinse gr. vj. Elixr. vitriol gtt. x. Pub. extract, glycyrrh 3jss. Aq. fontanae 5jj. M. Dose—a teaspoonful for a child between two and five years of age. INTERMITTING FEVER. 79 In cases of ague, which, from long continuance, or from some previous malady, are attended with visceral indurations or enlargements, the quinine, or the bark, must be given either after a gentle mercurial course, or in conjunction with mercu- rial remedies. The blue mass will in general answer best for this purpose, as it is mild, and less apt to pass off by the bowels than calomel. In many instances of this kind, the bark will, in fact, fail entirely in putting a stop to the continuance of the disease; and I have known it to do manifest mischief even when given in conjunction with mercury. In such cases, mer- cury is the appropriate remedy; and, under careful management, will rarely fail to arrest the disease. From three to five grains of the blue mass, taken thrice daily, until the gums become slightly affected, will generally suffice to remove the complaint. Besides bark and its preparations, a vast variety of other remedies, drawn both from the mineral and vegetable king- doms, have been employed with success, in the treatment of intermittents. As nearly all of them are, however, confessed- ly inferior to the cinchona, it will be sufficient here, barely to mention them. The most efficient of these articles are the following: viz. The barks of the dog-wood (cornus florida;) of the American tulip poplar (Liriodendron tulipifera;) of the horse-chesnut, (E. hypocastanum ;) of different oaks ; of dif- ferent species of willow; the Virginia snake-root; colomba; gentian; quassia, &c. Coffee is highly recommended by Grindel ; given in doses of from 15 to 20 grains every hour, it is said almost invariably to arrest the disease. {Richter.) The black, or celler spider's web, is highly recommended by Dr. Robert Jackson,* as a remedy for the cure of intermit- tents. He is of opinion, that it prevents the recurrence of the intermittent paroxysms more abruptly and more effectually than even bark or arsenic." I have employed this article in six cases ; two of these were speedily cured, the others resist- ed its powers entirely. Shrader speaks of this article as an effectual remedy for agues, in his Dispensatory, published as early as 1644. It certainly possesses very considerable pow- ers in allaying morbid irritability, and in calming the excite- ment both of body and mind. In my own person, it produces the most delightful state of mental and coporeal tranquillity, far exceeding that which is caused by opium.f It is given in five or six grain doses every three or four hours. The mu- riate of ammonia, is favourably mentioned by Richter as a re- medy in this disease.:}: He considers it especially useful in agues attended with gastric impurities, or a loaded state of the * London Medical and Physical Journal, vol. xxi. t Eberle's Therapeutics, vol. ii. p. 121, first edition. X Specielle Therapie. vol. ii. 80 INTERMITTING FEVER. bowels; and in cases connected with visceral indurations. It should be given in union with quinine or cinchona in sub- stance. I have used it myself, in cases attended with indura- tion and enlargement of the spleen, and with the most favour- able effects. The muriate of ammonia is, perhaps, the most powerful remedy we possess for resolving indurations, when given in very large doses internally. In Germany, it has of late years been much and very successfully used in enlargements of the prostate gland, and other similar affections. In my own practice, I have had the most satisfactory proofs of its very excellent powers in this respect. I have given it to the extent of three drachms daily. In intermittents, with indurat- ed spleen, it may be given in combination with quinine, in the proportion of twenty grains of the muriate of ammonia to two grains of the latter. The former ought to be continued after the quinine may no longer be necessary—that is, after the pa- roxysms have been arrested. Among the mineral preparations, arsenic is, undoubtedly, the most efficient, with the exception, perhaps, of the sulphate of zinc. Arsenic was employed in this disease near a century ago, by Jacobi ;* but it was not till Fowler and Brera pub- lished their experience, in relation to its medicinal powers, that it was brought into general notice as a remedy in agues. It is, unquestionably, a very efficient remedy in this disease; but, in individuals of a cachectic habit, or where there is a scor- butic tendency, it is apt to cause dropsical effusions, as well as great debility and symptoms of general depravation of the sys- tem. It appears, moreover, to be improper in phthisical con- stitutions, and where a strong phlogistic tendency prevails. Of the tendency of arsenic to produce anasarcous effusion, I have had a strong illustration within the present year. I pre- scribed Fowler's solution to a syphilitic patient, and, although his nodes and nocturnal pains were removed, he became uni- versally anasarcous. Arsenic appears to be best calculated to remove this disease without detrimental consequences, in indi- viduals of a firm and vigorous constitution. The usual mode of prescribing it is in the form of Fowler's solution, or the li- quid arseniate of potash. From 8 to 12 drops may be given every four or five hours during the intermission. I have ge- nerally given it in substance in union with opium, formed into pills, in the proportion of one-tenth of the oxyd of arsenic, to one-fourth of a grain of opium every three or four hours dur- ing the apyrexia. The sulphate of zinc is an excellent remedy for the cure of intermittents. 1 have very rarely failed to arrest the disease * De Arsenicosale alcalico domiti usu interno salutari.—(Acta Aca- dem. Elet. Mogunt. torn. i. p. 116.) INTERMITTING FEVER. 81 as promptly with it as with quinine. Dr. Firth, in a letter to Dr. S. Mitchell, of New-York, dated Calcutta, 1805, speaks in the most favourable terms of this article as a remedy in in- termittents. He asserts, that while prescribing in the Phila- delphia Dispensary, he found it to cure cases in which both the bark and the arsenic had failed :* Mr. Brand also observes, that " in the cure of intermittents, the sulphate of zinc is an admirable tonic." He gives the following formula for using it: R. Zinci sulphatis gr. jj. Aq. cinnamon. ----distillat. aa ^jss. Tinct. calombse 3g. M. fiat mistura. A table-spoonful is to be ta- ken every three or four hours. I have hitherto always employed it according to the follow- ing formula: R. Sulphat. zinci gr. x. Pulv. capsici. ann. 9jj. Conserv. rosar. q. s. M. in pil. No. xl. divid. S. One to be taken every two hours during the intermission. Black pepper, also, is strongly recommended by Dr. L. Frank for the cure of intermittents; and my own experience has afforded me several examples of its beneficial effects in this way. It is given in doses of from five to ten grains every two or three hours, either alone or in combination with some of the bitter tonics.f Tartar emetic has recently been successfully employed in in- termittents by Recamier, at the Hotel Dieu.\ Out of seven cases, five were quickly cured by tartar emetic given in ptisans, so as to produce both emetic and purgative effects. This arti- cle has also been employed externally with complete success in this disease. Dr. Pommer states, that in the winter of 1815, he was frequently disappointed with the use of the cin- chona, in the intermittents which occurred in the army of Wur- temburg, encamped on the Loire and Allier. Observing "that the fever generally disappeared on the eruption of pim- ples or pustules on any part of the body," he was induced to try what an artificial eruption would do towards curing those cases which had resisted the regular treatment. He accord- ingly directed frictions with the tartar emetic ointment on the * New-York Medical Repository, 1806. t Journal Complement, du Diction, des Sciences Med. No. 22. \ Revue Medicale for December, 1826. 11 82 INTERMITTING FEVER. epigastrium, and found it speedily successful in every case as soon as the pustules appeared.* There are few diseases over which the imagination has a more powerful control than the present one. It is through the agency of this moral cause, that amulets, and the various preposterous charms used by the vulgar, operate in their oc- casional success in removing this disease; and it is thus, too, that the tomb of Protiselaus was anciently so celebrated for the cure of agues. So powerful, indeed, is the influence which the mind exer- cises over the operations of the animal economy—so intimate and strong are the relations which subsist between the corporeal and moral parts of our nature, that there are few, if any dis- eases, in which we may not derive important advantages from calling forth the invigorating and benign powers of hope, or from dissipating the depressing emotions of sorrow and fear, and diverting the imagination from brooding over the causes, circumstances, and probable consequences of the disease, and directing it to objects of a more pleasing character. The sequela of this form of fever are often both obstinate and dangerous in their consequences. The most common of these morbid consequences of agues are:—oedema of the feet and legs; enlargement and induration of the liver and spleen; jaundice; dropsy ; and a general broken down state of the con- stitution. Authors mention'other sequela of this disease—such as tympanitis, hemicrania, deafness, vertigo, paralysis, and epilepsy. The dropsy and jaundice, which occasionally super- vene after very protracted agues depend, no doubt, most com- monly on the visceral indurations previously produced by the fever. In nearly all these secondary affections, mercury may be regarded as our principal curative means. A gentle alte- rative course, will often suffice to remove most of these affec- tions—especially the visceral obstructions, and the disorders which depend on them. Four grains of blue mass, with two of pulv. ipecacuanha, ought to he taken every night on going to bed, and a dose of salts taken every fourth or fifth day. When the disorder is obstinate, and does not show a disposi- tion to yield to this moderate mercurial influence, two, or even three pills may be taken daily, until the gums begin to exhibit marks of its influence on the system, when they should be dis- continued, and resumed occasionally so as to keep up a very moderate degree of the mercurial action. Some mild bitter infusion may be taken in moderate doses twice or thrice daily, during the use of the mercury. I have already mentioned the muriate of ammonia, as a va- luable remedy for the removal of visceral indurations. The * Journal der Practischen Heilkunde, 1823. INTERMITTING FEVER. 83 formula which I have employed with great success in cases of this kind, is as follows : R. Muriat. ammoniae ^ss. Pulv. extract, glycyrrh. |j. Tart, antimonii gr. j. Aq. fontanae _^ a iI i. M. ft. S. Take a table-spoonful every four hours during the day. Tartar emetic, in very small but frequent doses forms, also, a very useful medicine in cases of this kind—more especially for the removal of that dry and icterode state of the skin, with oedema of the feet, which is so common a consequence of protracted agues. The best mode, perhaps, of administering this article in these affections, is to dissolve it in a large quan- tity of water, or some mild and pleasant ptisane. I have ge- nerally directed one grain of tartar emetic to be dissolved in about three pints of water, and to be used freely as common drink. By continuing this drink, so as to consume at least a quart in twenty-four hours, for eight or ten days, the skin ge- nerally becomes clear; the bowels regular; the cutaneous transpiration natural; and the enlarged spleen, or liver, mani- festly diminished in size and hardness. Relapses are very apt to occur after the paroxysms have been arrested. The circumstances which seem most capable of causing a relapse are : exposure to cold and damp air; er- rors in diet and drink; the depressing passions, and renewed or continued exposure to the influence of koino-miasmata. All these causes ought, therefore, to be carefully avoided after the disease has been arrested, particularly where previous relapses. have already occurred in the same case. It is especially im- portant to avoid every thing which is calculated to derange the digestive organs. But nothing, I conceive, is better cal- culated to obviate relapses, than a delay in prescribing febri* fuge remedies until the apyrexia is complete, and all signs of a general or local inflammatory condition are removed, and the disease has run on at least over the seventh paroxysm in quo-* tidians, and the fourth in tertians. 84 REMITTING FEVER. CHAPTER VII. REMITTING FEVER. Bilious Fever; Saburral Fever. Febris pituitosa; Febris gastrica; Febris intestinalis; Febris mesenterica. Character.—Continued fever, with very conspicuous periodi- cal remissions, and exacerbations, and manifest derangement of the biliary organs. Between the simple autumnal remittent and intermittent fevers, there exists no essential or radical difference. They are produced by the same cause, and (lifter from each other only in the grade of violence and the duration of the parox- ysms. As remittents, however, assume a peculiar character, in relation both to their general phenomena and their course, and demand a treatment correspondingly modified, they are properly made a subject of distinct consideration, although some writers, following a different course, treat of them under the same general head. Symptoms.—The symptoms which occur in the forming stage of remittents, do not differ from those which usher in the intermittent paroxysm. Languor, drowsiness, a sense of anxiety ; aching pains in the back, head, and extremities, are the prominent symptoms of its initial stage. Slight chills are, however, often among the very first manifestations of indispo- sition—at first, they alternate, with flushes of heat, which lat- ter gradually increase in duration until they predominate wholly, and the febrile reaction is fully developed. When the fever is once completely established, the pains in the head, back, and lower extremities, become greatly aggravated. These pains, especially those seated in the back and legs, are sometimes so severe, as to resemble in violence, those which occur in acute rheumatism. The eyes soon acquire an icterode or yellowish tinge; the tongue becomes covered with a brown- ish fur; nausea, and occasionally bilious vomiting occur; a sense of fulness and weight or tension is felt in the right hypo- chondrium, and in the epigastric regions; respiration is more or less oppressed and anxious ; the urine is scanty and deeply tinged with bile; the pulse is full, frequent, but seldom very hard or tense; and the skin generally dry and hot. These symptoms continue until the succeeding morning, when a gen- tle perspiration appears on the superior portions of the body, and sometimes over the whole surface. The febrile excitement now abates, frequently, very considerably; but not so as to REMITTING FEVER. 85 amount to a state of apyrexia—the skin still remaining pre- ternaturally warm, and the pulse irritated. This remission continues but a short time—not more, commonly, than from one to two hours. The febrile excitement rises again with more or less celerity, until it has acquired its former violence, or, perhaps, exceeded it; and, after a certain period, again begins to abate, and gives place to another remission. In this way the fever proceeds, undergoing regular revolutions of ex- acerbations and remissions, until it either finally terminates in a perfect crisis and convalescence, or assumes a more uni- form or continued course. This description answers for the simple and usual form of the disease as it occurs in the autum- nal months of the temperate latitudes ; or, for the milder re- mittents of the warmer climates. There is, however, no form of fever wliich is subject to greater diversity in relation to its grade of violence as the present one. In the intertropical re- gions, it assumes the most fatal and violent character; and at almost every place where it may be regarded endemial, it is at- tended with circumstances which give it a somewhat peculiar character. It is, indeed, impossible to give any description of this disease which can have more than a very general applica- tion. We must content ourselves with a delineation of the pro- minent and characteristic outlines of its physiognomy; (if I may be allowed the expression;) and with a detail of those phenomena and circumstances which may be deemed essential, and which have a particular bearing upon its remediate ma- nagement. The ordinary mild remittents of this climate, generally as- sume the double tertian or quotidian type ; but the former type is, by far, the most common; for, although the exacerbations occur once every day, yet, we almost always find a very ma- nifest aggravation of all the symptoms on the odd or alternate days. The exacerbations of a remittent of the quotidian type generally occur several hours earlier than of those of the dou- ble tertian type—the former happening usually about nine or ten o'clock, and the latter not till towards noon, or an hour or two later. Remittents, although mild and regular in their commence- ment, are apt to assume an aggravated and dangerous charac- ter, if they continue unchecked beyond the ninth day, or second week. When this happens, the tongue becomes more and more loaded with a brown fur, and dry along the middle; deli- rium occurs more frequently and strongly ; the skin acquires a deeper tinge of yellow, and a greater intensity of heat dur- ing the exacerbations ; debility becomes more and more con- spicuous, and the bowels distended w ith flatus, and tender to ex- ternal pressure; and, finally, in many cases, watery and of- fensive discharges from the bowels, retention of urine, conti- 86 REMITTING FEVER. nued vigilance, restlessness, and almost constant slight deli- rium. In the paludal districts of hot climates, remittents rarely occur in the mild and simple form which they are wont to as- sume in the temperate latitudes. They generally acquire a highly aggravated and dangerous character; and under cir- cumstances particularly favourable to their occurrence, they are apt to as->ume a high degree of malignity from their very com- mencement. Remittents of this violent grade of febrile excite- ment, generally make their attacks suddenly, and with great impetuosity. The cold stage is short, and not often very severe. The febrile heat soon predominates and rises rapidly to a state of great intensity—and is attended with tormenting thirst, violent headach, excruciating pains in the loins and the infe- rior extremities, great anxiety of feeling and difficulty of breathing, with nausea, and a distressing sense of weight and fulness in the stomach. These symptoms continue for about twenty-four hours, when a remission, always very considera- ble, and frequently amounting almost to a perfect intermis- sion, takes place. The calm is, however, but transient. A second paroxysm soon ensues more violent and alarming than the first. The eyes now become yellow, watery, and red; the oppression and anxiety in the epigastrium is extremely dis- tressing, and a deadly sickness, with constant vomiting or retching, torments the patient. After the lapse of some time, these violent symptoms again abate, and a clammy perspira- tion appears on the surface of the body. During the two first paroxysms, the bowels are generally torpid. In this way, the paroxysms continue to recur, until either a salutary crisis or death takes place, one or the other of which not unfrequently happen in the third paroxysm. If the disease runs on beyond the fifth or sixth paroxysm, a very great degree of prostration ensues ; the remissions becomes less distinct; delirium almost constantly attends; and the skin acquires either that peculiar stinging heat, called calor rnordax, or becomes cool and ca- daverous to the touch. The pulse, in cases of this kind, fre- quently differs but little from its natural state ; more common- ly, however, it becomes quick, irregular, and frequent. In this aggravated and protracted state of the disease, various other symptoms usually occur in addition to those already mentioned, indicative of the fatal malignity of the disease. The lips become swollen, and of a livid or purple hue; the tongue becomes dark-brow n, or black—fetid and clammy; the eyes are red and watery, or quite dry ; the urine is dark- brown, offensive, or entirely suppressed ; the alvine discharges are reddish arid watery, or black, bloody, or colliquative, and attended generally with a tympanitic state of the abdomen ; REMITTING FEVER. 87 and petechia and haemorrhages occasionally occur in the last stage of the disease. In general, the violence of the disease will be in proportion to the suddenness and vehemence of the incursion. When the attack approaches gradually, with the ordinary premonitory symptoms mentioned above, the disease generally runs its course slowly. When, on the contrary, the invasion is sudden and violent, we may expect the disease to be rapid and violent in its progress. The first paroxysm only is usually ushered in by a very distinct cold stage—the succeeding exacerbations being rarely preceded by a sense of chilliness. If we take a general viewr of the phenomena of remitting fevers, we may readily perceive that they point to the particu- lar derangement of two important organs—the liver and the alimentary canal. We may perceive, moreover, that there are some cases of this disease, in which the phenomena of gas- troenteric derangement predominate ; whilst there are others in which hepatic disorder impresses its peculiar stamp or cha- racter on the disease. To the former we may apply the term gastric, aud to the latter hepatic. The intermittents of the former variety, namely, gastric re- mittents, are characterized by the following phenomena, viz: redundancy of vitiated bile in the stomach and bowels; a bit- ter taste; a thick yellowish layer of mucus on the tongue, be- coming dry, cracked, and of a dark-brown or black colour in the progress of the disease; total loss of appetite, and some- times extreme disgust for every kind of food ; a turbid, yel- lowish, or jumentose urine ; great weight and anxiety in the praecordia; bowels tender on external pressure, and distended with flatus ; great pain in the loins and knees ; intense pain in the forehead ; very distinct remissions ; a red or fiery edge and tip of the tongue; or after the brown or black crust scales off, a smooth, shining, and red surface of the tongue ; watery and reddish stools ; resembling the washings of flesh ; reten- tion of the urine; difficulty of swallowing liquids in the ad- vanced stage ; great craving for cool and acidulated drinks, &c. Those remittents which manifest predominant hepatic disor- der, that is, hepatic remittents, are characterized by intense febrile heat; violent pains in the head, and early delirium; fulness and tension in the right hypochondrium with pain and pulsation in the epigastrium and right hypochondrium; a clean tongue, at first; excessive irritability of the stomach ; frequent and forcible vomiting, without the ejection of any bile, the matter brought up consisting of a glairy fluid, mixed with the drinks that may have been received into the stomach; great torpor of the bowels ; a very yellow tinge of the skin ; and tunica albuginia; and towards the termination of the dis- ease, a copious discharge from the bowels of a dark or pitch- 88 REMITTING FEVER. like matter. In this variety of the disease the liver is mani- festly inactive, and in a state of great sanguineous congestion. That this is the case may be inferred from the absence of bile in the ejections from the stomach ; the clean tongue ; the sense of weight, fulness, and pulsation in the right hypochondrium; the great torpor of the bowels ; the intensely yellow colour of the skin ; and the excessive and continued retching and vomit- ing. This latter symptom, namely, extreme irritability of the stomach, may be regarded as a strong manifestation of san- gnineons engorgement and functional inactivity of the liver. We find this pathological fact exemplified in cholera,^ particu- larly in cholera infantum, in which disease there is seldom any bile whatever discharged during its early period ; and the appearance of this secretion in the discharges may be hailed as a very favourable occurrence. Towards the conclusion of this variety of remittent fever, the liver frequently recovers its ac- tion and relieves itself by pouring a large quantity of black bile, or perhaps blood, into the bowels, as is manifested, by the copious, dark-coloured or tar like alvine discharges, which usually occur in such cases. These large and very peculiar discharges, may indeed be regarded as the favourable crises of such fevers ; for convalescence generally soon follows their appearance, and except the disease be arrested by remediate treatment in the early period of its course, there are but few recoveries in which such discharges do not occur. Dr. Cart- wright describes an epidemic fever which prevailed in Monroe county, Mississippi, in the autumn of 1822, which was stri- kingly marked by the characteristic phenomena of this variety of fever. " The disease," he says, "was generally ushered in by a distinct chill, which was speedily followed by intense heat, thirst, and headach, and very severe pains in the loins. The anxiety and difficulty of breathing, the deadly sickness, sense of weight, heaviness, and pain in the stomach, increased as the fever approached its acme, until the suffering became intolerable. The exacerbations generally occurred in the even- ing, and a considerable remission, amounting in some cases to a perfect intermission, took place on the ensuing morning. On the evening < f the second d;iy a sudden and unexpected pa- roxysm, more violent than the fh*st one, came on, which was attended with a most horrid sensation of pain and oppression of the stomach, accompanied with deadly sickness and continu- ed vomiting, but with the ejection of very little fluid of any kind. The bowels during the first and second paroxysms were always in a state of obstinate constipation. About noon of the third day the third paroxysm generally came on. During this paroxysm the skin usually felt rather cooler than natural, and the pulse was commonly remarkably slow. By placing the hand on the abdomen, a pulsation was felt equal to that which REMITTING FEVER. S9 the heart produces in the thorax, and synchronous with the pulsations of that organ." During the first two paroxysms the tongue was but little furred ; but in the third it assumed a much worse appearance, having a dark red line running from its extremity over its dorsum, which soon changed to a black colour. The skin began to acquire a yellow colour during the third paroxysm. The paroxysms continued to recur until the fifth, seventh, or ninth day, when either death took place, or " enormous dark-coloured evacuations from the bowels occur- red, and the patient commenced to convalesce."* Before I leave this part of the present subject, it may be useful to advert again to the former or gastric modification of this disease, and to direct the attention of the reader more par- ticularly to the great tendency there exists in remittents, when they are prolonged in their course, to the occurrence of a high grade of irritation or subacute inflammation of the mucous membrane of the intestinal canal. In most cases of protracted remittents, even of the mildest kinds, the abdomen becomes somewhat tympanitic, and tender to external pressure; and the character of the stools, which are often found to resemble the washings of flesh, are a further evidence of such a condi- tion of the bowels. In a practical point of view, it is of the utmost consequence to be aware of this circumstance; for in many instances this secondary inflammation is excited by the too frequent employment of irritating purgatives, and the dis- ease greatly aggravated and protracted by such a course of treatment. Causes.—After what has been already said under the heads of koino-miasmata and intermitting fever, in relation to this subject it will be sufficient to observe, that besides koino-mias- mata, which are unquestionably the sole epidemic source of this form of fever, there are a variety of other causes capable of producing this malady. Worms and other irritating substances lodged in the bowels, may give rise to a regularly remitting form of fever. The disease known under the term of "infantile remittent," appears to arise from intestinal irritation. In the remitting fevers produced by causes of this kind, however, the biliary organs are much less apt to become implicated than they almost invariably are in the miasmatic remittents. What- ever may be the remote cause of remitting fever, however, it seems very evident that the principal morbid irritation is al- ways located in the abdominal organs, and more especially in the liver and mucous membrane of the alimentary canal. So unequivocal and universal is this gastric disorder or irritation, that some eminent physicians have, in consequence of it, de- signated the disease by the name of gastric fever. (Richter.) * Medical Recorder, vol. vi. IS 90 REMITTING FEVKR. Indeed, this term appears to me preferable to that of remittent, which has no reference to the pathological condition of the system, and might with equal propriety be applied to hectic fever, which though very distinct from remitting fever, has remissions and exacerbations almost as conspicuous and regu- lar as that disease. Treatment.—In the treatment of this disease there are three primary pathological conditions, according to which the general indications of remediate management must be direct- ed, viz: 1. Functional derangement of the liver and alimentary Canal. 2. Redundancy of morbid or vitiated secretions, and consequent irritation in the intestinal tube. S. An irritated increased action of the heart and arteries. Hence, the prin- cipal indications in the treatment are: 1, to moderate the fe- brile reaction of the arterial system ; 2, to remove out of the alimentary canal, the vitiated and irritating secretions which may be lodged in it; 3, to restore the healthy functions of the liver and alimentary canal; and 4, to obviate gastro-intestinal irritation. I shall speak in the first place of the treatment proper in the milder or gastric variety of the disease. With regard to the first of these indications, physicians have expressed very discrepant sentiments concerning the particular means best calculated for its fulfilment. Some recommend a prompt and free employment Of the lancet as decidedly benefi- cial in the treatment of remittents, whilst others have admitted its occasional utility ; and others again represented it as fre- quently injurious, and rarely beneficial. In the ordinary autumnal intermittents of this climate, blood-letting, I am well satisfied, may be often properly dispensed with. The pulse in the milder cases of this disease, particularly in those instances where the intestinal canal is loaded with bilious and other sa- burral matter, is not often sufficiently hard and tense to war- rant copious or repeated abstractions of blood. In such cases, where there was no manifestation of strong local congestions or visceral inflammation, I have rarely found it necessary to draw blood. There can be no doubt, however, that in parti- cular localities, and under peculiar circumstances of atmo- spheric constitution and vicissitudes, remitting fevers may sometimes assume a character which demands the free use of the lancet. To condemn the use of the lancet universally, would be as erroneous as to enjoin its invariable employment Bleeding cannot be employed or withheld, merely on the ground that we are prescribing for a particular disease. In all mala- dies, the state of the pulse must be our guide ; and wherever it is found either hard or tense, whether it be full or contracted, blood may be safely, advantageously drawn, whatever may be the name or the general character of the disease. In cases that are attended with violent pains in the head__ REMITTING FEVER. 91 a full, vigorous, and hard pulse, with a very hot and dry skin, bleeding is unquestionably decidedly indicated, and ought not to be neglected. Having moderated the momentum of the cir- culation by venesection, where this measure is indicated, the attention should next be directed to the alimentary canal. Considerable discrepancy of sentiment has been expressed, in relation to the utility of emetics in the treatment of remitting fever. In the ordinary autumnal remittents of the temperate climates, gentle emetics will often afford some advantage; but their usefulness is probably much too highly estimated by the majority of those who are in the habit of employing them in this disease. I have of late years but rarely resorted to them in this form of fever, and I am inclined to think that they may be generally well dispensed with, without losing any peculiar remediate advantages. There exists a decided tendency to gastro-intestinal irritation in every modification of this disease; and, although the operation of an emetic may procure some temporary benefit, yet some risk will be incurred of its excit- ing a degree of permanent irritation, which will subsequently exercise a most pernicious influence upon the phenomena and progress of the disease. In the year 1822, I attended a consi- derable number of patients labouring under the milder form of remitting fever. During the early part of the season, I pre- scribed an emetic in the majority of cases that came under my care. In many of these cases, a great degree of gastric irrita- bility continued to prevail during the first period of the ma- lady, and in the advanced stages much tenderness and tympa- nitic tumefaction of the abdomen supervened. The disease, in these instances, was wont to run a tedious course—the abdomen became sore to pressure, and the alvine discharges often be- came watery, reddish, and painful—in short, unequivocal ma- nifestations of high irritation or phlogosis of the intestinal mucous membrane often supervened. Towards the middle period of the season I left off employing emetics entirely, and with the exception of one or two brisk cathartics in the com- mencement, confined myself to the use of the milder laxatives, to keep up the requisite discharges from the bowels. From this time on I met with but few cases in which the former un- favourable symptoms occurred. It must be confessed, however, that there are very respectable authorities to be adduced in favour of the use of emetics, not only in the mild, but even in the more rapid and violent varieties of this form of fever. Whatever doubts may be entertained in relation to the useful- ness of emetics in the ordinary forms of remitting fever, the weight of good testimony is, however, decidedly against their employment in those violent grades of the disease which occur in the hot climates, and in which there generally exists the ut- most degree of gastric irritability. That emetici may some- 92 REMITTING FEVER. times be administered without detriment, and even with benefit in these high and dangerous varieties of the disease, may be admitted, but it is most obvious that no small degree of danger must be incurred from the impressions of such a remedy upon the delicate and already irritated or highly irritable state of the mucous membrane of the stomach. The foregoing observa- tions apply with still greater propriety to the employment of what are termed emeto-cathartics. Chisholm speaks favour- ably of their employment, but there have been comparatively few practitioners who appear to have found them peculiarly beneficial. I do not doubt, that in the milder cases, the con- joined operation of an emetic and a purge will occasionally make a decidedly favourable impression on the disease ; but I am equally well satisfied, that much injury will sometimes re- sult from the irritation which they are calculated to produce. Whatever may be thought of the propriety of administering emetics or emeto-cathartics in this disease, almost universal ex- perience speaks decidedly in favour of the employment of pur- gatives, not only in the beginning, but at proper intervals throughout the whole course of the disease. In all instances where the irritability of the stomach does not forbid the admi- nistration of a purge, the bowels should be early and tho- roughly evacuated by a suitable purgative. A combination of calomel and jalap, in the proportion of 10 grains of each, will, in general, suffice to procure adequate evacuations. Having emptied the bowels well, by a brisk cathartic in the onset of the disease, recourse must next be had to such remedies as are calculated to restore the healthy functions of the liver, alimen- tary canal, and the skin, and to moderate the general febrile excitement, and obviate or remove the local congestions or in- flammations that may supervene. To correct the morbid condition of the liver, skin, and ali- mentary canal, constitutes the chief part of the treatment of this malady. For this purpose, the following combination will often answer extremely well: R. Pulv. nitrat. potassse 3j. Pulv. ipecac. Calomel aa gr. xii. M. ft. Di- vide into six equal parts. One of these powders is to be taken every two or three hours. The substitution of the ipecacuanha for the usual ingredient, tartar emetic, will obviate the tendency of this mixture to irri- tate the bowels, and to cause frequent and griping watery stools—and which rarely fail to aggravate the violence of the disease. Calomel is a most important remedy in this form of fever. Its power of altering the morbid condition of the liver and of the whole capillary system, together with its gentle REMITTING FEVER. 93 aperient effects on the bowels, renders it peculiarly calcu- lated to do good in this disease. To obtain these important advantages, the calomel should be early and regularly admi- nistered, and continued until slight manifestations of its speci- fic influence on the system may be noticed in the gums. When: this occurs, its use must be suspended. For more than fifteen years I have employed this remedy in nearly every case of re- mitting fever which has come under my management, where I have been called to the patient during the first two or three days of the disease. In a great majority of these cases, I found all the symptoms of the disease to abate, often very con- siderably, as soon as the mercurial influence became conspicu- ous ; and in many instances, a speedy convalescence ensued. Although a very gentle mercurial impression is generally de- cidedly beneficial in this malady, yet strong mercurialization or ptyalism appears to be generally detrimental—at least in the ordinary remittents of this climate. It is to be observed, moreover, that in the advanced periods of the disease, the con- stitutional operation of mercury will be much more apt to prove injurious than beneficial. In general, the salutary in- fluence of mercury is restricted to the first five or six days of the disease; and the earlier its general operation can be pro- cured, the more certainly will it prove advantageous. When the above combination of calomel, nitre, and ipecacu- anha excites active purging, as has sometimes been the case, we may not only lose the specific influence of the mercurial, but there is danger of superinducing inordinate irritation in the mucous membrane of the intestinal tube. Whenever frequent, painful, and watery stools follow the exhibition of the above com- bination, the nitre ought to be left out, and the ipecacuanha or small doses of Dover's powder added to the calomel. Through- out the whole course of this disease, a gentle and regular ac- tion of the bowels ought to be carefully promoted by mild lax- atives ; but, excepting in the very commencement, strong and irritating cathartics, especially when frequently administered, are generally decidedly prejudicial. There is no class of re- medies which is more indispensable in the treatment of re- mitting fevers than laxatives ; and yet, there are no medicinal agents which are so frequently abused, or improperly em- ployed in this disease, as this very class of evacuants. Violent and irritating cathartics when repeatedly administered in this form of fever, seldom fail to induce a state of irritation in the mucous membrane of the bowels, from which a train of dis- tressing and dangerous consequences arise in the advanced stages of the malady, which are often of more serious import than the original disease itself. The thin, watery, muddy, reddish, and foetid stools—the tympanitic and tender state of tbie abdomen—and the cerebral irritation which frequently occurs 94 REMITTING FEVER. in the latter period of the disease, are very generally the results of the frequent use of active and irritating cathartics in its treatment. " There is one fault which a physician sometimes commits in the treatment of bilious remittent fevers, and that, too, for the most part, when he thinks he is doing right. I allude to the too long continuation of purgative medicines. He is apt to think that the impurities have been long fixed in the bowels, and, in order to cleanse his patient thoroughly, and to leave nothing noxious behind, he persists in the use of purga- tives. What is worse, every appearance of these cases would seem to justify his suspicion of the existence of fixed impurities of long standing in the bowels, and confirms him in his design of at once, and for all, making a clean house. The longer he continues to give his purgatives, the fouler does the tongue be- come, and the more distressed the stomach ; the symptoms, in in short, of intestinal impurities become more and more con- spicuous, whilst he continues to dilute and to evacuate, with- out reflecting or knowing that he is himself the cause of all the noxious matter in the intestines, by constantly irritating them with his purgatives, and keeping up an afflux of fluids to the internal or villous coat. The most healthy individual will get a foul tongue and lose his appetite, if he take neutral purga- tive salts for several days in succession."* Although frequent and harsh purgation is decidedly detri- mental in the treatment of this form of fever, yet the total pro- scription of laxatives from the list of remediate agents suitable for its cure, is no less calculated to favour injurious conse- quences. There is always an abundance of vitiated bile and other morbid secretions poured into the bowels in this disease ; and the generation of acrid and irritating materials by the spon- taneous process of putrefactive and fermentative decomposition in the bowels, soon adds greatly to these sources of intestinal irritation, if the bowels be not from time to time gently eva- cuated by laxatives. Mere purgative enemata and bland dilu- ents are wholly inadequate to remove these permanent irritants from the bowels, or blunt their activity. The irritation which such intestinal impurities create, must be vastly more intense and protracted than the trifling and transient irritation of a laxative administered for their expulsion. In the commence- ment of the fever we may employ one or two active purges, viz: R. P. jalap. Calomel aa gr. xii. Or, R. Extract, colocynth. comp. gr. xii. calomel gr. x. M. Divide into four pills; to be taken at one dose; or, R. Calomel. . . . gr. x. to be followed with one ounce of sulphate of soda, in three hours after the calomel is taken. After the first, or, at most, the second thorough * Medical and Surgical Observations, p. 120. REMITTING FEVER. 95 purgation, the mildest laxatives, assisted with acidulated di- luents, ought alone to be employed for evacuating the bowels ; such as the Seidlitz powders ; small portions of Epsom salts, preceded by a few grains of calomel; castor-oil, with a few drops of laudanum ; a mixture formed of magnesia, castor-oil, and lemon syrup, constitutes an elegant, pleasant, and gentle laxative, which I have often used with very excellent effects. It is made by mixing very intimately in a mortar an ounce of the oil with a drachm of carbonate of magnesia, and then add- ing and mixing with it, about an ounce of any of the usual syrups. Of this a large table-spoonful is to be taken every hour, until the bowels are moved. From two to three eva- cuations ought to be procured every twenty-four hours, dur- ing the whole course of the disease. Much of the treatment of fevers of this kind depends on the judicious management of purgatives. Circumstances may indeed occur, which will render the employment of an active purge peculiarly bene- ficial even in the latter periods of the disease. This is par- ticularly apt to occur in those violent cases in which the liver at last pours out large quantities of black bile, and which, if not speedily removed, may cause a prostration or oppression of the system by exciting a state of general ner- vous irritation. Along with the remedies already mention- ed, some advantage may be obtained from the usual antiphlo- gistic diaphoretics—such as the effervescing saline mixture, the spiritus mindercri, and the free use of bland acidulated drinks. The following mixture will be found a decidedly use- ful remedy in cases attended with much restlessness, anxiety, and a hot and dry skin, where there is no particular determi- nation to, or excitement of the brain, and the febrile reaction is not very violent.* R. Liquor ammoniae acetat. §vjj. Spir. nit. dulc. %). Tinct. opii. acetat. gtt. 30 M. ft. Of this a table-spoonful may be taken every three or four hours. When the skin is very hot and dry during the exacerbations, the sufferings of the patient may be much alleviated by spong- ing the body with cool water, and suffering it to evaporate by the heat of the body. , When, either from the imprudent employment of irritating purges, or from other causes, the mucous membrane of the in- testinal canal is brought into a state of high irritation or sub- * Dr. Agnew on the late epidemic, intermittent, and remittent fever at Harrisburg. Vide Medical Recorder, vol. vi. p. 147. 96 REMITTING FEVER. acute inflammation, the disease generally loses its remittent form, and often assumes a low typhoid character, with almost constant delirium, a tender and tympanitic state of the abdo- men, a dry, dark-brown, or black crust on the tongue, with clean red edges; watery and reddish stools; great prostration; and a very dry and hot skin. Cases of this kind frequently run on for several weeks; and convalescence is always very gradual and tedious. When the fever assumes this aspect, our remediate measures must be chiefly directed against the intes- tinal phlogosis. Leeching the abdomen will often afford much benefit; and it ought never to be neglected where leeches can be had. A large emolient poultice will assist, very materially, in reducing the intestinal affection. I am perfectly satisfied that we may, in general, derive much more good from appli- cations of this kind than from blistering. Fomentations with flannel wrung out of hot water, will answer the same purpose; but this mode of fomenting is much more troublesome and va- riable in its impressions, than the application of warmth and moisture by means of a poultice, and probably not more effica- cious. Internally I have exhibited small doses of calomel and opium in such cases with manifest advantage. The one-sixth of a grain of the former with a quarter of a grain of the latter may be given every two or three hours. The bowels must be kept open by laxative enemata, and the patient requested to take freely of some bland mucilaginous fluids—such as barley water, very thin oat-meal gruel, or gum arabic dissolved in water. No other articles of food must be allowed, on any ac- count. In such cases, I have thought that considerable benefit was derived from epispastics on the legs just above the ankles. This measure is particularly useful when the extremities are cool, while the skin of the body is hot—a circumstance which is not uncommon in instances of this kind. An emulsion of balsam copaiva may also be frequently employed with unequi- vocal advantage. I have so often seen the most decided bene- fit derived from this article, in cases attended with great irri- tation, or subacute inflammation of the bowels, that I should consider myself as neglecting an important curative means, were I to omit prescribing it in diseases of this character. It may be given thus: R. Bals. copaiv. |ss. Sacch. albi. gss. Pulv. gum arab. 3jj- Misce. dein adde. Aq. fontanae gjj. M. ft. Take a spoonful every two hours. Although very considerable prostration often occurs in such cases, stimulants or tonics are by no means admissible. REMITTING FEVER. 97 Hitherto I have spoken only of the simple, or less violent variety of remitting fever—of those remittents which occur in the temperate latitudes, and which, though sometimes both vio- lent and rapid in their progress, do not assume that high and dangerous grade of febrile action which is so common and so fatal in hot climates. In the higher and malignant forms of remitting fever, a treatment diverse from the one I have just detailed is requisite. In these aggravated states of bilious remitting fever, the liver is deeply implicated, and the stomach is generally extremely irritable. Here, therefore, we cannot commence as we may in the simpler forms with emetics, or emeto-cathartics, and often not even with a purgative. In- stead of irritating the stomach by medicines of this kind, our first object often must be to allay the excessive gastric irrita- bility, in order to enable the patient to retain the remedies which his case may demand. Among the means which expe- rience has shown to be best calculated to effect this purpose, blood-letting holds, perhaps, the first rank. To be beneficial in this respect, however, it must be early and copious. I have known excessive irritability of the stomach and retching promptly checked, in the onset of the disease, by one efficient bleeding. Sinapisms over the epigastrium will sometimes aid considerably to moderate the excessive gastric irritability, but applications of this kind cannot be generally used with proprie- ty until the reaction of the heart and arteries has been, in some degree, moderated by venesection. A draught of cold water is not only extremely grateful, but, when the skin is hot and dry, often very beneficial in restraining excessive vomiting in cases of this kind. The saline effervescing draught, artificial mineral water, (carbonated water,) the warm bath, lime-water and sweet milk, spiritus mindereri, have all been recommend- ed and used for this purpose. I have just stated that blood-letting is one of the best, if not the most effectual means for allaying the extreme irritability of the stomach which is apt to occur in the violent grades of this disease. This observation applies, however, to such cases only as are attended with high vascular reaction ; for where the vital energies are prostrated, this evacuation is of course inadmissible. Having allayed the gastric irritability where it was excessive, our principal reliance must be placed in the ju- dicious employment of calomel. The liver in this violent grade of the disease is generally congested, torpid, or otherwise de- ranged to a very great degree; and our remediate efforts must, therefore, he particularly directed to this viscus. Experience, indeed, has fully demonstrated the excellent effects of calomel in this affection. There are some practitioners, it is true, of great respectability, who do not approve of the free employment of mercury in this disease; but by far the largest proportion 13 98 REMITTING FEVER. of those who have practised in warm climates—particuarly of the American and British practitioners, have given their de- cided testimonv in favour of the mercurial treatment ot the higher grades of miasmal fevers. In no country m the world, perhaps, is calomel so freely employed in the treatment of this malady as in the southern sections of the United Mates. The almost unanimous testimony of our southern physicians (many of whom are deservedly held in high estimation for their talents and medical acquirements,) in favour of this prac- tice, will scarcely permit us to doubt of its general usefulness. The American practitioner, free from the trammels of systems, and the dogmas of the schools, pays no further regard to the verba magistri, than is sanctioned by his own experience and ob- servations. He inquires, observes, and reflects for himself, and adopts that mode of treatment which he finds, from varied ex- perience, most successful. A practice, which has received the approbation of* a numerous portion of the profession, may be confidently regarded as founded on individual experience and observation, and not adopted on mere authority, and entitled therefore to full confidence. As it is of the utmost consequence to make an early and de- cided mercurial impression on the system, the calomel ought to be given in large and frequent doses. From ten to twenty grains of this article should be administered every four or five hours, until the gums begin to show its influence, or until the evacuations become manifestly bilious. While we thus endea- vour to produce a general mercurial action, and especially to restore the regular functions of the biliary organs, the bowels should be kept freely moved by additional aperients, if the ca- lomel do not produce this effect by itself. If the bowels are not freely evacuated by the two first doses of calomel, an ad- ditional purgative ought to be administered. For this pur- pose, an ounce of the sulphates of sodae, or of magnesia; or from fifteen to twenty grains of the compound extract of coloeynth ; or a dose of calomel and jalap, will generally answer well. In general, however, very active purges will be less beneficial or proper than the milder ones. Indeed, so long as the liver remains inactive and engorged, it will rarely be advisable to repeat even the purgatives I have men- tioned. After the first efficient mild purge, it will generally be much the best plan to keep the bowels open by laxative ene- mafa, and the use of tamarind water, or the seidlitz powders, if these can be had. When the liver begins to act and to pour its dark bile into the bowels, however, laxatives of a more ac- tive character become indispensable. In cases attended with a distressing sense of sickness, accompanied with soreness in the epigastrium, leeching, succeeded by a large blister over this region, will often afford much relief. Experience does not, REMITTING FEVER. 99 however, offer much in favour of the employment of blisters as a general remedy, either in this or more mild variety of the dis- ease. Little or no advantage is to be obtained from the ordinary diaphoretic remedies in the higher grades of the disease. Nitre, indeed, and the antimonial preparations are wholly out of the question where there is much gastric irritability. Where the stomach will hear it, James's powder in small doses with calo- mel may often be advantageously employed. The saline effer- vescing draught, and the spiritus mindcreri, will also some- times aid in allaying the sickness of the stomach, and relaxing the torpor of the cutaneous exhalents. In all instances, per- haps, the enjoyment of cool acidulated drinks—such as lemo- nade, thin barley water with a little fresh lemon juice, ought to be freely allowed. Tamarind water also is an excellent beverage in cases of this kind, on account particularly of its aperient properties. Drinks of this kind tend to moderate the intense febrile heat, and they do good, moreover, by diluting and obtunding the acrimony of the vitiated fluids which are al- most continually generated in the alimentary canal. The propriety of employing tonics during the remissions of the disease is a point which has been very variously represent- ed by different writers. Lind, Clark, Balfour, and a host of others contend zealously for the vigorous exhibition of bark as soon as a considerable remission occurs in the disease. Dr. James Johnson, on the contrary, with a number of other late wri- ters on this disease, condemns this practice in terms of unquali- fied reprobation. Dr. Burnet, in his Essay on the Bilious Re- mittents along the Mediterranean, asserts that under "the use of the cinchona, the mortality has been great; relapses fre- quent ; and the supervention of dysentery manifestly more fre- quent." I presume that the cinchona, may be highly injurious, or beneficial, according to the period of the disease, or the cir- cumstances under which it is administered. Where there are no violent visceral congestions—where the liver has resumed its regular action, and where with these favourable circum- stances the remission is complete, the bark or the quinine in large doses will often do a great deal of good. The authority of many of the most respectable of our southern brethren might be cited in confirmation of this remark. There can be no ques- tion, indeed, that so long as the liver remains torpid and en- gorged, the bark will not only be useless but generally deci- dedly injurious. After the bile makes its appearance in the evacuations, in those cases in which the liver is as it were locked up in the first stage, and a complete remission occurs, much benefit may be expected from the liberal exhibition of this tonic, provided no local inflammations be present. The affusion of cold water has been highly extolled by some, 100 REMITTING FEVER. in the treatment of this disease. It does not appear, however, that this measure can be often safely resorted to in the more violent grades of bilious remittents, where there exist great con- gestions and derangements in the biliary organs, or where the bowels are loaded with bilious and other saburral matter. (Rich- ter.) Where such objections to its use do not exist, and the skin is very hot and dry, and violent pain in the head with de- lirium is present, cold water thrown on the patient will often produce prompt and manifest abatement of the febrile symptoms. It is, notwithstanding, a good general rule to delay the cold af- fusions until evacuations both by venesection and by the bow- els have been premised, and particularly until the liver has in some degree regained its activity; and above all, they must never be used unless the skin be dry and above the natural tem- perature. During the period of convalescence, mild tonics—such as infusions of cinchona, gentian, columbo, or serpentaria, will generally assist in restoring the tone of the digestive organs. The bowels must not be suffered to remain constipated; and the diet should be simple, mild, and digestible—such as ani- mal broths, rice, barley, a little boiled or broiled mutton, lamb, or tender beef. CHAPTER VITI. YELLOW FEVER. Synonymes.—Typhus icterodes ; Maladie de Siam ; Bulam fever; Vomitusprieto; Causus. Yellow fever has been the theme of interminable discus- sion and controversy—a theme which has drawn forth the best and the worst feeling of the human heart—which has furnish- ed motives, on the one hand, for the most active exertions of philanthropy and self-devotedness, and on the other, for all the bitterness and uncharitableness of feeling, which man in his most degraded moments is capable of manifesting. There is no form of fever more variable in the violence and character of its symptoms than the present one. In the seasoned and acclimated inhabitants of those regions where the disease is endemic, it is often as mild as ordinary bilious fever. But in the young and robust, who have not yet been seasoned to the climate, it seldom fails to make its attack with an over- whelming impulse; commencing and terminating in death often within 48 hours, and sometimes sooner. YELLOW FEVER. 101 The disease usually begins with a sudden feeling of giddi- ness, pain in the back, loins, and extremities, faintness and debility, with slight creeping chills, and nausea. After a pe- riod varying from a few to 12 hours, these initial symptoms are succeeded by a sudden development of vehement arterial reaction, accompanied with a dry and intensely hot skin, flush- ed face, red eyes, extreme headach, tormenting thirst, intole- rance of light, pain in the loins and lower extremities, a sen- sation of weight and tension at the stomach, white, and some- times clean tongue. Towards the end of the first 20 hours after the febrile excitement is developed, the patient begins to vomit frequently, particularly after taking drinks; the ejec- tions consisting, at first, of such fluids only as may have been taken into the stomach ; hut after these have been thrown off, bile often in abundance is brought up, varying in colour from pale yellow to dark green, and frequently so acid as to exco- riate the fauces and lips. The heat and tenderness in the epi- gastrium now increase, the countenance assumes an indescri- bable expression of distress and hopelessness; there is great restlessness and sighing, and more or less delirium usually supervenes. In some cases slight pain is experienced on swal- lowing; "and about this time an urgent sensation of hunger often comes on, and a remarkable want of power in the lower extremities, resembling partial paralysis." This paroxysm lasts usually from 24 to 36 hours, but in some instances consi- derably longer; and then all the symptoms, with the exception of the nausea and the vomiting, greatly abate—the pulse re- turning to its natural standard, and the skin acquiring a moist and temperate condition. So complete,indeed, is the remission in some cases, that the patient is induced to flatter himself that all danger is now7 passed. More commonly, however, the pa- tient remains in a state of tranquil indifference, amounting to a sort of stupor, without any apparent concern as to present or future situation. This is an ominous calm; for after a few hours, the pain and burning sensation in the stomach return with increased violence; the vomiting becomes frequent and distressing—the fluid brought up containing minute flakes or flocculi, resembling the crust washed from a port-wine bottle, but little or no bilious matter. The desire for cool drinks is extremely urgent, but every thing which is swallowed is im- mediately ejected from the stomach with great force. The eyes and skin about the neck and breast now acquire a yellow hue. This second paroxysm continues commonly from 12 to 36 hours, and is succeeded by a new train of symptoms, which mark the last stage of the complaint. The pulse now sinks both in frequency, force, and volume; the tongue is dark- brown or black; the vomiting becomes almost incessant, and exceedingly forcible—the matter thrown up consisting of a 102 YELLOW FEVER. black ropy fluid, resembling coffee-grounds suspended in a glairy liquid. The extremities become clammy and cold ; and the acrid or burning sensation in the stomach, acquires a most distressing degree of violence. Diarrhoea usually occurs at this period—the discharges being green or black, " and the patient often complains of being unable to pass his stools, from a want of power in the abdominal muscles." By this time the whole surface of the body is of a dirty yellow colour ; and hic- cough, haemorrhages, violent delirium, coma, insensibility, or convulsions, sooner or later terminate the patient's sufferings in death. Such is the ordinary course of this fatal malady. In many instances, however, the attack is much more overwhelming; the patient being seized at once with loss of muscular power and general oppression of the nervous system, and falling down as if stunned with a blow. In other instances, violent and furious delirium ushers in the disease, terminating in a few hours in insensibility and convulsions. Sometimes the disease commences and proceeds to a fatal termination in so insidious a manner, that the patient himself and those about him are scarcely aware that he is much indisposed. In such cases there is, however, always a remarkable change in the expression of the patient's countenance, as well as in his usual temper and habits. In almost all instances of this disease, the countenance is expressive of intense anxiety and despair during its early period, and of gloomy or sullen abandonment in the last stage. The period at which the skin begins to assume a yellow co- lour is very variable. It sometimes occurs within the first 48 hours, and sometimes not until the fourth or fifth day. Various opinions have been expressed with regard to the immediate cause of this yellow hue of the surface. Some ascribe it to the serum rendered yellow by dissolved red globules of the blood, and effused under the cuticle. Dr. Fordyce attributes it to the superabundant secretion of sebaceous matter by the glands of the skin; and Dr. Saunders supposed it to depend on a pecu- liar state of the lymph in the subcutaneous cellular tissue. Many however maintain, and with correctness, I think, that the yellow hue in question is of an icteric character, depending entirely on the deposition of bilious matter under the cuticle. The black matter thrown from the stomach in the latter period of this disease, does not consist of bile, as was once generally supposed, but of minute flakes of coagulated blood suspended in the gastric mucus, produced by sanguineous exhalation from the abraded surface of the mucous membrane of the stomach. The black matter discharged in some of the higher grades of bilious and typhus fevers differs essentially from the " black vomit" of yellow fever. The former will dissolve in water. YELLOW FEVER. 103 and communicate a deep bilious tinge to it; whereas the black matter which forms the black vomit of the present disease con- sists of small insoluble flakes, which are held suspended in a viscid fluid, and will not communicate a yellow or greenish tinge to water when agitated with it. " In taste also they differ. The black matter which occurs in common bilious fever is always intensely bitter; but that which is thrown up in yellow fever is either insipid or acid." (Bancroft.) Post mortem appearances.—The stomach and liver are the organs upon which the disease exerts its principal force. The former, especially, always shows the strongest marks of pre- vious inflammation and its consequences. Its coats are often thickened, and the mucous membrane is always strongly in- jected, abraded, and in many parts gangrenous, or totally dis- organized. The duodenum and small intestines also almost invariably exhibit marks of inflammation. In many of the more aggravated cases, the liver undergoes much structural derangement. Dr. Chisholm has found the liver " in a dis- solved or putrid state or sphacelated, and of the consistence, feel, and colour of rotten cork, or full of abscesses." Dr. Phy- sick rarely found the liver much diseased, but the stomach was always inflamed and gangrenous in parts.* Cause.—In relation to the origin and mode of dissemination of yellow fever, physicians have been at great variance; and the subject is still much disputed, although the weight of good testimony is greatly on the side of its miasmatic or do- mestic origin. After an attentive examination of the princi- pal observations which have been published on this subject, it appears, indeed, difficult to adopt any other opinion than that which alleges its origin from miasmatic effluvia, "exhaled from masses of public filth containing putrescent matter, gene- rated under a high range of temperature." That this is the case, seems to be sufficiently demonstrated by the following circumstances:—1. Yellow fever always appears in the lowest and most filthy parts of towns; and those localities in which it is most prevalent, are in the immediate vicinity of marshes or soils favourable to the production of miasmata. 2. Yellow fever never occurs in cold seasons—a high range of atmosphe- ric temperature being essential to the generation of its cause. 3. Heavy rains, storms, and the supervention of cold weather, never fail to put an immediate check to the disease.f 4. Yel- low fever always appears simultaneously and is intermixed with bilious remittents. Dr. Ramsay states, that in the yel- low fever of Charleston, in 1804, "neglected intermittent frequently terminated in yellow fever." Dr. Rush also states, in relation to the yellow fever in this city in 1802, that "in- * New-York Medical Repository. t Rush's Medical Inquiries. 104 YELLOW FEVER. termittents, the mild remittent, the inflammatory, bilious, and the malignant yellow fever, have, in many instances, all run into each other;"* and, he observes, that Dr. Saunders, nearly a century ago, noticed this conversion of marsh and yellow fever into each other. Yellow fever is, moreover, always most severe in the immediate vicinity of those localities which favour the generations of marsh miasmata. Dr. Caldwell, speaking of the yellow fever of this city in 1803, says, "as the fever receded from the low ground and malignant atmos- phere of Water street, it became more and more mild and ma- nageable till its evanescent shades in Second street were, in many instances, much lighter than the common remittent of the country." During the prevalence of the yellow fever in Baltimore, "the bilious or remitting fever in its ordinary form, prevailed in that town, and continued until it was gradu- ally lost in the severer form of yellow fever as the season ad- vanced." (Davidge.) 5. The miasmatic origin of the disease may be inferred also from the fact, that the recurrence of it has often been, in a great measure, prevented by removing the sources of pestiferous exhalations in situations where it for- merly prevailed almost annually to an alarming extent. Our own city may be cited as a prominent example of the efficacy of cleanliness in preventing the occurrence of this disease. (Bancroft.) If these views be correct, in relation to the ori- gin of the disease, we are forced to reject the opinion so stout- ly maintained by some, of its being in any respect contagious. Indeed, if yellow fever did possess tbe power of generating its own virus, and communicating itself by contagion, the fact, as Dr. Bancroft observes, must have been proved ten thousand times by the most irrefragable testimony, and yet there is, perhaps, no incontestible case on record where the disease was thus communicated. The city hospitals established in the neighbourhood of this city and at New-York, furnish us with a striking refutation of the supposed contagious nature of this disease; for, in no instance, was the disease communicated to those who were employed about the sick. The same observa- tions were made at the encampment near Baltimore, during the prevalence of this disease in that city in 1819. The recent very ample investigation of this subject by Dr. Chervin, has resulted in a mass of testimony, which can scarcely leave any pretext for doubting of the non-contagious nature of this dis- ease. But, although yellow fever be not contagious, it may, no doubt, be introduced into seaports in ships; unquestiona- bly, a pestiferous miasm may, under favourable circumstances, be generated in the holds of ships while navigating in hot cli- mates ; which, when suffered to escape at the wharves, may * Medical Repository for 1802. YELLOW FEVER. 105 give rise to the disease in question. When the miasmata are thus introduced, however, the disease engendered by it, will not prevail epidemically, but only among those who ap- proach the infected vessel, or the cargoes, and will disappear entirely when these are removed to a distance. (Bancroft.) The sporadic cases which occurred at the Wall about 1804, at Perth-Amboy in 1811, at Middletown in Connecticut in 1819, and at New-York in 182 S. Take a tea-spoonful three or four times daily. J CHRONIC ENTERITIS. 223 patients took the sulphate of copper with opium, in doses of three grains, three times daily.* I have employed a decoction of the slippery elm bark, in conjunction with occasional leeching, and the use of small doses of balsam copaiva, with the happiest effect in several in- stances of this disease. CHAPTER XVI. ACUTE PERITONITIS. Symptoms.—Acute inflammation of the peritoneum is fre- quently ushered in by a feeling of lassitude; pain in the limbs; and slight creeping chills, alternating with flushes of heat. Headach, and a sense of weight or uneasiness in the epigastrium are usually among the first symptoms. Acute pain is often felt in some part of the abdomen at the very commencement of the disease. Occasionally, however, the pain does not occur until the febrile reaction is established, and in some instances it comes on suddenly, with much violence during or immediately after the first sensation of chilliness. The abdominal pain is fre- quently, for a time, confined to a small space, but it generally soon spreads throughout the whole or a greater part of the ab- dominal cavity. Pain does not, however, always occur in this affection. In some instances of the most aggravated character, little or no pain, but only slight uneasiness is felt in the abdo- men—(Andral.) Sometimes the abdominal pain " moves irre- gularly about, remaining for a few hours in one spot, and sud- denly removing to another." In all instances,pressure on the external surf ace of the abdomen is extremely painful. To avoid this source of suffering, the patient lies on his back, with the knees and shoulders raised, in order to take off the tension of the abdominal muscles, and the pressure of the bed-coverings. The bowels are constipated, or moved with considerable diffi- culty ;f the pulse is frequent, more or less tense, contracted, and sharp, and occasionally, though rarely, it is round and full. The tongue is moist and at first covered with a thin white fur, the edges and raphe becoming sometimes red in the progress * Med. Chirug. Transactions. t " Constipation," says Dr. Johnson, " is as general a concomitant of peritoneal inflammation as dysenteric purging is of inflammation of the mucous membrane of the intestines."—Med. Chir. Rev. Sept. 1820, p. 167. 224 ACUTE PERITONITIS. of the malady. In many instances, the stomach sympathizes strongly with the abdominal affection, the patient being ha- rassed with frequent nausea and vomiting in the early stage of the disease. The face is usually pale, exhibiting a peculiar sharpness of feature, and an expression of great anxiety. Con- stant wakefulness is very commonly present throughout the whole course of the disease, but delirium rarely occurs except towards the conclusion of fatal cases. Generally, in the course of from twenty-four to thirty-six hours, the abdomen becomes tumid, tense, and elastic, from flatulent distension of the in- testines ; and extremely tender. Respiration is oppressed and laborious in the latter period of the disease ; inspiration, espe- cially, being short, difficult, and attended with an expression of pain in the countenance. The secretion of urine is almost invariably more or less diminished, and in some instances al- most wholly suppressed. When the peritoneal coat of the blad- der is the seat of inflammation, "the evacuation of the urine will almost uniformly be suspended," and much pain felt in the pelvis. The peritoneal covering of the inferior surface of the diaphragm is occasionally the principal or sole part of this membrane which is inflamed, and in this case almost constant hiccough attends—(Scoutteten.)* Acute peritoneal inflammation is generally very rapid in its progress. It seldom continues beyond the sixth or seventh day without terminating either in resolution or in death, or passing into the chronic or subacute state. It often terminates fatally as early as the third day; and Andral asserts that its progress is occasionally so rapid, " that only a few hours intervene be- tween the origin of the inflammation and death." When the inflammation assumes the subacute grade, it will frequently be prolonged to the thirtieth or fortieth day before it proves fatal. Acute peritonitis is particularly prone to terminate in gangrene. When this occurs the abdominal pain suddenly sub- sides; the pulse becomes very small, frequent, and often inter- mitting ; great muscular prostration ensues; the extremities are cold and clammy ; and the countenance pale, hollow, and contracted. Slight wandering delirium usually occurs at last in cases that terminate in this way. Causes.-—Acute peritonitis may be produced by mechanical injuries of the abdominal viscera; violent and long-continued corporeal exertions; stricture of the colon and rectum ; per- foration of the stomach or bowels by slow ulceration, and the consequent passage of the ingesta or feces into the cavity of the abdomen; extravasation of blood, urine, or bile, into the peri- toneal cavity; the action of cold on the surface of the body, * Med. Chir. Rev. June, 1824, p. 199. See also, Archives Generates, &c. for December and February, 1824. ACUTE PERITONITIS. 225 causing sudden suppression of the perspiration ; wet and cold feet; drinking cold water while the body is in a free state of perspiration; parturition: sudden suppression of the hemorr- hoidal discharge, or of the menses ; metastasis of erysipelas, (Abercrombie;) and of rheumatism, (G. Andral.)* Post-mortem appearances.—Pathological investigations have now fully established the fact that the peritoneum may be vio- lently inflamed without the inflammation extending to the sub- jacent structures. That portion of this membrane which covers the stomach, intestines, and other viscera, has often been found strongly inflamed, and even gangrenous, while the other struc- tures of these organs were perfectly sound. (Broussais, Aber- crombie, Armstrong.) In some cases the peritoneum exhibits large patches of a deep-purple, and occasionally even of a black colour. Strong adhesions between the intestines very fre- quently occur; and in some instances there is more or less ad- hesion formed between the intestines and the inner surface of the abdominal cavity. Scoutteten found, in several instances, subperitoneal emphysema. Sometimes these adhesions are formed without the intervention of false membrane, (Scoutte- ten,) but much more frequently pseudo-membranous layers form the bond of union. White membraniform concretions are generally found also on different parts of the peritoneal sur- face of the stomach, liver, and bowels. Effusion into the ab- dominal cavity of a whitish fluid containing small flocculi of lymph, or of a reddish or yellowish fluid, almost always oc- curs. Blood has been found effused into the abdomen in acute peritonitis. In some cases the fluid is thick, and of a straw-colour, " resembling diluted pus with a very peculiar odour;" and in other instances, a soft, white, sebaceous matter resembling soft butter is found deposited in the interstices formed by the con- volutions of the intestines. Andral found a number of small tubercles between the peritoneal and mucous membranes of the bowels, some of which were softened down, and had burst through the peritoneum. In nearly all instances, a greater or less ex- tent of the peritoneum is found strongly injected. The occurrence of effusion, or suppuration into the abdominal * Andral, jun. has related a case of peritonitis which manifestly arose from translated rheumatism. (Repert. Generale, &c. No. 4.) Dr. James Johnson, in reference to this case, observes: " We think the most scep- tical pathologist will hardly deny that there was in this case a transfer- ence of inflammation from the joints to the peritoneum." This patient was received into La Charite whilst labouring under acute rheumatism. Several venesections were practised. After some days the rheumatism suddenly ceased, and acute pains soon came on in the abdomen. The ab- dominal pain speedily acquired great violence, and death took place on the third day from the disappearance of the rheumatism in the joints. On dissection, strong and extensive signs of inflammation were detected in the peritoneum. 29 226 ACUTE PERITONITIS. cavity, is generally announced by a diminution of the pain and tenderness of the abdomen, attended with a sense of weight and oppression in the hypogastric region ; rigors; coldness of the extremities; a soft and feeble pulse, and sometimes slight diarrhoea. Treatment.—The first and most important remediate mea- sure in the treatment of acute peritonitis is blood-letting. There is no inflammatory affection, in which prompt and decisive bleeding is more essential to success in its treatment than the present one. No definite directions can be given as to the quantity of blood which it may be necessary to draw. The first bleeding ought to be carried to the extent of making a very obvious impression on the system ; and it should be repeated as soon as the pain and febrile reaction rise again, if the first do not break up the violence of the disease. I have opened a vein three times in as many hours, before a permanent impres- sion was made on the disease. The period during which blood- letting may be employed with a prospect of advantage in this disease, is in general limited to the first twenty-four hours from its commencement; and in many instances a lapse of twelve hours will render this powerful remedy abortive, or even detrimental. When blood is promptly and very efficiently abstracted soon after the inflammation is developed, the disease is often prostrated at once, so as to yield without much diffi- culty to other suitable measures. After the violence of the local and general symptoms has been in some degree subdued by venesection, topical bleeding from the abdomen with leeches will in general contribute con- siderably to the further reduction of the peritoneal inflamma- tion. The abstraction of blood by leeches is generally much more decidedly beneficial in peritonitis than in any other va- riety of abdominal inflammation, and should, indeed, always be resorted to whenever leeches can be procured. After leech- ing has been employed, it will be useful to apply a large emol- lient poultice over the abdomen, which will keep up a moderate discharge of blood, for some time, from the leech-bites; and by its relaxing effect tend to promote the cutaneous exha- lation from the external abdominal surface. Instead of a poul- tice, cloths wrung out of hot water may be kept applied to the abdomen with advantage. As soon as the abdominal pain and tenderness are somewhat moderated by the means just mentioned, a stimulating purgar tive should be administered in a dose sufficiently large to excite active purging. Indeed, the employment of active cathartics in this disease deserves to be regarded as perhaps next in import- ance to venesection. In no case can they be omitted without losing the benefit of an important remedy. In nearly all in- stances of peritoneal inflammation, there is considerable diffi- ACUTE PERITONITIS. 227 culty in moving the bowels; and it generally requires strong doses of the most active articles of this kind to procure free evacuations. General experience goes to show, that the advan- tages which purgatives afford in this disease are usually pro- portionate to the activity of their operation. This does not accord, however, with the observations of Broussais, who affirms that active purging is hurtful in peritonitis, on account of the vermicular contractions which it excites in the intes- tines, and its consequent increase of the morbid sensibility of the peritoneum. Dr. Abercrombie also regards active purga- tion as seldom necessary, and often detrimental in this disease. Independently, however, of the many authorities of the first respectability that might be cited in favour of the use of active purgatives in this malady, I have too often had the most un- equivocal evidence, in my own practice, of the decided useful- ness of purging in peritoneal inflammation, to admit, in my mind, of any doubt concerning the efficacy of this practice. Upon this point, Dr. Johnson makes the following judicious remarks: "In abdominal inflammation, provided the mucous tissues are not inflamed, purgatives excite the secreting ves- sels, not only of the whole internal surface of the intestines themselves, but of the glandular organs whose secretory ducts open into the primse via?, and thus powerfully deplete locally the vascular system of the abdominal viscera. When the por- tion of the peritoneum reflected over the intestines is inflamed, but where the villous coat is unaffected, I hesitate not to assert, from personal experience, that constipation of the bowels will in nine cases out of ten be a feature of the disease ; and in such cases I maintain, that to excite the natural action of the mucous membrane, immediately after proper vascular depletion, is a very powerful means for checking the peritoneal inflammation; in the same way that a free expectoration from the mucous membrane of the bronchia relieves the vascular turgescence and inflammation of the parenchymatous structure, or pleural covering of the lungs."* Of all our purgative remedies, cistor-oil in union with spi- rits of turpentine, has appeared to me the most valuable in the present affection. I have, in a considerable number of in- stances of puerperal peritonitis, derived signal advantage from this remedy, f I have usually prescribed it according to this formula: * Med. Chir. Rev. September, 1820. t In one remarkable case of peritonitis, I endeavoured to procure purging by means of calomel and jalap and infusion of senna, without success for a whole day. The disease had acquired so great a degree of violence that I had nearly lost all hopes of the patient's recovery. Fi- nally, I ordered a mixture of two ounces of castor-oil with six drachms of spirits of turpentine, and directed the patient to take a table-spoon- 228 ACUTE PERITONITIS. R. 01. ricini §ii. Spir. terebinth. 3vi- M. S. Take the half at once, and the remain- der in two hours if purging has not commenced. It is not always necessary, however, to resort to the use of this active purgative at once. In some instances, a full dose of calomel and jalap, or of infusion of sena, or of castor-oil, will procure adequate discharges ; but where these articles fail to produce the desired effect, the turpentine and castor-oil in union, will almost invariably bring on copious purging. I have used with much advantage, a mixture of cremor tartar and powdered jalap in this affection. This will seldom fail to produce very abundant watery discharges from the bowels. There are few articles which excite so copious a discharge from the intestinal exhalents as cremor tartar; and when gi- ven in union with jalap, its operation is generally prompt and active. From twelve to fifteen grains of the jalap to forty grains of cremor tartar, may be given every hour until the bowels are freely moved. Dr. Pring strongly recommends the use of calomel in puerperal peritonitis, in ten grain doses every six or eight hours. " Copious stools," he says, " quickly fol- lowed a sudden salivation, and a favourable convalescence was afterwards maintained by purgatives of the weaker sort." The application of a blister to the abdomen will often do con- siderable good, where, after decisive blood-letting and purg- ing, some tenderness on pressure remains on the inflamed parts. Leeching, if practicable, should always be premised to vesication; but neither of these local remediate means can be resorted to with a prospect of benefit, until the acute character of the disease has been subdued by prompt and copious general depletion. The blistered surface should be dressed with some application capable of keeping up a free discharge; and for this purpose, the mercurial ointment is, perhaps, the most useful in the affection. Mercurial frictions have indeed, of late, been particularly recommended in the treatment of this disease. M. Velpeau has reported four cases (Rev. Medicale, Jan. 1827,) in which two drachms of mercurial ointment applied by frictions to the abdomen every two hours until the mouth be- came sore, appeared to do much good. M. Laennec also cured several cases of subacute peritonitis by mercurial frictions. ful every half hour. After the fourth dose purging began, and brought off an enormous quantity of dark-coloured and extremely offensive fecal matter. The patient was greatly relieved by this evacuation, and could bear considerable abdominal pressure, which before was insupportable; —in short, all the symptoms were strikingly mitigated. Convalescence soon ensued under the use of purgatives, and a large blister to tbe ab- domen. ACUTE PERITONITIS. 229 As soon as the mouth became sore, the symptoms began to de- cline. (Rev. Medicale, Mai, 1824.) I have met with one case in which the supervention of the mercurial action appeared to exert a strong influence in arresting the further progress of the disease. This was a very acute case. Copious venesection was practised, and large doses of calomel administered with castor-oil as purgatives; on the third day, the mouth was found to be sore and the breath fetid; convalescence speedily ensued. Among the internal remedies beneficial in this disease, opium with calomel deserves to be particularly mentioned. After the violence of the local and general symptoms has been broken down by energetic venesection and purging, we may, in gene- ral, resort to this combination with great advantage. I can speak with much confidence of the usefulness of this remedy, having, for the last ten years, employed it in this disease with unequivocal benefit in a considerable number of instances. In puerperal peritonitis especially, opium either alone or in com- bination with calomel, is often peculiarly serviceable. "In puerperal fever," says Dr. Armstrong, " in which the perito- neum chiefly sustains the intensity of the inflammation, opium may be given with considerable advantage, particularly when the local pain and constitutional irritation are excessive; though in that stage of excitement, it must not for a moment be for- gotten, that bleeding and purging are the principal measures. When the stage of collapse approaches, opium may, perhaps, be accounted the primary measure, since the allaying of irri- tation is then the principal object. Whenever opium is admi- nistered in any species of abdominal inflammation, the dose should be large; for a small dose often stimulates, whereas a large one is a direct sedative. This narcotic may be very usefully administered in this affection at the same time that cathartics are employed ; for opium in large doses, whilst it allays the pain and general irritation, often manifestly pro- motes the operation of purgatives in peritoneal inflammation. I have usually prescribed this article in combination with ca- rSmel, in the proportion of two grains of the former to three of the latter every three or four hours. Antimony and nitre are seldom admissible in this disease on account of the great gastric irritability which usually prevails. Digitalis, however, has been recommended as a useful article in this affection. When the pulse remains irritated and sharp, after the disease has been in a great degree subdued, digitalis in small, but frequent doses, may be advantageously used. One grain should be given every two or three hours until the frequency and tension of the pulse is sufficiently moderated. Most practitioners employ this remedy in much larger doses than the one just mentioned; but I have generally found the 230 ACUTE PERITONITIS. action of the pulse more speedily moderated when given fre- quently and in small portions, than in larger ones at longer intervals. When a state of collapse ensues after the inflammation has been overcome by the means already mentioned—an event which occasionally occurs in puerperal peritonitis—it must be counteracted by the employment of stimulants. Wine, the carbonate of ammonia, opium and camphor, and Dover's pow- der with quinine, are the best articles for this purpose. " There is a period in some cases of abdominal inflammation where the disease is just subdued, but where there is a kind of balance between recovery and gangrene. The pain will vanish ; the pulse become weak; the vital powers appear to sink, and a coldness overspread the body. The symptoms are too often indicative of mortification; but every experienced practitioner must have occasionally witnessed cases of recovery even from this alarming state. Here we must give wine; for, if gan- grene have commenced, no harm can ensue from the remedy; and if it have not commenced, the wine may happen to give a salutary stimulus to the nervous and vascular systems, when stagnation of the vital fluids is on the point of taking place, and where further evacuations would be instant death."— (Johnson.) The nourishment throughout the whole course of the disease should be of the mildest and weakest kind. A little thin bar- ley or rice-water, may serve at once for food and drink. The greatest care must also be taken to guard the patient against taking cold during the period of convalescence; as a renewal of the disease, in a subacute form, is extremely apt to occur from this and other exciting causes. CHRONIC PERITONITIS. The approach of chronic inflammation of the peritoneum, when not the sequel of the acute form of the disease, is so gra- dual and insidious, that it seldom becomes the object of medi- cal attention until incurable structural changes have taken place, or effusion into the cavity of the abdomen. It is, in- deed, only by attending to the passage of the acute into the chronic form, that we are enabled to give an account of the early symptoms of the latter. When the peritoneum becomes affected with chronic inflammation, more or less uneasiness and tenderness is experienced in the abdomen; and when pres- sure is made externally, or the patient coughs, sneezes, or performs any sudden motion by which a concussion of the body is produced, a feeling of soreness is felt about the umbili- CHRONIC PERITONITIS. 231 cal region. In many instances, there is slight pain in some part of the abdomen, which may be either continuous or occa- sional. In no instance, however, is the abdominal pain severe ; for serous membranes in a state of chronic inflammation never give rise to acute pain ; and many cases are recorded in which this structure was found completely disorganized from chronic inflammation, without the patient having complained of any pain whatever. The abdomen generally becomes fuller, and in some instances elastic, or more or less tympanitic. Fre- quently, a sense of tightness and pricking soreness is felt across the lower part of the abdomen, after fatigue from bodi- ly exertion. "There is no tension of the skin of the abdomen as in the acute species ; on the contrary, the skin and abdomi- nal muscles often sit loosely upon the peritoneum, which gives a sensation to the touch, as of a slight bandage underneath, over which the skin and muscles may be felt as it were to slide. The patient always complains more of tightness than of pain ; and as the tightness is much increased by any con- gestion in the bowels, the relief which he experiences from evacuating their contents, leads him to attribute his sensations to an habitual costiveness."* On feeling the external surface of the abdomen, we some- times find deep-seated spots of induration which are more or less tender to the touch. (Abercrombie.) In some instances, the patient experiences a sensation as if a ball were rolling about the abdomen. Broussais ascribes this sensation to the adhe- sion between the different convolutions of the intestines into a round and moveable mass. Such adhesions between the coils of the intestines may be suspected, says Armstrong, "by a lobulated or irregular feel of the bowels under the hand when passed over the abdominal integuments." The bowels in this affection are generally torpid. The pulse is often not percep- tibly affected; except in the advanced periods of the disease, and towards evening in the early stage, when it usually be- comes jerky or somewhat accelerated, quick, and contract- ed. The appetite is generally sufficiently strong, nor is the function of digestion particularly disordered; but in some in- stances, vomiting occasionally occurs. The fac^ and whole surface of the body are generally pale, with an expression of ill-health and langour in the countenance. Slight febrile ex- acerbations towards evening, with more or less oppressed re- spiration and cough when the patient lies horizontally on the back, and the appearance of oedema of the feet with paucity of urine, are pretty certain indications that effusion is taking place into the abdomen. The affection is not unfrequently connected with disease of the lungs. * Pemberton on the Viscera. 232 CHRONIC PERITONITIS. Chronic peritoneal inflammation varies greatly with regard to its duration. It sometimes terminates in fatal disorganiza- tion and effusion within a few months; and cases occur which continue in a very slow and insidious way for many months, and even for several years, before the system is worn down by the general irritation it ultimately causes. Causes.—Chronic is frequently a sequel to acute peritonitis. It sometimes occurs as the consequence of acute mucous in- flammation of the intestinal canal,—the inflammation passing from the former membrane to the peritoneal covering of the bowels. Long continued torpor and congestion of the portal system from hepatic torpor or protracted constipation, is pro- bably sometimes the cause of this affection. It may also be the consequence of acute or chronic inflammation of the so- lid viscera of the abdomen—particularly of the speen and liver. Blows or injuries inflicted on the abdomen; difficult parturition; suppression of perspiration, and of hemorrhoidal discharge, metastasis of erysipelas, &c, will sometimes give rise to this affection. Post-mortem appearances.—More or less fluid is invariably found effused into the cavity of the abdomen in those who die of this affection. This fluid is commonly of a whitish or whey- like colour; sometimes it is limpid and yellow ; and occasion- ally it is found of a reddish appearance, with small flocculi of false membrane floating in it. Occasionally, though rarely, the extravasated fluid is mixed with a considerable portion of blood; and instances occur in which it appears to consist of pure blood. (Scoutteten.) I have met with a case of this lat- ter kind. The intestines are often glued together in different parts by the intervention of false membranous matter; some- times sacs are formed by these membraniform exudations, and the intestines, containing purulent matter or other fluids of various appearances. Occasionally the intestines are found agglutinated into one mass, " and partly covered with thick- ened and adherent omentum." (Broussais.) Thickening of the peritoneum is a very common post-mor- tem phenomenon in this affection. In some instances, this membrane, though thickened and otherwise disorganized, is but little injected or red; in other cases, it is found reddish and highly injected. Very frequently the surface of the peri- toneum is covered with innumerable small white granulations of a tubercular character.* Bayle states, that in a subjectJie * " It is always difficult, and frequently impossible," says Dr. Arm- strong, " to predicate that tubercles exist on the serous membrane of the abdomen. But when the skin assumes a delicate hue—when the conjunctiva is blanched—when the expression of the face is more soft- ened and pensive than natural, and especially when the patient has any cough, a presumption of their existence might be excited." CHRONIC PERITONITIS. 233 examined where these tubercular depositions were very abun- dant, he could easily scrape them off with a scalpel; and where this was done, the peritoneum underneath appeared perfectly sound. In some instances, the peritoneum is considerably thickened by granular depositions between its two layers. (Gasc,* Broussais, Abercrombie,! Pemberton.) The mesen- teric glands are usually enlarged and indurated. Treatment.—Chronic peritonitis might, perhaps, be gene- rally removed, if it could be subjected to remediate treatment during its incipient or early period. Such, however, is the ob- scurity and uncertainty of its early phenomena, that it rarely becomes an object of medical attention until it has proceeded to an extent which renders the most judicious treatment almost invariably abortive. Broussais, indeed, for a considerable time regarded this affection as wholly beyond the reach of remediate management. Subsequent experience, however, convinced him that if proper remedies are applied during the first twenty or thirty days of the disease, it may sometimes be effectually sub- dued, and he thinks it possible that it may yield even at a much later period of its course. This writer accounts for the great difficulty of curing this form of peritoneal inflammation by re- ferring it to the impossibility of producing the absorption of the tubercular matter which is so constantly deposited between the layers of the peritoneum, and which therefore keeps up a continued irritation in this membrane. External irritating and depleting applications to the abdomen, constitute our most effi- cient means for combating this affection. Leeching is decided- ly indicated, and often, no doubt, contributes considerably to the removal of the disease, where disorganization or effusion has not yet occurred. After the local abstraction of blood, a large blister should be applied over the abdomen, and kept discharg- ing by dressing it with mercurial ointment. From several in- stances which have lately come under my notice, I am inclined to regard pustulation, by means of tartar-emetic ointment, more efficacious than blistering. We may also use stimulating frictions, followed by emollient applications to the abdomen with a prospect of advantage, more especially where the gene- ral system is in too irritable a state to admit the more irritat- ing applications just mentioned. The application of moxa to the abdomen has never, I believe, been recommended in the treat- ment of this affection. From its known powerful influence in sub- duing deep-seated inflammations, it is not improbable that con- siderable and prompt benefit might be derived from this appli- cation in the present affection. The warm bath has also been recommended as a useful auxiliary in the remediate treatment * Dictionaire des Sciences Medicales, vol. xl. t Edinburgh Medical and Surgical Journal, No. lxiii. 30 234 CHRONIC PERITONITIS. of this disease. Within the last few years, frictions with mer- curial ointment have been used with success in this affection by Velpeau and Laennec ; and from the accounts which they have published, this remedy would seem, indeed, to be entitled to very great consideration. The latter writer has reported seven cases of chronic and subacute peritonitis which yielded to mercurial frictions. Two drachms of the ointment should be rubbed in every two hours, until the gums become slightly affected. Diuretics also are strongly recommended in the treatment of this disease, but they can be regarded only as auxiliary to the more direct and efficient applications al- ready mentioned. Broussais advises the use of diuretic articles in the way of frictions on the abdomen. The tincture of cantharides, or of squills, may answer for this purpose. If any advantage is to be derived from this class of remedies, however, it will probably be better to exhibit them by the mouth, whilst other more efficacious applications are made to the abdomen. Dr. James Johnson recommends the following com- bination as a particularly powerful and useful diuretic in the present, as well as in other affections: R. Acidi tartarici 9i. Soda3 carbon. gr. xxiv. Infus. digitalis fl. ^ss. Spir. setheris nitrici fl. §i. Tinct. scillse M. iv. Aq. menthae §ii. M. ft. This dose to be taken twice or thrice daily. Mild laxatives must from time to time be used, so as to ob- viate costiveness and consequent irritation from this source. Castor oil, or the acetate of potash, and cremor tartar will commonly answer well for this purpose. Although active pur- gatives are not among the means generally recommended in this disease, I have in a few instances known decided benefit to result from the employment of the following mixture: R. Crem. tartar. ^iss. Pulv. scillse 3i. Pulv. sulphat. potass. 3ii. Tart, antimonii gr. ii. M. ft. S. Take 3ss. three or four times daily. This combination produces copious watery discharges from the bowels, and stimulates the kidneys to increased action. To allay the general irritation which is apt to occur in this disease, we may give small doses of Dover's powder, or full doses of extract of hyoscyamus, or of conium maculatum. From the diaphoretic tendency of the first of these articles, it deserves, I think, a preference in this affection. It is of great CHRONIC PERITONITIS. 235 importance in the management of this disease to restrict the patient to the weakest and mildest articles of nourishment. Dr. Johnson observes, in reference to the possibility of procur- ing the absorption of the tubercular matter deposited in the peritoneum in this disease: " There can be little doubt that the absorbents might be made to act upon many extraneous and morbid growths in the human body by rigid abstinence alone, if patients had fortitude to persevere in the measure. For our own parts, we should place more confidence in this than in any other remedy; and practitioners should at all times bear in mind, that without strict abstemiousness, there is little hope of a cure in chronic peritonitis."—(Med. Chir. Rev. Sept. 1820.) CHAPTER XVII. ACUTE HEPATITIS. Symptoms.—Although not a very frequent disease in the temperate and colder latitudes, hepatitis is one of the most common maladies engendered by the influence of an intertropi- cal or hot climate. The acute form of this disease often makes its attack suddenly, and with great vehemence, particularly in those parts where it prevails endemically ; as along the sandy coast of Coromandel, and the marshy districts of Bengal. When the invasion occurs thus suddenly and violently, the pa- tient is seized, without scarcely any previous symptoms of in- disposition, with pain in the right hypochondrium, accompanied with a sensation of tightness across the abdomen ; difficult re- spiration ; and an inability to continue in the recumbent posi- tion ; the patient feeling easiest when in a sitting posture with the body inclined forwards. This mode of attack is frequently observed in the intertropical regions. In the more temperate latitudes it usually comes on in a more gradual and less impe- tuous manner; the patient at first complaining only of a feel- ing of tightness in the right hypochondrium and epigastric re- gions, with slight incipient febrile symptoms for a considerable time before the true character of the disease becomes obvious. The pain attending acute inflammation of the liver, is apt to extend itself to parts remote from the liver, more espe- cially to the breast, and to the clavicle and shoulder of the right and sometimes the left side. Mr. Annesley observes, that when the internal structure of the liver is the seat of the inflamma- tion, the pain is generally heavy and aching; but when the 236 ACUTE HEPATITIS. surfaces or the ligaments become affected, it is usually acute, tensive, and pungent. In some instances these sympathetic pains are even more severe than those experienced in the liver itself. Pressure on the right hypochondrium always greatly aggravates the pain in that part; and a similar effect is almost invariably produced by an attempt to lie on the left side; al- though in some instances the reverse obtains, the patient feel- ing most ease when recumbent on the left side. A dry and troublesome cough, with more or less difficulty of breathing, are common attendants on this disease. When these symptoms are connected with considerable pain in the thorax, the disease may be readily mistaken for pneumonia. Nausea and bilious vomiting frequently occur in acute hepatitis, and in general the severer these symptoms are, the less cough and difficulty of respiration will be experienced by the patient. In many in- stances, there is a distressing "feeling of anxiety at the epi- gastrium and prsecordia, accompanied with frequent sighing, particularly when pressure is made simultaneously on the right hypochondrium, and under the right shoulder-blade." A more or less jaundiced hue of the white of the eyes and skin about the breast, face, and neck, is one of the most constant pheno- mena of this disease—(Louis.)* The urine, also, is invariably highly imbued with bile, exhibiting a deep yellowish brown colour. The thirst is usually very urgent, and the skin hot and dry. The pulse is generally full, active, and firm ; but in some in- stances it is small, tense, and quick; and this is said to be the case when the concave surface of the liver is the principal or exclusive seat of the inflammation, and the consequent parti- cipation of the peritoneal surface of the stomach or colon in the hepatic inflammation. The tongue is coated with a white or thick yellowish fur, and the taste is often bitter; or, " it is smooth and glossy, marked by fissures, and lobulated." (An- nesley.) In general, the bowels are costive ; yet, in many instances of the disease in hot climates, diarrhoea attends from the be- ginning of the malady. (Chisholm.) Cases of this kind often commence like dysentery. The patient is seized with violent griping, followed soon by small watery or slimy discharges from the bowels, accompanied with soreness at the pit of the stomach or of the right side. If pressure is made on the right hypochondrium, the patient shrinks from the touch, yet the pain in this part is seldom violent. " The degree of violence * Mr. Annesley states, that jaundice is not a frequent concomitant of hepatitis in India, unless the ducts or gall-bladder become involved in the disease, or when it supervenes to biliary calculi, or other obstruc- tions of the ducts. ACUTE HEPATITIS. 237 of the bowel affection," says Dr. Johnson, " will very gene- rally indicate the degree of rapidity and danger of the hepatic inflammation. A scalding sensation in making urine almost al- ways occurs; and the brain often sympathizes strongly with the liver in this affection, giving rise to more or less mental disturbance." Diagnosis.—Pain in the right clavicle and shoulder has generally been regarded as one of the most characteristic phe- nomena of hepatitis. This symptom, however, is much less common than is generally supposed. M. Louis* doubts whe- ther it is really indicative of hepatic inflammation, and thinks it arises usually from some affection of the lungs or pleura. Upon this subject Mr. Annesley observes: "The pain some- times complained of at the top of the right shoulder, and so im- properly stated as being one of the chief signs of hepatitis, is, when present, certainly characteristic of the disease in the right lobe ; but unfortunately this symptom is only occasion- ally present; and the inexperienced practitioner who has been taught to look to this as a distinctive mark of the disease, infers, when it is not observed, that the liver is sound."f Hepatitis may be distinguished from pneumonic inflamma- tion, by the following diagnostic circumstances. In pleuritis, the cough and oppression in the chest are much severer than in hepatitis. In the latter affection, the patient rests easiest when lying on the affected side; in the former, the reverse obtains. In hepatitis, pressure on the right hypochondrium greatly ag- gravates the pain, whilst pressure on the intercostal spaces produces little or no increase of suffering; in pleuritis, the former does not, hut the latter does increase the pain. When the substance of the lungs is inflamed, the difficulty of breath- ing and the pain are aggravated by lying on the sound side, as in hepatitis ; but in the former affection, respiration is per- formed chiefly by the action of the abdominal muscles and the diaphragm; whereas, in the latter, (hepatitis) breathing is effected almost entirely by the action of the intercostal mus- cles—the chest being sensibly dilated and collapsed by the act of respiration, whilst ths abdominal muscles are quiescent. The pneumonic symptoms are always most conspicuous when the convex surface of the liver is inflamed. The diagnosis between hepatitis and inflammation of the stomach is rarely attended with any difficulty. The latter affection is almost invariably attended with a very contracted and weak pulse, whilst in the former it is generally moderately full and hard. In gastritis, great muscular prostration usually * Repertorie Med. No. ii. 1826. t Researches into the Causes, Nature, and Treatment of tbe Diseases of India, &c. By James Annesley, Esq. 238 ACUTE HEPATITIS. attends from the commencement of the disease, and every thing taken into the stomach is commonly almost immediately re- jected ; in hepatitis, the strength is at first not much impaired, and although frequent vomiting may occur, it is not so readily excited by ingesta as in gastritis. In the former, pressure on the right hypochondrium—in the latter, pressure of the epi- gastric region causes most pain. From the pain produced by the passage of biliary concretions through the gall-ducts, or by spasm of these passages, hepatitis is distinguished by the absence of fever in the former, the pulse rarely rising above 90 beats in a minute, and the heat of the skin being but little or not at all raised above the healthy standard. In spasm, or irritation by biliary concretions of the gall-ducts, the pain often intermits for a time; in hepatitis, it is continuous. In the former affection, the easiest posture is when the body is bent forward on the pelvis; in hepatitis, the patient leans a little to the right side, with the knees slightly drawn up. When the inflammation is confined to the peritoneal covering of the liver, there is always more pain and fever than when the glandular structure of this organ is the seat of the disease. (Abercrombie.) Acute hepatitis rarely continues beyond the sixth or seventh day, without tending either to resolution or suppuration. When the latter has taken place, the pain becomes moderated ; the patient experiences a sense of weight and throbbing in the re- gion of the liver, with irregular rigors ; more or less profuse night sweats; a sense of sinking, with anxiety and oppression in the prsecordia; a clammy skin ; and a sense of formication. In some cases, " nearly the whole of the right lobe becomes one enormous abscess." In some instances, adhesion takes place between the parts surrounding the hepatic abscess and the internal surface of the abdomen; and when this occurs, and the abscess points outwards, the pus may be discharged by puncture or incision, and the patient often cured. When the abscess is about pointing externally, the general fulness, dis- tention, and pain in the region of the liver and epigastrium, which occurs before the suppurative process commences, are at first somewhat increased ; but as the suppuration goes on, and the matter proceeds outwardly, a soft and more or less cir- cumscribed tumour makes its appearance, whilst the general fulness and tenderness in the right hypochondrium in a great measure subside. " When the abscess advances beneath the false ribs, or near the epigastric region, it is generally suffi- ciently perceptible; but when it points higher up, or more posteriorly, so as to come beneath the ribs, then a bulging out of the hypochondrium is merely marked, with fulness of the intercostal spaces, and pain and soreness limited almost en- tirely to one spot. In the great majority of abscesses, the ACUTE HEPATITIS. 239 direction is to the exterior and superior surface of the liver, and hence the communication so frequent with the diaphragm and lungs when they fail in pointing more externally." (An- nesley.) Sometimes the liver forms adhesions with the colon, or some other portion of the intestinal canal, and the abscess bursting into them, the pus will be discharged by stool. Dr. Saunders thinks it probable, that the matter formed in the substance of the liver, may sometimes pass into the bowels through the biliary ducts. When adhesions form between the liver and diaphragm, the abscess often bursts into the cavity of the thorax, or into the pulmonary cells, in which latter case it is often copiously brought up by expectoration. Dr. Wil- son* observes, that there is perhaps no instance of recovery after this accident; an observation, however, which has been abundantly contradicted by the experience of others. I have seen an instance in which an enormous quantity of thin red- dish pus was discharged from an hepatic abscess through the lungs, followed by a perfect recovery of the patient's health. Annesley mentions cases of this kind ;f and Schmidtmann^: relates two instances of a similar character and successful ter- mination. § Purulent expectoration sometimes attends hepa- titis, from the inflammation extending to the mucous membrane of the bronchial tubes or to the substance of the lungs, without any direct communication between the abscess in the liver and the cavity of the thorax. Cases occur in which the hepatic abscess bursts into the cavity of the abdomen, and these are almost necessarily fatal. It has been doubted whether an ab- scess containing laudable pus, can be formed in the parenchy- matous structure of the liver. Louis states, that by far the greater number of abscesses which occur in the proper sub- stance of the liver do not contain genuine pus, but a fluid less homogeneous, containing small flakes of blood of a darkish gray colour, or like the washings of flesh. In 430 dissections he found hxxtfive instances of purulent abscess in the substance of the liver, and not one in its coverings. When genuine pus is formed in hepatitis, the abscess probably occurs in the cel- lular membrane, between the peritoneal covering and the glan- dular structure of the liver. || * On Febrile Diseases. X Loco. Citat. t Summa Observationem Medicarum, vol. ii. § Louis asserts, that abscesses in the liver are incurable; for in all his examinations he never found a single instance of cicatrization in the liver. Dr. Johnson remarks, upon this assertion: " that those who have practised in India know that abscesses of the liver will heal occasion- ally, whether they are opened externally, or make their way into the intestines."—Med. Chir. Rev. January, 1827. || Memoire on Abscesses of the Liver. By M. Louis.—Repertorie Med. No. ii. 1826.) 240 ACUTE HEPATITIS. Gangrene also, though very rarely, occurs in hepatic inflam- mation. (Bichat.) Annesley seems to doubt, however, whe- ther this mode of termination ever takes place in hepatitis. He states that he never met with an instance of this kind, although his opportunities for observation were very ample. In some instances, the disease terminates in a softening of the structure of the liver. Annesley sometimes found the sur- face of this viscus " marked with red, brown, brick-coloured, greenish-brown, and even with almost black spots and streaks, while the internal structure is inflamed, congested with blood, much tumefied, and softer than natural." Abercrombie found the parenchyma of the liver soft, broken down, and nearly of a black colour.* It is supposed by Dr. Saunders,f that in the acute variety of this disease the capillaries of the hepatic artery are exclu- sively implicated in the inflammation ; and that in the chronic form, the inflammation exists in the extreme branches of the vena portse. The same opinion is expressed by professor Puchelt;^: and Winslow ascribes both varieties to an inflamed state of the vena porta?. There is certainly no good reason why the capillaries of the vena portse may not become the seat of inflammation ; and when we take into consideration the pe- culiarity of the hepatic circulation, the opinion of Dr. Saun- ders is not without considerable plausibility. Causes.—Dr. Saunders and others ascribe the frequent oc- currence of hepatitis in hot climates, to the prevalence of a peculiar miasm in these regions. There can, indeed, exist but little doubt, that koino-miasmata often contribute materially to the production of this disease; but their agency is proba- bly rather predisposing than exciting, in relation to this af- fection. Miasmata, unquestionably, possess an especial power to derange the biliary functions; and it may be reasonably presumed, that where, from the general prevalence of this cause, in conjunction with high atmospheric heat, the liver is in an habitual state of morbid excitation or functional derange- ment ; every adventitious exciting cause—such as the sudden influence of a cool and damp night air; errors in diet, and consequent gastric derangement; the intemperate use of spi- rituous liquors, &c. would be peculiarly apt to develop inflam- mation in the biliary organs. Dr. James Johnson has advan- ced some novel and very plausible sentiments in relation to the etiology of this disease. He observes, that "between the extreme vessels of the vena portarum in the liver, and those on the surface of the body—in other words, between the biliary * Pathological and Practical Researches, &c. &c. Edinburgh 1828. t On the Liver. & ' X Uber das venen System, &c. Leipsic, 1815. ACUTE HEPATITIS. 241 secretion and the perspiration, there exists one of the strongest sympathies in the human frame ; and that, whatever increases or decreases the action of the cutaneous exhalents, increases or decreases also the secretion of bile in the liver. Knowing, therefore, as we do, how uniformly high atmospheric tempera- ture excites excessive perspiration, we cannot be at a loss to account for the frequency of hepatitis in hot climates. The excessive and continued perspiration occasions a loss of tone in the extreme vessels of the surface ; and this loss of tone in the capillaries of the skin, is accompanied by a corresponding loss of tone in the secretory vessels of the liver. As, however, the perspiratory vessels, from their excessive and long-conti- nued action become debilitated and extremely sensible to the slightest degree of cold, so when the temperature of the atmos- phere is suddenly reduced, as is generally the case in hot cli- mates during the night, when the dew falls, the extreme ves- sels of the surface are instantly struck torpid, which, in con- sequence of the sympathy just mentioned, is immediately fol- lowed by a similar torpor of the secretory vessels of the liver. The perspiration and biliary secretion being, therefore, thus simultaneously arrested, and the passage of the blood through the liver obstructed, a commotion is raised, which, as there al- ready exists a congestion in the portal circle, falls mainly upon that system and gives rise to inflammation." That there ex- ists a strong sympathy between the liver and the skin, is strik- ingly illustrated by the fact that in chronic hepatic inflam- mation, or in torpor, or scirrhus of this organ, the skin is always dry and harsh—it being nearly impossible in these affections to excite a perceptible general exhalation from the surface. It appears to me, nevertheless, that the influence of malaria is too much overlooked in this sympathetic doctrine. High and continued atmospheric heat is so universally attended with the extrication of miasmata, that it would seem extremely dif- ficult to say how much of the previous hepatic excitation and consequent atony is to be ascribed to the one or the other of these causes. That a very considerable share of the effect in ques- tion is to be placed to the account of malaria, seems to be de- monstrated by the fact, that bilious and hepatic affections are far from being common on board of ships cruizing in tropical seas, and where the materials for the extrication of miasma- tic exhalations are absent, although the influence of atmosphe- ric heat is constant and great. Besides the exciting causes just mentioned, there are many others of a less general character capable of giving rise to this affection. Violent and fatiguing exercise; contusions of the 31 242 ACUTE HEPATITIS. right hypochondrium; metastasis of gout* and rheumatism; wounds and injuries of the cranium ;f atmospheric vicissitudes; a draught of cold water while the body is in a state of free perspiration; irritation from biliary concretions in the gall ducts; suppression of hemorrhoids; violent rage; terror:}: and mental despondency,^ &c. may all give rise to acute inflam- mation of the liver. Hepatitis may be excited in children by the irritation of dentition.|| Treatment.—-In this disease, as in other inflammatory affec- tions, the abstraction of blood is a primary remedy. There are two reasons for resorting to decisive blood-letting in the commencement of this affection—namely, the necessity of promptly lessening the general momentum of the circulation, as well as the congestion in the liver and portal vessels; and the importance of subduing the general phlogistic condition as early as practicable, in order to favour the effects of mercurial remedies, upon the prompt influence of which much of our re- liance must be placed. (Johnson.) As soon as blood has been drawn to an extent sufficient to make a manifest impression on the system, an active mercurial cathartic must be administer- ed. From 15 to 20 grains of calomel, followed in about two hours by a full dose of castor-oil, or of an infusion of senna and manna, constitutes an appropriate and efficient purgative in this disease. It is often necessary to repeat the bleeding se- veral times in the course of the first few days, before the arte- rial reaction becomes permanently moderated ; and this is par- ticularly apt to be the case in the disease as it occurs in tem- perate latitudes. In warm climates, a frequent repetition of venesection is not often necessary or even proper—one or two efficient bleedings in the commencement of the disease being in general sufficient to bring down the febrile reaction. The application of leeches to the epigastric and hypochon- driac regions, will often contribute very materially to the re- * Quantis implicetur, says Schmidtmann, periculis hepatitis ex poda- gra retropulsa subnata lugubri illustris Augusti Gottl. Richter, praecep- toris mei summe colendi interitu probatur; qui quippe ex podagra hepar petente et inflammante, annum agens septuagesimum, post paucos ab invasione dies occubuit.— Observ. Medicar. torn. ii. p. 231. X Louis doubts this:—The rise, however, of hepatic inflammation and abscesses from this cause, is well established by the testimony of many observers. See the memoirs of M. Bertrandi and M. Andouille', in the M£moires de l'Acad. Roy. de Chirurg. torn. iii. p. 439. X A very striking and interesting case of this kind is related in the Annuaire Medico-Chirurgicale for 1822. § Schmidtmann mentions an instance of hepatitis caused by terror; " Jam memoravi me deprehendis^e,hepatitidem terrore esseexcitatam." —Summa Obs. Med. vol. ii. p. 197. Hippocrates speaks of terror as an exciting cause of this affection: De internis adfectionibus. Sect. iii. cap. L. || Hufeland's Journal der Pract. Heilkunde, vol. xviii. p. 62. ACUTE HEPATITIS. 243 duction of the hepatic inflammation; but one or two efficient bleedings from the arm should always be premised to the local abstraction of blood. It may be necessary to re-apply the leeches where, after the adoption of the measures just indicat- ed, the pulse still retains some activity, and the local symp- toms are not considerably relieved. The bowels should be kept in a loose state throughout the whole course of the disease ; and calomel must always consti- tute a principal ingredient in the purgatives employed. From eight to twelve grains of this preparation may be given at first, every six hours, and followed by the exhibition of a small dose of Epsom or Glauber's salts; or of castor-oil, or infusion of senna and manna, if after ten or twelve hours the calomel do not procure free evacuations. After the general arterial reaction has been moderated by direct and local de- pletion, and the bowels well evacuated, our principal depen- dence should be placed on the speedy induction of moderate ptyalism, in conjunction with blisters applied over the region of the liver, and moderate purgation. The practice of giving opium with calomel in this affection, particularly after the violence of the phlogistic excitement has been broken down by venesection, was long ago recommended as decidedly bene- ficial by Dr. Robert Hamilton; and it has since his time re- ceived the warm sanction of many of the most eminent practi- tioners. " I know from pretty ample experience," says Dr. Johnson, " that in conjunction with antimonial powder, opium forms a most admirable auxiliary to mercury in acute hepati- tis ; not only soothing many uneasy sensations of the patient, but determining to the surface and promoting a diaphoresis, which is of infinite service in this, as in most other affections."* Dr. Armstrong also expresses his confidence in the usefulness of this narcotic in hepatitis ; and in my own practice, I have had unequivocal evidence of its beneficial effects in this mala- dy. From three to four grains of calomel, with half a grain of opium may, be given every four or five hours, and continued until the gums are obviously affected. The addition of two or three grains of the pulvis antimonialis to each dose of the ca- lomel and opium, will do good not only by its diophoretic powers, but also, as it would seem, by its tendency to favour the induction of the mercurial influence, and our main object must be to bring the system under this influence as early as possible. Whilst these articles are given, it will generally be necessa- ry to exhibit an occasional dose of castor-oil or one of the sa- line purgatives. In the more violent and rapid cases of this disease in hot climates, it is often very difficult to obtain the * The Influence of Tropical Climates, &c. vol. i. 244 ACUTE HEPATITIS, timely operation of mercury on the system, merely from its internal exhibition. Where there is reason to apprehend dif- ficulty in this respect, mercurial frictions should be used in ad- dition to the internal employment of calomel. One or two drachms of the ung. hydrarg. may be rubbed in on the arms or thighs three or four times daily, where ptyalism appears to be tardy in its appearance. Dr. Johnson states, " that the absorption of mercury into the system, and the consequent early induction of general mercurial action, is accelerated by causing the patient to swallow a considerable quantity of warm diluting drink, as thin water-gruel, every night at bed- time." The application of blisters large enough to extend over the whole right hypochondriac and epigastric regions, is a highly useful remediate measure after bleeding has been efficiently practised. They almost always give considerable relief to the local pain, and by creating a permanent determination to the external surface immediately over the inflamed liver, they tend in no small degree to subdue the local affection. As auxiliaries to bleeding, purgatives, calomel, and antimo- nial s. will in general be useful where the stomach is not too irritable. The pulvis antimonialis, in doses of about three grains, may be given either in combination with calomel and opium, or in union with nitre, or the sulphate of potash, every three or four hours ; and to promote the diaphoretic operation of these remedies, as well as the specific effects of the mercury, the warm or tepid bath will frequently be found very useful. When the inflammation has terminated in suppuration, an event which is announced by the occurrence of rigors, a sense of sinking and anxiety in the prsecordia, night sweats, and oc- casionally formication of the skin, with a fulness and feeling of weight about the margin of the ribs, and a dull throbbing pain in the liver, the further employment of mercury with a view to its general influence, is improper. " If the local symptoms and the state of the pulse and of the system seem to require it, the application of a few leeches in the vicinity of the tumefaction will be generally serviceable ; and afterwards poultices should be assiduously employed, with a view of promoting the exter- nal pointing of the abscess."—(Annesley.) The bowels also should be regularly though gently evacuated, after the forma- tion of abscess has taken place, which may be best done by five or six grains of calomel, followed, in a few hours, by a small portion of one of the neutral purgative salts. When the ab- scess does not point externally, nothing more can be done than "to palliate symptoms as they rise, and wait for the event." In instances where the abscess does point outwardly, and the fluctuation of the matter can be distinctly felt, an opening ACUTE HEPATITIS. 245 should be made into it, and exit given to its contents. " But this operation ought not, however, to be undertaken precipi- tately, and before the purulent formation has made its way sufficiently near to the external surface of the organ, or before the part at wliich it points has formed adhesions to the oppo- site part of the abdominal parietes. The practitioner should also be fully convinced, from the state of the tumour in the hepatic region, and from the history of the case, that abscess actually exists, and that the tumour does not proceed from an excessive accumulation of bile in the gall-bladder. When the pain and general fulness are diminished, and replaced by a distinct tu- mour, without acute pain, soft and fluctuating at its apex, or with a soft elasticity and slight lividity or redness of the sur- face, and a somewhat hardened and elevated base, the opera- tion may be undertaken with every expectation of success." The operation of paracentesis thoracis has been successfully performed in cases where the abscess had burst into the cavity of the thorax. An interesting case of this kind is related by Mr. Huggins, in the London Med. Repos. for July, 1827". After suppuration has taken place, and the matter found a favourable exit, there is, perhaps, no remedy wliich will af- ford so much advantage as thenitro-muriatic acid. It may be employed both internally and externally as a foot-bath, in the manner recommended by Dr. Scott. Equal parts of the nitric and muriatic acids is the proportion in which they are usually employed. From a half to a whole drachm of this mixture di- luted in a sufficient quantity of water may be taken daily; and in order to prevent the acid from coming in contact with and injuring the teeth, it should be sucked through a small glass tube or a quill: or the feet and legs may be immersed from thirty to forty minutes every evening in a warm bath, of the strength, at first, of half an ounce of the acid mixture to a gal- lon of water, and afterwards gradually increased in strength to the amount of six or eight drachms to the gallon. In two in- stances of hepatic suppuration from acute inflammation, the patients recovered completely under the protracted use of this bath. Considerable advantage may also be obtained, in suppura- tion of the liver, from small doses of the muriate of mercury in union with the extract of cicuta, in the proportion of one-tenth of a grain of the former, to two grains of the latter, three times daily. Mr. Annesley has derived advantage from the nitric acid in combination with laudanum, hyoscyamus, or conium, particu- larly when the abscess has opened into the lungs. When, in cases of this kind, the system becomes much exhausted, and the night sweats are copious, or where the digestive powers fail, re- course ought be had to some of the tonic bitters, in conjunction with nitric acid, and the extract of conium. 246 CHRONIC HEPATITIS. CHRONIC HEPATITIS. Chronic inflammation of the liver, when not the conse- sequence of an acute attack of the disease, begins, generally, with symptoms of functional disorder of the digestive and bi- liary organs; and in many instances, dyspepsia sterns to be the only affection present. The patient complains of irregular appetite, and impaired powers of. digestion ; acidity; flatu- lence; slight colic pains; occasional, nausea, and vomiting; and a sense of fulness in the region of the stomach. In many instances, a slight dull pain and weight is felt in the right hy- pochondrium, accompanied in some cases with a dragging pain in the right shoulder. Most commonly, however, no distinct pain is experienced in the region of the liver, except when firm pressure is made on this part. In such instances, a sense of uneasiness and tightness is usually felt in the right hypochon- drium ; and if examination be made, a manifest tumefaction is often discovered in this part. The white of the eyes, and skin of the face, neck, and breast, become tinged with a yellowish hue, and the countenance acquires a contracted and sickly aspect. The bowels are always very irregular, costiveness be- ing most common, alternating in some instances with diarrhoea, the discharges being frequent, scanty, dark-coloured, offensive, slimy, greenish, or watery and muddy. The urine is gene- rally highly tinged with bilious matter, and creates a sense of scalding in the neck of the bladder on being voided.* The tongue is for the most part white, and rather dry ; the taste bitter or disagreeable; and in the advanced periods of the dis- ease, the gums often have a peculiar and unnatural firmness. One of the most constant and characteristic symptoms of chronic hepatitis, is a dry, harsh, and constricted state of the skin—(Johnson.) So torpid are the cutaneous exhalents in this affection, that almost every effort to produce a general mois- ture or even softness of the skin is abortive. A short dry cough, with slight difficulty in breathing, is a frequent atten- dant on this disease. In the chronic, as in the acute form of this disease, the patient can seldom rest so easy on the left as on the right side. As the disease advances, emaciation becomes more and more conspicuous; slight febrile exacerbations come on towards evening, attended with a burning heat in the palms of the hands and soles of the feet; the nights are restless; and when the inflammation terminates in suppuration, hectic and rapid emaciation consume the vital powers. * Mr. Rose and Dr. Henry asssert, that urea and lithic acid are not found in the urine of persons labouring under hepatitis. CHRONIC HEPATITIS. 247 When the convex surface of the liver is the principal seat of the inflammation, the pain will be referred to the thorax; but when the concave surface is the part chiefly affected, the patient generally refers the pain to the stomach or bowsls. Chronic inflammation of the liver often occurs as a conse- quence of the acute variety of the disease ; but it more fre- quently arises from the slow operation of the same causes which excite acute hepatitis. From the great frequency ot chronic affections of the liver in warm and miasmatic situa- tions, there can exist but little doubt that the slow and conti- nued operation of marsh miasmata is a principal cause of this affection. That this miasm has a particular tendency to pro- duce biliary derangement, seems evident from the sallow and jaundiced appearance of those who reside in marshy districts. The liver being in a state of almost constant excitation in situations of this kind, and finally disordered in its functions, is especially predisposed to become the seat of congestion and slow inflammation, on the supervention of any other cause ca- pable of deranging the cutaneous or digestive functions. Post-mortem appearances.—Chronic inflammation may ter- minate variously. No recent traces of inflammation are de- tected in the liver on post-mortem examination. The viscus usually exhibits an ash or clay-colour, and is generally some- what changed in its healty, or natural shape. Dr. Saunders observes, that the lower margin of the left lobe, which in the healthy-liver is thin, is commonly found rounded and gibbous in chronic hepatitis. In some instances the liver is of a much more firm and solid consistence than natural, although its weight is often specifically lighter than the healthy organ. In some cases, particularly in hot climates, the liver suffers much greater organic destruction than mere change of consistence and colour. Dr. Lind found the liver, in persons who had died of this disease, so eaten through as to resemble a honey-comb. Suppuration is a common termination of chronic hepatic in- flammation in India. " Not unfrequently very minute abscesses are scattered through the substance of the liver, both with and without the appearance of a distinct cyst, the matter collected being of a firm or cheesy consistence and yellowish white co- lour."—(Annesley.) Sometimes, however, one large abscess is found in the structure of the liver. Tubercles of various sizes and appearances are occasionally found imbedded on the surface and interspersed through the substance of the liver. These morbid depositions vary in consistence " from a gristly or cartilaginous state to one of semi-fluidity ;" the firmer ones when divided often presenting either a concentric or radiated texture. In the most chronic cases, the substance of the liver acquires almost a cartilaginous consistence. Annesley states, that in those who had been addicted to the use of spirituous 248 CHRONIC HEPATITIS. liquors, the substance of the liver, besides small tubercles, ex- hibited " a cheesy consistence and texture of a deep nankeen- like colour." Occasionally the liver is firm, and much dimi- nished in size, and its internal structure has sometimes exhi- bited a parboiled, scabrous, dry, and spongy appearance.* Treatment.—General depletion is very rarely indicated in this variety of hepatic inflammation. In cases of a subacute character, more especially when they occur as the consequence of an acute attack of the disease, it will sometimes be useful to abstract small portions of blood ; but even in instances of this kind it will be better to deplete by leeches applied to the epigastrium. "In the chronic hepatitis of India," says Annes- ley, "there are few cases where repeated though moderate leeching will not be advantageous. After each leeching, an emol- lient poultice should be applied over the right hypochondrium, and a mercurial aperient administered at night. When the phlo- gistic action of the liver has been reduced, (where such reduc- tion may be indicated by the local pain, and action of the heart and arteries,) by moderate depletory and aperient measures, recourse should be had to a more regular adminis- tration of mercurial remedies. In the employment of mercury in this affection, however, it must be managed so as not to produce active ptyalism. Full salivation seldom proves bene- ficial, and may do injury in this form of the disease. A mode- rate, unform, and prolonged mercurial influence will generally procure all the advantage that this remedy is capable of afford- ing. From three to four grains of blue pill, in combination with a grain of the extract of conium, or of hyoscyamus, should be given three times daily, until the gums become slightly af- fected.f The medicine is then to be discontinued until the soreness of the gums is going off, when it is to be resumed and given once or thrice daily, so as to keep up a uniform impres- sion on the system without producing ptyalism. During this mercurial course, mild laxatives should from time to time be given, so as to keep up a regular action of the bowels. For this purpose, small doses of Glauber's or Epsom salts, or of powdered rhubarb, may be given every second or third day, according to the state of the bowels. Mr. Annesley recommends the following aperient pill in this affection: * Researches into the Causes and Treatment of the Diseases of Warm Climates. By James Annesley, Esq. p. 470. t I have been in the habit of uniting small portions of ipecacuanha to the blue pill and conium, in this and other chronic complaints. Thus: R. Massae hydrarg. Si- Extract, conii maculat. 3ss. Pulv. ipecac. $i. M. Divide into 30 pills. S. Take two every morning, noon, and evening. CHRONIC HEPATITIS. 249 R. Hydr. submuriatis 9'i. Extract, colocynth. comp. 9ii. Antim. tart. gr. i. Pulv. ipecac. gr. iv. Sapon. castil. gr. x. 01. carui q. s. M. ft. pilul. xviii. S. Two of these pills may be taken every night on go- ing to bed. In most cases one pill will be sufficient. To preserve the tone of the stomach, as well as the regular action of the bowels, it will be useful to prescribe a weak in- fusion of some of the tonic bitters—as gentian, colomba, and quassia. A table-spoonful of an infusion of this kind, with ten or twelve drops of nitric acid, may be taken morning, noon, and evening. Dr. Johnson recommends the following formula as an excel- lent tonic in this affection: R. Decoct, taraxac. fiv. Carbonat. Sodse 3i. Extract, taraxac. 5ii. Tinct. gentian 3ii. Misce. S. Take two or three table-spoonfuls twice daily. " The more the taraxacum is employed," he says, " the more certain proofs will it afford of its utility." The aperient and diuretic qualities of this root are unquestionable.* In speaking only of a moderate mercurial action, I refer par- ticularly to this affection, as it is usually met with in the tem- perate latitudes. In the intertropical regions, chronic hepatitis is generally much more rapid in its progress, and is much more apt to terminate in abscess than in the colder climates. In consequence of this it is often necessary to employ the mer- cury more freely, and to carry it to the extent of producing salivation. Chisholm and Johnson recommend the production of moderate ptyalism, and there can be no question of the ge- neral propriety of this practice in hot climates. The nitro-muriatic acid bath was some years ago strongly recommended to the profession, as a remedy in this variety of hepatitis, by Dr. Scott, and it has since received the approba- tion of many other practitioners, whose opportunities for test- ing its virtues in this way were very ample. "As a general rule," says Dr. Scott, "it may be observed, that whenever the mercurial preparations are indicated, the nitro-muriatic acid will be found useful—with this difference, that in cases where mercury is highly injurious, from delicacy or peculiarity of con- stitution, or from other causes, the nitro-muriatic acid may be * Med. Chir. Rev. Jan. 1829. 32 250 CHRONIC HEPATITIS. employed with safety and advantage." Dr. Johnson, who speaks very favourably of this remedy in chronic hepatitis, gives the following directions for using it. " Into a glass ves- sel capable of holding a pint or more of fluid put eight ounces of water; and then pour in four ounces of nitric, and the same quantity of muriatic acid. One ounce of this mixture to a gal- lon of water will form a bath of a medium strength. The feet and legs of the patient are to be immersed in this bath at the temperature of about 96°, and kept there twenty minutes, or half an hour, just before going to bed. This should be done every night, and the same bath will remain good for five or six nights." If no pricking or itching sensation is felt in the feet and legs after they have been immersed for twenty or thirty minutes, more of the acid must be added to the bath. The ni- tro-muriatic solution may also be used with benefit in the form of a wash. Two or three drachms of the above mixture should be added to a pint of warm water, and the body and thighs sponged with it, night and morning, for fifteen or twenty mi- nutes at a time. Mr. Annesley states, that " he found great ad- vantage from employing this solution in the form of a poultice in torpor of the liver, and in chronic affections of the organ at- tended with enlargement, and a deficient and morbid state of the biliary secretion." Mr. Annesley speaks in the most fa- vourable terms of this remedy in chronic affections of the liver. Where the structure of this organ is enlarged, and the biliary and intestinal secretions disordered, he declares this mixed acid, "one of the most valuable remedies we possess." I have fre- quently used it in affections of this kind, and generally with marked advantage. The internal use of the nitrous acid also has been found very beneficial in this affection. From two to four drachms diluted in a large portion of somefmucilaginous fluid, may betaken in the course of twenty-four hours. It seldom fails to induce more or less ptyalism, when its employment is continued for some time; but it often acts beneficially without the production of saliva- tion. It may be given simultaneously with mercury. (Annes- ley.) Sir James M'Grigor, indeed, thinks that peculiar advan- tages result from the conjoined use of these remedies. Blisters are decidedly beneficial in chronic hepatitis; but I have generally seen more advantage derived from pustulation of the right hypochondrium by frictions with tartar emetic oint- ment. The white precipitate ointment forms a most excellent counter-irritating application in this affection. Two drachms of white precipitate, rubbed up with an ounce of lard, and ap- plied two or three times daily by frictions to the region of the liver, will seldom fail to bring out a copious crop of large sup- purating pustules, more permanent than those which are pro- duced by tartar emetic, and much less painful and irritating. CHRONIC HEPATITIS. 351 A seaton in the right hypochondrium has been found very use- ful in the more chronic instances of this affection. The diet should be light, unirritating, and digestible; and the patient must especially avoid a cold and damp atmosphere, or the influence of sudden changes of atmospheric temperature. In general, persons who are affected with this disease are pecu- liarly sensitive to low temperature; and it is a matter of con- siderable consequence to the successful issue of our remediate efforts, to place such patients in a temperature perfectly agree- able to their sensations and uniform in its grade. SPLENITIS. The physiological relations of the spleen are as yet but very imperfectly understood; nor have the diseases to which it is subject, been "either carefully studied or clearly revealed." " Our ignorance of its use during health, has rendered us less alive to its conditions in disease; and the obscurity of its functions when natural, has made their study when disordered less interesting in its object, and less successful in its issue." It does not appear that this viscus is often the seat of active or acute inflammation, although chronic inflammation is probably much more common than is generally suspected.* When acute- ly inflamed, the patient commonly feels a heavy pain under the false ribs of the left side, which is considerably increased by external pressure. The left hypochondrium is said to become fuller than natural, and in some instances, considerable pain is felt under the right scapula. The skin generally becomes slightly jaundiced, and the urine highly tinged with bilious matter. A burning and oppressive sensation in the stomach, with nausea and vertigo, particularly when the patient raises himself in bed, and other dyspeptic symptoms frequently at- tend the affection.f In chronic splenitis, slight uneasy and occasionally painful sensations are from time to time experienced by the patient; there is difficulty in lying on the left side ; dyspeptic symp- toms ; a cachectic aspect of the countenance ; and the temper is gloomy, morose, and desponding, or variable and fretful. Per- sons affected with chronic inflammation of the spleen, are said to be prone to attacks of vomiting of blood—(Marcus, Rich- ter,)—more especially when the inflammation has terminated in induration of this viscus. The blood, perhaps, passes into the stomach through the vasa brevia. * Richter thinks that chronic splenitis is even more common than chronic hepatitis.—Die Specille Therapie. band. i. s. 576. t Marcus, Vide Annalen der Medizin, band. vii. s. 327. 252 SPLENITIS. From the foregoing symptoms, it is manifest that the diag- nosis between this affection and hepatitis must always be at- tended with considerable uncertainty. The pain in the left side, and the vertigo when the head is raised or on sitting up, are the only symptoms mentioned that are not as common in the latter as in the former affection. Inflammation of the spleen may terminate in suppuration, softening of its structure {ramollissement,) hypertrophy, and induration. Suppuration, however, occurs but very rarely in this affec- tion. M. Jaquinelle relates an instance in which a large ab- scess in the spleen had burst into the colon; and Wardrop found nearly the whole structure of this viscus converted into an abscess containing a purulent fluid. Softening of the structure of this organ is a very common occurrence, particularly " after some forms of general dis- ease." In fatal cases of typhus, ramollissement of the spleen is almost always present.* This softening consists of "a broken down semi-fluid pulp, resembling black currant jelly." (Abercrombie.) Enlargement of the spleen is particularly apt to occur in remittents and intermittents. It is probable, however, that this condition is rarely the consequence of inflammation,— being the result, generally, of great and protracted sanguine- ous congestion of this organ. During the cold stage of inter- mittents, the spleen always becomes greatly engorged with blood, and when this disease continues along time, enlargement, induration, and sometimes a complete disorganization of this organ takes place. Dr. Vetch states, that in the only three cases of intermitting fever which he has known to terminate fatally during the cold stage, the spleen was found so much distended with blood, and its structure so much altered, that it resembled a mass of dark uncoagulated blood, which was bro- ken down by slight pressure of the finger. This state of the spleen is attended with great increase of its vascularity; whilst little or no morbid change usually occurs in its proper sub- stance. Dr. Abercrombie observes, that "one of the most * Dr. Vetch, physician to the Charter-house, mentions the following symptoms as generally accompanying enlargement of the spleen. There is little or no pain complained of by the patient; " the appetite is usual- ly good, yet the powers of assimilation are obviously deficient; the pa- tient loses flesh; is incapable of any muscular exertion; his features have a dark, bilious, or mahogany hue, but the conjunctiva preserves a white and healthy appearance; perspiration is in time wholly suspended, and the skin acquires the appearance and feel of satin; the lips are pale, and there is generally much wasting of the gums; the urine is limpid and secreted very rapidly, but contains little or no urea. The patient's mind is desponding and morose; and coldness of the lower extremities." —Msd. and Phys. Journal, 1824. SPLENITIS. 253 singular facts in the pathology of the spleen, is the very rapid manner in which enlargement of it takes place; and the equal- ly rapid manner in which it subsides."* In some instances, tubercles and hydatids are found in the spleen ; and authors mention a pale induration of this organ as an occasional phenomenon. (Diemerbroeck.) Dr. Aber- crombie mentions also, infiltration of a gelatinous fluid, and deposition of adipose matter into the substance of the spleen. Treatment.—Acute inflammation of the spleen, is to be en- countered with the usual antiphlogistic remedies proper in vis- ceral inflammations. Decisive blood-letting, purgatives, and counter-irritating applications to the region of the spleen, con- stitute the principal means for combating this affection. The warm bath, after the active state of the disease has been in some degree reduced, is said to be a useful auxiliary. In the chronic form of the disease, leeching and pustulation of the left hypochondrium by frictions with tartar emetic oint- ment ; the warm bath; mercurial laxatives; a seton in the left side ; alterative doses of blue pill with extract of hyoscya- mus ; diaphoretics; and the protracted use of minute doses of tartar emetic, are the remedies upon which our chief depen- dence is to be placed. In enlargement and induration of the spleen, particularly when it occurs as the sequel of intermitting fever, I have found no remedy more useful than large doses of the muriate of am- monia. The formula given in the chapter on intermitting fever may be employed with a pretty certain prospect of suc- cess in cases of this kind. Small doses of tartar emetic also, are decidedly beneficial in enlargement of the spleen. One grain dissolved in two quarts of some bland fluid or water may be taken in place of the common drink, and continued for eight or ten days. Alterative doses of blue pill with ipecacuanha, in the proportion of two grains of the former to one of the latter, will frequently succeed in removing this state of the spleen. The bowels must be regularly moved by some mild aperient; and the diet should be mild, digestible, and nourishing. The warm bath, and frictions with dry flan- nel or the flesh-brush, will assist in the removal of this affec- tion. NEPHRITIS. The symptoms which characterize acute inflammation of the kidneys, are not in general obscure or equivocal—being usual- ly readily distinguished from those of other painful affections * Med. Chir. Rev. January, 1829. 254 NEPHRITIS. seated in the neighbourhood of these organs. When this af- fection is excited by cold, it commences commonly like other diseases from this cause, by slight chills and flushes of heat— the febrile reaction preceding the occurrence of pain in the loins. When the disease proceeds from contusions, strains, and irri- tation of renal calculi, cantharides, or other irritating sub- stances absorbed into the circulation, or from metastasis of gout and rheumatism, the first intimation of its occurrence is an acute pressing pain in the right or left lumbar region, or in both. The pain* is deep-seated and of a severe aching charac- ter, and but very little aggravated by external pressure. Any sudden concussive motion of the body, however, always in- creases the pain considerably. The pain often darts down along the ureters,—the testicle of the affected side is retracted towards the abdominal ring, and a sense of numbness is expe- rienced in the thigh. Nausea and vomiting occur in most cases, and violent colic pains in some. The bowels are torpid; the urine is very small in quantity, high-coloiured, sometimes tinged with blood; and the desire to void it is frequent, ur- gent, and troublesome. When both kidneys are inflamed, the secretion of urine is generally almost entirely suppressed;— this, indeed, happens sometimes when the inflammation is seated but in one kidney, the other having its functions dis- turbed sympathetically.! The patient is easiest when he in- clines his body towards the affected side, so as to take off the tension of the lumbar muscles. When in bed, he lies either on the affected side or on the back, with the body inclined towards this side. In some instances, a dull heavy pain is at first felt low down, seemingly where the ureters enter the bladder, and afterwards passes slowly up along the ureter until it reaches the kidney, where it becomes stationary. The pulse in nephritis is full, hard, and frequent, in the early period of the affection; but after the second or third day, it generally be- comes smaller and more frequent, particularly where much * W. Bouillaud asserts, contrary to the general statement of patholo- gists, that pain does not always attend renal inflammation. t This is always a very unfavourable occurrence. Total or almost entire suppression of the urinary secretion can never continue long in any affection without adding greatly to the danger of the disease. Complete ischuria renalis, even without the irritation of local inflam- mation, seldom continues beyond four or five days without producing fatal oppression of the brain.—(Sir H. Halford, Transactions of the Col- lege of Physicians of London, vol. vi.) There is a case mentioned, however, by Dr. Laing, in vol. x. of the Edin. Med. and Surg. Journal, where the secretion of urine was suspended for nine days without ter- minating fatally. The great danger of suppression from this secretion in nephritis was long ago noticed by Aretaeus.—De Causis et signis Morborum, acut. lib. ii. cap. ix. p. 22. NEPHRITIS. 255 nausea and vomiting occur. The surface is above the natural standard of temperature, and usually very dry and parched. Diagnosis.—From inflammation of the psoas muscle, ne- phritis may be distinguished by the pain in the former affec- tion being always considerably increased on bending the body forwards, whereas, in the latter disease, this position general- ly lessens the pain. Nephritis is almost always attended with more or less nausea and vomiting, and frequent desire to pass off the urine, which is not the case in psoas inflammation, un- less the kidneys become affected at the same time. From lumbago, nephritis is distinguished by the paucity of the urine, the disury, the nausea and vomiting, the pain shooting down the ureters in the latter affection; and by the great in- crease of pain on assuming the erect position, or by any mo- tion of the muscles of the loins in the former, whilst in the lat- ter, little or no increase of pain occurs from these causes. Nephritis is generally rapid in its course. It seldom conti- nues beyond the seventh day without terminating in resolution or tending to suppuration. When the disease is about termi- nating favourably by resolution, the fever and pain decline ; the skin becomes uniformly moist; the urine is copious, tur- bid, or charged with mucus; and the nausea and vomiting cease.* The symptoms which denote occurrence of suppura- tion are—frequent chills or shiverings; a dull, heavy throb- bing, instead of the preceding acute pain in the kidney ; a slight abatement of the febrile symptoms; and a feeling of heaviness or numbness in the affected part. In some instances, the abscess bursts into the pelvis of the kidneys and is then discharged with the urine. This is not so favourable an occurrence as might at first sight appear. I have known purulent matter discharged with the urine for up- wards of nine months, from a renal abscess. In some in- stances, more or less pus is discharged with the urine for se- veral years—producing at last hectic and great emaciation, or what has been called tabes renalis. A puruloid substance in the urine must not, however, be too hastily pronounced as the result of renal suppuration, or as genuine pus. The irri- tation of a calculous concretion in the kidneys, will sometimes give rise to a secretion resembling pus; and the same dis- charge may occur from subacute inflammation of the neck of the bladder. Genuine pus in the urine may generally be dis- tinguished from a puruloid fluid mixed with this secretion, by the former sinking down and forming a thin uniform layer along the bottom of the vessel in which the urine is left standing; * Aetius says that a watery and pellucid urine, indicates a slow and difficult declension of the disease—aquosae autem mictiones, et purse ac pellucentes aegre morbum secerni indicant.—Sermo. xi. cap. xvi. 256 NEPHRITIS. whereas, the latter substance remains partly suspended in the urine, and does not settle down into a close layer along the bottom of the vessel.* In some cases, the abscess points externally, and may be evacuated by an incision into the soft fluctuating tumour. Cases are on record which terminated favourably after the matter had obtained exit in this way; but in many instances of this kind, a fistulous opening remains, which it is always extremely difficult and sometimes imposssible to heal—the pa- tient gradually sinking under symptoms of hectic.f Authors mention instances of renal abscesses having opened into the intestines; and Richter states, that the matter has found its way into the liver and even into the cavity of the thorax4 Renal abscess has also been known to burst into the cavity of the abdomen, giving rise to rapid and fatal peritonitis ;§ and instances have occurred, in which the matter has passed down along the psoas muscle, and pointed at the upper part of the thigh, like psoas abscess. Inflammation of the kidneys, occasionally, though rarely, ter- minates in gangrene. Scirrhus, or induration of the kidneys, also, sometimes results from this affection. Bonetus relates several examples of this kind.|| M. Bouillaud mentions a change of the parenchymatous substance of the kidneys into a tuberculous or encephaloid matter, as the result of renal inflam- mation ; and in several cases he found the structure of this or- gan converted into a yellowish sebaceous matter.^ Treatment.—As in all other phlegmasial affections, prompt and efficient blood-letting constitutes the primary remedy in this disease. In addition to general bleeding, leeching, or what appears to be better, cupping over the lumbar region must not be neglected. Active purgatives also assist materially in re- ducing the local inflammation. Six or eight grains of calomel, followed in three or four hours by a full dose of castor oil, or three or four pills of the formula given below, will generally an- swer this purpose well.** The bowels must be kept in a loose state by the daily administration of aperients; or by laxative * Van Swieten observes, when the matter comes from the bladder, there is discharged with the urine a sort of foliaceous fragments; but when it proceeds from suppuration in the kidneys, it is more uniformly mixed with the urine.— Comment, vol. x. p. 38. t Hie autem morbus molestus est ex eoque plures ad renum tabem deveniunt.—.Htppocrafes, De Intern. Affect, cap. xvi. t Specielle Therapie. b. i. p. 615. | Vogel. Handb. t. iv. p. 398.—Richter Sp. Therap. || Sepulchret. Anat. torn. ii. IT Observations on the Anatomy and Diseases of the Kidneys, &c. By J. Bouillaud.—Journal Complementaire. »* R. Extract, colocynth. compos. 9i. Calomel gr. xii. M. Divide into 6 pills NEPHRITIS. 257 enemata throughout the whole course of the disease. Much re- lief will sometimes be obtained from anodyne emollient injections, particularly in theevening after the freeoperation of a purgative. Indeed, the assiduous employment of soothing emollient enemata, either with or without laudanum, is always a most useful auxi- liary in the treatment of this affection. For this purpose we may use an infusion of flaxseed, or simply warm water mixed with a portion of milk; or a thin decoction of barley. Fomen- tations to the external lumbar region will likewise be proper, particularly in the early period of the disease, immediately af- ter leeching or cupping has been practised. A large emollient poultice is a more convenient, and probably a better applica- tion for this purpose. Blisters are very generally regarded as objectionable in this affection, on account of the tendency of cantharides to irritate the urinary organs when absorbed into the circulation. I have nevertheless derived decided benefit from blistering the region of the inflamed kidney, without hav- ing ever known any injurious consequences resulting from it. By suffering the vesicatory to remain no longer than is neces- sary to inflame the skin—which is seldom more than four or five hours, and then applying an emollient poultice, a full blister will be raised; and I have never known strangury to occur where this mode of vesicating was adopted. I have pursued this practice in ten or twelve cases of nephritis, and generally with evident advantage. Sinapisms may also be used, after adequate depletion, with a prospect of benefit; but they are not equal, in efficacy, to blisters, in this as in other internal inflam- mations. From the close sympathy which exists between the skin and the kidneys, considerable benefit usually arises from the em- ployment of suitable-diaphoretics in this affection. Where the stomach is not too irritable, antimonials* may be employed ; but where much nausea and |vomiting attend, it will be better to depend on the use of the warm bath, more especially the steam-bath, for the production of diaphoresis. Hot bricks, wrap- ped in flannels previously moistened with vinegar and water, and laid under the bed-coverings near the patient's body, will seldom fail to bring on a more or less copious and uniform per- * R. Spir. nit. dulc. §i. Vin. antimonii 3U- Tinct. opii gr. xxx. M. S. Take a tea-spoonful every hour or two. Or— R. Spirit mindereri Siv. Tart, antimonii gr. i. Spir. nit. dulc. 3ii. Syrup limonis |ii. Tinct. opii gr. xxx. M. S. Take a table-apoonful every two hours. 33 258 NEPHRITIS. spiration. The nitrate of potash cannot be used with propriety in nephritis, on account of its tendency to excite the activity of the kidneys, an effect which could hardly fail to do mischief in the inflamed state of these organs. All stimulating diuretics indeed must be carefully avoided—copious draughts of mucila- ginous diluents being the only proper means for promoting the urinary secretion. After the inflammatory condition of the sys- tem has been in some degree subdued by the antiphlogistic mea- sures already mentioned, small doses of Dover's powder repeat- ed every three or four hours, will tend to keep up a general dia- phoresis, as well as to moderate the local pain and general ir- ritable state of the system. Much relief may also be derived after proper depletion and purging, from the occasional use of anodyne enemata.* A slight sensation of pa;". and soreness is apt to remain in the affected kidney for several days, and sometimes weeks, after the disease has been subdued. Here uva ursi, in con- junction with small doses of opium or Dover's powder, is the best remedy. From twenty to thirty grains of the uva ursi, with the fourth of a grain of opium, or three grains of Dover's powder, may be taken four times daily. This remedy is no less useful in cases where the inflammation has terminated in suppuration. I have known the extract of conium, with an infusion of uva ursi, to be employed in suppuration of the kid- ney with complete success. Three grains of the extract was taken three times daily, and a wine-glassful of the infusion (one ounce of the uva ursi to a pint of water) every four hours. Minute doses of muriate of mercury with this extract,! have also been found beneficial in abscess of the kidneys. The use of lime water, to the extent of from four to six ounces daily, has been recommended in suppuration of the kidneys. (Richter.) Decided benefit has also been derived from the balsam copaiva; but this article must be avoided as long as there is any evi- dence of inflammatory action present. CYSTITIS. Symptoms.—Violent burning, lancinating, or throbbing pain in the region of the bladder—extending to the perineum, * R. Pulv. opii » gr. ii. Mucilag. g. arab. gss. Lactis. tepefact. ?v. Or— R. Tinct. opii 3i. Infusi. lini. gvi. M. ft. enema. This injec- tion may be repeated two or three times daily. t R. Muriat. hydrarg. gr. vi. Extract, conii maculat. 3iss. M. Divide into 45 pills. S. Take one every morning, noon, and evening. CYSTITIS. 259 and in some instances to the testicles and the upper part of the thighs; attended generally with a sense of constriction in the hypogastric region. The pain is greatly increased by pressure made immediately above the pubis; and the perineum feels sore to the touch. There are frequent, but often ineffec- tual efforts to void urine, more or less strangury or dysury being usually present. The small portion of urine which passes off is deep red, and often tinged with blood. In some cases there is a constant stilicidium of urine. Nausea and vomiting, with great anxiety in the prsecordia, are seldom absent in this affection. The bowels are constipated, and there is often a sensation of tenesmus, from the inflammation extending to the lower part of the rectum. The pulse is full, hard, and frequent; the skin hot and dry; the thirst urgent, and the pa- tient is restless and dejected. If the disease continues un- checked in its course, more or less swelling occurs in the loins, with increased tenderness in the hypogastrium and perineum. Some diversity occurs in the symptoms, according to tbe par- ticular part of the bladder in which the inflammation chiefly exists. When the neck of the bladder is inflamed, great pain is felt in the perineum, and total retention of urine sometimes occurs, or the patient is tormented with dysury or incessant feelings of strangury. In this case, the introduction of a ca- theter or bougie causes extreme suffering. " When the poste- rior part of the bladder is affected, the rectum suffers more particularly, and the patient is harassed by a most distressing and constant tenesmus. Sometimes the inflammation occupies that part of the bladder in which the mouths of the ureters are situated, which thus become involved in the affection, and a suppression of urine, more or less complete, and its conse- quences take place; in this case, there is commonly more or less pain and tenderness on pressure in the hypogastric re- gion." (Prout.) Like other inflammations, cystitis terminates either in reso- lution, suppuration, gangrene, or induration and thickening of the coats of the bladder. Resolution, besides the abatement of the pain and fever, is attended with general and uniform diaphoresis; a turbid and rather copious urine, passed with little or no pain; and an ability to bear pressure on the epi- gastrium and perineum. On dissection, the inner membrane of the bladder is generally found minutely injected so as to give a uniform red appearance to the whole surface. In some instances, the inflammation is confined entirely to the internal coat; in others, it extends to the muscular tunic ; and some- times even to the peritoneal covering.* Suppuration is not a frequent termination of this affection. * Wilson on the Urinary Organs, p. 297. P 260 CYSTITIS. (Richter.) Abatement of the violence of the fever and pain, accompanied with chills or rigors, and the sudden appearance of a white matter in the urine, indicate the occurrence of sup- puration. In some instances, abscesses are formed in the coats of the bladder, particularly near its neck; and in others, the abscess forms in the cellular structure surrounding the neck of the bladder. When suppuration occurs in the mucous mem- brane, or when the abscess between the tunics of the bladder bursts into its cavity, the matter will be discharged with the urine. Sometimes the abscess points externally, and may open into the rectum or vagina, or sink down and infiltate into the cellular membrane of the pelvis. The abscess has also been known to burst into the cavity of the peritoneum ; and in some instances the matter has made its way into the labia pudendi, and the loose structure of the scrotum. In some cases, the coats of the bladder are thickened and indurated, particularly the internal one. Sometimes fungoid elevations of the mucous membrane occur; at others, indura- tions are found in different parts, resembling small scirrhous tumours, and some of these are occasionally ulcerated. Firm adhesions have been noticed between the bladder and rectum, as well as between the bladder and uterus, in consequence of acute cystitis. It is sometimes very difficult to distinguish some of these results of inflammation of the bladder from calculus. Gangrene is a frequent termination of cystitis. The majo- rity of instances that prove fatal within the first six or seven days, terminate in gangrene. The occurrence of gangrene is announced by sudden cessation of the pain ; cold extremities; profuse and clammy perspiration; great prostration of strength; a cadaverous expression of the countenance; slight confusion of the mind; a small, frequent, and weak pulse; and hic- cough. Causes.—Cystitis may be produced by mechanical irritating substances in the bladder; retained urine; external injuries on the hypogastric region ; irritation from acrid substances absorbed and conveyed to the bladder—as cantharides, turpen- tine, &c; metastasis of gout and rheumatism ; irritating injec- tions forced into the bladder; irritation from the introduction of a bougie, or catheter ; gonorrhoea ; suppression of hsemorr- hoidal discharge, and of perspiration ; cold applied to the feet or lower portion of the abdomen ; injury sustained in parturi- tion, or from the use of obstetrical instruments. Treatment.—Acute cytitis is a rapid and highly dangerous affection, and must be promptly met with the most efficient an- tiphlogistic measures. Efficient blood-letting must be prompt- ly practised, until the activity of the pulse is moderated. Af- ter general bleeding, leeching is of the utmost importance in CYSTITIS. 261 this affection. The leeches must be applied to the perineum, about the anus, and to the hypogastric region ; and, when the pulse will admit of it, they should be reapplied. Immediately after leeching, an emollient poultice must be applied over the hypogastrium, pubis, and perineum. The bowels must be kept open by gentle laxatives and mucilaginous enemata. Much re- lief is generally obtained from an emollient anodyne enema, immediately after the rectum has been emptied by a laxative. Attention must be early paid to the evacuation of the urine, should the bladder be found distended by it. Great care should, however, be taken to avoid all unnecessary irritation from the introduction of the catheter. When the. neck of the bladder is in- inflamed, the pain caused by this operation is generally extremely severe, and sometimes it is impossible to reach the bladder, from the great irritability and spasmodic contraction of its neck. This can in some degree be obviated by introducing three or four grains of opium into the rectum an hour before the cathe- ter is used, accompanied with an efficient abstraction of blood, both by venesection and leeching. To promote the action of the cutaneous exhalents, we may employ the warm bath; or, what is better, the steam-bath, as mentioned under the head of nephritis. Some of the milder diaphoretics, such as spiritus mindereri, diluted with barley-water or flaxseed tea ; or small and frequent doses of pulvis antimonialis; or of Dover's pow- ders, may be usefully exhibited, with a similar view. The hip- bath is particularly recommended by Richter as a local appli- cation in this affection. After the violence of the local and ge- neral inflammatory action has been moderated by the foregoing means, much benefit may sometimes be derived from the inter- nal use of opium and calomel. Richter observes, that opium is a primary remedy in cystitis, particularly when given in union with mercury. Prout also recommends the internal use of this combination. A grain of opium, with two grains of calomel, may be given every four hours. In cases of a subacute character, the employment of opium and calomel, in conjunction with leeching, emollient anodyne injections, and fomentations or poultices to the hypo- gastrium and perineum, is particularly beneficial. Nitre and blisters are apt to increase the local irritation, and cannot, therefore, be resorted to without considerable risk of doing in- jury. " If blisters be employed," says Prout, "they should be used with caution and permitted to remain only for a short time, and afterwards such dressings applied as tend to keep them open." The mode of blistering mentioned, when speak- ing of the treatment of nephritis, may, perhaps, be safely adopted in this affection. Considerable advantage is said to accrue from the repeated injection of mucilaginous fluids into 262 CYSTITIS. the bladder, by obtunding the acrimony of the urine, and sooth- ing irritation. CHRONIC CYSTITIS. Chronic inflammation of the tinner membrane of the blad- der is not an uncommon affection, and is generally described under the name of cystirrhoza. In some instances, this affec- tion is the consequence of acute cystitis ; but it may arise, at once, from the action of the same causes which produce acute inflammation of the bladder. The symptoms which accompany chronic mucous inflammation of the bladder, are—slight lanci- nating pains, attended with a sense of heat or burning in the region of the bladder, and a feeling of weight and tenderness in the perineum; frequent and harassing desire to pass urine, with occasional spasmodic action of the bladder and urethra. The urine is loaded with more or less of a tenacious mucus. Slow fever generally attends, accompanied with thirst; general de- bility, " particularly about the back and loins ;" and, in pro- tracted cases, much emaciation and exhaustion occur. There is generally considerable derangement of the digestive func- tions; loss of appetite ; sometimes nausea and vomiting; cos- tiveness ; tongue covered with a white or brown fur; and the skin is harsh and dry. " In slight and incipient cases of this affection, the urine, when first passed, generally appears of a whitish colour, and is more or less opake and turbid, with the appearance of flocculi floating through it. On standing, how- ever, for some time, it becomes more or less transparent, and the mucus will be found together in a mass at the bottom of the vessel."—(Prout.) The writer just quoted states, that in most cases the urine is acid; but others assert that it common- ly exhales an ammoniacal odour, and that it is rarely acid. In some cases the quantity of mucus discharged with the urine " is enormous, amounting occasionally to several pints in the day; and in this case it not only comes away diffused through the urine, but also in the form of large coagula, which, by blocking up the urethra, give origin to the most distressing symptoms— particularly to a sense of severe burning pain along the whole course of the urethra." Sometimes this mucus is easily diffused in water or the urine; but in inveterate and violent cases, it is often so extremely tenacious that it is very difficult to mix it with the urine. When suffered to cool, the mucus, says Prout, is sometimes so tenacious " that it may be drawn into strings of considerable length, and the vessel may be fre- quently inverted without its falling out." In the worst cases, particularly when ulceration of the inner surface of the blad- CHRONIC CYSTITIS. 263 dcr exists, copious discharges of blood, at times, take place. I have known an instance of this disease which continued for five or six years, and at last terminated fatally, from the super- vention of acute inflammation in consequence of irritating injections. In this case, more or less haemorrhage occurred from the bladder almost every month. The discharge of mu- cus was always very considerable. On dissection, two large ulcers of the mucous membrane were found near the neck of the bladder. Dr. M'Dowell found, in this affection, the mu- cous surface of the bladder to present " different degrees of vascularity, from merely a few patches of a dark or bright red colour to an entire vascularity, in some cases so marked, as to appear as if the bladder had been daubed over with blood ; the veins in general are turgid ; the membrane much thickened; frequently numerous ulcers occur, covered with a tenacious brownish coloured lymph; these a^ sometimes deep and nu- merous, so as to give a honey-car* l> appearance to the mem- brane. The inflammation someti \.s e^dsJ-njcomnlete sphacelus of the interior of the bladder."* " Blood," says Dr. M'D., "is often discharged in very large quantity; and, together with the abundant mucus, a white powdery sediment, or sani- ous matter, is mixed with the urine." This affection is most apt occur in old and gouty subjects, and persons of an irritable and scrofulous habit are said to be particularly predisposed to it, " more especially if they have been accustomed to free living, or been given to venereal ex- cesses, or have suffered from these affections or gout." Treatment.—In the early stages of the complaint, we must endeavour to reduce the chronic inflammation by local, deplet- ing, and counter-irritating measures. Cupping along the loins, with the occasional application of leeches to the perineum, and about the anus, may be accounted our most efficient remedies during the first period of the disease. If the pulse is active and the pain in the pelvis considerable, general blood-letting may be very beneficially resorted to. The bowels must be kept in a relaxed state by the occasional use of gentle purgatives, such as castor-oil, or magnesia. I have known much benefit to re- sult from a caustic issue on the upper and inner part of the thigh. Advantage would probably be derived also from frictions and pustulation with tartar-emetic ointment on the upper part of the thighs, or on the loins. When the general and inflam- matory symptoms have subsided, either in consequence of the application of the remedies just stated, or by the long conti- nuance of the disease, astringents, with some of the narcotic extracts, may be resorted to with a prospect of advantage. Dr. * Dublin Transactions, vol. iv. 264 CHRONIC CYSTITIS. Prout prefers the uva ursi to all other articles of the astringent kind in this affection. " Given in combination with hyoscyamus, and steadily persevered in for a considerable time, the uva ursi seldom fails to diminish the irritation and quantity of mu- cus, and thus to mitigate the patient's sufferings." Within the last five or six years, the buchu leaves (diosma crenata,) have been strongly recommended to the profession as a valuable re- medy in this and other chronic affections of the bladder. Dr. M'Dowell employed it successfully in three cases, according to the following formula: R. Infus. buchu §vii. Tinct. ejusdem ------cubebae aa |i. M. S. Take an ounce of this mixture three times daily. The use of this reme- dy should be continued foKJhree or four months. I have heard of the succe.vsful employment of an infusion of the pipsissewa,-^itonnrpn'fraumbellata,) in a case of this disease. In several inveterate cases of this disease, I have prescribed the muriated tincture of iron, with infusion of peach-leaves, with very manifest benefit. In one instance, a perfect cure was ef- fected by the tincture of iron, in conjunction with uva ursi. Frictions over the groins and the hypogastrium with camphorat- ed oil has appeared to me serviceable in some cases. Besides these, a great variety of other remedies have been recommend- ed for the cure of this affection. Balsam copaiva; turpentine; balsam peru; camphor; madder; and many of the vegetable astringents are mentioned by writers as often beneficial in this complaint. From the known good effects of balsam copaiva in chronic inflammation of mucous membranes, there is some reason to presume that advantage might be obtained from its use in this complaint. Experience does not, however, furnish us with with much testimony in its favour. I have given it in a few cases, but in these it appeared to give additional uneasi- ness in the bladder, without diminishing the mucous discharge. Different kinds of injections into the bladder have also been recommended as beneficial in this affection ; such as flaxseed tea; infusion of marsh-mallows; or barley-water. When re- tention of the urine occurs from a spasmodic constriction of the neck of the bladder, relief will often be obtained from seven or eight drops of the muriated tincture of iron given every half hour. The diet should be simple and digestible, and every kind of stimulating beverage carefully avoided. Fatiguing exercise, or riding on horseback, or in a carriage over rough roads, ge- nerally aggravates the symptoms. The drink should be bland and mucilaginous. One patient under my care, always felt himself much relieved by drinking the infusion of the malva CHRONIC CYSTITIS. 265 rotundifolia, a common plant in this country. I have also pre- scribed the constant use of slippery elm bark tea with benefi- cial effect. CHAPTER XVIII. PNEUMONIA. The term pneumonia is employed, in a general sense, to designate acute inflammation within the cavity of the thorax, whether seated in the pleura, the mucous membrane of the bronchia, or in the proper substance of the lungs. The gene- ral characteristic symptoms of acute inflammation in the chest are:—cough, difficult and painful respiration, fixed pain in the thorax, and fever. Considerable difference occurs, how- ever, in the character of these symptoms, as well as in the other usual concomitant phenomena, according as the one or the other of the three structures just named is the principal or exclu- sive seat of the inflammation. Cullen was of opinion, that the pleura can never be inflamed without an extension of the in- flammation to the pulmonary structure; pleuritis, according to his views, being always accompanied with more or less of pe- ripneumonic inflammation. The observations of later patholo- gists,* however, have proved that the pleura is often exclusive- ly inflamed, and that pleuritic inflammation is generally marked by symptoms sufficiently characteristic to enable us to distinguish it from acute inflammation of the proper pulmonary substance. Without doubt, pleuritis is very generally attend- ed with inflammation of the subjacent tissues ; but its occa- sional separate existence is equally unquestionable. In pleuritis a violent and pungent pain is felt in the chest, generally on one side, which is always greatly increased by a full inspiration, or on coughing. Respiration is hurried, short, and generally most oppressed when the patient lies on the af- fected side. The cough is short and dry, or attended with a glairy and nearly colourless sputa, and stifled as much as pos- sible to avoid the great increase of pain which it occasions. When the inflammation extends to the lungs, the expectoration is generally mixed with more or less of blood. The face is generally suffused with a vivid flush ; the pulse hard, full, vi- * Laennec. 34 266 PNEUMONIA. gorous, and frequent; the tongue covered with a thick white fur; the skin hot and dry ; and the urine of a deep red colour, and small in quantity. The act of respiration is performed chiefly by the action of the diaphragm and abdominal muscles, the motion of the ribs being restrained by the patient, on ac- count of the increase of pain which it always causes. Acute inflammation of the pleura, is not, however, always attended by the foregoing unequivocal manifestations of its presence. In some instances, the disease, though rapid in its course and violent, is attended with scarcely any pain or cough. Baglivi mentions examples of this kind ; and Schmidt- mann has given the history of several cases of what he calls pleuritis occulta.* Mr. Tacheron gives an account of a fatal case, in which there was but little pain, and no cough, al- though the pleura was found, on dissection, coated with a yel- low albuminous matter, a line in thickness, and a large quan- tity of fluid effused into the thorax.f Bichat also refers to the circumstance of the occasional absence of pain in the chest in acute inflammation of the pleura. Pleuritis is most apt to attack persons of a vigorous and ple- thoric habit of body. The sudden influence of cold, when the body is in a state of perspiration from active exercise or con- finement in a heated room, is its most common exciting cause. Pleurisy may also arise from metastasis of other affections— particularly of rheumatism, gout, and erysipelas ; and it has been known to occur in consequence of suppression of the cata- menial and hsemorrhoidal discharges. Pleurisy from translated rheumatism or gout, is by no means an uncommon occurrence. I have met with a considerable number of cases of this kind, and one recently which was a strongly marked instance. The patient was affected for seve- ral weeks with severe rheumatic inflammation of the left elbow joint. A cold poultice was applied to the joint in the evening, and on the next morning, the pain and redness had in a great measure subsided. In the afternoon, a severe pain came on in the left side of the thorax, which rapidly increased in vio- lence, and soon exhibited all the characteristic phenomena of pleurisy, whilst the pain in the elbow disappeared entirely. It was successfully treated with blood-letting, blisters, and the internal use of calomel and opium. In a few weeks after re- covering from this attack, subacute rheumatic inflammation occurred in the elbow of the right s\de.\ * Summa Obs. Med. vol. i. p. 108. t Recherches Anotomico-Pathologiques, &c.—Vide Med. Chir. Rev. March, 1824. X For much interesting information concerning rheumatic pneumonia, the reader is referred to Stoll's Ratio Medendi, &c. part i. p. 82—and to Schmidtmann's Summa Observ. Medicarum, torn. i. p. 62, et seq. PNEUMONIA. 267 Pleurisy and depots of pus in the lungs, are sometimes ra- pidly developed after capital surgical operations. M. Velpeau, in a very interesting memoir, has given the following as the result of his observations on this subject: 1. "Those who die of acute diseases succeeding surgical ope- rations or profuse suppurations, generally fall victims to pleurisy, and the formation of abscesses more or less numerous in the lungs." 2. "That kind of pleurisy hitherto undescribed is of a pecu- liar nature, and might be denominated the pleurisy suc- ceeding surgical operations." 3. " That this disease differs from simple pleurisy in the la- tency of its progress, the rapidity of its course, and the almost invariable certainty of its fatality." 4. "That the pleurisy and formation of depots of matter are rarely accompanied by characteristic local symptoms sufficient to give notice of their existence." M. Velpeau ascribes these secondary pneumonic affections to the absorption of pus, and its passage into the current of the circulation.* Post-mortem appearances.—On dissection, the pleura is ge- nerally found uniformly red, or punctuated with small red specks of irregular shape and very close together. Laennec states, that these red points " occupy the whole thickness of the pleura, leaving small intermediate spaces retaining the natural white colour." The pleura is not often found thicken- ed in consequence of inflammation. Extravasation on the in- ner surface of this membrane is a never-failing occurrence in fatal cases of this disease. Laennec thinks that this extrava- sation commences with the inflammation. The matter thus thrown out by the vessels of the inflamed pleura, consists of a semi-concrete or pseudo-membranous substance; or of coagu- lable lymph; or of sero-purulent fluid effused into the cavity of the chest. This fluid generally contains small flocculi or filaments of coagulable lymph or concrete pus, and is either of a light-yellow colour and nearly transparent, or reddish, as if a small portion of blood were mixed with it. Adhesions be- tween the costal and pulmonary portions of the pleura occur in nearly all instances through the intervention of false mem- branous substances.f * Revue Medicale, December, 1826. f The false membranes produced in pleurisy, generally change after some time into a kind of cellular tissue, " or rather into a true serous membrane like that of the pleura. This change," says Laennec, " is produced in the following manner: the serous effusion which accom- panied the membranous exudation is absorbed; tbe compressed lung ex- pands, and the false membrane investing it aud the costal pleura be- 268 PNEUMONIA. Prognosis.—Acute pleuritis is not, in general, a very dan- gerous affection in subjects of a good and vigorous constitu- tion. There is no inflammatory affection which is more under the control of an active antiphlogistic treatment. In subjects, however, of a weak habit of body—and especially in such as are predisposed to phthisis pulmonalis. pleurisy, if not a disease of much immediate danger, is to be dreaded on account of its tendency to develop pulmonary consumption. When the in- flammation extends to the substance of the lungs, the patient may sink at an early period from effusion into, or disorganization of its structure. The following circumstances may be regard- ed as indicative of imminent danger in this affection. A fre- quent effort to sit up, particularly when there is a wheezing sound in the trachea, bloody expectoration,* and an obstructed pulse. The supervention of diarrhoea is a most unfavourable sign; convulsions and coma are no less ominous of a fatal ten- dency. Schmidtmann asserts, that he has never known an in- stance of recovery from this disease after convulsions and coma had supervened. PERIPNEUMONIA. When the parenchymatous substance of the lungs is the principal or sole seat of the inflammation, the disease is desig- nated by the termperipneumony. In this variety of thoracic in- flammation the breathing is much oppressed, particularly when the patient is in a horizontal posture ; an obtuse pain is felt in the chest, generally in the region of the sternum, sometimes in the epigastrium, and occasionally in the side or scapular re- gion. The cough is attended with a copious viscid expectora- tion, mixed more or less with blood. The skin is hot and dry; the urine high-coloured and scanty ; and the pulse frequent, come united in one substance. By degrees, this substance becomes divided into layers pretty thick and opaque, which are separated by a very small portion of serosity. About this time the blood-vessels begin to make their appearance in it, the first rudiments of which have the aspect of irregular lines of blood, much larger than the vessels which are to take their place. After a time the pseudo-membranous layers become thinner and less opaque; the lines of blood assume a cylindri- cal shape and ramify in the manner of blood-vessels. Eventually, the layers of the false membrane become quite transparent, and nearly as thin as those of the ordinary cellular tissue. By degrees, it acquires the firmness of the natural cellular substance, and becomes the bond of a firm union between the lungs and the costal pleura." * Baglivi says, " Erectum sedere velle in morbis acutis pulmonum perniciosum ac ferme lethale, praesertim, si adsit sibillus in aspera arte- ria, et difficultas excreandi sputi, et licit cum talibus signis pulsum bo- num videris, noli credere, nos fallit."— Opera Omnia, p. 42. PERIPNEUMONIA.^ 269 full, obstructed, labouring, but rarely very hard; but in the advanced stage of the disease, it usually becomes weak, soft, obstructed, and irregular. In violent cases, tending to effu- sion or disorganization of the inflamed portion of the lungs, the countenance acquires a livid aspect, and the veins of the neck become turgid. The patient generally lies on the affect- ed side, although in some instances, the reverse position is pre- ferred. "The sputa are white, slightly yellowish or green- ish, somewhat diaphanous, and intermixed with bubbles of air. The tenacity of the matter expectorated is so great, that we may often reverse the vessel which contains it, and retain it in this position for a time without detaching it from its. sides." Laennec regards this kind of sputa as pathognomic of this af- fection, " since it is the only one," he says, " that is found ex- clusively in it." In this, as in the former variety of pneumonic inflammation, the symptoms are sometimes so inconspicuous and equivocal in their character, that the true nature of the disease may remain doubtful, or be entirely mistaken until fatal disorganization has occurred in the pulmonary structure. An instance of rapid fatal pneumonia is reported by Dr. Damiron, one of the physicians of the hospital ValDe Grace, in which no pain what- ever was complained of by the patient, nor did epigastric pressure produce any uneasiness. The breathing was difficult, the cough frequent, the expectoration ropy and copious. On dissection, three-fourths of the right lung was hepatized, and the left lung was black and crepitous.* M. Andral has relat- ed seventeen cases in which one or more of the characteristic signs of the disease were absent. In several instances, there was neither pain nor cough, f PNEUMONIA BILIOSA. There is a modification of pneumonia which, from the pro- minent symptoms of hepatic disorder which it exhibits along with the ordinary phenomena of pneumonic inflammation, has been termed bilious pneumonia. This variety of the disease oc- curs during the cold and variable seasons in districts abound- ing in sources of miasmatic exhalations. It appears to be the result of the combined agency of koino-miasmata and atmos- pheric vicissitudes. The initial symptoms of this modification of the disease differ very little from those which usually.usher in an attack of ordinary bilious remittent fever. In some in- * Med. Chir. Rev. October, 1825. t Clinique Medicale, &c. Par. G. Andral, Paris, 1824. 270 PNEUMONIA BILIOSA. stances, a sense of fulness and tension is experienced in the right hypochondrium a few days previous to the supervention of the disease, and occasionally dysenteric symptoms occur be- fore the fever commences. In almost all cases, considerable pain is felt in the back and extremities during the premonito- ry period. The skin from the beginning is more or less tinged with bile, and the conjunctiva, especially, is often conspicu- ously icterode. The face is flushed, " and a sickly mixture of red and yellow, upon close examination, betrays the existence of a disturbed state of the liver." (Potter.) Acute pain in the forehead is almost constantly present. The pain in the chest is sometimes extremely severe and pungent; but more com- monly it is obtuse, and attended with a sense of weight or op- pression in the breast. In some cases, the fever continues for several days before the pectoral pain supervenes. The expec- toration is not very copious—the sputa being of a frothy yel- lowish appearance, marked frequently with streaks of blood. The fever is generally attended with manifest evening exacer- bations and morning remissions. When vomiting takes place, an occurrence very common in this affection, more or less of bilious matter is generally thrown up, although, in some in- stances, the secretion of bile appears to be entirely suspended; the ejections consisting of nothing else than gastric mucus and the ingesta. The tongue is at first white with a yellowish streak along the middle, which, as the disease advances, be- comes dark-brown and dry. The urine is always of a deep yellow or bilious colour; and the pulse is generally small, fre- quent, and quick, with a slight degree of preternatural tension. Post-mortem appearances.—The morbid structural changes produced in the lungs by inflammation, are: 1. Engorgement, the inflamed portion of the lungs exhibit- ing externally a brown mottled or violet colour, " which forms a strong contrast with the gray or pale rose-colour of the healthy part." It is of a firmer texture and heavier than in the sound state—feels crepitous under the finger, though less so than in the healthy condition ; and on being pressed be- tween the fingers, the air-cells will be perceived to contain a considerable portion of extravasated fluid. When the engorg- ed portions of the lungs are laid open with the knife, a large quantity of a frothy reddish serosity runs out, and the inter- nal structure exhibits a livid red appearance. If portions of the engorged lung are pressed until all the fluid has been squeezed out, they become as elastic and crepitous, and of the same colour as the healthy part, if air be blown into them. Simple engorgement appears to be the result of the weakest grade of acute inflammation, and may even arise mechanical- ly from mere sanguineous congestion during the last moments of life or in articulo mortis. (Andral.) If the inflammation is PNEUMONIA BILIOSA. 271 intense, and terminates in the above engorged condition, the structure of the lungs is at the same time softened or friable, being readily broken down when pressed between the fingers. To distinguish mere engorgement by extravasated fluid from sanguineous congestion and engorgement from inflammation, we must judge less, says Andral, from the colour than the de- gree of firmness of the pulmonary structure. In almost every instance arising from inflammation, the substance of the lungs is rendered more or less friable. 2. Hepatization presenting at first sight the appearance and consistence of liver. In this variety of structural change, the lung is impermeable by air, and is entirely deprived of its crepitous feel under the finger, and sinks when put into water. When cut into, a small portion of a reddish fluid issues with- out exhibiting any frothy appearance. If we examine the in- cised surfaces with a lense, we perceive that the lung has lost its cellular structure—the pulmonary substance exhibiting a red granulated appearance ; and on being pressed between the fingers is found to be readily broken down and reduced to a reddish pulp. (Andral.) When a lung is hepatized, its volume seems much greater than natural, " but this apparent enlarge- ment is caused merely by the diseased lung not collapsing. This morbid condition has been called red hepatization. 3. Gray hepatization.—This seems to be the result of a more intense degree of inflammation than that which gives rise to red hepatization. In the present morbid condition, the pulmonary structure is granular, condensed, and impermeable to air, as in the preceding variety; but its colour is grayish or yellowish pale, and when cut into, discharges copiously an opaque yellowish or grayish fluid, which is manifestly purulent and almost entirely without smell. In some cases, the pus does not issue spontaneously from the incised surfaces, but on pressing the tissue moderately, small drops of purulent fluid are forced out. In this variety of disorganization, the pulmo- nary tissue is softened and readily converted into a grayish pulp by pressure between the fingers. Acute inflammation of the lungs never terminates in induration of its structure; this termination is peculiar to chronic pulmonary inflammation. According to Andral, there are two varieties of induration, the red and the gray. 4. Gangrene.—This is a very rare termination of acute in- flammation of the lungs. Andral gives an account of two in- stances of this kind. In a late number of the Journal Hebdo- madaire, there are several cases reported which terminated in gangrene of the pulmonary structure. These cases were at- tended with an intolerably fetid and gangrenous breath, par- ticularly during the fits of coughing, and the matter expecto- rated was of a chocolate colour and emitted a most offensive 272 PNEUMONIA BILIOSA. smell. On dissection, a considerable portion of the lung was found converted into a putrid mass, containing fragments of pulmonary texture, and of a black or violet colour. The sur- rounding portions of lung were infiltrated and partly hepatiz- ed. Dr. Chambers also, has published some cases of gangre- nous suppuration of the lungs, in which he refers particularly to the intolerable foetor of the breath as a diagnostic sign of this mode of termination. Andral states, that at first the ex- pectoration is a greenish liquid, then dirty gray, at times red- dish, and exhaling an extremely fetid smell.* The formation of abscess from pneumonic inflammation, is also a very rare occurrence. Both Laennec and Andral as- sert, that pulmonary abscess is among the most uncommon terminations of acute inflammation of the lungs. The former met with but four or five instances in several hundred cases which he examined; and the latter writer states that he has met with one case only. Laennec observes, that "nothing is more uncommon than to find the inflammation confined to the superior lobes of the lung." This, however, is contradicted by the observations of Andral, who, in 88 cases found 47 with inflammation of the inferior lobe; SO of the superior lobe, and eleven instances in which the whole lung was affected. Diagnosis.—The most important diagnostic signs between pleurisy and peripneumony, are those obtained by percussion of the chest and by pressure made on the abdomen. In peri- pneumony percussion made with the extremities of the fingers brought together in a line, produces an obscure dull sound, which is best estimated by comparing it with the sound pro- duced by percussion of the healthy side of the chest. In pleu- risy, on the contrary, no difference can be perceived in the sound produced by percussion of the two sides of the thorax. In peripneumony, firm pressure on the abdomen with both hands, so as to push up the diaphragm against the lungs, al- most invariably excites cough, great oppression, and a sense of suffocation ; whereas, in pleurisy, no such effects result from abdominal pressure. "If, then, we find united in the same patient a clear sound of the painful side on percussion ; insensibility to abdominal pressure; smallness and rapidity of the respiration ; an increase of pain on full inspiration ; parti- cular uneasiness on lying upon the affected side ;f and, lastly, * Schmidtmann, in an account of a case of pneumonia which termi- nated in gangrene of the lungs, says, " impar sputes saniosis, fuscis, nigris, putentibusque reddendis."—Sum. Ob. Med. vol. i. p. 80. Cases of gangrene of the lungs are also reported by M. Martinet and Recamier in their Hospital Reports.—See Revue Medicale for 1827. t This arises from the lungs pressing on the inflamed pleura when the patient lies on the affected side. PNEUMONIA BILIOSA. 273 pain upon firm pressure of the intercostal spaces of the affect- ed side, we have little reason to doubt of the existence of pleu- ritic inflammation." (Roux.) Peripneumony is characterized by an obscure pain in the chest; great efforts at inspiration, in order to supply the sus- pended functions of one part of the lungs ; increased suffering on firm abdominal pressure, and a dull obscure sound on per- cussion of the chest. Difficulty of lying on the sound side is generally mentioned among the characteristic symptoms of peripneumony; but Andral asserts, that this observation is by no means correct. The most common position is on the back. Auscultation, or the employment of the stethoscope, has of late years attracted much attention, as a means for obtaining a correct diagnosis in pectoral diseases. Interesting informa- tion, with respect to the particular condition of thoracic affec- tions, is no doubt to be obtained from this mode of examina- tion ; but it requires much careful experience before a sufficient tact is acquired to procure satisfactory information in this way. M. Andral, who has paid much attention to this subject, has given the following account of his experience in auscultation in pneumonic inflammation. " No sooner does the pain and difficulty of breathing come on, than the ear, applied to the thoracic parietes, recognises a notable modification in the nature of the noise heard at each inspiration, and as the inflammation advances, the noise undergoes fresh modifica- tions, which indicate, with more or less precision, the situation and degree of the affection. The voice is also modified. " At the commencement of the disease, whilst the lung is in the state of simple inflammatory engorgement, the noise of respiration in the affected part loses its clearness, and is more or less mixed with the dry-rattle, which Laennec terms crepitous, from the resemblance it bears to the noise emitted by common salt when thrown upon hot coals. It also bears considerable resemblance to the peculiar noise occasioned by folding or doubling a piece of parchment. The noise of natural respiration is always altered and obscured by this rattle, but is not always entirely masked or concealed by it. As the inflam- mation increases, the rattle becomes more and more manifest, until at length it entirely conceals the inspiratory murmur. The presence of crepitous rattle indicates engorgement, or the first stage of in- flammation ; and so long as it continues, it shows that the inflamma- tion (in a great part at least) has not advanced beyond the first de- gree. From its greater or less intensity, and from its more or less strong admixture with the natural respiration, we may derive indica- tions of the degree to which the engorgement extends, and whether it is passing into the state of hepatization or otherwise. Whilst the noise of natural respiration predominates over the crepitous rattle, we may conclude that the inflammation is slight; but, if the rattle in- creases, and predominates in its turn, until at length it completely S5 274 PNEUMONIA BILIOSA. masks the respiration, we may be certain that the inflammation is ad- vancing, and that it is passing on to the second degree. " At a more advanced period, the crepitous rattle gradually ceases to be heard ; and if the natural respiration then returns, we know the disease is subsiding; but if there be no respiratory murmur audi- ble, or if the natural respiration is replaced by another kind hereafter to be described, we may be certain that the disease is becoming more serious, and that the lung is hepatized. " M. Laennec has established the fact, that, in many cases, when engorgement of the lungs is succeeded by hepatization, the ear ap- plied to the chest feels the motions of the thoracic parietes, but does not hear any respiratory noise, either natural or pathologic. We have often verified this statement; but we have also frequently observed, in the same stage of the disease, another very remarkable phenome- non, which appears to have escaped Laennec's attention. In certain cases, where the lung is in the state of red or gray hepatization, the noise of respiration does not disappear, but is modified in a singular manner, and is evidently different from the natural kind. It seems as if a person placed near the auscultator's ear breathed forcibly through a brazen tube ; there is at the same time a peculiar kind of resonance of the voice, wherever this kind of respiration is audible. The modification of the voice, is not properly either egophony or pec- toriloquism; it approaches more nearly to that form of resonance which is observed in dilatation of the bronchia. Whenever cases, presenting this double modification of the voice and respiration have proved fatal, dissection has constantly presented either red or gray hepatization or pleuritic effusion. " The explanation of this modification of the voice and respiration seems easy. It appears to us to depend upon the air not being able to penetrate farther than the large bronchial tubes ; and, for this rea- son, the phenomena are manifested, not only in pulmonary hepatiza- tion, but also where the lung is compressed by pleuritic effusion :— and, in short, wherever the air is prevented reaching the air-cells of the lungs. " Whilst auscultation of the diseased side affords the different signs already enumerated, the respiration of the healthy side is heard with much greater intensity than in the physiological state ;—as if it were necessary for the healthy lung to receive a greater quantity of air in a given time, in order to supply the deficiency of the diseased one. " When the inflammation occupies a circumscribed portion, situ- ated at a distance from the surface of the lung, more especially a part of the base of the centre or of the root, auscultation teaches us no- thing concerning the seat or degree of the disease."* Prognosis.—A copious expectoration of a thick uniform yel- lowish matter, is one of the first, and perhaps most encourag- ing symptoms, indicative of a favourable turn of the disease. When this symptom occurs in connexion with an increased flow of sedimentous urine, and gentle but general diaphoresis, * Med. Chir. Rev. October, 1826, p. 514. PNEUMONIA BILIOSA. 275 we have good grounds for predicting a favourable issue of the disease, more especially, if at the same time the oppression and pain in the chest abate, and the cough is less troublesome. When, on the contrary, the pain and oppression become more generally diffused throughout the thorax; when the cough is dry, or attended with dark or red liquid sputa; when, along with a sense of suffocation and great anxiety, the countenance and lips become livid, and the pulse soft, irregular, and labouring ; and finally when delirium, coma, or convulsions supervene, or a sense of coldness is felt in the interior of the body, whilst the surface is very warm, the danger is to be considered as very great. A rattling respiration, accompanied with lividity of the countenance and a constant effort by the patient to bare the breast and to raise his head and shoulders from the bed, are almost certainly fatal indications.* The supervention of diarrhoea, in this disease, is a very unfavourable circum- stance.f The prognosis in pneumonia, is nevertheless attended with considerable uncertainty. Instances of unexpected reco- very occur, after the most dangerous symptoms have made their appearance; and, on the other hand, death sometimes speedily supervenes in cases apparently free from particular danger.:): Treatment.—Both in pleuritic and peripneumonic inflamma- tion bleeding is the first and most important remediate means. The extent to which it is to be carried must be entirely regu- lated by the degree and obstinacy of the pain, and state of the pulse. In pleurisy, we are generally obliged to abstract more blood than in peripneumonia, before the arterial reaction is suf- ficiently moderated. Whether the pleura or the proper sub- stance of the lungs be the seat of the inflammation, however, a sufficient quantity of blood should be drawn at once, to make a manifest impression on the pulse. The blood should be suffer- ed to flow without any regard to mere quantity until a diminu- tion of the pain and oppression in the chest, as well as of the action of the pulse, ensues. If the action of the pulse and the pain increase again after the first efficient bleeding, more blood must be drawn, and again to the extent of producing a very manifest impression on the system. The blood should be drawn in a full stream from a large orifice. In pleurisy it is some- times necessary to repeat the venesection three or four times in the course of the first twenty-four hours, before the violence * Richter Specielle Therapie. band. i. p. 415. Baglivi Opera, p. 42. t Baglivi Opera, p. 35. Riverius, Praxis Medica, torn. i. p. 72. X Plus una vice vidi lata morbi facie, et aegroto atque adstantibus sibi gratulantibus, ex pneumonia subito mortem accidisse. At non raro etiam contrarium observavi: rebus ferme conclamatis et «groto ad sty- gis confinia posito, prudenti atque audaci medicatione cum e manibus libitinae evacisse.—Schmidtmann, Ob. Med. torn. i. p. 25. 276 PNEUMONIA BILIOSA. of the disease is broken down. More caution, however, is ne- cessary in the employment of the lancet in peripneumonic in- flammation. Here, although prompt and very efficient blood- letting is decidedly beneficial, and without the least risk in the commencement of the disease, yet it is necessary to proceed with caution in the repitition of this measure as the disease ad- vances, lest dangerous prostration be induced. In violent at- tacks of peripneumony, the pulse is sometimes small, frequent, oppressed, and but slightly tense from the beginning of the disease. This state of the pulse may be owing to an oppressed or congested condition of the heart and large internal veinous trunks; but it depends also, occasionally, on an impaired state of the vital powers, particularly, in what has been called ner- vous, or typhoid pneumonia. In such cases a vein should be opened; and if the pulse rises while the blood is flowing, we may proceed with confidence in the further abstraction of blood. Should the pulse become still weaker, however, the bleeding must be immediately stopped. Richter observes, that where the pulse is small in the commencement of peripneumony, the physician should place his fingers on the pulse, and request the patient to make two or three strong inspirations, or to excite him to cough, by causing him to inhale the fumes of vinegar. If by these exertions, the pulse becomes fuller and more active, we may be assured, he says, that there is still sufficient energy in the heart and arteries to justify the abstraction of blood.* The blood drawn in these affections exhibits a thick, sizy, or buffy coat, on the surface of a more or less cupped coagulum ; and so long as the blood exhibits this appearance, bleeding may be regarded as a proper measure. The disappearance of the buffy coat is not, however, to be considered as a certain indica- tion that blood-letting is no longer proper; for where the action of the pulse, and the degree of pain in the chest, are such as to indicate the propriety of further abstractions of blood, bleeding may be confidently employed, notwithstanding the absence of the buffy coat on the drawn blood. " Some practitioners," says Dr. Millar, "havedirected blood to be drawn, till the si- zy crust which generally covers its surface, disappears. But this rule is extremely equivocal: in some, the blood puts on this appearance at the beginning, in others, not till towards the de- cline of the disease, and sometimes, no crust is observed through the whole course of the disease. The only certain indication, there- fore, arises from the mitigation or violence of the symptoms." Local bleeding by leeches, seldom procures any particular ad- vantages in the early periods of these affections, beyond that wliich arises from its general depleting effects. After the dis- ease has been in a great measure subdued, and venesection is * Specielle Therapie. band. i. p. 418. PNEUMONIA BILIOSA. 277 no longer indicated, leeching may no doubt be occasionally beneficial. In this case, small and repeated doses of digitalis, also, will sometimes contribute materially to the further reduc- tion of the general and local inflammatory action. A half a grain in union with 6 or 8 grains of nitre may be given every three hours, until its effects on the pulse or stomach are mani- fested. Although gentle aperients are decidedly beneficial in pneumo- nic inflammation, yet general experience goes to show that ac- tive and repeated purging is much more apt to prove prejudi- cial than useful. This is more particularly apt to be the case after free expectoration has been established. Before the com- plete establishment of the expectoration, Dr. Johnson states, that he has known purgatives decidedly beneficial in common pulmonic inflammation. Dr. O'Halloran also employed active purges with advantage in pneumonia, among the British troops at Gibraltar. (Med. Repos. No. 8.) Nevertheless, as a gene- ral rule, active catharsis may be regarded as improper, unless, perhaps, in the very commencement of the disease. Small doses of one of the purgative neutral salts, or of castor-oil, may be given, from time to time, so as to keep up a regular but moderate action of the bowels ; or laxative enemata may be used with advantage for this purpose. Emetics are equally improper in pleurisy and in peripneu- mony ; but in bilious pneumonia, they may be accounted as among our most useful curative means. Richter states, that in this variety of the disease, emetics will often remove the pain in the chest as by a charm ; and Stoll makes the same obser- vation. (Ratio. Meden. torn, i.) In the few cases of this mo- dification of pneumonia in which I have prescribed, I have had the most satisfactory evidence of the utility of emetics in its treatment. They generally bring on a uniform diaphoresis, promote expectoration, and allay the pain in the thorax, often almost immediately. They usually bring up an abundance of bilious fluid from the stomach. Cooling diaphoretics are very useful auxiliary remedies in these affections. Nitrate of potash with minute portions of antimony, the pulvis antimonialis, and the muriate of ammo- nia, are the best articles of this kind in the present disease. Richter particularly recommends the last mentioned article in the treatment of inflammatory pectoral affections ; and my own experience coincides entirely with his observations concerning its usefulness. It may be given according to the formula men- tioned under the head of intermitting fever. With a view both of diminishing the action of the heart and arteries, and of promoting expectoration, nauseating doses of tartar emetic are generally manifestly beneficial. In Italy, large doses of this article are almost exclusively relied on in 278 PNEUMONIA BILIOSA. the treatment of pneumonic inflammation. Rassori and his followers make this the principal, and in some instances, al- most the sole remedy. They exhibit it to the extent of from a scruple to several drachms in twenty-four hours; and they as- sert that when given thus freely, it seldom excites either vo- miting or strong purging, but always a most decided sedative or contra-stimulant impression on the sanguiferous system. M. Laennec speaks decidedly in favour of large doses of this antimonial in acute pulmonary affections. He asserts, that in those cases of pneumonia which are treated solely by bleeding, the pulmonary engorgement discoverable by the stethoscope, continues much longer than in cases in which the tartar eme- tic has been given in large portions. He thinks, that given to the extent of from 12 to 20 grains during the day, this article acts specifically in subduing inflammation, and powerfully pro- motes absorption.* Dr. Fontaneilles, of Milan,f whose expe- rience confirms the observations of Rassori on this subject, ob- serves, that the power of the system to sustain large doses of tartar emetic, depends wholly on the system being in a morbid condition; for when in a healthy state, or after the disease is removed, the ability of taking large doses of this medicine without injurious consequences does not exist. It would seem, moreover, that the power of bearing large doses of antimony in peripneumony, varies in the different stages of the disease. It is greatest at the acme of the disease—being less prominent in the beginning and in the decline of the inflammation. Dr. Fontaneilles generally gives about twelve grains per day in the first stage of the inflammation ; but after the disease has advanced to its acme, from a scruple to half a drachm are ad- ministered in the same period. If the medicine produce active vomiting the dose must be diminished; but so long as the pow- er of bearing it without great nausea and vomiting continues, the dose should not be lessened, although the symptoms of the disease may be declining. Many practitioners have strongly recommended the employ- ment of calomel and opium in peripneumonic inflammation; and my own experience has furnished me with repeated exam- ples of the utility of this practice. :|: After the disease has con- * Revue Medicale, Mai, 1824—Hospital Reports from La Charite". t Archives Generates, February, 1824. X Methodi Hamiltonianse commendatio ab illustri Sam. Gottl. Vo- gel,(a) cujus auctoritatem tanti semper feci, me movit earn tentare; et tentando edoctus sum, ejus inventum et vulgationem magnum praxeos medicse esse incrementum. Prima pericula omnem longe superabant expectationem meam; quare viginti abhinc annis et ultra non facile morbus inflammatorius mihi qbvenit;—et multi centeni mihi obvenere —cui opium et calomel faustissimo cum successu non opposuissem.— Schmidtmann, Sum. Obser. Medicar. torn. i. p. 27. (a) Handbuch der Pract. Arzneywissenshaft, 4 ter. theil. s. 25. u. 231. PNEUMONIA BILIOSA. 279 tinued for three or four days, and the action of the heart and arteries has been duly moderated by depletion, opium often does much good by allaying the pain and cough, and power- fully promoting a salutary expectoration. There is nothing to be apprehended from its stimulating effects. When given in combination with minute doses of tartar emetic or with calo- mel, after adequate abstractions of blood, this article has a more decided tendency to increase the expectoration and com- plete the resolution of the disease than perhaps any other in- ternal remedy we possess. When the pain and cough continue to be troublesome after venesection has been efficiently prac- tised, a grain of opium in union with two grains of calomel, given every four hours, will seldom fail to bring great and permanent relief. Where, however, the expectoration is free and of a proper consistence, opium, if it be at all used, should be given in much smaller doses. One-fourth of a grain of this narcotic, with one-tenth of a grain of tartar emetic, or two or three grains of pulv. doveri. may, under such circumstances, be given every four or five hours. In pneumonic inflammation from metastasis of rheumatism or gout, this article is especial- ly beneficial. Richter states, that when pneumonia is the con- sequence of repelled cutaneous eruptions, of measles, scarlati- na, or of irregular gout, camphor, given in combination with ipecacuanha and opium is, in general, a highly useful remedy. After blood has been decisively abstracted, one grain of cam- phor in union with the same quantity of opium and two grains of ipecacuanha, will often, he says, remove the pain and cough as by enchantment. If the pain returns the dose must be re- peated. Expectorants may be employed with advantage after the violence of the inflammation has been reduced by blood-letting; but the benefit to be derived from this class of remedies is, upon the whole, much less considerable than might be infer- red from the known salutary influence of a free expectoration in this affection. In the early or active stage of the disease, all articles of this kind, with the exception of tartar emetic, kermes mineral,* or mucilaginous fluids, are liable to do mis- chief. When the violence of the disease has been moderated, and the inflammation is about terminating in resolution, opium with tartar emetic, as has just been mentioned, will, in gene- ral, assist materially in establishing the expectoration. An infusion of the rad. polygal. sweetened with honey, may be * R. Kermes. mineral. gr. xv, Extract, glycyrrh. 3ii. Aq. fontanae ssvii. Syrup Scillae. ziii. M. S. Take a table-spoonful every two hours. 280 PNEUMONIA BILIOSA. beneficially given during convalescence from pneumonic inflam- mation. The patient should be allowed the free use of demul- cent drinks—such as barley-water, flaxseed tea, or a solution of gum arabic, to which honey or currant jelly may be added. Blisters are among our most valuable means for subduing pneumonic diseases. As soon as the firmness and activity of the pulse have been reduced, a large vesicatory should be ap- plied over the region of the affected part. Baglivi observes, that in some instances of pleurisy, great difficulty of breathing and suppression of the expectoration occur about the fifth or sixth day. In such cases, two blisters, he says, applied to the inside of the thighs, will generally produce a favourable change in all the symptoms. Triller recommends the same practice.* In protracted cases of pleuritic inflammation, where symp- toms of effusion are present, a combination of calomel, digitalis, and squills has been found particularly serviceable, f 1 have found the diuretic mentioned under the head of chronic perito- nitis, very useful under circumstances of this kind.—(Seepage 234.) In cases that terminate in empyema, paracentesis thoracis is recommended; and we are not without a considerable number of examples of the successful performance of this operation, both in empyema and vomica. Dr. Samuel Calhoun, in his edition of Gregory's Practice of Medicine, states, that " he has known a case in which this operation had the happiest ef- fect, though the opening into the cavity of the abscess was deep, and penetrated far into the lungs." For similar instances of successful paracentesis thoracis, the reader is referred to the works of Werlhof4 Donald Monroe, Stoll,§ Richter,|| Hoff- mann,^ B. Bell, and Aug. Gott. Richter.** M. Jowett has reported a very interesting case of empyema successfully treated by this operation ;ff and we might go on to cite many * De Pleuritide, p. 48. f R. Calomel $i. Pulv. scillse 9ii. ----digitalis ^i. Conserv. rosar. q. 5. M. Divide into 20 pills. S. Take one three times daily. Opera. Hanov. 1775, p. 775. Ratio Medendi, vol. iii. p. 155. || Chirurgische Bibliotheck, band. 3. s. 464. Band. 4. s. 476. Band. 6. s. 590. Band. 7. s. 311. Band. 8. s. 728. H Unterricht von dem Collegium der Aerzte in Munster. ** Medico-Chirurg. Observations. tt Med. Chir. Rev., July, 1826, M. Jowett observes, " I have twice very recently had occasion to resort to paracentesis of the thorax, in hopeless cases of effusion arising from pleurisy. In both instances, the PNEUBIONIA BILIOSA. 281 more instances of this kind. I have been thus particular in referring to authorities in favour of this operation in cases of empyema or thoracic effusion, from the equivocal manner with which it is spoken of by Dr. Gregory in his practice. Para- centesis thoracis, he says, is probably advisable in certain cases both of vomica and empyema; but the observations of authors on this piece of practice are very scanty."* When there is reason to believe that hepatization of a por- tion of the lungs has taken place, benefit may still be obtained, in some instances, from external irritating applications. Fric- tions with tartar emetic ointment, or with an ointment made by mixing two drachms of the white precipitate with an ounce and a half of lard, will answer well for this purpose. Setons, and caustic issues, also, are useful in cases of this kind; or continued blistering with emplast. lyttx. Internally, advan- tage may probably be derived from small doses of muriate of mercury in union with conium or belladonna. One-tenth of a grain of this mercurial, with from two to three grains of the extract of conium may be given three times daily. Diuretics, also, have been recommended both in hepatization and in sup- puration of the pulmonary tissue—more especially in thoracic effusion. When suppuration has occurred, the strength of the system should be supported by digestible and nutritious diet, opium, or extract of conium,—but the more diffusible stimu- lants must be avoided. operation was the means of prolonging, although it did not eventually save the lives of the individuals." To prevent the admission of air into the cavity, M. Jowett recom- mends the operation to be performed in the following manner: " Hav- ing made a small incision through the integuments only, in the place se- lected for the operation—which will, most commonly, be in the back, in the sixth or seventh intercostal space—thrust a small trocar carefully through the muscles and costal pleura; having withdrawn the trocar and left the canula in the wound, join a tube, connected with a Reid or Weiss' syringe to the canula, and slowly abstract the fluid by the sy- ringe, continuing to work it as long as the piston moves freely, or until symptoms come on which render it necessary to desist. Then remove the canula from the wound without previously separating it from the syringe; approximate the edges of the integumeuts by plasters, and ap- ply a compress to make it more secure." * " The history of the operation of paracentesis thoracis for empyema or hydrothorax, would well deserve an article in a periodical journal. Kurt Sprengel has given a most erudite history of this operation, from the days of Hippocrates to the close of the last century, occupying 87 pages of letter-press."—Dr. Johnson, Med. Chir. Rev. vol. v. p. 273. 36 282 ACUTE BRONCHITIS. ACUTE BRONCHITIS. Peripneumonia Notha. The pathological character of acute bronchitis is very close- ly allied to common catarrh ; and, in truth, the latter affection may be regarded as the lowest grade of mucous inflammation of the bronchia. (Hastings.) This form of pneumonic inflam- mation is most apt to attack old people and infants, or persons of phlegmatic and debilitated habits. It generally commences, like ordinary catarrh, with lassitude, chilliness, slight cough, and a sense of oppression and tightness about the prsecordia. In many instances, the disease seems at first of no very, seri- ous character. The patient complains of little or no pain in * the breast—a sense of weight and constriction in the thorax being the only uneasiness experienced in that part. In these cases, the febrile symptoms are but moderate. As the disease continues, however, the oppression at the prsecordia increases; the countenance is expressive of anxiety ; respiration becomes more and more laborious, and is attended with a wheezing or rattling sound, as if tbe air were forced through a narrow aperture clogged with a viscid fluid. In most instances, there is a considerable degree of hoarseness. In the advanced period of the disease, respiration is much more difficult in the recum- bent than in the erect position ; and hence patients generally desire to have the head and shoulders propped up with pillows. At first the cough is dry ; but a copious secretion of viscid transparent mucus, resembling the white of eggs, soon occurs, and with it considerable abatement of the violence of the cough ensues. So long as the sputa preserves this appearance, the disease may be regarded as unchecked in its violence; but when the inflammation is about terminating in resolution, the matter expectorated loses its transparency, " and becomes mix- ed with yellowish-white or greenish masses, which are scanty at first, but continue to increase more and more, until at last they compose the whole of the expectoration."* In nearly every instance of this disease, a very severe pain is felt across the forehead, and this is always greatly aggravated by cough- ing. When the secretion of mucus into the bronchia is very copious, and respiration is much obstructed, considerable drowsiness occurs. The tongue is white, and covered with trans- parent mucus; the skin is dry, and its temperature generally but very little above the natural standard. The blood is com- monly buffy, and sometimes cupped. Infants are especially * Clinique Medicale, &c. Par G. Andral. Deuxieme partie, p. 53. ACUTE BRONCHITIS. 283 liable to this affection. In them the disease manifests itself by a short, quick, oppressed, and wheezing respiration; un- easiness by being placed in the recumbent position; slight cough, somewhat hoarse at first, but humid and rattling as the disease advances; a uniformly pale and anxious countenance ; pulse frequent and tense ; skin above the natural temperature on the trunk—but the hands and feet are cool, or about the regular temperature. The respiration varies greatly: occa- sionally it becomes easy and free—and then suddenly becomes alarmingly oppressed, threatening instant suffocation. The progress of the disease is usually rapid. If it is not arrested, the breathing becomes more and more oppressed ; " the child falls into a comotose state; a slightly livid tinge makes its appearance on the lips, from which the pallid cheeks are not entirely free. But even at this late period, gleams of hope sometimes burst upon us. For a short time the difficulty of respiration may seem to subside, and the child to be better. But these hopes are never realized ; for even the next exacer- bation may terminate in suffocation." The disease sometimes terminates fatally as early as the third day, though more com- monly its course is protracted to the fifth or sixth day. Acute bronchitis is always attended with great muscular debility. In robust plethoric subjects, the febrile reaction is some- times as vehement as in pleuritis. In cases of this kind, the inflammation generally passes to the substance of the lungs. Little or no pain, however, is felt in the breast; but the tight- ness and oppression are extremely distressing, and the breath- ing very laborious. Unless the inflammation is promptly subdued, effusion into the bronchial cells takes place; the lips become purple; the face and extremities cold ; the pulse small, labouring, and obstructed ; the breathing short and incomplete; and at last drowsiness, partial coma, and suffocation close the scene.* In some instances, acute bronchitis is complicated with hepatic disease; a complication which occurs, not unfrequent- ly in persons addicted to the intemperate use of spirituous liquors. (Hastings.) Cases of this kind, besides the pneumonic symptoms already mentioned, are attended with tenderness and fulness of the right hypochondrium ; oppression in the prsecordia; nausea; bitter taste; vertigo; headach ; dark-co- loured and very fetid alvine discharges ; and in some instances symptoms of acute hepatic inflammation attend, more especially says the author just referred to, when the bronchitis occurs after measles. In children, cynanche trachealis often termi- nates fatally by the supervention of acute bronchitis. * A Treatise on Inflammation of the Mucous Membrane of the Lungs. By B. C. Hastings. 284 ACUTE BRONCHITIS. Diagnosis.—The characteristic symptoms of acute bronchitis are: great oppression and tightness in the breast, with little or no pain; severe pain in the forehead, greatly aggravated on coughing; a wheezing rattling respiration; uneasiness in the recumbent position ; pallor of the countenance ; a very copious secretion of viscid, frothy, and transparent mucus in the bron- chia ;* and generally a moderate grade of febrile excitement. Post-mortem appearances.—\n very acute and rapid cases, the lungs do not collapse on opening the thorax, and its whole structure appears to be engorged with a frothy serous fluid. The mucous membrane is generally minutely injected—some- times throughout its whole extent, and occasionally only in patches, the intermediate parts being nearly in a natural state. The smaller branches of the bronchia are usually filled with a tenacious mucus, bloody serum, or purulent matter. In acute bronchitis succeeding pustular exanthematous affections, mi- nute ulcerations, with uniform redness of the mucous mem- brane, frequently occur. In many instances, the substance of the lungs exhibits a reddened, hepatized, suppurated, or tuber- culated structure; and occasionally even the pleura is found inflamed with incrustations of false membrane, or effusion into the cavity of the thorax.f The wheezing respiration, and the great difficulty of breath- ing in this affection, are caused, no doubt, says Dr. Hastings, by the mechanical impediment to respiration from the redun- dant viscid mucus lodged in the smaller branches of the bron- chial tubes; and the severe headach arises probably from "the congestion of the pulmonary blood-vessels," interfering with the due return of blood from the head. Deficient decar- bonization of the blood, would seem to be the cause of the great muscular prostration which always attends severe cases of this disease. The prognosis in this affection is generally attended with much uncertainty; for in cases which appear to be going on without any particular danger, a sudden exacerbation will sometimes occur, and speedily terminate the patient's life. Death, in this disease, is almost always preceded by more or less coma, and occurs generally from effusion taking place into the substance of the lungs and bronchial cells. A copious expectoration is always a favourable sign, in this as in the other varieties of pneumonic inflammation. The less thoracic oppression and dyspnoea there is, the greater will be the chance of recovery from this disease. * M. Andral says, this mucus resembles the white of eggs, and is ex- tremely tenacious. Its tenacity and viscidity increase in proportion as the irritation of the mucous membrane is more considerable. t Hastings, Loc. Citat. p. 186. ACUTE BRONCHITIS. 285 Treatment.—Much discrepancy of opinion has been express- ed with regard to the value of blood-letting in this affection- some considering this evacuation as attended with much risk, on account of the great tendency to prostration and effusion into the lungs connected with the disease (Richter); whilst others rely, with much confidence, on prompt and decisive blood-letting. With proper discrimination, the abstraction of blood may be as beneficially resorted to in this as in any of the varieties of pneumonic inflammation. In the acute bron- chitis of very old persons, or of worn out and debilitated habits, it is indeed necessary to proceed with much caution in the use of the lancet; but even in cases of this kind, a moderate bleed- ing soon after the commencement of the disease, will in most instances prove serviceable. In infants, when I have been called early, I have almost uniformly resorted to one very decisive bleeding; and in most cases with unequivocal advan- tage. In the rapid and violent instances which occur in ro- bust, vigorous and plethoric habits, prompt and very efficient bleeding is indispensable. In all cases, however, and particu- larly in the latter variety, the blood should betaken at an early period; as soon after the development of the inflammation as possible. If it is delayed until the inflammation and pulmo- nary congestion have given rise to effusion or a copious secre- tion of bronchial mucus, the chance of benefit from it will be greatly diminished, and detriment probably be the consequence. So long as the cough is dry, we may draw blood, with a fair prospect of advantage; and a sufficient quantity ought to be taken away at the first bleeding to make a manifest impression on the action of the heart and arteries, as a repetition of it will seldom he borne more than once or twice. Cathartics are recommended by some writers, but except in the very commencement of the complaint, they are of doubtful propriety. The bowels should be kept in a loose state by laxa- tive enemata, or the exhibition of the milder aperients, such as castor oil, or small portions of one of the laxative neutral salts. When this affection is complicated with abdominal disease, cathartics may be freely employed with much advantage. Emetics are generally recommended as among the most use- ful remedies in the affection. They usually procure immediate relief of the oppression in the chest and dyspnoea; and excite a general diaphoresis, as well as a more free expectoration. In the bronchitis of infants, they are especially serviceable, by expelling the viscid mucus wliich clogs the bronchial cells, and thus facilitating respiration and thereby sustaining the powers of the system. Hastings observes, that an aqueous solution of tartar emetic is the best medicine for this purpose in adults; and ipecacuanha in children. I have generally preferred using a mixture of viuum antimonii and syrup of squills, in 286 ACUTE BRONCHITIS. children labouring under this complaint. From 15 to 20 drops of the former with half a tea-spoonful of the latter may be given every twenty minutes until vomiting is produced, to a child from one to three or four years of age. Expectorants also are useful remedies in this affection. In the early period of the disease, mucilaginous mixtures, or an- timonials should be employed for this purpose. Thus, R. Tart, antimonii gr. ii. Sal. tartar. 3vi. Aq. fontanse |iiss. Mel. optim. liiss. M. S. Take a table-spoonful every hour. But after the general arterial excitement has been moderated, we may resort with much advantage to the stimulating expec- torants. R. G. ammonia 3i. Infusio. poly gal. seneg. §viii. Oxymel. Scill. ±i. M. ft. S. Take a table-spoonful every two or three hours. When the pulse becomes very small and weak, some of the more active stimulants should be exhibited along with expec- torants. For this purpose, camphor and the carbonate of ammo- nia are perhaps the most valuable. I have used the following mixtures with much benefit in cases of this kind: R. Pul. camph. $ii. ----g. arab. 3ii. Syrup Scillse ^i. Triturate them in a mortar, then gradually add, Aq. fontanse ^vi. Tinct. opii g. lx. M. S. Take a table-spoonful every hour or two. Or—R. Carbon, ammonise 3H. Extract glycyrrh. ^ss. Aq. fontanse 3v"i« Acid scillse gss. M. S. Take a table-spoonful every hour or two. In instances of this kind, Hoffmann declares, that the follow- ing combination has often, in his hands, afforded complete relief in cases apparently hopeless: R. Flor. benzoes gr. vi. P. camphor gr. ii. Sacchar. alb. $i. M. This dose to be taken every two hours.* Opium cannot generally be given with advantage in this affection, after the bronchial secretion is fully established. By * Richter's Specielle Therapie. b. i. p. 424. ACUTE BRONCHITIS. 287 its tendency to suspend for a time the efforts to expectorate, it may readily give rise to dangerous accumulations of mucus in the bronchial tubes. *'In combination with small doses of calomel, opium may sometimes be beneficially exhibited at an early period of the disease. When conjoined, these remedies not only diminish the cough, and assist expec- toration, but seem likewise to regulate the secretion in adults." (Hastings.) In the bronchitis of old people, I have given opium and calomel in the proportion of half a grain of the former to two grains of the latter every three or four hours with much benefit in the early period of the disease. In very young children, however, opium is always to be used with the great- est caution. External irritating applications to the thorax are highly im- portant means in the cure of this disease. Immediately after blood has been efficiently abstracted, a blister should be applied over the anterior surface of the chest, and the surface kept dis- charging, by some irritating ointment. In children, I have known much benefit to result from the application of leeches to the chest after general bleeding. A large emollient poultice should be applied immediately after the leeches have been re- moved ; or a blister may be laid over the breast and suffered to remain until the skin is inflamed, when it is to be replaced by a poultice. The warm bath may also be used with a good effect, where the skin is dry and harsh. A regulated temperature of the atmosphere in the patient's chamber is of no small degree of importance in the management of this disease. The air of the room should be kept comforta- bly and uniformly warm, so as to favour the action of the cu- taneous exhalents.* Low or sudden variations of temperature are extremely apt to have a prejudicial influence in this affec- tion. During the debility, which generally remains after the dis- ease has been subdued, benefit will often be derived from mild and nourishing diet, and the use of weak infusions of colomha. gentian, &c. CHRONIC BRONCHITIS. Chronic inflammation of the mucous membrane of the bron- chia, is an affection of very frequent occurrence in cold and variable climates. In its simplest form it constitutes those pro- tracted catarrhal affections which are so common during win- ter in old persons, and in such as are predisposed to pneurao- * Broussais, Histoire des Phlegmasia Chroniques, torn. i. p. 149. 288 CHRONIC BRONCHITIS. nic irritation. Cases of this kind generally commence with the cold weather, and continue to the end of winter. They are cha- racterized by a troublesome cough, attended with copious expec- toration of a viscid muco-purulent, or a whitish frothy mat- ter; uneasy and somewhat oppressed respiration, accompanied at times with wheezing ; more or less weight and uneasiness in the epigastrium ; loss of appetite; a slightly furred tongue ; irregular action of the bowels ; a quick and irritated pulse, particularly towards evening ; and deep red and scanty urine. The coughing usually occurs in fits of considerable violence, being almost always most severe in the morning on rising from bed, or on passing from a warm to a cold air. Sudden atmos- pheric vicissitudes, also, seldom fail to increase the violence and frequency of the spells of coughing; and the same effect is usually produced by the inhalation of various vapours, fine dust, smoke, and occasionally by the act of swallowing food. Occasionally, slight transient pains are felt in the chest, but more frequently no painful sensations whatever are experienced, except immediately after a fit of coughing, when a general ach- ing pain is left for a few moments in the breast. There is another variety of chronic bronchitis, which, in its general phenomena and effects upon the system, bears so close a resemblance to tubercular phthisis, that it is not unfrequent- ly mistaken for this latter affection. This, as well as the for- mer variety, is the consequence generally of neglected catarrh ; and it occurs occasionally as the result of an acute attack of bronchial inflammation. At first the symptoms resemble those of ordinary catarrh—the expectoration being viscid, thick, and opake, but not yellow; containing small lumps, of a firm or viscid grayish translucent mucus, wliich sink in water. Mixed with these sputa, we sometimes find small membranous or flaky substances, which float on the surface of water—(Hastings.) As the disease advances, this viscid mucus becomes more and more mixed with a yellowish opake fluid, resembling pus, and often slightly streaked with blood. In many instances the sputa, at last, acquire a whitish opake appearance, resem- bling cream, and sometimes a uniformly greenish yellow co- lour, which readily sink in water. At first the pulse becomes slightly accelerated and tense towards evening ; and the heat of the surface varies in the course of the day, being sometimes above, and at others below the natural standard. Partial sweats about the head and breast occur during the night. The thirst is generally considerably increased ; the urine is high- coloured, and deposits a copious reddish sediment on cooling. A sense of soreness in the chest, with an occasional transient stitch in the side, occurs in the majority of instances; but there is very rarely any fixed pain in the thorax. The cough is usually severe—particularly on rising out of bed in the CHRONIC BRONCHITIS. 289 morning, at which time, the respiration is more or less wheez- ing, and attended with a feeling of tightness in the breast. If the disease continues unchecked in its course, the expectoration becomes at last purulent and extremely copious. Debility and emaciation increase rapidly, and the difficulty of breathing, and sense of weight and tightness across the chest, become more and more distressing. The pulse is now generally very fre- quent, being seldom under one hundred and twenty in a minute. In the early part of the day the face is usually pale, but a deep flush on one or both cheeks is commonly observed during the evening febrile exacerbations. The tongue becomes clean, and in many instances " it assumes a shining appearance, and is redder than in health." There are generally profuse and exhausting night sweats at this advanced stage of the disease; and to- wards the termination of fatal cases, colliquative diarrhoea, and oedema of the ankles, supervene as in tubercular phthisis pul- monalis. Indeed, in the latter stages of the disease it is generally difficult, if not impossible, to distinguish it with certainty from tubercular consumption; nor is it less fatal in its tendency after it has advanced to this stage, than genuine pulmonary consump- tion. When chronic bronchitis is complicated with hepatic dis- ease, an occurrence by no means uncommon, it forms what authors have termed " dyspeptic consumption." In this variety of the disease we have, in addition to the ordinary phenomena of chronic bronchial inflammation, various symptoms indicative of hepatic disorder—such as tenderness and tension in the right hypochondrium ; irregularity of the bowels, with unnatural stools; a sallow hue of the skin, and yellowness of the con- junctiva ; flatulency ; indigestion, with variable appetite ; in- creased dyspnoea, and cough after taking hearty meals; furred and brown tongue ; foul breath; and occasional nausea or vomiting. In some instances of this variety of bronchitis, no symptoms indicative of pulmonic affection occur in the com- mencement of the malady, the only manifestations of disease being such as are usually present in liver affections. A dull pain or tenderness in the right hypochondrium, with increased uneasiness by lying on the left side ; irregularity of the bow- els ; foul tongue ; and depression of spirits are, in such cases, the first symptoms complained of by the patient. «' The first warnings of disease in the bronchial membrane are slight. There is a dry cough, unattended with any pain. By degrees the cough becomes more troublesome, and when it continues for some time, a tenacious mucus is expectorated. The breath- ing, too, is in some degree affected, and the patient complains of weight and tightness across the chest." The bronchial af- fection now advances with more or less celerity, until a copi- 37 290 CHRONIC BRONCHITIS. ous purulent expectoration, and the usual symptoms of hectic, are fully established.* Diagnosis.—The following diagnostic circumstances between chronic bronchitis, in the early period of its course, and tuber- cular phthisis, will in general enable us to distinguish these two affections from each other. In chronic bronchitis the face is generally pallid, and the lips of a bluish hue. In tubercular phthisis the lips are red, and the cheeks more constantly flush- ed. " In the beginning of chronic inflammation of the bron- chia, the hands and feet are often cold, and the temperature of the surface altogether more variablethan in tubercular consumption." More or less inflammation and soreness usually occurs in the upper portion of the pharynx, during the early period of chronic bronchitis, which is very rarely the case in tubercular phthisis. In the former affection the expectoration is free almost from the commencement, and continues to be blended with a large portion of transparent viscid mucus to the end of the disease.f In tubercular consumption, on the other hand, the cough is for a long time short and dry. Chronic bronchitis is attended with much more oppression in the chest, and wheezing respiration, though less pectoral pain than true pulmonary phthisis.:): The paroxysms of hectic fever are much less regular in chronic bronchitis than in tubercular phthisis. Post-mortem appearances.—On opening the thorax the lungs do not collapse; the capillaries of the mucous membrane are dilated and strongly injected, giving, in some instances, an ap- pearance to this membrane, as if it were composed of a con- geries of vessels—(Hastings.) This membrane is generally considerably thickened, and in many cases it is found ulcerat- ed in different parts of its extent. The bronchial cells are usu- ally found engorged w ith purulent matter, mixed with a bloody serous fluid, and a portion of frothy mucus. In some cases the bronchial membrane is covered with numerous minute pimples or eminences, bearing some resemblance to pustules—(Arm- strong.) Sometimes the inflammation is found to have extend- ed from the mucus membrane to the surrounding cellular and pulmonary structures. Sometimes the submucous cellular tex- ture exhibits only a state of redness and vascular congestion; * A Treatise on Inflammation of the Mucus Membrane of the Lungs, &c. By Charles Hastings, M. D. p. 277. t " Early in the disease," says Dr. Hastings, " the absence of pain during inspiration; the capability of resting on either side in bed, (when there is no abdominal disease;) the wheezing noise in respiration; the leaden colour of the lips, and the pallidity of the countenance; the ap- pearance of the sputa, consisting almost entirely of mucus, occasionally streaked with blood, are symptoms sufficiently well marked to distinguish chronic inflammation of the bronchia from tubercular phthisis."—Loco. citat. p. 290. X Dr. Armstrong, on Consumption, &c. CHRONIC BRONCHITIS. 291 in other instances this tissue is found condensed and elastic by the deposition of lymph into its interstices. When the inflam- mation has extended to the substance of the lungs, we usually find it somewhat hard and dense, with loss of its natural elasti- city and compressibility—(Badham.) In some cases the pleura is found thickly sown with minute tubercular depositions. Broussais states, that in the fatal cases of chronic bronchitis among the soldiers of the French army, induration of the sub- stance of the lungs was almost a universal pathological phe- nomenon;* and he ascribes the great frequency of this disor- ganized state of the pulmonary structure to repeated exposures of the soldiers to wet and inclement weather, while in a state of debility and privation. He states that more or less exten- sive portions of the parenchymatous substance of the lungs were almost always found in a state of red hepatization, inter- spersed with softened and broken down parts, as if putrefac- tion had taken place in these points. Causes.—Chronic inflammation of the mucous membrane of the bronchia may occur as the sequel of acute bronchitis. It most commonly, however, arises from neglected catarrh. It is the consequence sometimes of measles ; of hepatic disease; and of protracted disorder primarily located in the digestive or- gans. It may also proceed directly from the influence of at- mospheric inclemency and vicissitudes of temperature; and from the inhalation of irritating vapours or particles of matter floating in the atmosphere. It occasionally occurs, also, in consequence of hooping cough—particularly from taking cold while under the influence of this affection. Treatment.—The principal indications te be kept in view in the treatment of chronic inflammation of the mucous membrane of the bronchia, are:—1. to diminish the general excitability and moderate the irritation of the sanguiferous system ; 2. to correct the functional derangement of the skin, liver, and ali- mentary canal; and, S. to lessen the excitement and determi- nation of blood to the lungs. In the early stage of the disease, the activity of the pulse will sometimes call for moderate general bleeding; but this evacuation can seldom be often repeated, even in moderate quantities, without the risk of doing injury by its tendency to increase the general irritability and weakness which attend this affection. Where the general phlogistic excitement indi- cates the propriety of bleeding, it will always, perhaps, be better to trust to occasional leeching or cupping. After the disease has assumed the character of phthisis, the abstraction of blood may be regarded as altogether improper. From the intimate sympathetic relation which subsists be- * Phlegmases Chroniques, torn. i. p. 144. 292 CHRONIC BRONCHITIS. tween the skin and the lining membrane of the bronchia, it is a matter of great importance in the treatment of this affection, to keep up a regular action of the cutaneous exhalents ; for, in proportion as we increase the activity of these emunctories, so will we lessen the afflux of the fluids to the lungs. For this purpose, the patient should be directed to wear flannel next the skin, and to protect himself by proper clothing against the influence of cold and sudden atmospheric vicissitudes. An equable and mild temperature will generally contribute great- ly to the successful management of this disease. Indeed, no remediate treatment can effect much in this complaint, when the patient is much exposed to a damp, variable, and incle- ment atmosphere. If his situation or circumstances do not admit of his visiting warm and uniform climates, the patient should remain in his chamber—the air of which must be kept at a comfortable and regular temperature—during the cold and variable seasons of the year. When the weather is mild, ex- ercise in the open air will, in general, prove salutary in this affection. External irritating applications to the breast, are among our most useful means for combating this disease. Blisters may be employed for this purpose; but pustulation by fric- tions with tartar emetic, or white precipitate ointment, will produce a more permanent, and, in general, a more efficient counter-irritation. Setons, or caustic issues, are much re- commended by some writers ; but their good effects are not in general equal, I think, to those which may be derived from more extensive irritation. Broussais recommends the applica* tion of large emollient poultices over the breast. He asserts, that he has cured inveterate cases of catarrhal inflammation by the continued use of poultices of this kind. They are to be preferred to blisters, he says, in nervous, irritable, and pletho- ric patients. In the milder variety of chronic bronchitis de- scribed above—that is, in those chronic catarrhal affections which are apt to occur in old persons during the winter, mild emetics have been found useful by dislodging the viscid secre- tions with wliich the bronchial cells become engorged; but their beneficial effects are generally only palliative. To mo- derate the general irritability of the system and the velocity of the circulation, digitalis may be advantageously employed. In the advanced stages of the disease, when the expectoration has acquired a purulent character, I have known considerable benefit to be obtained from the use of digitalis and tinct. of the balsam of tolu. according to the following formula: R. Tinct. digitalis 3SS> -----tolutani 5i. M. S. Take a tea-spoonful three times daily. CHRONIC BRONCHITIS. 293 At an earlier period of the disease, small doses of digitalis in union with pulvis antimonialis, will sometimes prove service- able, by lessening the momentum of the circulation and sus- taining the regular action of the cutaneous exhalents. Dr. Hastings speaks very favourably of the effects of squills in the advanced stage of this complaint—more especially in those cases which assume the character of chronic cough. I have used this article, in combination with the seed of phelan- drium aquaticum, with much benefit in a considerable number of cases. I usually order it thus: R. Sem. phelandr. aquat. 3lss* Pulv. scillse gr. xii. Pulv. opii gr. ii. M. Divide into eight equal parts. S. Take one three times daily. The phelandrium is much extolled by some German writers as a remedy in this disease. The use of the tincture of colchicum is recommended by some in the treatment of this affection. Hastings observes, that he has found it to allay the cough, promote the expectora- tion and flow of urine, and keep up a regular action of the bowels. It may be used, he says, where squills, from their greater tendency to excite the sanguiferous system, are inad- missible. From twenty to thirty drops may be given three times daily. I have, in a few instances, known this medicine in union with the tincture of belladonna, to produce excellent effects in this disease. Twenty drops of the former may be given with from thirty to forty drops of the latter thrice a day. Certain of the vegetable balsams have of late years been particularly recommended in chronic inflammation of the bronchia. Of these, the balsam copaiva is decidedly the most useful. Dr. Armstrong observes, that this article 4< seems in many cases to exert a specific influence over the mucous mem- brane of the trachea and its branches ; it increases the flow of urine; generally keeps the bowels regularly open, and some- times excites a peculiar itching in the skin. At first, it should he given in doses of from thirty to forty drops three times a day, and gradually increased afterwards to sixty or eighty drops at each dose." I have myself used this article with pro- minent benefit in the advanced periods of the disease; but, in many instances, little or no apparent benefit resulted from its use; and, in a few cases, it was evidently injurious, both by weakening the tone of the digestive organs, and by increasing the general febrile irritation. Morgagni employed this bal- sam in conjunction with sulphur in chronic catarrhal affec- tions ; and Armstrong asserts, that he has given this combi- nation with unequivocal advantage in the present disease. I have usually given the balsam according to this formula: 294 CHRONIC BRONCHITIS. R. Sodse subcarbonat. 3iss. Vitel. ovor. No. iii. Sacch. albi.- §ss. Bals. copaib. 3vi. Aq. fontanse iv'"« Tinct. opii gtt. Lx. M. S. Take a table-spoonful three times daily. Armstrong has found an emulsion of the spirits of turpen- tine very efficacious in this disease; but its powers are too ir- ritating to admit of employment in the ordinary cases of the disease. Of late years a great deal has been said of the inhalation of the fumes of tar, in the treatment of chronic inflammation of the mucous membrane of the lungs. That this remedy has been employed with some success in this complaint, the testi- mony published by men of eminence and respectability, does not permit us to doubt. It appears to be now generally ad- mitted, however, that its powers are by no means so salutary as was at first asserted. Hastings states, " that in chronic bronchitis, the inhalation of tar-fumes seems to assist other remedies in restoring the mucous membrane to its healthy se- cretion ; and in some very obstinate cases, the inhalation alone has appeared to remove the diseased action in the mucous membrane of the lungs. In other instances, the inflammation has been aggravated and rendered acute by it. When the ha- bit of the body is irritable, and the inflammation at all active, the symptoms are increased by its use; but if the disease have been long in a chronic state, and the habit of body not irrita- ble, relief may expected from it."* I have employed this re- medy in perhaps a dozen cases; in a few instances, I found it particularly beneficial, though generally, it failed to do any good whatever. The fumes of resin have also been recom- mended in the present complaint. A few pieces may be thrown upon hot coals on a shovel and brought near the patient, so as to cause him to inhale the fumes. The tar is used by placing it in a dish over hot coals, and suffering it to evaporate slowly until the air of the patient's chamber is well impregnated with the fumes. If the cough and dyspnoea are aggravated by these inhalations, which frequently happens, they must be discon- tinued. The inhalation of powdered vegetable substances, dispersed in the air breathed by the patient, has been used with marked benefit in the phthisical stage of chronic bronchial inflamma- tion. Dr. Darwin mentions the inhalation of the dust of cin- * Loco. Citat. p. 309. CHRONIC BRONCHITIS. 295 chona as having afforded relief in chronic pulmonary com- plaints. I have known the inhalation of the dust of oak bark effect a complete cure in an instance of chronic bronchitis. The Peruvian bark has been found a useful remedy in this affection, when the night sweats are profuse and the general debility considerable. Given with diluted sulphuric acid in such cases, its beneficial effects, says Dr. Hastings, are some- times very evident. It tends to restrain the debilitating night sweats, and "to alter the secretion from the mucous membrane of the lungs." In chronic bronchitis succeeding hooping- cough, I have used the sulphate of quinine with marked advan- tage. In several instances of this kind, I gave this article in union with the extract of conium, with the happiest effect. Opium is often decidedly beneficial in this disease. Given in combination with ipecacuanha, or in the form of Dover's pow- der, it always procures great temporary relief, and may mate- rially assist other remedies in the reduction of the bronchial inflammation. It is inadmissible, however, so long as there is much febrile irritation ; but in the advanced period of the dis- ease, particularly in the chronic bronchial inflammation of old or debilitated subjects, where the system is irritable and the cough frequent and troublesome, six to eight grains of Do- ver's powder, given in the evening, will suspend the cough and procure comfortable rest during the night. The extract of conium or hyoscyamus with ipecacuanha, may also be use- fully employed, for the purpose of allaying the general irrrita- bility and cough, and improving the character of the expecto- ration. The same intentions will, in general, be answered by full doses of lactucarium. This article is particularly recom- mended by Dr. Duncan, in the management of pulmonary af- fections. It may be used with benefit in instances where opium, from its constipating effects, or other disagreeable con- sequences, is inadmissible. The dose is from two to three grains. The prussic acid has been employed with benefit in this af- fection. From its powerful tendency to reduce the general excitability of the system, it is, without doubt, well calculated to do good in this complaint. Its variable and dangerous ac- tivity, however, renders it an extremely precarious and ha- zardous remedy. I have known a few instances in which con- siderable relief was obtained from this medicine; but in the majority of cases no advantage was derived from it, and in two it produced alarming prostration. It may be given ac- cording to this formula.* * The deleterious effects of the pifussic acid may be speedily counter- acted by a full dose of the aq. ammonia, or of a solution of the carbo- nate of ammonia. 296 CHRONIC BRONCHITIS. R. Acid, hydrocyanici. gtt. viii. Mucilag. g. arab. £ss. Sacch. albi. 3ii. Aq. fontanse §v"i' M. S. Take a table-spoonful every three or four hours. The inner bark of the ampelopsis hedera has been employed with much advantage in the advanced stage of chronic bron- chitis. It is given in decoction, in the proportion of an ounce of the bark to a pint of boiling water—of which a wine-glass full is to be taken four times daily.* In a single instance in which I have lately used this article, I obtained marked benefit from it. The cough gradually declined, the expectoration be- came improved and diminished, and the general irritation of the vascular system subdued. The bark of the white willow in the form of powder, formed into an electuary with sulphur and honey, was employed with much success by Dr. Kerckhoff, in the last stage of consump- tion from chronic inflammation of the mucous membrane of the bronchia, f The root of the actea racemosa has been employ- ed by some American physicians in chronic pulmonary affec- tions. I have had some experience with this article in the treatment of chronic inflammation of the mucous membrane of the lungs ; and its effects have appeared to me beneficial in se- veral instances. I have found it to diminish the velocity of the circulation, and to render the expectoration less copious and of a more natural appearance. It is given in decoction in the proportion of an ounce of the root to a pint of water. A table-spoonful of it is to be taken every four hours during the day. Its operation is slow, and requires protracted use to ob- tain any particular advantage from it. When chronic bronchitis is complicated with hepatic disease, mercury must be used in conjunction with the other remedies employed for the bronchial affection. Small doses of blue pill should be given until the gums are very slightly inflamed; and this degree of mercurial action must be sustained so long as there is any tenderness in the right hypochondriac or hypo- gastric regions, and the alvine evacuations indicate deficient or vitiated biliary secretion. I have used the following pill with peculiar benefit in this modification of the disease. R. Massse. hydrarg. 3L Aloes soccot 9i. Tart, antimonii gr. iii. M. Divide into 30 pills. Take one every morning and evening. * See Dr. Atkin's paper in the Philadelphia Med. and Surg. Journal, October, 1826. 6 t Transact, of Load. College of Physicians, vol. vi. CHRONIC BRONCHITIS. 297 In some instances, calomel will agree much better with the stomach than the blue pill—the latter giving rise to general irritation and more or less gastric disturbance. When calo- mel is used, it should be given in very small doses, and may be advantageously combined with the extract of conium. PHTHISIS PULMONALIS. Pulmonary Consumption. The assemblage of morbid phenomena, usually designated by the term consumption may arise from various pathological con- ditions of the respiratory organs, which, in a practical point of view, it is of much consequence to discriminate from each other. Thus, the symptoms by which physicians are in the habit of recognizing the presence of consumption may depend : 1. On chronic inflammation of the mucous membrane of the bronchia; 2. On ulceration and chronic inflammation of the la- rynx or trachea; 3. Chronic inflammation of the pleura; 4. Inflammation and the formation of vomica, orabscessesin the pa- renchymatous substance of the lungs; 5. Ulceration of hepa- tized lungs; and, 6. Softening of tuberculous matter in the lungs, with more or less chronic inflammation and disorganiza- tion of the pulmonary tissue. Of the first of these varieties of pulmonary disease, I have already treated under the head of chronic bronchitis; and this, the catarrhal or pituitous consumption of authors, constitutes, probably, the majority of the reputed cases of phthisis pulmo- nalis in cold and variable climates. Ulceration of the larynx or trachea gives rise to what is term- ed laryngeal or tracheal consumption, a variety of phthisis, which is generally rapid in its course, and always of a most fatal tendency. Tracheal and laryngeal consumption, usually begin with a slight tickling cough; an obscure feeling of uneasiness or pain in some part of the trachea or larynx; occasional oppression of breathing, and slight febrile irritation in the evening. One of the first and most constant symptoms of this variety of the disease is a change of the voice; which becomes indistinct, hoarse, feeble, and whispering. The patient is apt to feel and press the larynx or trachea with his fingers. When the larynx is the seat of the local affection, the first words in the morning are uttered with considerable difficulty. The pain in the larynx or trachea, is always increased by coughing, external pressure, and by the inhalation of irritating vapours. When the tra- chea is the part affected, an increase of the pain is experienced 38 298 PHTHISIS PULMONALIS. on bending the head backwards, or on turning it round. This is not the case when the larynx is the seat of the disease ; here the pain, as well as the cough, is increased by the use of stimu- lating gargles and the inspiration of cold and damp air. In laryngeal consumption, the cough is generally violent early in the morning, until something is expectorated ; and like spas- modic cough, it often subsides'for a considerable time, and then returns in sudden and violent paroxysms, the inspiration during the fit of coughing being striuulous, as in croup. A fit of cough- ing is almost always excited, when the patient begins to swal- low ; and it seems at first as if the cough were excited only by quick and careless swallowing, yet as the disease advances, the utmost caution in this respect will not prevent this act from exciting the cough. (Armstrong.) The quantity of the sputa is not great in the laryngeal variety of the disease; but, in tra- cheal phthisis it is often abundant, consisting chiefly of a viscid, transparent, and frothy mucus, with small masses of purulent matter floating in it. When the disease is once fully establish- ed, the usual symptoms of hectic fever occur, the body wastes rapidly, the skin becomes sallow, and the face generally pale, with a transient flush on one or both cheeks in the evening, and a peculiar haggard and anxious expression of the counte- nance, with an irritable and dejected state of the mind. The ordinary causes of this variety of phthisis are : neglect- ed catarrh; whooping-cough; measles, and syphilis. Dr. Arm- strong mentions an instance, which was excited by an external tumour pressing on the wind-pipe. The third variety of consumption mentioned above, depends on effusion into the cavity of the thorax from chronic inflam- mation of the pleura. While the effusion into the cavity of the chest is going on, the lung becomes more and more sepa- rated from the surface of the thorax, being gradually compress- ed by the accumulating fluid, until it is reduced to a very small size, and more or less disorganized in its structure. Whilst this is going on, ulceration sometimes takes place in some part of the pulmonary pleura, and the corresponding substance of the lung, and an opening is thus made into the bronchial tubes through wliich the effused sero-purulent fluid is discharged by coughing or expectoration. When this takes place, irritative fever, with night sweats, frequent cough, emaciation, and in short, all the ordinary symptoms of phthisis pulmonalis usually supervene. This form of pneumonic disease is generally the consequence of acute pleuritis. This affection is characterized by a sense of oppression in the chest on lying down ; difficult and hurried respiration on ascending stairs, or muscular exer- tion ; short, disturbed sleep ; paucity of urine; a short, tickling cough aggravated on first lying down; spells of hurried and oppressed breathing after speaking; and generally, more or PHTHISIS PULMONALIS. 299 less soreness of the external surface of the affected side of the chest. 'The patient is easiest when in a sitting posture ; and " if requested to take a deep inspiration while in the erect po- sition, he will generally do it with little apparent difficulty; but lay him down flat, and cause him to fetch his breath deep- ly, he will be almost certain to complain of pain, tightness, soreness, load, or some kind of inconvenience in the chest." (Armstrong.) Death often occurs suddenly, and is almost in- variably preceded by considerable oedema of the legs and feet. In some instances, after the effused fluid is discharged through the lungs, the progress of the disease becomes arrested, and the patient recovers a tolerable state of health. When this occurs, the affected side of the thorax contracts to a very manifest de- gree, forming what Laennec describes under the name of con- tracted chest. In some instances, where ulceration establishes a communication between the bronchial cells and the cavity of the pleura, more or less of pneuma-thorax occurs; but more generally adhesions take place around the fistulous opening, which prevent the escape of air into the chest from becoming so considerable as to compress the lungs. (Laennec.) Consumption from the formation of an abscess in the lungs, is an extremely rare occurrence, although formerly supposed to be one of the most common forms of the disease. Laennec states as the result of his observations, that small abscesses in the pulmonary tissue are not found above four or five times, and large ones not above once in several hundred cases. He regards almost the whole of the reported cases of pulmonary abscesses of the lungs as excavations formed by the softening of tubercular masses. It is nevertheless probable from the ob- servations of others, that abscess of the lungs is not so uncom- mon as is asserted by Laennec. Armstrong mentions several instances of this kind, and cases are related by Morgagni, Baiilie, Foubert, Wright, Heller, Lettsom, and many others. Tubercular or scrofulous phthisis, is the most fatal and un- manageable form of pulmonary consumption. In the com- mencement of the disease, slight aching pains, with a sense of tension or tightness, is experienced in some part of the chest, together with a short and dry cough, which is readily excited by muscular exertions. Respiration is shorter and more fre- quent, and deep inspiration is usually attended with a feeling of uneasiness and tightness in a particular part of the breast. These symptoms gradually become more conspicuous ; and at length slight febrile irritation occurs towards evening, and the pulse and respiration continue to be somewhat accelerated throughout the whole day. A fit of coughing usually occurs in the morning, and the patient rises out of bed in a relaxed, languid, and feeble condition. An extreme liability to catarrh, on the slightest exposure to cold and damp air, exists. The 300 PHTHISIS PULMONALIS. bowels are usually somewhat torpid ; the tongue is moist, often clean and of a pale pink-colour, or covered with a thin white fur. By degrees the cough becomes more frequent and trou- blesome—particularly in the evening and morning, or at night on awaking from sleep. Great sensibility to low temperature is usually manifested by the patient. As the disease advances, the albuginea acquires a peculiar pearly whiteness ; the skin, lips, tongue, and fauces become dry in the afternoon ; slight chills regularly occur towards evening, followed by distinct febrile exacerbations, during which one or both cheeks are suffused with a circumscribed flush; a dry and burning heat is felt in the palms of the hands and the soles of the feet; the breathing is very quick and short, and the pulse very frequent, small, quick, and tense. These febrile paroxysms continue until towards midnight, when they terminate in more or less profuse perspiration, which continues till morning, leaving the patient exhausted, languid, and depressed. Previous to the occurrence of these latter irritative phenomena, the expectora- tion which at first was scanty and frothy, becomes thicker and purulent, and occasionally streaked with blood. By degrees the sputa assume more and more the character of genuine pus; the evening exacerbations become more distinct, the night sweats more profuse; the burning in the palms of the hands and soles of the feet more distressing; the cough more fre- quent and violent; and emaciation makes evident progress, attended with increasing failure of strength—in short, hectic fever is now completely developed—the pulse being seldom less than 130 during the evening exacerbations, although ge- nerally languid, weak, soft, and not much above its natural frequency in the morning. Towards the unfavourable termi- nation of the disease, oedema of the feet, and colliquative di- arrhoea, almost invariably come on, accompanied with a weak and hoarse voice, often aphthse in the fauces, difficulty of swal- lowing, and sometimes ulcerated throat. The mind generally continues to be unaffected to the last; but in some instances, " a degree of languid delirium occurs for some days, and occa- sionally total imbecility for a week previous to death." It is a remarkable circumstance, that pulmonary consump- tion is very generally suspended in its progress by pregnancy. I have met with five or six instances of this kind. As soon as the delivery of the child has taken place, the consumptive symptoms resume their force, and generally advance with ra- pidity to a fatal termination. It is equally remarkable that the symptoms of pulmonary consumption occasionally, though indeed very rarely alternate with mania. I am at this time attending a young lady in the last stage of phthisis, who has for four months past been in a state of continued mental derangement. She complains of no PHTHISIS PULMONALIS. 331 pectoral uneasiness, and does not appear to be conscious of la- bouring under this disease; although her body is now ex- tremely emaciated, and she coughs almost continually, and has a copious purulent expectoration. Tubercular consumption probably never occurs, except in individuals of a strumous diathesis; and it is doubtful, as Dr. Armstrong observes, whether tubercular matter be ever form- ed in the lungs, without a constitutional or hereditary predis- position to them. Be this as it may, it appears to be well as- certained, that wherever this predisposition does exist, any cause which is capable of irritating the lungs may give rise to the deposition of tubercular matter into their substance, and lead consequently to the development of phthisis pulmonalis. Tubercular matter would seem to be formed by a kind of exu- dation or secretion into the pulmonary tissue; and as it ap- pears to be unorganized, may be regarded as an extraneous substance, obstructing the pulmonary circulation, and giving rise to more or less local irritation. Tubercular depositions in the lungs do not, however, inevitably lead to consumption ; for it would seem to be well ascertained that tubercles may ex- ist in the pulmonary structure in a dormant state—that is, without entering into the process of softening, or exciting in- flammation—and without giving rise either to local inconve- nience, or general disturbance of health—(Armstrong, Laen- nec.) In individuals of a scrofulous habit, the formation of tubercles is sometimes very rapid, when pulmonary irritation is excited by some accidental irritating cause. In the begin- ning, tubercles have the appearance of semitransparent grains; and as they gradually increase in size, they become united into irregular masses, and assume a yellowish and opaque appear- ance. M. Laennec asserts, that the conversion of the tubercular matter into a soft pus-like fluid, is not effected in a manner similar to what takes place in suppurative inflammation ; but by a peculiar process of softening, wholly distinct from suppu- ration. The softening commences in the centre of the tubercle, and gradually proceeds outwards, until the whole mass is con- verted into a whitish cream-like matter, which, making its way into the bronchial tubes, is discharged by expectoration, leav- ing a kind of fistulous cavity. These tubercular excavations become lined with " a species of morbid membrane, of a white and opake appearance, and very soft consistence; external to which, another membrane of a semi-cartilaginous structure is formed. Bayle thinks that the pus expectorated in scrofulous consumption, is secreted chiefly by the lining membrane of the tubercular cavities; but Laennec asserts, that the greater part of the purulent matter expectorated proceeds from the mucous membrane of the bronchia, which always suffers irritation and chronic inflammation, to a greater or less extent, in every va- 302 PHTHISIS PULMONALIS. riety of pulmonary consumption. Purulent expectoration from this source occurs in some instances of tubercular lungs, even before the tubercles have undergone the process of softening. Every case of tubercular phthisis, consists therefore of at least two, and sometimes three simultaneous processes; namely, 1, "the proper tubercular action either in a state of growth or increase, or in that of softening or destruction ; 2, of a de- gree of chronic inflammation of the mucous membrane of the bronchia; and, 3, sometimes of inflammation of the pulmonic tissue, of a chronic character, and tending to hepatization." Causes.—As has already been stated, persons may be deci- dedly predisposed to phthisis, and even affected with a tuber- cular state of the lungs, and yet escape the disease, if no ade- quate exciting cause supervene to rouse it into action. In some instances, functional or organic disease of the liver developes the disease where the predisposition to it exists. Catarrhal affections, however, are by far the most common exciting causes of the disease. The tubercles may also be excited into action by a fixed irritation located in any of the principal vis- cera, more especially in the alimentary canal. Repelled cu- taneous eruptions have a strong tendency to develope the tu- bercular action, as indeed all other morbid impressions on the skin have in subjects of a phthisical habit. The sympathy between the external surface and the lungs is intimate and strong, and an irritation seated in the former, seldom fails to manifest itself in the latter organ—more especially when the lungs are in a state of habitual debility or predisposition to morbid action. It is on this account, that phthisis pulmonalis is so common a disease in cold and variable climates, where the cutaneous function is so liable to sudden and frequent in- terruptions or variations of activity. Among the ordinary exciting causes of this affection, we may also mention the heal- ing up of old discharging sores; atmospheric vicissitudes; the abuse of mercury; intemperance in the use of spirituous liquors; sedentary occupations; excessive venereal indulgence, and onanism ; copious losses of blood ; the depressing passions; the admission of irritating vapours or fine particles into the lungs—to which latter cause, stone-cutters, glass-grinders, millers, needle-grinders, &c. are particularly exposed. Prognosis.—The different varieties of pulmonary disease men- tioned above, vary very considerably in the degree of sanability peculiar to them respectively. That form of consumptive dis- ease, which depends upon chronic bronchial inflammation, is by far the most under the control of judicious remediate treat- ment ; and where the mucous tissue remains free from ulcera- tion, or the subjacent pulmonic structure has not become con- solidated, recoveries are by no means uncommon. Laryngeal and tracheal consumptions are extremely danger- PHTHISIS PULMONALIS. 303 ous affections. I have never known an instance of recovery from this variety of the disease. Cases of recovery have, how- ever, been related by authors, but the number of such instances is very limited. Consumption from chronic pleuritis, is much more difficult of cure than that which depends on chronic inflammation of the mucous membrane of the lungs; yet in some instances, the dis- ease subsides, and the patient regains a considerable degree of health. When a cure is effected, the effused fluid is either gradually absorbed while the lung expands, or it is discharged through the lungs by an opening into the bronchial tubes from the cavity of the pleura, or it escapes externally by an opening into the cavity of the chest through the intercostal spaces. Tubercular consumption may be regarded as an incurable disease ; for tubercular matter, so far as we know, is wholly incapable of being absorbed or otherwise removed. " Previous- ly to the knowledge of the true character and mode of develop- ment of tubercles," says Laennec, " and while consumption was considered as a consequence of chronic inflammation, and slow suppuration of the pulmonary tissue, medical men did not question the possibility of curing this disease by a suitable mode of treatment, especially if taken in time, and during the first stage. It is now, however, the general opinion of all those who are acquainted with the actual state of our knowledge re- specting the pathology of diseases, that the tubercular affec- tion, like cancer, is absolutely incurable, inasmuch as nature's efforts towards effecting a cure are injurious, and those of art useless." However impossible it may be to remove tubercular matter when once formed, or to cure consumption depending on it, there can exist no doubt that we may occasionally so re- tard, or even arrest its progress by proper management, as to prolong life to a very considerable extent. Nay, it is equal- ly certain, that by carefully avoiding those causes which tend to favour the conversion of tubercular matter into a pus-like fluid, persons who are manifestly strumous, or affected with incipient tubercles in the lungs, may pass through a long life without the actual development of consumptive symptoms. Al- though tubercular consumption may be regarded as incurable by art, yet in some rare cases a spontaneous cure has taken place after the softening of the tubercular matter, and the for- mation of an ulcerous excavation. Laennec, upon whose au- thority this statement is made, mentions ten cases which termi- nated favourably in this way. Such cures, he says, are effect- ed in two ways ; 1. by the cavity becoming invested by a new membrane of a semi-cartilaginous structure, which, when com- pletely formed, constitutes a kind of internal cicatrix, analo- gous to a fistula, and "is, in many cases, not more injurious to health than this species of morbid affection;" 2. the cure 304 PHTHISIS PULMONALIS. may also be effected by a spontaneous obliteration of the cavi- ty by a cicatrix consisting of cellular, fibrous, or cartilaginous structure. Such cures are, however, extremely rare, and de- pend in no manner on medical treatment—(Laennec.) Treatment.—Of the treatment appropriate to catarrhal con- sumption, I have already spoken fully, under the head of chro- nic bronchitis, and the subsequent therapeutic observations refer chiefly to tubercular phthisis. Notwithstanding the uncontrol- lable and fatal character of tubercular consumption when once fully developed, patients labouring under this form of disease are not to be abandoned to their fate, without making an effort to arrest, or at least to retard its progress, for although the hope of curing the malady, after its complete establishment, is wholly fallacious, experience has fully demonstrated the fact, that, by judicious management, we may often keep the tubercles in a dormant state, interrupt their progress, or at least great- ly retard their passage into an active condition. In consump- tive habits, every thing which tends to irritate the system, more especially the respiratory organs, should be carefully avoided. Attention ought, above all, to be directed to the re- gular maintenance of the perspiratory function ; and with this view, the patient should be directed to wear flannel next his skin; to protect himself by proper clothing against the in- fluence of low temperature; and to avoid, as much as his cir- cumstances may admit, the effects of atmospheric vicissi- tudes. In the incipient stage of every variety of pulmonary consumption, our constant object should be to counteract the inflammatory diathesis of the system, and to remove all sources of irritation. The regimen must be strictly antiphlogistic. In general, vegetable and farinaceous diet, with milk, is the only pro- per nourishment for a patient labouring under incipient phthisis. The system in all phthisical habits is peculiarly excitable, and readily thrown into a state of general and injurious irritation by even weak exciting causes. It would be in vain to expect a a reduction of the local pulmonary irritation, so long as the system generally is in a state of preternatural excitation. In conjunction with a mild unirritating diet, the wearing of flan- nel next the skin, and the careful avoidance of inclement and variable weather, gentle exercise, cither by walking, riding on horseback, or in an open carriage, when the air is mild and uniform, will tend to invigorate the system, and lessen its mor- bid irritability. Bleeding is highly recommended by some in the early pe- riod of phthisis pulmonalis ; and when cautiously employed in cases attended with an evident iuflammatory condition of the general system, its effects are often beneficial. To draw blood copiously, or very frequently, however, would, in most in- stances, prove injurious by increasing the debility and morbid PHTHISIS PULMONALIS. 305 excitability of the system. The abstraction of blood by cup- ping or leeching, in cases which indicate the propriety of di- rect depiction, will in general answer all the purposes, which can be expected from this measure. To expect to effect the permanent reduction of the quickness, tension, and frequency of the pulse by venesection, is a fallacious hope. The system in this disease is preternaturaliy excitable or irritable; and in order to reduce the volocity and momentum of the circulation, measures must be employed which tend to subdue this morbid ir- ritability, an effect which cannot be obtained from venesection. To accomplish this purpose, we possess no remedies which are so safe and so effectual as digitalis, and small doses of tartar emetic. The former of these articles has a powerful tendency to diminish the excitability of the heart and arteries, and con- sequently the velocity of the circulation. Much diversity of opinion has been expressed in relation to the value of this me- dicine in consumptive affections. My own observations have led me to the conviction, that under careful management, and in conjunction with a well regulated diet, and proper attention to the cutaneous functions, much good may be derived from its employment in incipient phthisis. Its salutary operation would seem to depend on its power of lessening the activity of the heart and arteries, and thereby moderating the momentum of the circulation, and consequently the general and local irritat- ed condition of the disease. Among the most important remedies we possess in the early periods of phthisis, are such as operate through the medium of the skin, or such as establish a regular determination to the external surface of the body. Blisters, issues, or setons, can never be properly omitted in incipient consumption. I have repeatedly known the insertion of a caustic issue or a seton on the chest, to remove every symptom of approaching consump- tion. Even in cases completely developed, counter-irrita- tion, in any of these modes, will generally aid very materi- ally in retarding the progress of the malady. I am disposed to ascribe more remediate power in chronic pectoral affections to setons and issues than to blistering, and of these two, I generally prefer the latter. Pustulation with tartar emetic, or with the white precipitate ointment, is also a very efficient mode of counter-irritation in this affection. I have seen much benefit derived from both these appli- cations in its incipient stage. When the pustules are formed, emollient poultices should be applied to them, and renewed two or three times daily, until they are healed. Whatever coun- ter-irritating measure be adopted, it should be regularly perse- vered in, until all the threatening symptoms have entirely dis- appeared, or its manifest inefficiency is ascertained. To aid the effects of flannel next the skin, and of a warm and S9 306 PHTHISIS PULMONALIS. equable temperature in maintaining a regular action of the cu- taneous exhalents, advantage may be derived from the use of small portions of tartar emetic dissolved in some mild diluent beverage, in the commencement of the disease. A grain or a grain and a half of this antimonial may be dissolved in a pint of gum arabic water, and drank during the day. M. Lenthois of Montpelier, speaks strongly in favour of this remedy in phthisis. His mode of employing it is as follows:—A grain of tartar emetic is to he dissolved in eight table-spoonsful of water; this is to be mixed with four quarts of water, or a ta- ble-spoonful to the pint, which the patient is directed to use as his common drink at meals, and at all seasons and hours. Dr. Armstrong directs the use of this article in doses sufficiently large to excite nausea and occasionally vomiting. "I sus- pect," he says, "that if a regulated temperature and the exhi- bition of tartarized antimony were more early and persever- ingly employed than they usually are, our success in preventing the development of phthisis might be much greater than it commonly is." The employment of emetics in this disease was formerly much recommended by some writers. Dr. Ma- ryatt gave the sulphate of copper and tartar emetic in doses of from two to five grains of the former with two grains of the latter twice a week, and without allowing the patient any kind of drink for several hours afterwards. Dr. Senter advises to give the blue vitriol in conjunction with ipecacuanha (seven grains of each) in the morning before receiving anything into the stomach, and withholding all kinds of drink for some time afterwards. The account which Lenthois gives of the useful- ness of tart, antim. in the present affection is certainly exagge- rated ; but, although not perhaps of itself sufficient to arrest the progress of incipient phthisis, it deserves, nevertheless, very considerable attention as an auxiliary means. Unques- tionably, however, the most efficient of all measures for coun- teracting the tendency to phthisis, or arresting its develop- ment or progress, is a removal to, and residence in a mild, genial, uniform, and salubrious climate. The influence of such an atmosphere, aided by proper diet, regular and gentle exer- cise, and external revulsives, with an attention to the hepatic and intestinal functions, will do all, perhaps, that remediate treatment is capable of effecting towards permanently arrest- ing the progress of the disease in its incipient stage. The climates of Naples, of Nice, of Florence, and of Rome, and lately of Egypt, as well as of some of the southern parts of France and Spain, have been particularly recommended to con- sumptive invalids. Nothing, however, is to be expected from the influence of a warm climate after the disease is once fully developed. It is only in the incipient stage of the complaint PHTHISIS PULMONALIS. 307 that any permanent advantages can be obtained from this source, in scrofulous phthisis.* Upon the foregoing remediate measures—namely, occasion- al small bleedings, external irritating applications, antimonials, a regulated temperature, a simple unirritating diet, and exer- cise by walking or gestation, our hopes must be mainly placed in our efforts to arrest the disease in its incipient stage. A variety of other remedies have, however, been recommended in this affection ; and of these, prussic acid has of late years at- tracted the greatest attention. Could the dose be regulated with any degree of certainly, so as to procure its influence without the risk of dangerous prostration, advantage might, no doubt, be derived from its employment. Possessing, as it does, a direct and most powerful tendency to subdue the irri- tability and sensibility of the system, it would seem to be pe- culiarly calculated to do good in the present affection, in which a particularly excitable condition is so conspicuous. When the disease is once completely established, and puru- lent expectoration with hectic fever has supervened, we can no longer hope to procure a favourable issue by remediate ma- nagement ; and all our efforts must be directed to the pallia- tion of the symptoms and the prolongation of its course. With the exception of depletion, the remedies already mentioned as most apt to arrest incipient consumption or prevent its de- velopment, are also among the most useful means in retarding its progress when fully established. When the system is much exhausted in the confirmed stage of the disease, tonic reme- dies are commonly resorted to, but although I have tried them often in scrofulous phthisis, I do not remember having ever derived any obvious advantage from them—but most common- ly, they increased the general irritation.f Where it becomes necessary to support the strength of the system, we may allow a more nourishing diet, particularly the more digestible and nourishing kinds of meat—such as tender beef-steak or mutton. To check the profuse and exhausting night sweats which occur in the advanced periods of the disease, I know of no re- medy which is so effectual as the acetate of lead. I have fre- quently prescribed this article with unequivocal benefit in this respect. Four or five grains of the acetate may be taken in * See Dr. Carter's " Remarks upon the Effects of a warm Climate in Pulmonary Consumption and some other Diseases."—Medico-Chirurg. Transact, vol. vi.—See also, Medical History of the British Army in Spain.—Medico-Chirurg. Transact, vol. vi. X The tonics most commonly employed in phthisis pulmonalis, are the mistura feri compos., the quinine, and particularly Dr. Griffith's mix- tore,—thus: R. Myrrh. 3i. terendo mortario cum spirit, piment. 3V1. aq. distil, gviss. dein adde subcarbon. potassae 35s. sulphat. ferri. gr. xii. syrup. 3ii. M. Take |ii. four times daily. 308 PHTHISIS PULMONALIS. the evening. I have known some patients who, after having experienced the relief which it frequently procures, would not do without it. The best mode of giving it is in union with opium. Some of the mineral acids are also recommended for this purpose. Of these, the diluted sulphuric acid, or the elixir of vitriol is the best. Opium is a highly valuable pal- liative in the advanced stage of phthisis. It generally allays, for a time, the violence and frequency of the cough ; tends to diminish the night sweats, as well as the general feelings of distress, illness, and discomfort; and at last, assuages the pangs of approaching dissolution by its soothing and oblivious effects on the nervous system. When opium produces disa- greeable effects from idiosyncracy, the lactucariun may be used in two or three grain doses with excellent effect. We may also employ Dover's powder in union with the extract of hyo- scyamus as an anodyne palliative, where opium by itself is objectionable. Six grains of the former with three grains of the latter may be given every night. Dr. Bourne, professor of the practice of physic in the uni- versity of Oxford, speaks strongly in favour of the employ- ment of uva ursi in consumption. He asserts, that he cured nine cases out of sixteen, by the use of ten grains of uva ursi with one-third of a grain of opium three times daily. In con- sumptive symptoms from chronic bronchitis, I have derived much benefit from these two articles given in combination ; and the cases related by Mr. Bourne, were probably of this kind.* Expectorants are sometimes useful to palliate the cough. Flaxseed-tea, decoction of the lychen icelandicus, solution of gum arabic, infusion of tussilago or of marshmallows, the camphorated tincture of opium, and syrup of squills in equal proportions, or syrup of poppies with tincture of tolutan, may be used for this purpose. Small doses of opium and tartar emetic, as recommended by Pariset, will generally answer very well.f The inhalation of tar-fumes is not adapted to the treatment of tubercular consumption. In the catarrhal variety of the disease, much benefit may be occasionally derived from this and similar inhalations. Nor is mercury a remedy calculated to do good in the present form of phthisis, although much re- commended by some practitioners. The cases of consumption which are reported as having yielded to ptyalism were, no doubt, dependent on chronic mucous inflammation, unconnect- * Cases of consumption, &c. healed by uva ursi, &c. By Diu Bourne, London, 1806. t R. G. opii gr. x. Tart, antim. gr. iv. Conserv. rosar. q. s. M. Divide into 40 pills. S. Take one every four hours. PHTHISIS PULMONALIS. 809 ed with a strumous habit or tubercles in the lungs. Too little discrimination was formerly made between the different varie- ties of pulmonary disease attended with consumptive symp- toms ; and it is to this circumstance that we may ascribe the discordant and contradictory statements that have been pub- lished in relation to the effects of different remedies and modes of treatment. Laryngeal and tracheal phthisis appear frequently to com- mence with an obscure inflammation in some part of the larynx or trachea, which may continue for months before ulceration occurs. This incipient stage is characterized by more or less hoarseness, change of voice, and disturbed respiration; and it is only during this early period of the disease, before ulce- ration has taken place, that any decided and permanent benefit can be derived from remediate treatment. Whenever, there- fore, we find hoarseness of voice with cough, disturbed respi- ration, and a slight prickling pain in the larynx or trachea to continue for some time, particularly when there is no reason to ascribe these symptoms to common cold, we ought immedi- ately to adopt the most active measures for the removal of the affection. Should ulceration not have taken place, we may, perhaps, succeed in preventing it, and in saving the life of the patient. (Armstrong.) One of the most indispensable curative means is a mild and uniform temperature. On no account should the patient be suffered to expose himself to a cold or hu- mid atmosphere. While these precautions are observed, blis- ters should be applied to the throat, and the blistered surface kept discharging by irritating dressings. Armstrong recom- mends the use of balsam copaiba in the early stage of this va- riety of the disease. In several cases which have lately come under my care, the use of the muriate of ammonia, according to the. formula mentioned at page 83 of this work, appeared to do much good. When the disease arises from syphilis, mer- cury may be regarded as the principal remedy in conjunction with a regulated temperature and blistering. In consumptive symptoms from chronic pleuritis, our prin- cipal reliance must be placed on external revulsive applica- tions to the chest, the use of calomel so as to produce gentle ptyalism, and diuretic medicines. Blisters or tartar emetic ointment should be repeatedly applied so as to keep up a con- stant irritation on the external surface of the chest. Internal- ly, we may give calomel and squills in combination, with a view both to a general mercurial impression and the produc- tion of diuresis. 310 CYNANCHE TRACHEALIS. CYNANCHE TRACHEALIS. Croup, hives. Symptoms.—This disease sometimes comes on suddenly and acquires the utmost degree of violence, in the course of a few hours. More commonly, however, its approach is gradual, the first symptoms being those of ordinary pulmonary catarrh. A dry and hoarse cough, with slight difficulty of breathing, and a change of the voice, are generally the first intimations of its invasion. This very peculiar hoarse and rough cough, with its accompanying slightly oppressed breathing, continues some- times, with occasional remissions, for several days before the disease assumes its characteristic form and violence. More or less febrile excitement is generally present from the very com- mencement of the disease. Sooner or later the respiration be- comes more difficult and distressing ; the febrile reaction rises higher; the voice becomes more indistinct, whispering, or an- nulled ; pain and uneasiness is felt in the larynx ; and the cough becomes more sonorous. The disease now advances rapidly to its state of full development, and all the symptoms acquire a most alarming and distressing degree of violence. The coun- tenance is flushed ; the eyes prominent, injected, and heavy; the pulse frequent, tense, and quick ; the skin dry and hot; and the respiration extremely difficult and anxious. Inspira- tion is especially difficult, and accompanied with a very pecu- liar ringing or stridulous sound. The cough at this time is often quite dry ; but in some instances there is a copious and very tenacious albumenoid fluid secreted in the larynx and tra- chea from the very onset of the disease ; and in all cases this viscid secretion occurs in the advanced stage of the malady. If the disease is not checked in its violence and progress, the breathing acquires at last a degree of oppression inexpressibly distressing; the little patient manifests, in the expression of its countenance and actions, the utmost degree of anguish and suffering; the head is thrown backwards, and the mouth kept open ; the eyes are half closed or cast about with an imploring expression for relief; the voice is extinct; the lips livid ; the face pale and covered with large drops of sweat; sensibility is rapidly diminishing; slight coma ensues ; the extremities be- come cold and clammy ; and finally breathing stops and closes the agonizing scene. Such are the ordinary course and symptoms of this frightful malady. Much diversity, however, occurs in relation to the degree of violence and rapidity of these phenomena. In some instances, not more than a few hours elapse between the com- CYNANCHE TRACHEALIS. 311 mencement and fatal termination of the disease. In other cases the symptoms proceed slowly to their acme, and the disease is protracted for many days, and occasionally even for several weeks, assuming a chronic character, without, perhaps, hav- ing at any time manifested a very alarming degree of violence. The ordinary period occupied by this disease is from two to five days. Causes___Cynanche trachealis is one of those inflammatory affections for which a predisposition appears not unfrequently to be congenital. It is certain, at least, that the children of some families are particularly predisposed to the disease, whilst in others it never makes its appearance. In what this predis- position consists, we cannot tell. To say that it depends on a peculiarity of the organization of the mucous membrane of the larynx and trachea, may be correct; but what these organic peculiarities are, it would be in vain to inquire. Besides this original or natural predisposition, there is another one much more universal and influential in its agency, namely, age. Cynanche trachealis is, indeed, almost peculiar to the age of childhood, being vastly more common in children between the first and fifth year of age, than in the whole subsequent and anterior periods of life. It is, nevertheless, not wholly con- fined to the years of infancy and childhood ; for occasionally, though rarely, it occurs in adults, and sometimes even in very advanced age. This peculiar aptitude to the disease in early childhood, may depend, in part, on the peculiar condition of glottis or larynx at this age; for that there exists some pecu- liarity in this portion of the respiratory passage during infancy and childhood, unconnected probably with mere size of aperture, is manifest from the characteristic voice at this early period, and its remarkable changeduring the period of pubescence. But there is another circumstance which may have a large share in the so common occurrence of this malady during infancy, namely, the almost universal custom of dressing children so as to keep the neck and upper part of the thorax perfectly bare, and thus rendering them more liable to the injurious influence of cold in these parts. Certain exanthematous affections also, often give rise to an increased aptitude for this disease. This is espe- cially the case with scarlatina, measles, and milliary fever. With regard to the general habit of body most favourable for the production of this disease, observation would seem to show that florid, robust, and fat children are much more liable to the disease than such as are of an opposite habit. The principal exciting cause of this disease is cold or sud- den vicissitudes of atmospheric temperature, and hence its greater prevalence during the variable, damp, and cold months of autumn and spring than in the more temperate and uniform season of the summer. Cynanche trachealis is said to have 312 CYNANCHE TRACHEALIS. prevailed epidemically, but contrary to what obtains in this respect with epidemic catarrh, these epidemic cynanche are al- ways of a very limited sphere with regard to the extent of country which they embrace. In general this disease is most apt to prevail after, or during the prevalence of measles or scarlatina. During the period of convalescence from these af- fections, there appears to exist an especial aptitude to cynanche from the influence of cold. It would seem, moreover, that the liability to this disease is often considerably increased by hav- ing suffered an attack of it. I have known the same indivi- dual suffer five or six attacks of the disease during the period of childhood. Cynanche trachealis is a phlegmasial disease, consisting es- sentially in an inflamed condition of the mucous membrane of the superior portion of the respiratory tube. The correctness of this pathology is confirmed not only by the known charac- ter of its most common exciting cause, but especially also by the more direct evidence of the symptoms of the disease, and the appearances discovered on post-mortem examination. The observations of Bretonneau in France, and of Macken- zie in England, published within a few years past, go directly to the establishment of this view of the nature of the disease. Both these observers assert, that the inflammation often com- mences in the fauces and on the tonsils, and descends thence into the trachea; a progress of the disease which may be verified by occular inspection. I have myself seen several cases of croup which commenced by a kind of erysipelatous or superficial in- flammation about the tonsils and soft palate; and, in one in- stance, this inflammation continued for four days, and was the object of medical attention before it extended into the trachea and gave rise to the symptoms of croup.* The inflammation * It is surprising that a disease so manifestly phlogistic in its character, should still be viewed by some of the Gorman and French writers as es- sentially spasmodic in its nature, or at least, as wholly independent either of a local or general inflammatory condition. Several of the late continental writers on this disease regard the fever and inflammation, which they acknowledge sometimes to exist, as wholly accidental, and as in no manner essential to the perfect constitution of the malady. Among the principal anti-phlogistic pathologists in relation to this affection, may be mentioned Des-Essartz, Banafox, {a) Ruette, (6) Schenck, (c) Lob- stein, (d) Professor Masse regards impaired or disturbed function of the pneumo-gastric nerves as the proximate cause of this disease. The symptoms which characterize this disease, he asserts, bear a very strong resemblance to those which result from the division of the eight pair of nerves. The inflammation which occurs in the mucous membrane of the respiratory passages, is, according to his views, secondary, and the consequence of the disordered function of the pneumogastric nerves. (a) Jour, de Med. Chir. Pharm. &c. torn, xxxvii. November, 1816. (b) Traits de 1'Asphyxia connue sous le nom de Croup. (e) Bib. Med. torn. xii. p. 256. (d) Mem. de la Society Med. d'Emulation 8° annfe ii*. part. p. 538. CYNANCHE TRACHEALIS. 313 which gives rise to the characteristic phenomena of this dis- ease, rarely remains confined to the larynx and trachea. In many instances, it extends downwards into the bronchia, and sometimes even into the small ramifications, giving rise to the simultaneous existence of acute bronchitis and laryngeal in- flammation. The danger from this disease is always greater, cxteris paribus, in proportion as the inflammation passes down into the bronchial ramifications. Indeed, when bron- chitis co-exists extensively, the result must almost inevitably prove unfortunate. In some instances, the laryngo-tracheal inflammation termi- nates after a shorter or longer period from its commencement in the formation of a false membrane; which, according to the latest and most accurate observations, appears to consist of a concreted albumenoid secretion.* In other instances, the in- flammation terminates in the secretion of a muco-purulent matter of an opake and yellowish appearance, without the for- mation of a pseudo-membranous substance. There are other cases again, and these are perhaps much the most common, in which the inflammation produces neither false membrane nor a puruloid opaque matter, but an extremely copious secretion of a very viscid, limpid, and frothy mucus.f M. Blaud, in his excellent work on this disease, maintains that these dif- ferent modes of termination constitute good grounds for divid- ing the disease into three principal varieties, indicating three different grades of inflammation. The inflammation is at the highest grade of violence in those cases which are attended with the formation of a false membrane. It is less violent in the instances where there is only a muco-purulent secretion formed ; and in those cases in which a copious secretion of a te- nacious, limpid, and frothy mucus occurs, the inflammation is at its lowest grade. In the first and most aggravated variety of the disease, the cough and respiration is always dry or free from that peculiar rattling sound in the respiratory passages which occurs when these contain viscid secretions. This dry- ness of the cough usually continues for many hours after the disease is fully developed. The pain in the larynx is often very considerable, and the febrile reaction is usually particu- larly violent. The period at which the false membrane is formed, after the commencement of the inflammation, appears to vary considerably. In some cases, M. Blaud found the * According to the experiments of Schwilgu£, this membranous sub- stance is insoluble both in cold and in boiling water, but perfectly so- luble in a solution of the alkalies. By incineration, it yields deuto- carbonate of sodium, proto-phosphate of lime,&c.; corresponding thus entirely with the properties of coagulated albumen. f Nouvelles Recherches sur la Laryngo-Tracheite. Par P. Blaud . A Paris, 1824. 40 314 CYNANCHE TRACHEALIS. larynx and trachea lined with such a membranous substance, although the whole course of the disease did not occupy more than twenty hours; in other instances, several days appeared to elapse before it was formed. Occasionally, only a part of the internal surface of the larynx is found coated with this concretion ; but in some instances, it has been found to extend into the bronchia, and even into its smaller divisions. Some- times, instead of a membranous expansion, we find, on dissec- tion, the upper part of the trachea almost entirely blocked up by a thick mass of the concreted albumenoid secretion lodged just within the glottis. In cases in which this membranous substance is not formed, the cough early becomes somewhat humid, and the respiration rattling; and before the disease has continued many hours, the mucus in the larynx and trachea is so copious as to threaten suffocation by obstructing the glottis. M. Blaud thinks, that the extremely viscid mucus which is formed in these milder cases, is entirely different in its properties from the secretion which occurs in the former variety—and that it is incapable of being so inspissated as to give rise to a pseudo-membranous substance. Whatever may be thought of M. Blaud's division of this dis- ease, or of his sentiments in relation to the radical distinction between the inflammation and secretion which give rise to membranous structures, and that inflammation and its conse- quent mucous secretion which occurs in cases unattended with the formation of false membrane, it must be admitted that there exists, at least a twofold diversity in relation to the immedi- ate local consequences of the laryngotracheal inflammation— namely, one variety in which false membrane is formed, and in which the cough and respiration are at first dry, or do not indicate the existence of much mucus in the respiratory pas- sages ; and another variety in which the cough and respira- tion are humid, in the early period as well as throughout the disease, and in which a very copious secretion of transparent and extremely viscid mucus occurs. The former are ex- ceedingly dangerous, nay, almost hopeless, unless subdued by the most prompt and powerful antiphlogistic measures in their very onset. The latter are much less dangerous, and may ge- nerally be cured by more moderate antiphlogistic measures, and the expulsion from time to time of the tenacious mucus from the larynx and trachea. In nearly all cases, the mucous membrane of the larynx and trachea is found very manifestly congested on dissection; and the glottis is very frequently discovered to be considerably nar- rowed by a kind of thickening or tumefaction of its lips. With regard to the ratio symptomatum, it may be observed, that the immediate cause of the distressing difficulty of respira- CYNANCHE TRACHEALIS. 315 tion, and finally of death, consists in an obstruction to the in- tromission of the air into the lungs. The circumstances which cause the exclusion of the air from the lungs, consist either in a spasmodic closure of the glottis, or in an occlusion of this aperture by tumefaction of its sides, or by the formation of false membrane or a mass of concreted lymph, or finally, by an excessive quantity of a very ropy and viscid mucus closing up the passage. Death is also sometimes the imme- diate consequence of an effusion into, and consequent choking up of the bronchial cells, a mode of termination which almost always occurs when the inflammation descends into the bron- chial ramifications. Spasmodic contraction and closure of the glottis may be caused by irritation excited by the upper por- tion of the false membrane. Prognosis.—Laryngo-tracheitis is always to be regarded as a very dangerous affection. Formerly }he majority of cases terminated fatally; but under the present improved patho- logy and mode of remediate management, the proportion of fatal cases is greatly diminished. Frightful and unmanage- able as this disease is when suffered to pursue its course un- controlled, or when opposed by inadequate means, it is, never- theless, almost as much under the dominion of a prompt and vigorous' antiphlogistic treatment as any of the more serious phlegmasial affections. The degree of danger appears to be proportionate to the violence of the inflammation, and the ex- tent to which it may have passed downwards into the pulmo- nary passages. It would seem, also, that the more sudden the attack, when attended with strong febrile excitement, the greater in general is the danger. When, however, the disease supervenes suddenly without fever, the attack may be presumed to be purely spasmodic, and may readily yield. The shriller and more sonorous the cough, the more reason is there to ap- prehend danger. It must be observed, however, that the prog- nosis in this disease is often exceedingly fallacious. Sometimes the symptoms yield, and promise a speedy convalescence, when a violent exacerbation will suddenly supervene and de- stroy the patient; and on the other hand, death may appear to be impending, when, on the sudden expulsion of a membrane, or even without such an occurrence, a rapid change for the better will ensue and lead on to full convalescence. Diagnosis.—There is but one disease which may be mistaken for laryngo-tracheitis, namely, spasmodic, or cerebral croup. From this latter form of disease it may be distinguished: by, 1. The attack of cynanche laryngo-trachealis, generally coming on gradually, with the ordinary initial symptoms of catarrhal affections; spasmodic croup always supervenes sud- denly, and is rarely preceded by catarrhal symptoms. When the former does come on suddenly, which is sometimes the case, 316 CYNANCHE TRACHEALIS. it is so manifestly a febrile affection, that by this circumstance alone it may be readily distinguished from the spasmodic dis- ease. 2. Cynanche is essentially a febrile affection ; spasmodic croup is free from fever, except it be accidentally present. 3. Cynanche is often attended with considerable remissions, but no complete intermissions, except perhaps immediately af- ter vomiting. Spasmodic croup is often marked by complete intermissions of considerable duration. 4. Cynanche is always attended with a hoarse and sonorous cough, and frequently with a copious secretion of viscid mucus in the trachea. Spasmodic croup is rarely accompanied with much cough, frequently none at all, and it is always dry.* 5. The peculiar stridulous sound of the cough and inspira- tion, so characteristic of cynanche laryngo-trachealis, does not occur in spasmodic croup. 6. In spasmodic croup the pulse is small and contracted, and the skin not above the natural temperature. In cynanche the pulse is in an excited and irritated state, being generally full, frequent, quick, and tense, and the temperature of the surface is febrile, except towards the fatal conclusion of the disease, when, from the imperfect function of the respiration, animal heat ceases to be generated in its normal proportion. Treatment.—From what has been said above, of the nature and character of this disease, it is obvious that the general in- dications to be kept in view in its remediate management are: 1. To subdue the local and general inflammatory action as speedily as possible; and, 2. to promote the discharge of the viscid and coagulable secretions which are lodged within the superior portions of the respiratory tube. For the fulfilment of the former of these indications, the most prompt and energe- tic antiplogistic measures must be adopted. He who loses sight of, or neglects this all-important indication, and places his hopes in one or more of the empyrical remedies that have, by different practitioners, been extolled for their supposed specific tendency to counteract the tracheal affection, will, we may be confident, have but little reason to be flattered with his success in the management of this malady.f * Dr. Rush has published an account of a dissection of a child that had died of spasmodic croup. In this subject no membrane, nor even mucus was found in the respiratory passages, nor did the lungs exhibit the slightest traces of previous disease. t It is owing to physicians not attending to the essentially inflamma- tory nature of this affection, and the consequent indispensableness of prompt and vigorous antiphlogistic measures, that this disease was for- merly so much more frequently fatal than it appears now to be. It is, also, owing to this error, or rather to the erroneous views which have been so common concerning the pathology of this disease, that so many physicians have objected to the employment of blood-letting, and ex- CYNANCHE TRACHEALIS. 817 The remedy upon which we must place our principal reliance for the reduction of the tracheal inflammation is blood-let tingf in conjunction with external vesicating or irritating applica- tions to the throat. Here, however, as in most of the other phlegmasial diseases, the good effects of the lancet are confined to the early period of the disease. If bleeding be neglected, or inefficiently employed, in the first stage of the malady, its progress will be extremely perilous, whatever other remediate measures may be adopted. When called to a patient labouring under this disease, in whom the manifestations of high febrile excitement and active tracheal inflammation are conspicuous, a vein should be opened, and the blood suffered to flow until an approach to syncope be induced. So soon as this effect is pro- duced, all the distressing symptoms usually subside. If in the course of an hour or two the difficulty of respiration reappears, and the pulse be not soft and feeble, more blood should be drawn, and again to the extent of inducing an approach of syncope. I have been obliged to open a vein three or four times in the course of twelve hours, before a permanent and decisive impression was produced on the disease. Such copious depletion is, however, demanded only in cases where the local and general inflammatory action is strong—where the pulse is tense, hard, quick, and vigorous, attended with a dry and sono- rous cough and respiration. Such cases are apt to terminate in the formation of a false membrane in the larynx ; and our efforts ought to be prompt and vigorous to reduce the inflam- mation below the grade necessary for the formation of pseudo- membranous matter. After the effusion which gives rise to the membrane has taken place, bleeding will afford but moderate and temporary advantage. It must also be observed, that where the disease is attended with but moderate symptoms of febrile excitement; where the pulse is not hard, or tense, though accelerated ; and especially where, in addition to these manifestations of a moderate febrile excitement, the cough and respiration are attended, early, with a copious, transparent, and viscid mucous, blood-letting need very seldom be employed to the extent just mentioned, and may even, in some instances, be wholly dispensed with.* pressed their willingness to confide in mercury, poly gala senega, carbo- nate of ammonia, and hepar sulphuris, to the exclusion of the direct and powerful antiphlogistic means, long so universally and so successfully practised by American physicians. * In no country is blood-letting so actively employed in this, as in- deed in all other inflammatory affections, as in America. The value of this evacuation in the present disease has been long understood by Ame- rican physicians, whilst in Europe it was, until late, looked upon as an equivocal, if not an injurious measure. Even those who admitted the inflammatory nature of the disease, bled but very sparingly. To this there are indeed some remarkable exceptions. Ferriar recommends 318 CYNANCHE TRACHEALIS. Emetics are important remedies in this disease, and may, indeed, be regarded as indispensable in its remediate manage- ment. Assisted with warm pediluvium, mercurial purgatives, and rubefacients to the throat, I have frequently subdued mild attacks of the disease without the aid of direct depletion. In those cases which are early attended with a copious secretion of viscid mucus in the larynx and trachea, emetics are especial- ly useful. They tend not only to expel this tough mucus from the larynx, and thus to give a temporary freedom from the dyspnoea $ but also to equalize the circulation and to promote the cutaneous exhalation, as well as to diminish the general arte- rial excitement by the nausea which precedes and accompanies their operation. In infants affected with this disease, the oc- casional employment of an emetic is particularly important; for at this early age no voluntary efforts are made to dislodge and expel the viscid secretion from the larynx, and which, if not removed, may by itself cause suffocation. In those violent cases, which manifest a highly inflammatory character, and in which the cough and respiration are dry during the first stage, there is commonly but little advantage gained from the opera- tion of an emetic, so long as this dryness of the larynx and trachea continues. In such cases, the proper period for the ad- ministration of emetics commences with the appearance of the viscid secretions, which always sooner or later occur in the respiratory passages, and from which the disease derives its most serious and dangerous character. Without doubt, from the general antiphlogistic tendency of nausea and emesis, some benefit may result from the exhibition of emetics before any morbid secretions occur in the larynx; but the peculiar advan- tages of this class of remedies are most assuredly more conspi- cuously displayed when the upper portions of the wind-pipe are clogged with a viscid fluid, which requires expulsion. In the advanced periods of the disease, there exists often so much torpor or insensibility of the system in consequence of the im- perfect decarbonization of the blood and vascular congestion in the brain, that great difficulty is experienced in procuring the operation of emetics. To obviate this gastric insensibility and procure emesis, we must endeavour to diminish the san- guineous cqngestion in the head, and this may in general be readily accomplished by putting the patient's feet in warm water, and applying a napkin, wet with very cold water, to bleeding, ad deliquium. {Med. Histories.) " This," says he, " is the es- sential point, without which no relief can be effected." The same prac- tice is strongly inculcated by Drs. Bayley and Middleton. {Cases of Angina Trachealis, with the Cure, in Letters to William Hunter, M. D. 1781.) And in the late medical journals observations may be found equally favourable to decisive depletory measures in this formidable malady. CYNANCHE TRACHEALIS. 319 the head. The abstraction of blood, too, while the patient is maintained in a sitting or erect posture, will rarely fail to in- sure the operation of an emetic under the circumstances in question. The articles I prefer as an emetic in this disease are calomel in combination with tart, antim. I commonly adminis- ter from five to six grains of the former article with one-fourth of a grain of tart, antim. to a child of from two to five years old. I have frequently given from eight to ten grains of calo- mel alone, and have very generally found it to excite active vomiting in a short time. The peculiar advantages which appear to me to belong to this practice are the protract- ed and great degree of nausea which the calomel produces, an effect which has a powerful antiphlogistic tendency ; and the alvine evacuations which almost always speedily ensue. Be- sides these effects, great benefit may be expected from the early constitutional influence of the calomel, an influence which, in the present disease, especially, is very generally acknow- ledged to be highly salutary. Be this as it may, however, universal experience decides in favour of the great utility of emetics in this disease. Tart, antim., ipecacuanha, sulph. zinci, squills, sulp. cupri, have all been used and recommend- ed in this affection, and where the object is merely the expul- sion of the tracheal mucus, or pseudo-membranous matter, any of these articles may answer our purpose.* In some instances, where the accumulation of the tenacious secretion is very rapid, it becomes necessary to repeat the emetic three, four, or five times in the course of twenty-four hours. M. Jadelot recommmends the following mixture as an emetic in croup, after proper depletion has been practised: R. Infus. polygalse §iv. Syrup ipecac. 5i. Oxymel scillse 5iii. Antimon. tart. gr. iss. M. Take a spoonful every fifteen minutes, until vomiting is produced. Purgatives are useful auxiliary means in the treatment of this disease. In the onset of the complaint, the bowels should be briskly evacuated, and two or three evacuations should be subsequently procured daily until the inflammation is subdued. After the first purge, which should be energetic, it is best to employ the gentler articles of this class of remedies ; for very active catharsis tends to exhaust the resources of the system * I have, in a few instances, prescribed an infusion of the lobelia inflata, with the happiest effect. From its known very powerful influence upon the respiratory function in asthma, independent of its emetic operation, there is some reason for presuming that in relation to the present disease it may possess peculiar virtues, and my limited experience with it in- clines me to this opinion. 320 CYNANCHE TRACHEALIS. without procuring any peculiar advantages over milder aperi- ents, and may even do much harm. After the first cathartic, it will in general be sufficient to keep the bowels in a loose state by laxative enemata. Mercury.—Calomel, given with a view to its constitutional influence, is a remedy which has been, and by many is still much extolled in the treatment of this disease. Many of the continental writers seem to look upon it as decidedly the most valuable means we possess for removing the local tracheal af- fection. In our own country, too, this article has found some eminent advocates as a remedy in inflammatory croup. The late Dr. Rush placed great reliance on its powers in this dis- ease ; for he asserts, that when given in large doses in the com- mencement of this disease, and continued afterwrards in smaller doses, " it is hardly less efficacious in this complaint than the Pe- ruvian bark'is in intermittents." Dr. Hosack also speaks very favourably of the employment of calomel, and James's powder in combination, given at short intervals in the second stage of the complaint; and the late Dr. Bard placed much reliance on its powers. That the constitutional influence of mercury is calcu- lated to do good in croup, I am well persuaded from my own experience. It tends in no small degree to reduce the local laryngo-tracheal inflammation, and to counteract, as it would appear, the formation of the pseudo-membranous exudation. Its operation in this respect is, however, much too slow to af- ford particular advantage in the more acute and rapid cases of the disease, many of which run to a fatal termination in less than twenty-four hours. Where the complaint assumes some- what of a chronic character, we ought not to lose the advantages which may be derived from this remedy. My usual mode of giving this article after the first or second emetic is to exhibit one grain every hour or two, with about one-fourth of a grain of ipecacuanha. The warm bath, also, is a very useful auxiliary in the treat- ment of this disease. Employed along with the remedies already mentioned, its benefits are often very considerable, more espe- cially where the skin is very dry and hot. Its usefulness is, however, confined to the early periods; for, in the advanced stages, the skin is generally bathed with profuse perspiration, and the pulse weak and soft. Concomitantly with the preceding remediate measures, ex- ternal rubefacient and vesicating applications to the throat ought, in all instances, to be employed. One of the first mea- sures after bleeding should be the application of a blister, or some irritating substance to the throat of the patient. I pre- fer the application of the spirits of turpentine to blisters or any other similar article. The action of the turpentine on the skin is prompt and powerful, and if the derivative powers of such CYNANCHE TRACHEALIS. 321 applications be proportionate to the degree of irritation and pain they produce, few articles can equal the present one in this respect. A piece of flannel may be imbued with the tur- pentine and applied round the neck. Children seldom will bear this application for more than twenty or thirty minute3 at a time. It must, therefore, be removed and reapplied from time to time, according to the violence and permanency of its effects on the skin. In general, it has appeared to me that active rubefacients are preferable to blisters in this complaint. They generally act with promptitude and force—a circumstance of no small consideration in a disease which often runs its course in a few hours. A blister requires from four to five hours before its effects on the skin can be of any particular avail. An efficient blood-letting ought always to precede such applications in cases attended with high febrile excitement. The oil of the mo nar da punctata, with an equal proportion of camphorated liniment, forms also an excellent rubefacient in this affection. Where the disease proceeds slowly, the use of a blister will be preferable to rubefacients. With regard to the local abstraction of blood by means of leeches, general experience does not enable us to ascribe any peculiar advantages to it. It has never yet appeared to me to afford any greater advantage than if the same quantity of blood had been drawn with the lancet. Besides the foregoing remediate measures, which may be justly regarded as decidedly the most direct and powerful means for combating this malady, a number of other remedies have been recommended—some of which have been distin- guished with the title of specific. Among these pretended spe- cifics, the poly gala seneka and the hepar sulphuris (deuto-sul- fure of potassium) have attracted the most attention. The former of these articles is, without doubt, a useful medicine in certain states of this disease; but it is, most assuredly, far from possessing the powers which were formerly ascribed to it by Archer and others. In the commencement of the disease, es- pecially in the more violent cases, it is objectionable on ac- count of its stimulating properties; but after the complaint has been in some degree subdued, or lost its acute inflammatory character, its influence is often conspicuously beneficial. For the removal of the dry and hoarse cough and slight oppression of the respiration, which in some instances remain after the in- flammation has been subdued, we possess no remedy equal in usefulness to the polygala. It is, moreover, a decidedly useful remedy in all instances of chronic croupy affections, and in the catarrhal and pectoral affections which remain as the sequela of this and other acute affections of the respiratory organs. It is best given in decoction. An ounce of the root to a pint of boiling water suffered to simmer for 15 or 20 minutes, and af- 41 322 CYNANCHE TRACHEALIS. terwards sweetened with honey. The dose of this is about an ounce every hour or two, according to the urgency of the symptoms. With regard to the hepar-sulphuris, a remedy introduced to the notice of the profession about 16 years ago, in a prize essay on this disease presented to the French Ecole de Medecine,* little can now be said in commendation of its powers. Its introduction was founded on the erroneous doctrine that croup consists es- sentially in a morbid coagulability of the tracheal mucus, and which, it was asserted, the sulphurct of potash had the power of preventing or altering. It need scarcely be observed, how- ever, that a remedy which might possess such power, with- out, at the same time, exerting any influence in subduing in- flammation, could afford us but little advantage in this affec- tion ; and the result, indeed, of later experience goes to show that this at first highly lauded remedy exerts no decided influ- ence over the tracheal inflammation. It would be waste of time, to pass in review the various other remedies of this kind which have at times been praised, and again abandoned as cu- rative means in this disease. As well might we look for spe- cifics for the cure of pleurisy, phrenitis, or gastritis, as to ex- pect to find one for laryngo-tracheitis. It has already been stated ahove, that the exudation of albu- menoid fluid, which forms the false membrane, frequently com- mences on the surface of the tonsils, and thence spreads along the arches of the palate, and at last descending, cover the in- ternal surface of the pharynx and oesophagus, as well as the larynx and trachea. According to the experience of Dr. Mac- kenzie, the application of a solution of the nitrate of silver to the tonsils, velum palati, and uvula, will in such cases frequent- ly remove the membranous crust completely, and produce speedy and great relief, and ultimately entirely remove all the symptoms. The solution employed by him is of the strength of a scruple of the nitrate of silver to an ounce of distilled wa- ter. I have seen one instance in which this application was made, and the result gave me a very favourable impression of this practice. It must of course be confined to those cases in which the fauces are found, on inspection, to present an irri- tated and inflamed condition. Dr. Laennec has lately publish- ed a statement, from which it appears that insufflation of very finely powdered alum generally affords great and speedy re- lief, not only in this variety of the disease, but also in cynanche laryngea and tonsillaris. With a view of expelling the false membrane, emetics have * Rapport sur les ouvrages envoy{«»0f«, effloresco; and is employed to designate those acute contagious affections, in which an efflorescence or eruption ap- • R. Flor. sulph. f i. Resin, guaiac. 5ss. Antim. crude 3iii. M. f. pfl. pondere gr. iii. S. Take from nx to eight pills, three times daily. VARIOLA. 379 pears on the surface of the body. The exanthematous fevers are of a strictly specific character:—that is, each affection of this kind has it specific, cause, and cannot, so far as we know, be produced by any other cause or combination of causes. In all of them, fever exists as the primary or essential disease— the eruption being a secondary affection, and the immediate consequence of the specific febrile excitement. Unless inter- rupted by constitutional idiosyncracy, or adventitious influ- ences, each of these diseases has its determined course, both in relation to the duration of its stages and the succession of its characteristic phenomena. They are all communicated by con- tagion ; and they possess the power of destroying the suscepti- bility of the human organization, to the subsequent morbific influence of their respective contagions, although instances do occasionally occur in which this power is more or less effec- tively opposed by the system, and in which, therefore, a second attack is possible. VARIOLA. Small-Pox. It is not known at what period the small-pox made its first appearance. In the writings of the Greek and Roman physi- cians, we find nothing which could lead us to believe that they had any particular knowledge of this devastating malady, al- though we can scarcely doubt that its origin was of a much earlier date.* The Arabian physicians were the first who gave a distinct description of this disease; and it is to the * Rhazes, indeed, refers to some expressions in the writings of Galen, which would seem to show that small-pox, though not described, was known by this Roman writer. " As to t^iose physicians," says Rhazes, " who affirm that the most excellent Galen has made no mention of the small-pox, and therefore that he did not know this distemper; surely they have either never read his works at all, or only very cursorily; nay, most of them do not know, whether what he plainly says of it is to be understood of that disease. For Galen, in a certain treatise, says: this * * * does good against the small-pox. And in the beginning of the four- teenth book of pulses, he says, that the blood is putrefied in an extraordi- nary degree, and that the inflammation runs so high that it burns the skin; so that small-pox and pestilent carbuncle are bred by it. And in the ninth treatise of the book Of the Uses of the Parts, he observes, that the super- fluous parts of aliments which are not turned into blood, and remain in the members, putrefy, and in time increasing, do ferment; whence, at last, are generated the pestilential carbuncle, the smallpox, and confluent inflamma- tions. Lastly, in the fourth part of his commentary upon the Timceus of Plato, he says, that the ancients gave the name of pxtj^uovw to every thing which produces redness, as the carbuncle and small-pox."—Treatise on the Small-Pox and Measles. By Abubecker Rhazes, chap. i. Translated by Thomas Stack, M. D-, F. R. S. 380 VARIOLA. small work of Rhazes, who lived about the beginning of the tenth century, that we must look for an account of its early history. It may be collected from the writings of Rhazes and others, that small-pox was probably at first brought from Ethi- opia into Arabia, and that it was thence conveyed into the Levant, Spain, and Sicily by the Saracens during their hostile irruptions into these countries.* In the eleventh and twelfth centuries, it gained vast ground during the wars waged by the Christian potentates against the infidel Saracens for the recovery of the holy land. From that time forwards, its deso- lating visitations were frequently renewed in every part of Europe, and there is perhaps no single disease, with which the Almighty has thought it good to afflict mankind, which has carried off so many victims to the grave as the present one.f Small-pox is divided into two varieties—namely, the distinct and confluent. In the former, distinct, elevated, distended, and circular pustules are scattered over the surface of the body; and in the latter the pustules are exceedingly numerous, de- pressed, irregularly circumscribed and confluent or coherent. There exists, however, no essential difference between these varieties; and the division is indeed altogether arbitrary, for in some instances the pustules are confluent on the face, while on the rest of the body they are distinct. The time which elapses between the reception of the variolous virus, and the first manifestations of its morbific influence on the system, is said to vary from about seven to twenty days; although by far the most common period of its inception is be- tween the ninth and fourteenth days. During this period of incubation, no obvious symptoms of indisposition occur—the individual retaining an apparently good state of health. It is stated by some, that the disease is apt to be most violent when this period is of short duration. Course and symptoms of the distinct variety.—The disease commences with a feeling of langour, weariness, aching pains in the back and lower extremities, slight creeping chills with flushes of heat and pain in the forehead. More or less nausea and vomiting, attended with great thirst, pain in the epigas- trium, and some degree of soreness in the fauces, speedily ensue. When the fever is completely developed, the skin and * It would appear, that small-pox was known in Europe as early as the seventh century. The word variolce occurs repeatedly, in some ma- nuscripts discovered by Dr. Woodville, in the British Museum, and in the Cottonian collections, written about the close of the eighth century; and Marius Aventicensis, bishop of Lausanne in the seventh century, uses these words: Hoc anno viriola cum profluvio ventris, Galliam, Ita- liamque valde afflixit.— Gregory's Practice, vol. i. p. 197. t It has been estimated, that before the introduction of vaccination, 450,000 individuals died annually of small-pox in Europe.—Rickter's Therapie. b. ii. p. 302. VARIOLA. 381 faces are dry, the tongue white and generally red at the point, the bowels torpid, and the urine scanty and of a deep red co- lour. During the first and second days of the fever, slight haemorrhages from the nose are apt to occur; the mind often becomes dejected and confused; and towards the end of the third day, the tongue usually acquires a bright red colour. Shortly before the appearance of the eruption, an unusual ten- dency to perspiration generally occurs in adults, and frequently much drowsiness, and sometimes coma supervene at this period. In children the eruption is often preceded by convulsions ; but the tendency to free perspiration very rarely occurs in them. In many cases, the hands and feet are cold throughout the whole course of the disease, more especially in very young children. The coldness of the extremities has by some been considered as the most certain diagnostic symptom of the erup- tive variolous fever; but the most frequent and characteristic phenomenon of this fever is the pain and soreness to pressure of the epigastrium, and the vomiting. (Philip. Febrile Diseases.) Both in adults and in children, a considerable increase of the febrile symptoms usually takes place a short time before the eruption begins to appear ; and in some instances severe cramps in the legs occur at this period. Towards the end of the third, or the beginning of the fourth day from the commencement of the disease, the eruption begins to make its appearance. The pustules appear first on the fore- head, and on the parts about the mouth and nose—next on the forearms and upon the breast and abdomen—and last of all on the lower extremities ; so that in about twenty-four hours the eruption is completed. The eruption consists at first of small red points, which by the middle of the second day become small elevations, with inflamed bases, which as yet discharge no serous fluid when punctured, but " the cuticle appears dis- tended by a sort of semi-transparent plastic lymph." Towards the end of the second day, some of these pustules present central depressions; and on the following day this characteristic de- pression becomes conspicuous in nearly all of them. Where there are but few pustules, they often remain elevated and pointed, with but a very slight central depression ; but where they are nu- merous, they assume an umbilicated form, or flattened with a dis- tinct depression of the centre. The fluid appears at first in the central points, and is of a limpid and serous character. The pustules continue gradually to increase in size, at the same time that their umbilicated form becomes more and more conspicuous. About the fourth day they assume a whitish colour, and become surrounded by a pale red areola; and when the pustules are very numerous, these areolae run into each other, and give a uniform appearance of redness to the interstitial spaces. The limpid fluid which appears at first in the central part of the 382 VARIOLA. pustules, gradually becomes more and more abundant—extends towards the basis of the pustule—and changes from its serous to a purulent character. This change occurs between the fifth and seventh day, and marks the commencement of the stage of Suppuration.—In the distinct variety, the fever which pre- cedes and accompanies the eruption always remits greatly, and frequently disappears entirely, as soon as the eruption is com- pleted. When suppuration commences, however, the febrile symptoms usually re-appear. As the process of suppuration goes on, the pustules become distended with pus, and losing the flattened form, acquire a spherical shape. About the eighth day, when the crop of pustules is pretty numerous, the face begins to swell; the upper eye-lids sometimes becoming so tumid and puffy as to close the eyes entirely. Towards the end of the tenth day the swelling of the face begins to subside, but instead of this, considerable tumefaction occurs in the hands and feet, and the interstitial spaces over the whole body be- come more or less swollen, tense, and sore. The period of suppuration is almost invariably attended with soreness in the fauces, and where the pustules are numerous, with a copious secretion of viscid saliva. In some instances, the increased flowflf saliva occurs with the commencement of the eruption, but its usual time of occurrence is after the suppurative stage has supervened. This secretion generally becomes so thick and viscid, that it is spit out with considerable difficulty, and renders swallowing difficult. On examining the mouth and fauces, they are found swollen and of a bright redness, and from the eustachian tubes becoming closed by the tumefac- tion, more or less obtuseness of hearing usually occurs. Dur- ing the latter period of the suppurative stage, a strong and very peculiar odour rises from the patient's body, and this ex- halation continues until the process of desiccation is completed. When the tumefaction of the face is very considerable, more or less drowsiness or oppression often occurs, and in some in- stances diarrhoea supervenes towTards the completion of the suppurative process. The secondary or suppurative fever va- ries in violence and duration, according to the copiousness of the eruption, and the activity of the suppuration. In mild cases of the distinct variety of the disease, this secondary fever rare- ly continues longer than two or three days, and is still more rarely attended with symptoms of much severity. The suppura- tion, like the appearance of the eruption generally, begins on the face, and lastly on the hands and feet. As the disease advances, the pustules gradually become yellower and more opaque, and arrive at their full state of maturity about the twelfth day.* * If a mature pustule be opened, which had previously presented a well-marked central depression, a yellowish pus will be found, below VARIOLA. 383 After the pustules have acquired their perfect state of develop- ment, they sometimes remain stationary for several days ; but more commonly a brownish spot makes its appearance on the centre of each pustule as soon as the process of suppuration is completed, acquiring at the same time a rougher and deeper yellow aspect. Soon after the occurrence of this change, the pustules begin to shrink, and become gradually drier, browner, and harder, until the matter is converted into brown crust. Desiccation always commences on the face, "this part being often covered with scabs, when the pustules on the extremities have scarcely arrived at maturity." When the scabs fall off, they leave a vividly red surface, which disappears very gradu- ally. In the mild cases of distinct small-pox, the suppuration seldom destroys the skin and subcutaneous cellular tissue, and the skin therefore does not become pitted or marked. In the more severe instances of this variety, however, the cacatrices remain with more or less distinctness—becoming more and more visible as the redness which remains, after the falling off of the scabs, gradually disappears. Confluent small-pox.—The pain in the back and extremi- ties during the eruptive fever, is almost always much more se- vere in the confluent than in the distinct variety of the disease; and, in general, all the febrile phenomena are usually more violent in the former than in the latter. The heat of the skin is very great; the thirst exceedingly urgent; the tongue dry, harsh, and sometimes covered with a dark-brown or blackish fur, and the nervous system is conspicuously depressed. In the distinct variety, the eruptive fever is almost invariably of the synochus or synocha grade. In the more aggravated in- stances of confluent small-pox, it often assumes a typhous cha- racter; although in the majority of cases, the eruptive fever is highly synochal. The tendency to copious perspiration, often so conspicuous in the distinct small-pox, is rarely observed in the confluent variety; but profuse diarrhoea sometimes occurs just before the appearance of the eruption, and still more commonly during the suppuration. It has been observed, that the secre- tion of saliva, commonly so abundant in this affection, is usual- ly very trifling, or almost entirely suppressed when diarrhoea attends. In general, the eruption appears at an earlier period in the confluent than in the distinct variety of the disease; and the time of its appearance is altogether much more irregular in the former than in the latter. In some instances, the pustules come out as early as the second day, and, occasionally, not which is a small, white, umbilicated disk, perfectly resembling in form and size, the pustule before the pus had altered its shape.—Cazenave. Practical Synopsis of Cutaneous Diseases, p. 142. 384 VARIOLA. until the fourth or fifth day after the commencement of the fever. In many instances of confluent small-pox, a roseolous rash or efflorescenc e precedes the variolous eruption—a pheno- menon which is occasionally observed also in the distinct va- riety. When the eruption is confluent, the small red papular points which appear at first run into each other, and form " a large red, tumefied, and somewhat rugose surface." The pa- tient at the same time is very drowsy, and the carotids beat strongly. The pustules of confluent small-pox are commonly irregular in shape and much less elevated than in the distinct small-pox; and the parts not covered with the eruption are pale and flaccid. The central depression is generally incon- spicuous; and about the third day the pustulated surface of the face becomes " covered with a kind of subcuticular whitish pellicle." The tumefaction of the face and hands, as well as the soreness in the fauces and the flow of saliva, are generally very great in the confluent variety. The reverse, however, is occasionally observed; for, in some instances of confluent small-pox, these symptoms are but very slight. When the suppuration is completed, a very manifest aggravation of the febrile symptoms occurs, constituting what is termed the sup- purative or secondary fever. The matter in the confluent pus- tules is of a whitish-brown and sometimes of a dark-colour, and of much less consistence than in the mild form of the disease; and in some instances, it acquires a very corrosive character. About the eighth or ninth day of the eruption, the matter be- gins to escape from the pustules, and hardens on the surface into extensive brown crusts, which fall off at periods varying from the fifth to the fifteenth day from their formation, and are succeeded by desquamations which finally leave deep marks or pits, which are often so united as to form "seams that tra- verse the face in all directions." Both in the distinct and confluent varieties of the disease, great itching attends the pe- riod of desiccation. The eruption of small-pox is not confined to the external surface of the body. The pustules occur also on the mucous membrane of the mouth, larynx, and trachea, and on the tongue—giving rise to more or less copious ptyalism, hoarse- ness, painful swallowing, difficulty of breathing, cough, viscid expectoration, and perhaps diarrhoea. The disease sometimes assumes, from the commencement, a highly inflammatory character. It begins with strong chills, succeeded speedily by intense febrile heat; a frequent, full, and hard pulse ; high-coloured and scanty urine; flushed coun- tenance; sometimes delirium; and in children often convul- sions. Internal inflammations, particularly of the brain or lungs, are apt to supervene in cases of this kind. When the former organ becomes the seat of the inflammation, violent VARIOLA. 385 delirium, coma, convulsions, or apoplexy ensue. Thoracic in- flammation is indicated by the occurrence of pneumonia, pleu- ritis, or effusion into the lungs. The eyes, too, are apt to be- come inflamed, and the parts not covered with pustules are vividly red and much tumefied. In some instances the attending fever, even in the distinct variety of the disease, is typhoid. The chilly stage is unusual- ly protracted; the pulse remains small, weak, and frequent, and the patient complains of much muscular prostration. Va- rious symptoms of nervous disturbance are apt to occur—such as vertigo, faintness, twitching of the tendons, and even con- vulsions. The urine is colourless and the face pale and sunken. The pustules come out slowly and irregularly, appearing si- multaneously on every part of the body, and sometimes first on the extremities, and are often congregated in irregular clus- ters. The eruption occasionally disappears on some parts without passing into the pustular state ; and slight causes, such as cold or mental agitation, may even cause the whole erup- tion to recede; in which case, convulsions, or apoplexy, or fatal congestion and effusion into the lungs are apt to super- vene. Suppuration goes on slowly and often imperfectly, the pustules becoming filled with a thin watery pus. The inter- mediate skin seldom becomes much tumefied, and remains pale. In the advanced period of the disease, the swelling of the face and extremities sometimes subsides suddenly, and the patient dies apoplectic. Desiccation generally commences several days earlier than in the ordinary course of the disease; and at this period the fever is apt to become much aggravated.* The disease sometimes manifests a highly malignant or pu- trid character—more especially the confluent variety. The heat is acrid (calor mordax;) the perspiration clammy and of- fensive* watery diarrhoea often occurs; the face is bloated and red • the eyes watery and inflamed ; the appearance of the eruption and its progress are irregular. The pustules com- monly acquire a dark or livid hue ; are surrounded with brown or almost black margins; and become filled with a bloody serum instead of pus. Colliquative hemorrhages, particu- larly from the nose, are common. Desiccation leaves very dark or black crusts, beneath which phagedenic ulcerations are not unfrequently formed.j- When the small-pox attacks females in the state of pregnan- cy, it frequently gives rise to abortion, more especially during the early periods of utero gestation. Such are the usual course and phenomena of the distinct and confluent varieties of small-pox. It is subject, however, to • Richter's Spacielle Therapie. b. ii. p. 297. t Ibid. p. 299. 49 3S6 VARIOLA. considerable irregularity, both in relation to its general pro- gress and the character of its particular symptoms. But the most remarkable variety of anomalous small-pox is that which has been termed the chrystalline, and in which, instead of pus- tules containing purulent matter, the eruption consists of phlyc- tense, or vesicles filled with a colourless transparent serum. These phlyctense soon become pale, and although not confluent, are never surrounded by inflamed margins. TJiis variety of the disease is of a most dangerous character. In many instances, no tumefaction of the face or hands occurs, a circumstance which is particularly indicative of great violence and danger; " for, instead of these swellings, the inflammation generally seizes on the brain." The secondary fever in this variety of the disease usually assumes an evident typhoid character. The sequelae of small-pox are very various, and often ex- tremely distressing. The disease may give rise to slow and wasting fever, dropsy, chronic cutaneous affections, phagede- nic ulcerations, necrosis, chronic ophthalmia, rheumatic pains, deafness, paralysis, struma, phthisis pulmonalis, mania, epi- lepsy, opacity of the cornea, staphyloma, dropsy of the eye, and cataract. The small-pox is sometimes remarkably modified by the influence of the contagion of measles. Sydenham observes, that in 1670-71-72, the small-pox and measles prevailed at the same in London, and that, during this period the variolous affection assumed an extremely irregular and violent character. The eruption, at first, resembled measles or erysipelas; in its progress, small vesicles filled with a colourless fluid ap- peared among the variolous pustules. The scabs formed on the pustules resembled concreted blood, and at last became al- most black. The influence of measles on the progress of small-pox, when the two diseases meet in the same individual, is equally re- markable. It has been frequently noticed, that the superven- tion of measles during the early periods of small-pox, causes this latter disease to remain nearly stationary until the morbil- lious affection has run its course, when the small-pox resume their progress and proceed to their regular termination. Thus, if on the second day of the small-pox eruption, the measles make their appearance, the small-pox will remain stationary until the measles have gone off, after which, the variolous dis- ease will resume its dominion and go on in the usual way. Post-mortem appearances.—The morbid appearances on dis- section vary, of course, considerably, according to the stage 0/ the disease during which death takes place, the violence of the particular symptoms, and the accidental affections with which it may be complicated. Sanguineous congestions in the brain and lungs are generally strongly manifested. Pustules are not unfrequently found in the larynx, trachea, and bron- VARIOLA. 387 chia, as far as the third division. In the pharynx too, the variolous pustules are sometimes pretty numerous, but they are very rarely found in the oesophagus. Traces of inflammation to a greater or less extent are almost invariably detected in the mucous membrane of the alimentary canal, and pustules of a variolous character are sometimes met with in the lower portion of the rectum. It is observed by Cazenave and Sche- del, that they had never in any of their dissections found the pustules on the mucous membranes distended with pus. It does not appear from the observations of those who have paid par- ticular attention to the post-mortem appearances in this dis- ease, that the variolous pustules are ever found on the viscera or in the closed cavities of the body. Some late writers as- sert, that the internal surface of the aorta almost constantly presents a vividly red appearance, but the frequency of this appearance is denied by Cazenave and Schedel. The pustules on the skin, when anatomically examined be- fore they are distended with pus, or before they have lost their umbilical form, present the following appearances: 1st. ••The cuticle preserves its natural thickness and is easily detached, leaving exposed a whitish and smooth surface elevated at the edges and depressed in the centre. 2d. "A small umbilicated disk of various thickness formed by a whitish substance, having a certain consistency, and which appears to be a real exudation from the inflamed dermis. This substance occupies the place of the mucous coat, and at first appears to be continuous with the layer which is immedi- ately under the epidermis, but afterwards is easily separated from it. This small body adheres to the dermis by its centre, where it is also much thinner, and often tears when it is at- tempted to be raised." If, when the cuticle is elevated by the pus, the pustule be examined with care, it will be found that the bottom of the pustule still presents the same umbilicated form that it possessed before the cuticle was raised and dis- tended by the purulent fluid. 3d. •' Finally, below this small disk, the dermis is found of a red colour, and sometimes covered with purulent fluid."* The true seat of the small-pox pustule appears to be in the reticular tissue which lies between the cutis vera and the cuti- cle. In its early stage, the pustule, when examined with a lense, exhibits a cellular structure, and from the sixth to the ninth day, a thin circular slough of the true skin may be ob- served at the bottom, which, on being finally cast off, gives rise to a depression or pit in the skin. Cause.—Small-pox, so far as we know, can arise only from one cause—namely, a peculiar contagious principle, which oc- * Cazenave, loc. cit. 388 VARIOLA. curs both under the form of a palpable matter and of an imper- ceptible effluvium; but of whose intimate nature and origin we are entirely ignorant. Observation has made us acquainted, however, with its obvious relations as a morbific agent, and with some of the influences, both vital and extraneous, which tend to modify its operation on the human system. It does not appear that age or sex exerts any controlling power over the operation of this contagion, and we know that even the foetus in the womb is not exempt from its morbific effects. Nor does climate or season, so far as the sensible atmospheric conditions are concerned, appear to exercise any influence either in re- tarding or favouring its dissemination. One of the most remark- able and mysterious phenomena of this, as well as of other epi- demic contagious diseases, is its recurrence at distant intervals in an epidemic form, depending, no doubt, on certain occult at- mospheric constitutions peculiarly favourable to the operation of the variolous contagion. The disease occurs, indeed, also sporadically; but during certain periods, its contagion may thus here and there manifest its presence, without passing from individual to individual, and be speedily extinguished, like sparks thrown among incombustible materials. What these at- mospheric conditions consist in, if in truth these phenomena depend on atmospheric modifications, we know not. Whatever may be the general cause to which these influences belong, it is probable, however, that its effects are exerted rather upon the human constitution by which its susceptibility to the operation of the variolous virus is either increased or diminished, than in modifying the activity of the contagious principle itself. The susceptibility to the operation of the small-pox contagion varies much in different individuals, not only in relation to the liability of becoming affected by it, but also to the degree of violence which the disease, arising from the same source of contagion, assumes. Thus, some persons, (though indeed very few) appear to be naturally insusceptible of the disease ; others are affected, even by inoculation, with great difficulty; and among a number of individuals exposed to the same contagion, the disease will assume a confluent form in some ; in others it will be severe but distinct; in a third, mild and distinct; and in others, again, it will be very mild, and scarcely attended with any eruption. These diversities in the effects of the con- tagion must be ascribed to original idiosyncracy, temperament, and to accidental modifications or conditions of the organiza- tion. One thing is well ascertained in relation to this point— namely, that whatever tends to reduce the general vigour and phlogistic habit of the system, tends also to lessen the violence of the variolous affection ; and it is to this circumstance that we owe all the peculiar advantages which are derived from inoculation. The variolous contagion possesses the power of VARIOLA. 389 destroying the susceptibility of the system to its subsequent operation, so that a second attack of perfect small-pox in the same individual, though an occasional, is far from being a common occurrence. Instances of a second, and even a greater number of attacks in the same person, have indeed been fre- quently noticed ; and when we take into account those incom- plete cases which are termed varioloid, secondary attacks of the disease may be considered as very frequent. Prognosis.—Small-pox is exceedingly various in relation to its violence and the degree of its dangerousness. The distinct and simple form is by no means a dangerous affection ; whilst the confluent variety is always attended with great hazard to life. In the more violent cases of the disease, death sometimes takes place as early as the fifth or sixth day ; but the greatest fatality occurs during the stages of suppuration and desiccation. The prognosis depends chiefly on the quantity of the eruption ; the character of the pustules ; the nature of the attending fever; and on the accidental morbid complications. However regular the progress of the disease may be, the danger is always great when the pustules are very numerous, more especially when, they are confluent. It would soein from estimates that have been made in relation to the mor- tality from small-pox, that nearly three out of five instances die in the confluent variety. The check which a very copious crop of pustules must ne- cessarily give to the cutaneous exhalation, and more especially the great irritation which is caused by so extensive a surface of suppuration, and perhaps the absorption of the pus itself, are the immediate causes of the fatal character of the confluent va- riety of the disease. In relation to the form and appearance of the pustules, it may be observed, that the more elevated they are, the more distinctly they are surrounded with red areola?, and the more regularly they become filled with a thick yellow- ish pus, the more favourable may be the prognosis. When, on the contrary, the pustules are flat or depressed, coherent or congregated in clusters, warty, empty, or filled with a colour- less watery fluid, it is a very unfavourable sign. It is a still worse indication when the pustules become filled with blood.* With regard to the character of the attending fever, the more decidedly phlogistic or typhoid it is, the more danger is there to **e apprehended. A moderately active state of fever is fa- vourable, but a tendency to a low grade of reaction is the re- verse. Richter observes, that when the disease is complicated with prominent catarrhal symptoms; or with difficult denti- tion ; or intestinal irritation from worms; much danger may be apprehended. In general, the prognosis is unfavourable when * Richter, loc. cit. p. 303. 390 VARIOLA. the disease occurs in old persons of enfeebled constitutions ; in plethoric, robust, and vigorous adults : and in very young in- fants. Pregnancy, or the puerperal condition, also tends to in- crease the daugerousness of the disease. It has been observed, that the period of life most favourable to a mild and regular course of the disease, is between the third and the tenth year of age. The age of puberty in females, is said to be a particular- ly dangerous period in relation to this complaint.* Convul- sions just before the -appearance of the eruption, are rarely at- tended with any serious consequences; but when they occur during the period of suppuration, the danger is always ex- tremely great. Suppression of the urine, or a very frequent desire to void it, is said to be a very unfavourable sign, when it occurs during the suppurative stage. It is also a particularly dangerous sign, when the pustules about the sixth or seventh day of the stage of suppuration, become collapsed, and the swelling of the face suddenly subsides, at the same time that the areolae dis- appear, and the intermediate skin becomes pale and flaccid. The sudden recession of the eruption, soon after its appearance, is always very dangerous. Of course, the supervention of visce- ral inflammation, or of sudden violent congestions of blood in the brain and lungs, are occurrences of the most alarming cha- racter. Treatment.—There is, perhraps, no disease in which false theory has led to such fatal consequences in practice, as small- pox. During the general prevalence of the doctrine of morbid humours, it was supposed that the variolous matter was form- ed by a species of fermentation in the blood, and that the more perfectly this matter was separated and cast upon the skin, the greater would be the chance of recovery. Great efforts were accordingly made to assist nature in establishing as copi- ous a crop of pustules as possible; and under this fatal delusion, all kinds of heating medicines and external warmth were dili- gently applied. When we reflect on the inevitable result of this practice, so long and so universally pursued, we see in it a frightful drawback on the amount of benefit conferred by the healing art, in relation to this disease, although this amount must be regarded as immense from the introduction of inocu- lation, and especially of vaccination. Among the moderns, Sydenham appears to have been the first, who saw the fatal tendency of the heating or exciting plan of treatment in small- pox. He revived the cooling or antiphlogistic treatment of the Arabian physicians,! a mode of management, which is now * Richter, loc. cit. p. 303. t The general plan of treatment laid down by Rhazes, differs in no essential point from that which was recommended by Sydenham. For the purpose of diminishing the violence of the disease in those who are exposed to the small-pox contagion, Rhazes advises, that " a vein be VARIOLA. 391 universally acknowledged as the only practice capable of miti- gating the violence and dangerous character of the malady. Instead, therefore, of supporting the excitement during the eruptive fever, that the eruption may be copious, we must en- deavour to moderate the febrile reaction, that the pustules may be as few as possible. By an early attention to the fulfilment of this object, the disease will often pursue a mild and simple course, which under the employment of exciting remedies, Would in all probability have assumed a confluent and highly dangerous character. It is upon the power which a mildly antiphlogistic treatment exerts in moderating the violence of the disease, or of rendering the eruption scanty, that all the advantages of inoculation depend. When an individual is inoculated, the phlogistic state or tendency of his system is diminished by purgatives, simple and cooling diet, and, in plethoric subjects, by bleeding ; in consequence of which, a less copious crop of pustules ensues, and the disease, in general, pursues a proportionately milder course. opened in those who are fourteen years old. To those who are younger, cupping-glasses must be applied, and their lodgings should be kept cool." The diet, he says, must " consist of yellow lentils, tarts of unripe fruits," and their drink " should be water cooled with snOw, or clear cold spring water, with which also their chamber may be sprinkled." They must frequently eat " acid pomegranates, and the inspissated juices of acid and astringent fruits." The patient must " go into cold water and swim in it, about noon. He must abstain from wine, and meats made by a mixture of flesh, onions, oil, butter, and cheese ;" as well as from " mut- ton, beef, shell-fish, and high-seasoned things, and hot seeds ; but, if the temperament be hot and dry, and apt to be inflamed, he must eat cool- ing and moist garden herbs, purslain, mallows, beets, gourds, cucumbers, sorrel, and small pompions. All acid things are proper to cool the blood and check the ebullition, especially the water called Al-raib, that is, the sour, bitter water, which swims upon butter-milk, exposed to the sun. When the variolous fever has supervened, care must be taken not to re- frigerate too much, so as not to extinguish preternatural and natural heat together." Nevertheless, when during the fever "you observe great pain in the back, redness of the face and eyes, a violent headach, a full pulse, with a straitness of breath, a red and turbid urine, and such a heat of the body as a man feels who has been for some time in a hot bath; there is then all the reason in the world to take away blood, even till the patient faints away. But, if the symptoms do not run very high, although they are manifest, draw blood but sparingly. In order more perfectly to extinguish the feverish heat, let the patient drink wa- ter, made cold in snow, very plentifully; so that he may feel the cold- ness of it in his bowels. If still the heat return, and the belly be full of water, make him vomit it up, and then give it him again. During the eruption and suppuration, the patient " must be kept in a room not very cold; he should drink frequently, a little at a time, of cold water." " As to the furnaces and baths, they are both destructive, at this time, by over- heating and weakening." When the eruption goes on slowly and with difficulty, the cooling and extinguishing remedies " must be absolutely forborn." The drinks " must be warm." (a) («) Rhazes, loc. cit. 392 VARIOLA. Sydenham resorted to the lancet as the principal means for moderating the febrile excitement. There can be no doubt, indeed, that bleeding must often prove very beneficial; hut, it seems to be admitted on all hands, that it cannot be employ- ed with great freedom, without considerable risk of mischief, unless the reaction be very violent, or the general phlogistic condition great. " It is an observation universally applicable," says Dr. Philip, "that blood-letting is only to be recommend- ed when the effects expected from it cannot be procured by other antiphlogistic remedies." Cathartics of the milder kind are always highly useful during the eruptive fever, in cases requiring a reduction of the general excitement. Very active purging—more especially in mild cases, or when the appearance of the eruption is at hand— is improper, as it may readily interfere with the regular pro- gress of the eruption, by the centripetal direction it tends to give to the circulation. Throughout the whole course of the disease, however, mild laxatives may be beneficially employed. These observations have a reference to the distinct variety of the disease; for in the more violent or confluent form, we may often derive great advantage from active purging during the eruptive fever. Calomel is one of the best purgative articles in small-pox. Its operation is sufficiently miid, and it would seem, that it possesses peculiar powers in moderating the vio- lence of the disease. (Mead, Boerhaave.) The neutral pur- gative salts, also answer well during the eruptive fever. Some have recommended emetics in the commencement of the disease, and where there are signs of vitiated secretions in the stomach, they may no doubt be useful when early adminis- tered. When given about the seventh day of the confluent va- riety, they are said to have no inconsiderable influence in mo- derating the secondary fever; but in general, they are most useful when given in the onset of the complaint. (Philip.) Diaphoretics of the refrigerant kind will assist in moderat- ing the eruptive fever. Nitre with small doses of tart, anti- mony ; the saline effervescing draught; spiritus mindereri; sweet spirits of nitre with vin. antim., a solution of muriate of ammonia, &c. may be used for this purpose. But the most grateful, and at the same time the most safe and valuable means for moderating the eruptive fever, and thereby lessening the number of pustules, is the cooling regi- men. The free admission of cool air into the sick-chamber during the eruptive fever, is in all cases, whether the disease be of the distinct or the confluent variety, of great importance; and it seldom indeed fails to mitigate the symptoms, in a great- er or less degree, throughout the whole course of the disease. The patient should lie on a mattress, with light and cool co- VARIOLA. 393 verings; and his drinks should consist of cool acidulated beve- rages. The temperature of the sick chamber must of course be regulated according to the season of the year, and the degree of febrile excitement present. In warm weather, the external air must be more freely admitted than in cold seasons; and more reduction of temperature is necessary when the excite- ment runs high than where it is of a low or feeble kind. There is but one form of small-pox in which the cooling regimen is said to be objectionable, namely the crystalline. The air sur- rounding the patient ought to be kept uniformly at a tempera- ture just low enough to give the sensation of moderate coolness. If the fever continues after the eruption is completed in the dis- tinct variety of the disease, it will still be proper to go on with the cooling treatment, together with mild laxatives, diaphore- tics, and antimonials. It has already been stated that in the confluent variety of the disease, the fever often assumes a low typhoid character; and in instances of this kind, the diet, instead of being cooling and diluent, should be more or less exciting and supporting. Where the general excitement is low and sinking, it will even he ne- cessary to resort to the more active stimulating and tonic re- medies, such as wine, carbonate of ammonia, camphor, musk, &c Camphor is a particularly valuable article in such cases where delirium attends. The Peruvian bark has also been very favourably mentioned as a remedy in such cases; and where the process of suppuration goes on tardily and imperfectly from want of general energy, large doses of this article, or of qui- nine, are indeed highly useful. Under similar circumstances—- that is, where the pustules are slow in filling up, or the fluid in them remains watery,—opium in combination with camphor has been found a very useful remedy. (Philip.) When during the progress of the disease internal visceral inflammations supervene, local abstractions of blood from the external region of the affected part, blisters, scarifications, and, where the general arterial action is not too low, bleeding from the arm must be resorted to. In instances attended with cerebral inflammation, much benefit may often be derived from flannel wrung out of hot water applied to the feet, at the same time that pounded ice is applied to the top of the head. The occurrence of profuse diarrhcea during the secondary fever of confluent small-pox, must be counteracted by astringent and absorbent remedies. From eight to ten grains of prepared chalk, with a grain of pulv. ipecac, compositus will generally answer our purpose in such cases. It is not, however, proper to arrest the discharge wholly in such cases. It should be moderated only. When violent and continued vomiting oc- curs, we may resort to opium and camphor. One grain of the 394 VARIOLA. former with two of the latter may be given every hour or two, according to the violence of the symptoms. To prevent the pustules from affecting the globe of the eye, and injuring the sight, pieces of* folded linen wet with cold wa- ter should be kept applied to the eyes during the eruptive fever. The application of camphorated spirits has been used for this purpose; but cold water is the most agreeable, and also the most effectual in this respect. When soon after the eruption has appeared, it is again driven in, (an occurrence which may proceed from the sudden appli- cation of cold and damp air, or from the supervention of ex- cessive purging or vomiting, or other rapidly exhausting cir- cumstances, such as sudden terror, or grief, or syncope, or excessive abstractions of blood,) recourse should immediately be had to means that have a tendency to determine the circula- tion to the surface, such as camphor and opium, carbonate of ammonia, warm bathing, sinapisms to the extremities, and gentle frictions with dry flannel or the flesh-brush. Where the retrocession arises from cold, an emetic, with stimulating frictions, will often promptly recal the eruption to the surface. The use of lunar caustic, as a local application to the pustules, has of late been recommended and successfully practised in France, for the purpose of lessening the number of pustules, and by so doing, rendering the disease milder and less danger- ous. In 1325, M. Velpeau read a memoir before the Royal Academy of Medicine, of Paris, tending to prove, that, if the pustules of small-pox are cauterized during the first two days with lunar caustic, their progress will be arrest- ed. This practice was fully tested some time after, by Dr. Meyreux. According to his report, it appears, that if the va- riolous pustules are opened with a lancet, and touched with a pointed piece of lunar caustic, on the first or second day of their appearance, they will be wholly destroyed, and leave no marks; but on the third day it will be quite useless. VACCINA. Cow-Pox. Long before the time of Jenner, it was known in some of the dairy counties of England that cows are subject to a pustular disease, which, when communicated to the hands of milkers, renders them insusceptible of the variolous infection. Although this fact was noticed, and even artificial inoculation with the vaccine matter successfully practised in an instance which was formally communicated to Sir George Baker; yet the whole credit of introducing the cow-pox into general notice is VACCINA. 395 due to Dr. Jenner. The benefits which this important disco- very has conferred on mankind are incalculable; and it is not a little consoling to reflect, that as the hand of Providence has in this instance provided a salutary check to one of the most fatal maladies with which man has been afflicted, there may yet be brought to light at some future period, other antidotal or prophylactic powers against the ravages of diseases, which are as yet in a great degree uncontrollable. Although Jenner had made successful experiments with the vaccine matter as early as the year 1796, he did not publish the result of his investigations until two years after. From that period on, the knowledge of the benefits of vaccination spread rapidly throughout Europe and this country; and there is now no civilized people on earth, amongst whom its blessings have not been largely experienced and gratefully acknow- ledged. Various opinions have been expressed with regard to the origin of the vaccine disease. Dr. Jenner, at first, ascribed its source to the grease of horses ; and this opinion is indeed supported by very strong, though perhaps not absolutely satis- factory evidence. It is asserted by some, for instance, that a pustular disease, in every respect similar to the vaccine affec- tion, may be produced both in the human subject and in cows by inoculation with the matter of grease. Friese, Loy, and parti- cularly Sacco,* affirm that they have succeeded fully with this experiment; and Mr. Ring states, that " he succeeded in pro- ducing the disease artificially in a cow by removing a scab from the teat, and applying the recent blackish matter of grease to the surface of the sore." The same author has published a letter from Mr. Rankin, relating a case of pustular disease strongly resembling the casual cow-pox, accidentally produced on the face and hands of a farmer, by the fluid oozing from the heels of a horse labouring under grease. It appears, moreover, that persons who have been affected with the pustular disease produced by the matter of grease, are rendered insusceptible to the contagion of small-pox. Dr. Jenner relates a case of this kind. Sheep, also, are subject to a pustular affection about the head and mouth, which is said to be communicable to the human subject, in whom it produces a disease very similar to that which is caused by the matter of grease, and which it is asserted, by Sacco and Richter, renders the human system in- capable of receiving the variolous infection. It has also been supposed, that the vaccine disease is essentially the same as small-pox, and that these two affections derive their origin from the same ultimate source. It is conjectured that the small-pox was at first derived from the cow-pox or grease of * Neue Entdeckungen uber die Kuhpocken, die Mauke u. Schaaf- pocken. Translated from the Italian, by W. Sprengel. 1813. 396 VACCINA. horses in Arabia, and that in the course of time it gradually degenerated by passing successively through tne human sys- tem, until it acquired the known virulence and activity of va- riolous contagion. In confirmation of this supposition, it is asserted that cases have occurred where the variolous matter inserted into the udder of cows, produced in them a pustular affection not to be distinguished from the cow-pox. Richter makes this observation on the authority of Gassner.* It is also asserted by Dr. Lisa, that sheep are effectually protected from the disease called sheep-pox, by inoculating them with variolous matter. Sheep inoculated in this way, are said to be- come affected with but one pustule at the point where the vari- olous matter is inserted.^ Symptoms and progress of the disease.—When the vaccine disease is communicated to the human subject, it proceeds through its course in the following manner. Towards the close of the second day after the insertion of the virus, a small point of inflammation may usually be seen where the puncture was made. On the third day this point is more distinct; on the fourth, it generally assumes the character of a small pim- ple encircled by a very faint and narrow inflamed basis or areola. This pimple now gradually enlarges, and on the fifth day begins to assume a perfectly regular and circumscribed form, with a flattened surface and a small depression at the centre, somewhat darker than the rest of its surface—an ap- pearance which it preserves throughout its whole subsequent course. About this period also, the vaccine pock changes from the pimple to a vesicle, containing a limpid fluid. From the fifth to the ninth day, the pock continues to enlarge in its cir- cumference, but not perceptibly in elevation, so that its flatten- ed appearance becomes more and more conspicuous. About the ninth day the pustule is at its full state of maturity, and it is at this period that the constitutional symptoms (if any occur) begin to show themselves. In some instances the glands of the axilla become painful and swelled, and a state of general lan- gour and drowsiness, with slight creeping chills and alternat- ing flushes of heat occur. Frequently, however, no constitu- tional symptoms whatever supervene. About the eighth day the slight circle of inflammation which surrounds the pustule in its early period begins to increase, until by the tenth or eleventh day it forms a broad and beautiful areola around the pock.. By the eleventh day, the centre of the pustule, which is slightly depressed, begins to assume a darker appearance, and this darkness gradually extends towards the circumference, so that by the fourteenth day the surface of the pustule is convert- * Specielle Therapie. t Mediz. Chirurg. Zeit. 1809. No. xliii. VACCINA. 397 ed into a brown scab. This scab becomes darker and darker, until it acquires a deep mahogany appearance. In a few days more the scab begins to separate at the circumference—still, however, retaining its attachment at the centre; and eventually falls off, generally between the third and fourth week from the time of vaccination, leaving a slight depression in the skin. The areola is usually most perfect about the seventh day after the commencement of the pustule, or on the eleventh day after the vaccination, and is connected with some degree of tumefaction and hardness. The foregoing description answers to the regular progress of the disease ; but various deviations are occasionally observ- ed in relation to some of the particulars just described. In some cases, for instance, the pustule furnishes well-formed vac- cine lymph as early as the fourth day of its progress. Much diversity occurs also with regard to the time when the disease first manifests itself after the vaccination is practised ; for in some instances eight or nine days, and occasionally even a longer period, intervenes between the vaccination and the com- mencement of the pustule. It often happens, that on the day succeeding the vaccination, considerable inflammation and elevation of the cuticle takes place at the point where the puncture was made. When this is observed, we may confidently predict the failure of the ope- ration. This inflammation continues for a day or two, and then subsides quickly without leaving any local affection. It seldom happens that more than the pustule which rises at the point of vaccination appears on the body. Occasionally one or more smaller pustules appear in the vicinity of the primary one ; and instances have occurred, in which a pretty numerous crop of pustules conies out on different parts of the body. In the report of the central vaccine committee of France, for 1818-19, it is stated that no inconsiderable number of cases were observed, in which a spontaneous eruption of many pus- tules came out after vaccination, and that the matter taken from these pustules produced the disease as perfectly in others as that taken from the primary pustules. It is a curious and interesting fact, that the vaccine disease occasionally counteracts or removes other affections of a chro- nic character—particularly chronic cutaneous diseases. In the report of the French committee just referred to, it is stated that "thirteen medical men have seen examples of vaccination proving the means of curing other eruptions, more especially the crustea lactea ;" and fully authenticated instances are re- corded of the removal of scrofulous swellings, ophthalmia, and hooping-cough, by vaccination. Of the power of the vaccine disease to moderate and abridge the course of hooping-cough, I have myself witnessed several unequivocal examples. 398 VACCINA. Another very important circumstance in relation to the mu- tual influence of the vaccine disease and other cutaneous affec- tions, is the well-established fact, that important varieties and modifications of the vaccine pustule are caused by herpetic, and other eruptive states of the skin. Dr. Jenner, in a paper pub- lished in the sixty-sixth number of the London Medical and Physical Journal, points out the fact, that a single serous blotch existing upon the skin during the progress of the vac- cine vesicle, may occasion such irregularity and deviation from the genuine course and character of the disease, that it cannot be depended on as a prophylactic against the variolous infec- tion. In a letter addressed by him to the medical profession generally, dated April, 1821, he observes: "I have found abrasions of the cuticle to produce the same effect—such, for example, as we find in the nurseries of the opulent, as well as in the cottages of the poor, behind the ears and upon many other parts where the cuticle is tender. We find irregularity in the vaccine vesicle, if the skin is beset with herpetic blotches, or even simple serous oozings from an abrated cuticle. A speck behind the ear, which might be covered with a split pea, is capable of disordering the progress of the vaccine vesicle." Diag?iosis.—An attention to the following circumstances, will enable us to distinguish the genuine from the spurious disease : 1. In the genuine disease, little or no inflammation, except what occasionally arises from the mere puncture of the lancet, can be perceived until about the third day, and sometimes not until several days later. In the spurious affection, on the con- trary, considerable inflammation and elevation of the skin at the punctured point, generally appears as early as the second day. 2. In genuine vaccina, the small point of inflammation which appears three or more days after the matter is inserted, in- creases gradually until about the seventh day after its first ap- pearance, at which time it is at its full state of perfection. In the spurious disease, the pustule arrives at maturity and finishes its course in a much shorter time. By the third or fifth day from the first appearance of the inflammation, scabbing com- mences. 3. In genuine cow-pox, a beautiful circular and circum- scribed areola almost always surrounds the pustule, and this areolar efflorescence is usually in its most perfect state about the seventh or eighth day. In spurious affections of this kind, an irregular superficial inflammation occurs on the first or se- cond day after the appearance of the pustule; and the pustule itself appears more like a common festering sore produced by a thorn, than a pustule excited by the vaccine virus. 4. The genuine pustule is perfectly circumscribed with a VACCINA. 399 flattened surface and a slightly depressed centre, and contains a colourless transparent fluid. The spurious pock is more elevated, not depressed in the centre, is irregular orangulated in its circumference, and contains an opaque purulent matter. According to Dr. Willan, the vaccine vesicle is to be regard- ed as imperfect when—1, though perfect in its form and ap- pearances, it is without an areola on the ninth or tenth day. 2, when the vesicle is very small; pearl-coloured ; flattened ; with a hard, inflamed, and slightly elevated base; a dark-red areola, and without a rounded or prominent margin. 3, when the vesicle is small, pointed, with a very extensive pale-red areola. The spurious disease may be produced—1, by the genuine vaccine virus acting on a system affected with some cutaneous disease; 2, by vaccinating with matter which has undergone more or less decomposition by long keeping ; 3, by vaccinating with matter taken from a spurious pustule; and 4, by the genuine vaccine matter being controlled, or in some way diverted from its regular operation by idiosyncracy, or a depraved condition of the system. Some difference of opinion has been expressed with regard to the period at which the vaccine lymph should be taken from the pustule, in order to obtain it in its most perfect and active state. Dr. Jenner advises that the virus be taken a short time before the areola is completely formed, and consequently soon after the lymph is secreted in the pustule, or about the sixth or seventh day. To obtain the virus, the edges of the pustule must be gently punctured with a lancet in several parts. The lymph will then ooze out, and may be collected and preserved between two glasses. Of late years, however, it has been more customary to vaccinate from the scab. For this purpose, no scab except from the most perfect pustule should be taken. It should be smooth, of a dark-brown or mahogany colour, and rather brittle than tenacious in its texture. When used, the margin which is of a lighter colour, should be removed with a knife, and a portion of the remaining dark, hard, internal part reduced to powder on a glass, and moistened or dissolved with a small portion of cold water. In taking either matter or the scab for vaccination, it is of great consequence to be well as- sured that the person from whom it is taken is healthy, and particularly that he was not affected with any cutaneous dis- order. A want of due care on this point, may give rise to ex- tremely unpleasant and even dangerous consequences. I have several times known obstinate and alarming cutaneous affec- tions communicated to children by vaccinating with matter taken from unhealthy subjects. It is a common belief among persons out of the profession, that the vaccine disease is apt to give rise to disagreeable eruptive affections, and such occur- rences are in fact not very unfrequent Accidents of this kind 400 VACCINA. probably depend most commonly on the matter having been taken from persons affected with some cutaneous disorder, or with a general cachectic or depraved habit of body. It seems, nevertheless, that the vaccine disease, communicated by the purest lymph, will occasionally excite pustular and other ex- ternal inflammatory affections, in persons of a strumous or scorbutic habit. General remediate treatment is seldom required during the disease. When febrile excitement attends, which is rarely the case, a reduction of the diet, with some mild aperient medicine, diluent drinks, with small doses of spiritus mindereri, or sweet spirits of nitre, should be ordered. In some instances, the in- flammation and swelling around the pustule become so great as to demand particular attention. This is most apt to occur when the vesicle is irritated by scratching or rubbing it. at the time when the areola is about making its appearance, more es- pecially when at the same time some other cause supervenes, calculated to produce general febrile irritation. To moderate the violence of the pain and inflammation, a weak solution of sugar of lead, or cold water, or poultices made of lead-water, may be applied to the inflamed part, and laxatives, with some of the milder refrigerant diaphoretics given internally. With regard to the proplry lactic, or protecting powers of the vaccine disease against the small-pox, the opinion of the pro- fession has undergone considerable change within the last ten years. It seems to be pretty generally admitted at present, that the vaccine affection, even in its most perfect state, does not so completely protect the system from the variolous infec- tion, as was formerly so confidently believed. From whatever cause it may proceed, it is beyond a doubf, that the failures of vaccination in preventing secondary small-pox, " have been steadily and progressively on the increase for some years past." "This circumstance," says Dr. Gregory, " cannot be met by a reference to the fact, that small-pox once gone through, does not always protect the subject from a second attack." Cases of small-pox after vaccination, are far more frequent than second attacks of small-pox. Dr. Gregory has given a table of the total number of admissions into the small- pox hospital in ten different years, and from this statement,'it appears that in the year 1810, the proportion of cases of small- pox after vaccination, to the whole number of admissions, was as 1 to 30; while in 1815, it was as 1 to 17 ; in 1819, as 1 to 6; in 1821, as 1 to 4; and during the year 1823, as 1 to 3i. Notwithstanding these facts, vaccination must still be re- garded as an invaluable means for lessening the amount of mortality, and as deserving all confidence as a protecting power against small-pox. For although it may not, in many cases, render the system wholly insusceptible to the va- VACCINA. 401 riolous infection, yet the number of instances in which it af- fords perfect immunity from small-pox, is beyond all compari- son greater than that in which it fails to afford complete pro- tection ; and even where it does not entirely subdue the sus- ceptibility to the small-pox, it almost invariably lessens it to such a degree, as to render this latter disease so mild and simple, as in most instances scarcely to require any remediate attention. It is believed by many, that the constitutional influence of the vaccine disease gradually lessens, until the system, though at first protected by it against the variolous contagion, regains in the course of years its original susceptibility to small-pox; and this opinion is in fact strongly countenanced by the results of experience. Some have supposed that the vaccine impres- sion continues only about ten years; others have limited its du- ration to seven years; and Dr. 1 eo Woolf, in an interesting memoir on this subject, has adduced facts and reasonings to show that this influence is effaced by the constitutional changes which occur at the age of puberty. That the prophylactic in- fluence of the disease suffers progressive diminution until it becomes, perhaps, wholly effaced, I am myself much inclined to believe, from facts which have come under my own observa- tion ; but the attempt to set any precise limits within which the gradual subsidence of this influence is accomplished, must necessarily be attended with great uncertainty; since it may well be supposed, that idiosyncracy, modes of living, and acci- dental as well as constitutional predispositions, and perhaps habitual extraneous influences, may give rise to much variation in this respect. From the general fact (if in truth it be so) that the constitutional impression of vaccination wears out in the progress of time, many physicians have of late recommend- ed revaccination, so as to renew its impression on the system; and this practice may be deemed a reasonable, and certainly not a detrimental, precautionary measure. Various modes have been proposed to test the sufficiency of a recent vaccination, as a protective power against the small- pox infection. For this purpose, some have advised revaccina- tion five or six days after the first operation. If the disease is perfect in its influence, a vesicle will rise at the point of the second vaccination, but it will differ in its progress from the first, by becoming surrounded with a complete areola, as early as the second or third day of its appearance, so that the areolae of the first and second vesicles commence nearly at the same time, and progress pari passu. Others have proposed tore- vaccinate about the end of twelve days from the first vaccination. If the first has been perfect, the second vaccination will either not succeed at all, or give rise only to a spurious or irregular pock. The most certain test, however, is inoculation with, 51 402 VACCINA. small-pox matter—a test from which we derive at once our re- liance in the general protecting powers of the disease, and in the genuineness of the particular instance. A distinct, circular, radiated, punctulated, and not very large cicatrix, may be regarded as a pretty certain indication, that the vaccine affection was perfect. When, on the other hand, the'scar " is large, and bears the marks of having been formed by high local inflammation, and wants the distinctive charac- ters just mentioned," there is much reason to apprehend that the system has not been secured against secondary variolous disease. MODIFIED SMALL-POX. Varioloid Affections. Soon after the general introduction of vaccination, exanthe- matous affections, closely resembling small-pox, were occa- sionally observed in individuals, who had previously under- gone the vaccine disease in a regular and satisfactory manner. These varioloid affections became more and more common; and within the last fifteen years, they have appeared in various countries in frequent and extensive epidemics. In the earlier periods of vaccination, these eruptions were generally regard- ed as chicken-pox, but subsequent inquiries led to the opinion with many, that they were the product of a peculiar contagion; whilst others were led to ascribe them to the variolous conta- gion acting on systems but partially protected against small- pox by previous vaccination; and this appears now to be the general opinion. From the earliest times of small-pox of which we have any records, this disease has indeed been frequently noticed under various modifications as remarkable and apparently as distinct as the form we now call varioloid. We find various irregular forms of the disease described by the earlier writers under the names of vesicular, pustular, and spurious small-pox ; swine- pox, sheep-pox, stone-pox, horn-pox, &c. all of which were re- garded as having but one origin, namely variolous contagion. Af- ter small-pox inoculation was introduced, spurious variola was by no means uncommon; and it has always been observed that genuine and spurious small-pox have in the same epidemics come in and gone out together, in the same manner as they have uniformly been observed to do since vaccination has been intro- duced. It appears, therefore, that various circumstances either of a constitutional or accidental character may modify small-pox MODIFIED SMALL-POX. 403 in a variety of ways; and as such modifications were abundant- ly observed before vaccination was practised, we need not be surprised that they should be so frequent now, when a new and very extensive modifying cause exists in the influence of the vaccine disease. That the present varioloid disease is in fact nothing but a modified form of small-pox, may be regarded as established by an abundance of direct and conclusive evidence. In the course of my practice I have met with several instances of varioloid disease, which were unequivocally of variolous ori- gin. Within the present year I produced a well-characterized varioloid eruption by inoculating with small-pox matter a per- son who had been satisfactorily vaccinated about ten years be- fore. It is unnecessary, however, to adduce any further evi- dence on this point. The works of several late writers abound in observations illustrative of the variolous origin of this dis- ease. Dr. Thompson, particularly, has placed this view of the subject in a strong light; and to his work on the history of small-pox the reader is referred for much interesting, and I think conclusive evidence on this point. By viewing the subject in this light, a great deal of that per- plexity and confusion which have existed in relation to those anomalous pustular and vesicular affections which usually pre- cede or accompany small-pox epidemics is entirely removed. We perceive that the same morbific agent, modified in its ef- fects on the human system by various causes, lies at the root of all this family of eruptive complaints. They are all, it would appear, the offspring of the same parent, and though diverse in their appearance, they possess enough of family likeness to ena- ble an accurate observer to refer them to a common origin. -----Facies non omnibus una, Nee diversa tamen, qualem decet esse sororum. As the degree of modifying influence of the different causes which are capable of producing variations in the effects of va- riolous contagion must be extremely various, it is obvious that the irregular or varioloid diseases which result from the com- bined agency of the modifying causes and the virus of small- pox, must be correspondingly diverse ; and we find indeed so great a diversity in this respect, that no description can be given of them which can have more than a general application. I confine myself, at present, to the consideration of that form of varioloid disease which results from the action of small-pox vi- rus on a system that has previously undergone the vaccine in- fluence. In many instances, as has been already stated, vaccination protects the system completely against infection from small-pox contagion. In other cases, the system is either only partially freed from its aptitude to variolous infection, or this suscepti- 404 MODIFIED SMALL-POX. bility, though for a time entirely subdued by the vaccine influ- ence, gradually returns and regains a greater or less degree of intensity. The disease which results from the action of small- pox contagion on a system thus partially deprived of its vario- lous susceptibility, and w hich has of late years been so common, deviates more or less conspicuously from regular small-pox, and is, in a great measure, divested of the dangerous character of the latter affection. Symptoms.—In a large proportion of cases of varioloid, the eruptive fever is so mild and inconspicuous, as scarcely to at- tract any attention. In some cases, however, the fever is as violent as in the severer instances of small-pox. In point of duration, too, it is very irregular, terminating sometimes as early as the second day, and at others not until the fifth day from its commencement. In all instances, whether mild or violent in its symptoms, the eruptive fever ceases suddenly on the appearance of the eruption ; so that patients who were con- fined to bed during the first three or four days, are generally up and about after the eruption has come out. In many cases a transcient uniform efflorescence precedes the appearance of the eruption; and a rash resembling measles, also, is not an unfrequent precursor of the varioloid eruption. The varioloid exantheme almost always appears at first in the form of small papula;, many of which dry off without becoming either vesicu- lar or pustular. Frequently, however, these small, firm, red papula? are converted into vesicles containing a watery limpid fluid, in the course of the first, and sometimes not until the se- cond day. About the third or fourth day these vesicles usually burst, or wither without assuming a pustular character, the fluid in them acquiring a whey-like appearance. In many in- stances, the vesicles are surrounded with a small and faint areola. "This variety," says Dr. Thompson, "in the mild- ness of the eruptive fever, the strictly vesicular character, short duration, and mode of disappearance of the eruption, corres- ponded (in the epidemic he describes) so exactly with the de- scriptions usually given of the mildest varieties of chicken-pox, as not to have been distinguishable from that disease." In many cases these vesicles become filled with a puruloid fluid, are slightly depressed in the centre, and by the third or fourth day are converted into thin, dark scabs, which separate and fall off usually about the sixth or seventh day after the appearance of the eruption. Occasionally the scabs do not separate until the tenth or even the twelfth day. Sometimes the vesicles remain distended with a colourless serum for four or five days, and then become pustular, containing a pus-like fluid, in which state they usually remain a few days longer before desiccation or scabbing commences. In most cases of varioloid disease after vaccination, papular, vesicular, and pustular eruptions MODIFIED SMALL-POX. 405 are interspersed through each other at the same time. Not un- frequently the disease assumes so nearly the appearance and character of distinct small-pox, that it is difficult to decide during the first five or six days, whether it should be regarded as a modified or regular variolous affection ; and cases some- times occur, in which the varioloid eruption is so abundant as to resemble confluent, rather than distinct small-pox. Very generally, however, the smallness of the pustules, the whey- like fluid which they contain, and particularly the early period at which they begin to dry and scab, wrill enable us to distin- guish such cases from genuine small-pox. Dr. Thompson ob- serves, that the areola and its pustule sometimes exhibit a re- markable resemblance to the areola and vesicle of the cow- pox—a resemblance which betrays the mixed variolous and vaccine character of the disease. Varioloid pustules very rarely leave any depressions in the skin. When the scabs remain adhering a long time, they oc- casionally leave slight pits ; but much more commonly warty or fungoid elevations remain. From the foregoing account, we perceive how extremely va- rious this affection is both in its general and local phenomena. We see that in some instances it exhibits a striking resemblance to chicken-pox, in others it approaches very near to genuine small-pox, and in some instances it exhibits no small degree of resemblance to the vaccine pustule. Notwithstanding this extreme irregularity of modified small-pox, the following cir- cumstances may be stated as its most common and character- istic features. 1. The eruption appears in successive clusters, occurring at uncertain periods between the second and fifth day. 2. The eruption seldom, if ever, enters into complete suppu- ration, as do the small-pox. 3. The eruption is not attended with fever, except in very violent cases. 4. Desiccation or scabbing invariably occurs much earlier than in regular small-pox;—commencing generally as early as the fifth or sixth day ; and the scabs usually separate by the eighth or ninth day, leaving red disks or tuberculous elevations instead of depressions. That the system should, in many cases, still remain liable to the morbific effects of the small-pox contagion after the pro- cess of vaccination has been undergone, is by no means sur- prising, when we reflect how often second attacks of genuine small-pox have been known to occur. The greater frequency of a second infection by variolous contagion in those who have suffered vaccination, than in persons who have already had small-pox, may be ascribed, in part at least, to some imperfec- tion or disturbance of the vaccine affection, by which its pro- 406 MODIFIED SMALL-POX. phylactic power is more or less weakened or destroyed. Dr. Jenner believed, that in all cases where small-pox occurs after vaccination, it is owing to the vaccine vesicle having been dis- turbed or rendered imperfect by one or more of the following circumstances, viz. 1, preoccupation of the skin by some chro- nic cutaneous affection ; 2, the use of spurious vaccine matter; 3, depriving the vaccine vesicle incautiously of its lymph, or otherwise injuring or irritating it by external violence, so as to give rise to common phlegmonous inflammation. Without doubt, however, modified small-pox, or a second variolous infection resulting in a spurious or modified form of the disease, may and often docs occur after vaccination appa- rently the most complete and satisfactory. When we sec small- pox occurring in the same individual a second time, even after a most severe attack of the disease, we cannot hesitate to be- lieve that the same may happen after perfect vaccination, for it is not reasonable to presume that vaccination can be a more certain preventive of the small-pox infection, than a severe at- tack of the small-pox itself. Indeed, facts illustrative of this truth have been abundantly recorded within the last ten years; and it may now be regarded as established, that vaccination does not in all instances afford immunity from the partial in- fluence of the small-pox contagion. It may be no less true, that a great majority of modified small-pox after vaccination, depends on some accidental imperfection in the vaccine disease, either from constitutional idiosyncracy, or from the causes just mentioned. It would seem from some observations of Dr. Gregory, that the aptitude to variolous infection, after vacci- nation, prevails in an especial degree in some families. The same writer infers from facts which have come before him, that modified small-pox, subsequent to vaccination, is most apt to occur in persons between the ages of fifteen and twenty-one. This corresponds with the opinion mentioned before, that the vaccine impression is probably weakened, or partially oblite- rated, during that general constitutional change which takes place at the age of puberty. My own observations, though limited, lead me to the same conclusion expressed by Dr. Gre- gory, with regard to the age at which the present disease is most apt to occur. By far the greater number of cases of mo- dified small-pox that I have yet seen, were in young people be- tween the ages of fifteen and twenty-one. Modified or spurious small-pox, as has already been inti- mated, is not, however, confined to those who have been sub- jected to the vaccine influence. It occurs also in persons who have had small-pox; as well as in those who have never had either this or the vaccine disease. This fact has been adduced in evidence, that the varioloid disease arises from a peculiar contagion radically distinct from that which produces small- MODIFIED SMALL-POX. 407 pox. It is contended, that if this malady were not a peculiar or specific affection, it could not reproduce itself in its charac- teristic form in persons who had not undergone the modifying influence of small-pox, or of the vaccine disease. In reply to this argument against the identity of these affections, it may be stated that, on the presumption of their common ori- gin, the varioloid eruption is an imperfect result of the vario- lous contagion; and it is therefore reasonable to infer that the virus of this imperfect form of the disease is also modified or incapable of producing the genuine affection, unless an extreme degree of susceptibility to the disease exists. That the vario- loid disease does, however, sometimes produce genuine small- pox in the unprotected, the authority of Thompson and others does not permit us to doubt; and I have myself seen at least two striking examples of this kind. As to the production of varioloid affections by the small-pox contagion in those who have already had small-pox, there does not appear to exist any difficulty in accounting for it satisfactorily. We know that an attack of small-pox does not always obliterate the constitutional predisposition to the variolous contagion. Even after the system has passed through the most perfect form of the disease, a second attack will in some instances occur. Now, between that state of the system produced by small-pox, which affords perfect immunity from a second infection, and that state in which the susceptibility to a subsequent attack is undiminished, a vast variety of grades of susceptibility must, we may reasonably presume occur, ac- cording to individual idiosyncracy, temperament, accidental concomitant influences, and perhaps the activity of the vario- lous contagion. If then after an attack of small-pox, the pre- disposition to this disease is not entirely, but only partially destroyed, ought we not to look for an imperfectly developed form of the disease, should a second infection take place ? It is in this way, we believe, that varioloid, or varicelloid erup- tions occur in persons who have once undergone small-pox. As to the occurrence of varioloid affections in those who have never had either small-pox or the vaccine disease, it maybe observed, that the degrees of natural susceptibility to the vari- olous contagion, are almost infinite in variety in different indi- viduals. We see in the same family, into which this contagion is introduced, one individual affected so slightly as scarcely to require attention ; another perhaps only indisposed with vario- lous fever, without any eruption ; a third one seized with a pretty severe attack of the distinct small-pox; and a fourth af- fected with the most aggravated variety of the confluent form of the disease. We may presume, therefore, that where the small-pox contagion acts on a system which is either naturally or accidentally indisposed to the full influence of its powers, it 408 VARICELLA. will produce either an extremely mild variolous eruption, or an irregular or modified one—in other words, a varioloid or va- ricellous affection. From these and other considerations, I am induced, in com- mon with many others, to regard varicella as a variety of spu- rious or modified small-pox, or at least as being referrible, for its ultimate source, to the same contagion which produces this disease. VARICELLA. As early as the time of Rhazes, exanthematous affections were noticed, which, though they did not appear to protect the system against the small-pox, bore a very strong resemblance to this disease. These varioloid eruptions were described by Vidus under the name of crystalli; and Senertus observes, that there are varieties of small-pox, which, instead of becoming filled with pus, are distended with a watery limpid fluid, which dry off in a few days. Riverius also speaks of these varioloid eruptions as common in his time ; and we find them mentioned by the writers of that period under various denominations—as bastard-pox, spurious-pox, lymphatic-pox. Sydenham speaks of them as a spurious variety of small-pox ; and Sauvages has given a description of them under the name of variola lyrnpha- tica. Up to the time of Morton, who introduced the term chicken- pox, the general opinion among physicians was, that varicella is an imperfect variety of small-pox. There were some, how- ever, even at this period, who entertained a different opinion, regarding the disease as a peculiar or radically distinct exan- thematous affection. In 1767, Heberden published a memoir,* in which he endeavoured to show that varicella is the result of a peculiar contagion, totally distinct from that which gives rise to small-pox. This soon became the prevailing opinion on this subject, and continued to be so until is correctness was again called in question by Dr. Thompsonf and other recent wri- ters. The -principal arguments that have been alleged against the common origin of these affections are: 1. The occurrence of epidemic small-pox without varicella; and the occasional prevalence of varicella without the occur- rence of small-pox. So far, however, as my inquiries extend, every epidemic small-pox that has been particularly described, * Transact, of the College of Physicians, vol. i. t An Account of the Varioloid Epidemic, &c. By John Thomp- son, M. D. &c. VARICELLA. 409 has been preceded, accompanied, or immediately followed by anomalous or varioloid affections, bearing the characteristic marks of varicella. Granting, however, that epidemic small- pox may have existed without the concomitant appearance of varicella, it does not follow that these affections are radically distinct. It is quite possible, that from the influence of certain atmospheric constitutions, the human system generally may at one time be so susceptible to the action of the variolous conta- gion, that nothing but the genuine and regular form of the dis- ease can be developed :—or so insusceptible as to enable this contagion to produce only a" spurious or varicellous disease. From this or some other occult causes, the small-pox itself as- sumes the most dissimilar characters. Some epidemics are mild ; others severe; and others malignant to a great degree: sometimes the pustules become filled with a bloody matter, and at others they are "crystalline." What reason then is there to doubt that the contagion may at times be so feeble, or the human system so indisposed to its influence, as to admit only of the production of a mild vesicular disease. 2. Varicella is more common now than before vaccination was introduced, when small-pox was more prevalent. This, however, only shows that since vaccination is practised, there are more systems insusceptible to the full effects of the vario- lous contagion than before this epoch, and argues therefore in favour of their identity. 3. Varicella occurs equally in those who have had small- pox, in those who have been vaccinated, and in those who have never had either of these affections. To this argument we may reply, that it is generally admitted, that varicella occurs much more frequently in those who have had small-pox, or the vac- cine disease, than in the unprotected. Drs. Bryce and Aber- crombie saw but three cases in which varicella took place in persons who had not either of the former affections. 4. Varicella, it is alleged, cannot be communicated by ino- culation. This is an error. Heim, who is quoted below, as- serts that they are very communicable in this way ; and Dr. Thompson, in his work on varioloid affections, gives abundant testimony on this point. 5. The occurrence of small-pox does not prevent or modify varicella. Dr. Thompson, however, asserts, that out of 155 persons whom he saw pass through the small-pox, " not one was afterwards affected with vesicular disease, although upon the supposition of the co-existence of a varicellous and a vario- lous epidemic, most, if not all of this number must have been exposed to the influence of both contagions." If, indeed, we adopt this argument as valid, we must conclude the small-pox and the vaccine disease are essentially the same disease, for, as is well known, they mutually prevent or modify each other. 52 410 VARICELLA. Symptoms.—Varicella is seldom attended with much fever. In many cases the febrile symptoms are scarcely obvious, yet in some instances the eruptive fever is almost as violent as in the severer cases of small-pox, and is attended with the same pains in the back, head, and extremities, as in this latter af- fection. The initial fever continues from one to three days, and terminates in the appearance of a vesicular eruption, which usually comes out first on the breast and back, next on the face and scalp, and lastly on the extremities. A troublesome tingling or itching in the skin generally accompanies the erup- tion. The eruption is often preceded, for a few hours, by a general erythematous rash, as in small-pox or varioloid after vaccination. The varicellous vesicles generally come out in succession during three or four days, so that at the same time, some of them will be just appearing ; others fully formed and filled with lymph ; whilst some will be shrivelling, and others again be already converted into scabs. The vesicles, in dif- ferent cases, assume different appearances ; and this has given rise to a division of the disease into three varieties; namely, the lenticular, and the conoidal varicella, and swine-pox. The eruption, in the first of these varieties, comes out very early, and consists, at first, of small, rather oblong, red, flat, and shining elevations, with a minute vesicle in the centre, which by the end of the second day, is somewhat enlarged and distended with a whitish lymph. This fluid assumes a pale yellow colour on the succeeding day, and on the following or fourth day, the vesicle becomes shrivelled, and in two days more is converted into a small brown crust. The scabs fall off about the ninth or tenth day, leaving red marks, but no depressions on the skin. In the second, or conoidal variety, the vesicles appear sud- denly, and are surrounded by a slightly inflamed margin. On the first day they are elevated, pointed, and filled with a lim- pid serum ; on the second day they are more distended, and contain a very pale yellowish fluid. On the third day they wither ; and at this time some of them contain a purulent mat- ter; and these vesicles generally leave pits in the skin when the scabs fall off. Scabbing commences on the fourth day, some of the scabs acquiring a dark brown, and others a yel- lowish and semi-transparent appearance. "A fresh eruption of vesicles usually takes place on the second and third day; and as each set has a similar course, the whole duration of the eruptive stage in this species of varicella is six days ; the last formed scabs, therefore, are not separated till the eleventh or twelfth day.* The third variety of varicella, or swine-pox, is characterized by large globose vesicles, with irregularly circumscribed bases, and inflamed margins. The transparent serum with which * Bateman, Practical Synopsis of Cutaneous Diseases. VARICELLA. 411 they are distended, assumes a whey-like colour on the second day after their appearance, and on the succeeding day they be- gin to shrivel, and some of them contain a purulent fluid. (Bateman.) Varicella may be communicated by inoculation ; and, it is alleged by Ileim, that they are even more communicable than regular small-pox.* Reil states, that small-pox is generally much milder when it occurs after varicella, than where this disease has not been gone through, more especially if the varicel- lous affection has been severe.f Varicella, like small-pox, rarely occurs more than once in the same individual. It is never at- tended with secondary fever; but the scabs, on falling off, not unfrequently leave depressions in the skin. The pits, or cica- trices, left by the varicellous eruption, differ considerably from those which are produced by small-pox ; and Heim, who re- garded these two affections as essentially distinct from each other, has adduced this circumstance among others in support of his views.. The pits of varicella, he asserts, are whiter than the rest of the skin, and quite smooth or even ; whilst those left by variolous pustules are the colour of the surrounding skin, and uneven like the surface of an orange. The margin of the varicellous pit is smooth and rounded ; in the pits left by small-pox it is generally somewhat indented or angulated. Hairs never grow in the disks of the former, in those of the latter they do. 'With regard to the remediate management of varioloid af- fections, it is only necessary to observe, that where the disease is so severe as to demand any medical attention, the treatment is to be conducted on the same plan that has been mentioned as proper in the milder varieties of small-pox. Varicella, how- ever, very seldom requires any medicinal applications. Gentle aperients, and a mild antiphlogistic diet, is commonly all that is necessary. CHAPTER XXII. MEASLES. Rubeola, morbilli. By the American, English, and French physicians, the terms rubeola and morbilli are applied to the same disease— * Heim, in Horn's Archiv. fur Medicinishe Erfuhrung, bd. vii. haft. 2, Jahrg. 1809. t Uber die Erkenntnis* und cur der Fieber. bd..« s. 386. 412 MEASLES. measles. The German writers, on the contrary, universally designate two distinct diseases by these terms—applying the latter only to the present affection, whilst the term rubeola is used by them to designate a different, though somewhat similar disease (rbthlen,) described by Willan, under the name of roseola. Measles, like small-pox, seldom occur more than once in the same individual; and it would even seem that a second attack of the former is less frequent than of the latter malady.* I have met with one unequivocal instance only of this kind. Home mentions a singular instance where an attack of measles was followed by enlargement of some of the lymphatic glands. After a lapse of about six months the glandular swel- lings subsided, and the patient became a second time affected with measles.f It does not appear, however, that the morbil- lious contagion possesses the same degree of activity as that of small-pox. Many individuals never become affected with the disease, however frequently they may be exposed to its conta- gion ; and it is by no means uncommon to find in the same fa- mily some affected by it, whilst others will escape infection, though constantly exposed to its miasm. Measles rarely occur sporadically. When they appear, many individuals usually become affected with them at the same time ; and the progress of the disease can never be traced from house to house, or from street to street, as we may frequently do with small-pox or scarlatina. This, among other facts, has been ad- duced in evidence that the disease is not propagated by contagion; but the fact of its being communicable by inoculation may be deemed sufficient to settle the point of its contagious character. Dr. Home succeeded in communicating the disease in this way in a number of instances; and more recent experience has ful- ly demonstrated the practicability of morbillious inoculation.^ In its general course and phenomena, this, like other epide- mic diseases, is subject to prominent modifications ; and sys- * See Dr. Baillie's paper, in the Transactions of a Society for the Im- provement of Medical and Chirurgical Knowledge, vul. iii. t Medical Facts and Experiments. Kichter, Specielle Therapie. X Vogel, Percival, Brown, Monro, and Tissot, recommend inoculation for measles; and Home and Horst practised it with success. More recently, professor Sparanza, in an epidemic which prevailed in the territory of Mantua, employed inoculation for measles with decided advantage. Six boys in the House of Industry, and afterwards he himself, were ino- culated. In all a mild and regular morbillious affection was the result. The experiment was afterwards repeated by himself and others with equal success. " A slight cut was made into one of the most vivid of the large blotches with a lancet, the point of which was covered with the blood effused. With this, small incised punctures were made on the arm, and a proper bandage applied."—Edinb. Med. and Surg Journ. 1836. See also, Bibliotheca Italiana. Agosto, 1825. MEASLES. 413 tematic writers have, in consequence, divided it into several varieties, according to the regularity or irrregularity of its symptoms, the nature of the attending fever, and the charac- ter and violence of the local affections. It is evident, too, that this disease is much under the influence of atmospheric consti- tutions ; for at one period it will be marked by symptoms so slight as scarcely to require any medical attention ; at another it will appear under a highly aggravated form ; in a third pe- riod we may find it to occur under every grade of violence from the simplest to the most malignant grades; and in a fourth, it " will hold a middle course between the mildest and most dangerous forms of the malady." (Armstrong.) Upon the whole, however, the regular and moderate cases are incom- parably more frequent than the instances of a violent or malig- nant character. In general, measles are apt to be more regular and mild dur- ing the warm and equable, than the cold and variable sea- sons ; and constitutional habit or idiosyncracy appears to have a very decided influence in modifying its character. It is from this latter circumstance that we sometimes meet with measles in all its grades of violence in children of the same family— several very remarkable instances of which have come under my observation. It would seem, from the observations of some, that the mor- billious fever sometimes occurs without any exanthematous af- fection.* Fevers, accompanied with the usual catarrhal symp- toms of this disease, though without the measly eruption, are by no means uncommon during the prevalence of epidemic measles; and Richter observes, that persons who have been thus affected, generally afterwards escape the morbillious dis- ease during the subsequent progress of the epidemic. Symptoms.—The period of incubation, or the time which intervenes between the first impressions of the contagion of measles and the actual commencement of the disease, varies from a few days to two and even three weeks. In general, however, from five to seven days may be regarded as the latent period of the infection. In the patients which were inoculated by Home, the eruptive fever generally commenced about the seventh day after the insertion of the contagion. The initial phenomena of morbillious fever do not differ from those which usually attend the beginning of catarrhal fever. A slight tenderness and redness of the eyes, with an increased flow of tears ; sneezing; cough ; and a watery discharge from * Morton mentions a morbillious fever which was wholly unaccompa- nied by an exantheme; and De Haen asserts, that cases of this kind fre- quently occur during epidemic measles, (a) (a) Febr. divis. vi. *. 6. See Reifs Fieberlehre. b. y.p. 216. 414 MEASLES. the nostrils ; together with slight creeping chills, and transient flushes of heat, are often among the first symptoms of the dis- ease. In some instances, the affection of the eyes and mucous membrane of the nose and respiratory passages does not super- vene until about the second or third day of the fever. In all cases, however, prominent catarrhal symptoms sooner or later occur, and may be considered as among the specific phenomena of the disease. The cough is at first dry and harsh, and is at- tended with oppressed breathing, and some degree of soreness in the fauces. Some of the lymphatic glands along the neck and margins of the eyelids often become swollen and tender. About the third day, and occasionally earlier, considerable nausea and vomiting is apt to occur; and where the fe- brile symptoms run high, slight delirium sometimes takes place on the evening of this day. In cases of a violent charac- ter, more or less'coma often precedes for a few hours the ap- pearance of the eruption ; and in small children convulsions are by no means uncommon at this period. The fever is gene- rally decidedly synochal ; the pulse in the ordinary forms of the disease being frequent, hard, and quick, and the skin dry and very hot. Generally between the third and fifth days, the eruption makes its appearance in the form of small red spots, apparently papular, first on the forehead, chin, nose, and cheeks, and then successively on the neck, breast, body, and extremities. These red spots, which resemble flea-bites, soon enlarge: and as their number increases, they run into each other, and form larger patches of an irregular or semi-lunar shape,* leaving intermediate spaces in which the skin retains its natural colour. During the first day of the eruption we may often notice a small vesicle in the centre of some of the measles. (Cazenave.) During the second day after its appearance, the eruption in the face is at its highest state of development. On the follow- ing day it begins to fade and subside, whilst on the rest of the body it is still vividly red. On the face the eruption may be felt slightly elevated above the surface of the skin ; but on the other parts the red patches do not appear to be sensibly raised. In severe cases the whole face becomes considerably swollen; and in some instances the tumefaction is so great as almost to close the eyelids. The fading and subsidence of the eruption proceeds over the body in the same progressive manner that it made its appearance, so that by the eighth day from the commencement of the fever it begins to disappear on the back * Bateman observes, " that this character of the blotches of tbe measly eruption, (their tendency to assume the irregular crescent shape,), was first noticed by Willan, and is important; for although entirely over- looked by ordinary observers, it is commonly very manifest, and there- fore a valuable diagnostic." MEASLES. 415 of the hands, where it is wont to remain longest. About the ninth day the eruption presents a faint yellowish appearance, and desquamation commences on the face, which by the tenth or eleventh day is completed over the whole body. The mor- billious eruption is not confined to the surface of the body. It appears in red spots on the gums; over the mucous membrane of the mouth ; upon the tonsils and uvula ; and, according to Frank, on the tongue. Leutaud saw the measly exantheme in the oesophagus, and upon the mucous membrane of the trachea, and even upon the surface of the abdominal and thoracic vis- cera.* The fever does not remit on the appearance of the eruption ; on the contrary, both the febrile and catarrhal symptoms usual- ly become sensibly increased when the rash comes out. As soon, however, as the eruption begins to fade, an evident amend- ment in all the symptoms usually takes place; and in most in- stances the fever disappears entirely by the time the rash has desquamated. Occasionally, indeed, the fever and cough con- tinue, and even become worse after the complete disappearance of the measly exantheme. Thecoma, Dr. Heberden observes, sometimes returns in violent cases, after the rash has gone off. About the time the eruption begins to decline, more or less diarrhoea is apt to supervene, which, if not violent, almost al- ways mitigates the general and local symptoms. Sometimes copious diarrhoea takes place just before the rash is about making its appearance. This is to be regarded as an unfa- vourable occurrence, since it tends to interfere with the regu- lar progress of the eruption, or to cause it to retrocede. Authors generally state that the eruption of measles makes its appearance about the fourth day; and in the majority of in- stances this will be the case. It is of some importance, how- ever, to bear in mind that even in cases which go on regularly the rash often comes out much earlier, and occasionally also later than the period just mentioned. Dr. Armstrong observes, "that the rash does not uniformly nor generally appear on the fourth day from the first development of the reaction. I have seen," he says, "the eruption come out at all times, be- tween the first and the seventh days, though perhaps, the most common period is between the third and fourth days after the occurrence of reaction." Such are the ordinary course and phenomena of measles. In its general character, as well as in the particular phenome- na, it is subject, however, to various irregularities and modi- fications, which often demand especial attention in the treat- ment of the disease. Throughout the whole course of measles there is generally a considerable tendency to inflammation, particularly of the eyes, and the respiratory organs. Arm- * Precis.de M^dec. p. 604. 416 MEASLES. strong divides the disease into three varieties or modifications, the simple, inflammatory, and congestive, and to these we may add the typhus, and the gastric modifications. 1. The inflammatory variety,* is characterized by a high grade of synochal fever; the pulse is vigorous, hard, and fre- quent ; the skin dry and very hot; the cough violent, painful, harsh, and dry; the cephalalgia severe, attended frequently with considerable delirium during the night; the eyes very red ; and the respiration much oppressed and often painful. Pleu- ritis ; peripneumonia with bloody expectoration; cynanche trachealis; bronchitis; cerebral inflammation ; or gastro-ente- ritis, are particularly apt to supervene in this modification of the disease. The rash commonly appears early, and is gene- rally vividly red. 2. The congestive modification of the disease, is characteriz- ed by the usual phenomena of an internal congestive state of the system. The reaction takes place slowly and imperfectly, and in some instances remains entirely oppressed. The face is pale, the pulse feeble and labouring, the bowels torpid, the breathing oppressed and slow, and the vital energies generally much depressed. If the internal congestions are not removed, coma or stupor, and in many instances, convulsions ensue. The eruption does not make its appearance, or it comes out slowly and imperfectly on some parts of the body. The ex- tremities are cold, and the features sunk and anxious. This form of the disease is most apt to occur in young children, and in persons of a feeble and delicate habit of body. Dr. Arm- strong has seen two instances of this kind in which the patients died comatose and convulsed. In both cases he found the lungs greatly engorged on post-mortem examination. 3. The typhus, or as it has been called, malignant variety of measles, is attended with the ordinary characteristic symp- toms of a typhus state of the system. The heat of the skin is burning or acrid, (calor mordax;) petechia} appear on those parts of the skin not occupied by the measly rash ; colliquative haemorrhages, diarrhoea, and profuse sweats are apt to occur; the vital energies are greatly depressed ; the pulse generally weak and frequent, and sometimes nearly natural. This va- riety of the disease, is always frightfully malignant and fatal. Fortunately, however, its occurrence is not common, although authors have described several epidemics of this kind. Sir William Watson has given an account of a putrid morbillious epidemic; but as he appears to have considered measles and scarlatina, modifications of the same disease, it may be doubted * Strictly speaking, every case of measles is inflammatory ; but the general and local phlogistic phenomena often predominate to such a de- gree, that such cases may with propriety be distinguished by the term MEASLES. 417 whether the affection he describes was the former or the latter malady. Nevertheless, the description he gives of the particu- lar phenomena of the disease, answers much more unequivocal- ly to measles than to scarlet fever.* 4. The gastric modification of measles, derives its distin- guishing phenomena from gastro-intestinal irritation, which in some instances modifies the general character of the disease very prominently. In cases of this kind the febrile symptoms are not very conspicuous; the pulse is small, weak, and unu- sually frequent; the cough is short, almost constant, and dis- tressing. Violent vomiting and purging sometimes occur be- fore, and immediately after the appearance of the eruption. The tongue is brown; the pain in the forehead severe; the measly rash pale and often indistinct; and a sense of tension and fulness is often felt in the epigastrium, or short cutting pains in the bowels. In some instances, great difficulty of breathing and a sense of pectoral oppression suddenly comes on, particularly in young and irritable children. Sometimes the patient is extremely restless, with much jactitation, an anxious expression of the countenance, and dyspnoea, particu- larly on assuming the erect position. (Dr. Armstrong.) Several German writersf describe a variety of morbillious disease under the name of false measles, which corresponds with the rubeola sine catarrho of Willan, and the rubeola sine febre of others. This modification of rubeola is characterized by a regular measly rash, without either catarrh, ophthalmia, or fever. It does not protect the system against a subsequent attack of febrile measles. " An interval of many months, even two years, has been observed, between this variety and the subsequent febrile rubeola; but the latter more frequently takes place about three or four days after the non-febrile eruption." (Bateman.) Sequels___It has already been observed above, that the ten- dency to local inflammations is always very considerable in measles, and this tendency is generally particularly conspicu- ous during the periods of desquamation and convalescence. There are few, if any diseases, which leave the system so sus- ceptible to the injurious influence of cold as measles; and it is, perhaps, chiefly from this circumstance, that inflammatory and other affections are so frequent during convalescence from this disease. It is indeed a common observation, that the affections which are apt to supervene on an attack of measles, are more to be dreaded than the disease itself,—and in reference to the ordinary or regular form of the disease, the remark is gene- rally correct * Watson.—Medical Observations and Inquiries, vol. iv. p. 132. t Vogel, Handbuch, Bd. 3, p. 203. Metzger, Vermischte Schriften. Bd. 418 MEASLES. The affections most apt to occur after measles, or during the period of desquamation, are pneumonia, croup, rheumatism, chronic ophthalmia, otitis, arachnitis, and bronchitis. In phthisical habits, an attack of measles often developes the tu- bercular action rapidly. It would seem that the morbillious affection has an especial tendency to develop lymphatic dis- eases and to rouse into action the strumous habit. Poriginous eruptions about the head, serous ulcerations behind the ears, scrofulous ophthalmia, strumous swellings about the neck, and other scrofulous disorders, are frequent sequelae of the disease. Sometimes induration of the mesenteric glands, and marasmus ensue. Herpes, anasarcous swellings, discharges from the ears, and boils on different parts of the body, are among the occa- sional consequences of this disease. Diagnosis.—From the earliest records we have of this dis- ease, down to the time of Withering, (1793) measles were ge- nerally confounded with scarlet fever.* The diagnosis between these two affections, is indeed sometimes attended with consi- derable difficulty; yet the catarrhal symptoms, and the cha- racter of the morbillious eruption, will always enable an expe- rienced observer to distinguish rubeola from scarlatina. The small vividly red spots, like flee-bites, their union into irregu- lar semilunar patches, and the natural colour of the interme- diate skin, distinguishes the measly rash from the large, irre- gular, more uniform, and raspberry-coloured efflorescence of scarlatina. In the former disease, the rash generally consists very obviously of small red spots running into each other, with the central points more vivid than the coalescing margin, so as to give a maculated appearance to the skin. In the latter dis- ease the redness is more diffused and uniform, consisting of an infinite number of very minute red points united together, re- sembling much the redness of a boiled lobster. These two af- fections differ from each other also in their general course or progress. The rash of measles generally comes out about the fourth day from the commencement of the fever. In scarlatina the eruption usually comes out on the second, and not unfre- quently on the first day. The coryza, sneezing, hoarse and dry cough, inflamed and watery eyes, so rarely absent in measles, can seldom fail to establish a certain diagnosis. Prognosis—Measles is not, in general, a very dangerous disease. It is only from becoming complicated with internal inflammation, or from having its regular progress interrupted by some accidental cause, that the disease is apt to assume a * Bateman says, that " the publication of Dr. Withering's Essay on Scarlet Fever—or rather the second edition of that work in 1793, may be considered, perhaps, as the date of the correct diagnosis of this dis ease."--Synopsis, p. 66. t London Medical Observations, vol. v. MEASLES. 419 very dangerous character. However violent the proper mor- billious symptoms may be, provided the disease goes on regu- larly in its course, the danger is not often very great. Ac- cording to the estimate of Percival, about one out of fifty cases of rubeola terminates fatally; and of this proportion one half are in subjects under two years old. Epidemics of this disease, of the most fatal character, have indeed been noticed.* Violent internal congestions, so as to prevent the development of fe- brile reaction, the sudden retrocession of the rash, soon after its appearance, from violent purging, the application of cold, or spontaneously, or from whatever cause, always greatly in- creases the danger. The occurrence of internal inflammation, particularly of the lungs, brain, or trachea, is a very alarming accident. Great difficulty of breathing, with a wheezing sound in the trachea, though not depending on inflammation, is attended with much danger in infants. Colliquative haemorr- hages, petechiae, and great muscular prostration, are among the most unfavourable signs. Women in the latter period of pregnancy, or in the puerperal state, are exposed to great risk from an attack of this disease. In general, nervous, delicate, and debilitated subjects are more apt to sink under this dis- ease, than persons of healthy and vigorous constitutions. Treatment.—In relation to the treatment of this disease, the practitioner will do well to bear in mind the important truth contained in the following observation of Dr. Armstrong. " From an impartial consideration of the facts which have come before me," says this writer, " I am convinced that our plan of treating measles (in its regular form) is too uniformly ac- tive when the eruptive fever is developed ; and that we should be more fortunate in the main, if we interfered less with the operations of nature in cases of a mild and regular character." Of the importance of this observation I am thoroughly per- suaded, both from my own experience and from what I have had occasion to w itness in the practice of others. Even where the general febrile excitement is considerable during the erup- tive fever, an active antiphlogistic or depletory treatment is not only generally unnecessary, but sometimes decidedly inju- rious, provided no local inflammations be present. We must view the eruption in this, as in other exanthematous affections, as a sort of critical or metastastic deposition on the surface, by which the animal economy endeavours to relieve itself from some internal morbific irritation. The appearance of the rash is essential to the perfect and safe resolution of the disease, and whatever greatly interferes with the regular progress of the * It is from the great fatality of such epidemics, that this disease ob- tained the name morbillus, or little plague. Were these epidemics measles'? Both small-pox and scarlatina were formerly confounded with measles. 420 MEASLES. precursory fever, has a tendency also to interrupt the regular appearance and character of the eruption. When, therefore, the eruptive fever is regular, not very violent, and unattended with internal inflammations or congestions, the remediate treat- ment should be gentle. In general, all that is required in such cases, is to keep the bowels open by mild laxatives, and to al- low the patient the free use of tepid diluent drinks; and in in- stances attended with a very moderate degree of febrile reac- tion, some of the mildly stimulating diaphoretic ptisans, such as infusions of sage, elder blossoms, marjoram, balm, or eupa- torium, should be ordered. In cases attended with a high grade of fever, moderate abstractions of blood are, without doubt, proper, and ought certainly not to be neglected. The refrige- rant diaphoretics, also, are decidedly indicated, and often suf- fice, without bleeding, to procure an adequate reduction of the general excitement. I have generally preferred the following mixture.* Small doses of antimonial wine, with sweet spirits of nitre, the saline effervescing draught, the ordinary nitrous powders, and particularly the mixture mentioned at page 132, may be usefully employed for this purpose. Although an active treatment is unnecessary, and often pre- judicial in the regular form of measles, this is by no means the case when the disease becomes complicated with visceral in- flammation, oppressive internal congestions, or other irregular and dangerous symptoms. When, after the initial stage of op- pression the febrile reaction does not take place, and the face remains pale and sunk, the pulse feeble, the breathing oppress- ed, with great prostration, and a torpid state of the sensorial powers, prompt and decisive measures must be adopted to re- move the internal congestions, and to excite the reaction of the heart and arteries. If this be not effected the eruption will not come out, and the patient will sink into a state of fatal stupor or coma. The treatment already given as proper in the conges- tive form of typhus, must be actively employed in such cases. The warm bath, stimulating frictions of the skin, hot flannel, or bottles filled with hot water applied to the body and extre- mities, sinapisms to the epigastrium, together with the use of warm and gently stimulating drinks, are the principal means upon which our dependence is to be placed in instances of this kind. Dr. Armstrong recommends moderate bleeding; but although a great advocate of depletion in the congestive state of fevers, he thinks that in congestive measles the lancet should be used with particular caution. The observations I have * R. Muriatis ammoniae 3"i. Pulv. extract, glycyrrh. *ss. Tart, antimonii gr. i. Aq. fontanae §viii. M. Dose—a dessert spoonful every two hours for a child between two and five years old. MEASLES. 421 made on this point, when speaking of the treatment of typhus, are equally applicable in this place. In several instances of congestive measles I have employed camphor, suspended in a mucilaginous fluid, with obvious benefit. I have also used the carbonate of ammonia, in the formula mentioned at page 149, with very good effect in a few instances of this kind. Both these stimulants are, however, more decidedly beneficial where the rash, after it has come out, suddenly recedes, than in the congestive state which precedes the exantheme. If .in cases of this kind, great difficulty of breathing, with a short dry cough, an irregular distribution of the animal temperature—" some parts being cool or cold, whilst others are preternaturally warm," and a feeble and quick pulse, with a death-like pale- ness of the face occurs, the danger is imminent, and unless prompt relief be obtained, " the patient sinks rapidly under an apparent load of phlegm in the bronchia." (Armstrong.) Cam- phor especially is a valuable medicine where a retrocession ot the eruption occurs. Armstrong speaks very favourably of a. large dose of calomel, in union with camphor, the pulvis anti- monialis, and a few drops of laudanum, in this congestive condition of the disease. When this accident is produced by excessive diarrhoea or vomiting, opium in union with camphor is the appropriate remedy. In conjunction with these reme- dies, blisters, sinapisms, stimulating frictions, the warm bath, or warmth applied to the surface in a dry way, maybe deemed indispensable in such cases. It should be observed, however, that moderate diarrhoea, except in very feeble subjects, is rarely attended by any unfavourable effects ; and in most in- stances procures considerable relief. In robust and plethoric subjects especially, a moderate looseness of the bowels should not be interfered with, unless symptoms of its injurious influ- ence upon the regular appearance and course of the rash super- vene. (Armstrong.) In cases complicated with visceral inflammation, a vigorous antiphlogistic treatment is demanded. Whatever may be thought of the employment of bleeding in simple and regular cases there can be no question as to the general propriety of resorting to this measure promptly and actively when visceral inflammations supervene. General and local abstractions of blood; blisters applied over the region of the affected part; mild laxatives ; antimony ; and nauseating doses, are the mea- sures upon which are chief dependence must be placed. When bronchitis or peripneumonia supervenes, much good may often be derived from antimonial emetics, more especially in very young children. Whatever organ, in short, may become the seat of the inflammation, it will be necessary to adopt such measures as are proper for the existing inflammation, inde- 422 MEASLES. pendent of the morbillious affection, paying attention only to the grade or character of the accompanying fever. Measles, attended with pneumonic and other varieties of vis- ceral inflammation, have indeed occasionally occurred, in which bleeding is said to have been not only useless, but often une- quivocally detrimental. Of this kind was the very fatal epidemic which prevailed at Paris in 1828; which, though almost al- ways complicated with inflammation of important organs— more especially with pneumonia, was found unmanageable by sanguineous evacuations.* In cases of this kind, opium and calomel would perhaps answer well. I say perhaps; for I have had no experience in instances of this dangerous and typhoid character; yet, from the excellent effects which I have derived from this combination in pneumonia typhoides, I should without hesitation give it a trial in this modification of measles. Blisters, cupping, and the warm-bath, may be deem- ed indispensable in such cases. It is of great importance, in the remediate management of measles, to guard the patient against the influence of variable temperature. Neither a very cool, nor a warm and confined air is proper in this disease. An equable temperature, which produces neither a feeling of much warmth nor chilliness, is the most suitable. When the eruptive fever is very moderate and the patient of a feeble and irritable habit, the temperature of the sick chamber should be such as to communicate a mode- rate sensation of warmth, and this is more especially proper in congestive cases. I have already adverted to the various disagreeable and dan- gerous affections which are apt to ensue during convalescence from this disease, and to their frequent dependence on the in- jurious effects of cold during this period. To obviate such con- sequences from this source, the patient ought to remain within doors, and to avoid every other exposure to the influence of a cold and damp atmosphere. "Even in summer convalescents should not be suffered to go out of doors except in the middle of fine days, and not without additional apparel." (Arm- strong.) The diet, during the declension of the disease and period of convalescence, should be mild and unirritating, and all kinds of stimulating drinks be carefully avoided. If the skin is dry and the pulse remains irritated after the rash has disappear- ed, advantage may be obtained from some of the more gentle antiphlogistic diaphoretics, and it will often be proper to con- tinue their use during convalescence. The spiritus mindereri, with a small portion of sweet spirits of nitre, and of vin. anti- moni. forms an excellent diaphoretic at this stage of the dis- * See Biett's Report in the Journal Hebdomadaire, No. xlii. MEASLES. 423 ease. Where the pectoral symptoms continue to be trouble- some during convalescence, the muriate of ammonia, with vi- negar of squills, and antimony, is one of our most useful reme- dies.* Tonics are almost always injurious during conva- lescence from measles. When the system is left exhausted and free from irritation, mild nourishing diet, with a weak in- fusion of serpentaria, will usually answer to promote the return of vigour and health. I conclude what I have to say on this subject, by the follow- ing very interesting observations of Dr. Armstrong: " It is a remarkable fact," says this writer, " that when any cutaneous affections arise after measles, the internal organs generally re- main free from disease; and even where some internal disor- der has existed, I have not unfrequently seen it disappear on the occurrence of some spontaneous eruption of the skin. In- deed there are many cases of this nature already on record. At all times we should, therefore, be most wary in meddling with vesicles, pustules, boils, and the like, when they come out after the measles; for although they may be temporary blemishes on the surface, they are often the occasion of saving the vital works within." CHAPTER XXIII. SCARLATINA. Scarlet Fever. Scarlet fever appears under every grade of violence, from the simplest and least dangerous to the most severe and malignant forms of disease. Fever—a peculiar exantheme and inflam- mation in the fauces, terminating rapidly, in some instances, in ulceration and sloughing, constitute the essential phenomena of the disease. In relation to the particular character and vio- lence of these morbid conditions, authors have divided the dis- ease into three varieties, namely, s. simplex, s. anginosa, and s. maligna. Symptoms ofs. simplex.—After an indefinite period, varying * R. Muriat. ammoni. 3iii. P. extract, glycyrrh. |ss. Aq. fontanse §vii. Acid, scillse §ss. Vin. antimon. gi. M. S. Dose—a table-spoonful every 4 hours for an adult. 424 SCARLET FEVER. from one to three or four days, of the ordinary premonitory symptoms of febrile diseases, the patient is seized with slight chills, alternating with transient flushes of heat, depression, nausea, pains in the loins, lower extremities, and head, a hot and dry skin, and a frequent and quick pulse. Generally within the first forty-eight hours after the commencement of the fever, a scarlet eruption comes out, first on the face, and then successively on the neck, trunk, and extremities, spread- ing finally over the surface of the mouth, fauces, and nostrils, and may even in some cases be seen on the albuginea. This rash consists of innumerable red points, which running into each other, give a diffused blush to the skin, resembling much the shell of a boiled lobster. (Armstrong.) In some cases, the scarlet efflorescence is uniformly diffused over the whole sur- face of the body; in others, it appears only in large irregular blotches, leaving the intermediate portions of skin of the na- tural colour. The miliary glands and papillae of the skin are often somewhat enlarged, giving a slight roughness to the sur- face, more especially on the breast and extremities. When the skin is pressed with the point of a finger, the redness disappears for a moment, leaving a transient white spot. With the com- mencement of the fever, or soon after its accession, a slight soreness and some difficulty of swallowing usually occurs, and the voice in most instances becomes thick and less sonorous. In most instances, the face becomes slightly swelled; the tongue is covered with a thick white fur, through which the enlarged papillae exhibit their scarlet points, and its edges and extremi- ties are generally red; the skin is very hot; and the pulse fre- quent, quick, and sometimes tense and vigorous. There is seldom much thirst, and the appetite is always much depressed. Considerable restlessness and occasionally slight delirium oc- curs during the evening exacerbations, both of which symp- toms, however, generally disappear on the approach of morn- ing. On the fourth day, the eruption and fever are generally at their most complete state of development, and on the fifth day both usually begin to decline, and continue to diminish pari passu until they have gone off entirely about the end of the seventh day. On the following day, the skin begins to desqua- mate. When the eruption is about disappearing the tenderness of the fauces abates; the perspiration is free; the urine depo- sits a copious reddish sediment; and in some cases diarrho&a takes place. Desquamation is usually attended with consider- able itching, and frequently leaves a slight tenderness of the skin over the whole body. Occasionally a considerable abate- ment in the febrile symptoms takes place as soon as the erup- tion makes its appearance. In some instances, indeed, the fe- ver is from beginning to end so slight as scarcely to attract no- SCARLET FEVER. 425 tice; but on the other hand, cases occur in which the general arterial excitement is very strongly developed. The disease sometimes commences and proceeds for a day very mildly, and then suddenly assumes all the violence characteristic of the an- ginose variety.* S. Anginosa.—In this form of the disease, both the fever and the anginose affection are much more violent than in the former variety. The forming stage of s. anginosa is almost always attended with considerable headach, precordial oppression, nausea, sometimes vomiting, and general muscular prostration. The fever is accompanied, from its commencement, with a feel- ing of stiffness and dull pain in the muscles of the neck and un- der the ears and angles of the jaw. Frequently, indeed, these local symptoms precede the occurrence of the fever; and on examining the fauces, the palate, tonsils and uvula present a red and slightly tumid appearance. The voice soon becomes hoarse, deglutition painful and difficult, and respiration is at- tended with a disagreeable sense of constriction in the throat. The febrile symptoms rise rapidly to their acme; the pulse ac- quires great frequency and quickness, but it is rarely either so vigorous, tense, and full, as in the simple variety of the disease. The thirst is generally urgent, and the heat of the skin usually more intense than in any other febrile affection. Currie and Willan have found the temperature of the surface as high as 108 and even 112 degrees of Fahrenheit's thermometer. The tongue soon becomes dry and very florid, particularly along the edges, with the inflamed papillae projecting from its sur- face ; considerable uneasiness or pain is felt in the head, and much restlessness, langour, and prostration prevails through- out the whole course of the disease. The eruption does not generally come out as early in this, as in the simple variety. It usually makes its appearance on the third day of the fever, and is seldom diffused over the whole surface, coming out in irregular and not very large patches on different parts of the body, particularly about the elbows. In some instances, the efflorescence disappears the day after it has * In reference to cases of this kind, Dr. Armstrong makes the follow- ing observations. " Simple excitement may readily produce inflamma- tion, and in fact is the most frequent cause of it; for if there be a latent weakness in any organ, the simple excitement, if not timely moderated, is sure to give rise to inflammation there. It is on this account, that many diseases merely marked by simple excitement at the beginning, are complicated with inflammation in their progress ; and hence it is, that apparently benign seizures of scarlatina may eventually become the causes and concomitants of serious affections of some of tbe viscera. It is indeed, only in subjects of the soundest constitutions that we ever see s'imple excitement uncombinedly exist throughout the disease ; and the reason why it so frequently occasions inflammation is, that some tis sue or other had been secretly in fault before its occurrence.—On Mea sles, Scarlatina, fyc. p. 157. 426 SCARLET FEVER. come out, and "reappears partially at uncertain times, but without any corresponding changes in the general disorder; and the whole duration of the complaint is thus lengthened, and the desquamation is less regular." (Bateman.) When the fever declines as early as the fourth or fifth day, the tonsils and palate seldom become ulcerated, the swelling and inflammation in the fauces passing off with the fever and the eruption without ulceration; but, when the fever is pro- tracted beyond this period, or when it is violent during the first three or four days, small ulcers form about these parts. which are rapidly converted into ash-coloured superficial sloughs. There is always a considerable quantity of viscid mucus secreted in the fauces, which often concretes into white flakes upon the inflamed parts, and presents the appearance of ulcers where in reality none exist. The parts should, there- fore, be carefully examined before an opinion is expressed as to the existence of ulcers. (Armstrong.) As the fever declines the sloughs in the throat begin to separate, ami leave red ul- cerated surfaces, which generally cicatrize without difficulty. Sometimes, however, instead of separating about the eighth day, the sloughs enlarge, become brown, and discharge an acrid sa- nious fluid; and in such cases the glands about the neck are generally swollen, hard, and painful; and the patient is harass- ed with painful diarrhoea and tenesmus. The inflammation occasionally extends into the trachea, and the patient dies un- der symptoms of acute bronchitis. The brain often becomes prominently affected during the eruptive stage, giving rise to deep and fatal coma. Abdominal inflammations may likewise supervene. " At first there are only slight pain and soreness in some part of the abdomen, with a quickened pulse and hur- ried respiration; but the pain and soreness gradually increase, and at length are attended with vomiting, eructation, fulness of the belly, and general restlessness. In six, seven, or eight days the abdominal soreness and pain abate or disappear, while the pulse grows rapid and feeble, the breathing more anxious, and the vomiting more urgent. Cold clammy sweats, and an universal collapse now speedily supervene, and are the imme- diate precursors of death." (Armstrong.) S. Maligna.—Although this form of the disease usually com- mences like the preceding variety, it soon betrays its violent and dangerous character. The eruption comes out at uncertain periods from the second to the fourth day ; and is usually pale when it first makes its appearance, acquiring, in most in- stances, a dark or livid hue in the progress of the disease. It is also very irregular in its duration, and often suddenly dis- appears soon after it has come out, and reappears on some parts of the body two or three days afterwards. The tempera- ture of the skin is variable, and not generally very intense ; SCARLET FEVER. 427 and the pulse, though in the commencement active, becomes small and feeble in the course of the second day. Delirium generally occurs at an early period, and often continues with occasional intermissions and exacerbations, throughout the sub- sequent course of the disease. In nearly all cases the sensorial functions suffer very considerable disturbance ; and, in aggra- vated instances, the eyes are dull and inflamed, and the cheeks suffused with a livid flush. The tongue is dry, and covered with a brown or dark fur; the breath fetid. On examining the fauces, gray-coloured sloughs are seen on the soft palate and tonsils, which soon acquire a brown, and at last a dark colour. The disease, however, sometimes terminates fatally under symptoms of cerebral oppression, before the ulcers in the throat become extensive, or acquire a very bad appearance. "In ge- neral," says Dr. Armstrong, " it is only when the fever is pro- tracted beyond the fourth day that the ulcers are converted into ill-conditioned, black, and fetid sloughs." There is gene- rally a large quantity of very viscid mucus secreted and lodged in the fauces, giving rise to difficulty of respiration and a rattling noise in the throat. When the sloughs are foul and extensive, a thin acrid fluid is usually discharged from the nose, occasioning irritation and excoriation of the'parts with which it comes in contact. In cases of a particularly violent charac- ter, collapse supervenes towards the middle or end of the second week of the disease. When this occurs the heat of the surface sinks ; the pulse becomes very frequent and feeble; the tongue dark, brown, or black ; the aninal powers become greatly prostrated; painful diarrhoea often ensues; and in some in- stances petechias and haemorrhages from various parts occur towards the fatal termination of the disease. The fever and ulcerous affection of the throat exist not unfrequently without an eruption at any period of the disease. Death sometimes takes place as early as the second or third day, and Bateman observes, that occasionally the symptoms continue to be mode- rate, until at an advanced period they suddenly assume a ma- lignant and rapidly fatal character. Dr. Armstrong has described three modifications of malig- nant scarlet fever—namely, the inflammatory, the congestive, and the mixed; the latter being attended, he says, at once with much internal congestion, and a moderate reaction of the heart nn/1 Q PfCI'lCS* The first of these modifications (inflammatory) corresponds with the putrid variety of Richter.* It commences with vio- lent fever ; the pulse is full, strong, and hard ; the heat of the surface intense; delirium occurs early ; in short, all the symp- toms indicate a high grade of inflammatory excitement. The * Specielle Therapie. bd. ii. p. 466. 428 SCARLET FEVER. eruption comes out early, and is at first vividly red, assuming a darker or purple hue as the disease advances. In its com- mencement, and for a day or two, it resembles s. anginosa, differing from this variety in the early supervention of a ty- phus state or collapse, and in the affection of the throat assum- ing, in a few days, the gangrenous condition mentioned above. At an early period of the disease the animal powers sink; the pulse becomes small, feeble, and frequent; the heat of the sur- face acrid and burning ; the rash purplish ; colliquative diar- rhoea and haemorrhages; and occasionally petechias, or a,mi- liary eruption ensue. The most characteristic circumstance of this modification, however, is the extremely violent degree of the anginose affection, and in its decided and early tendency to terminate in extensive gangrenous ulceration. It is this mo- dification of the disease that was formerly commonly described under the name of putrid sore-throat. In the congestive modification the reaction does not ensue; the patient becomes pale, faint, and oppressed; he complains of deep-seated pain and a sense of weight in the head, attended with giddiness, nausea, much anxiety and oppression in the prsecordia, and great muscular prostration. Respiration is quick, short, or slow and impeded ; " and there is often a mix- ture of lividity and paleness in the face, and the eyes are usu- ally dull, acquiring a fatuous or inebriated expression in the course of the disease. The mind at first alarmed and confused, or dejected, soon becomes disordered with delirium ; or an in- difference to surrounding objects, and a stupor succeeds, under which patients frequently expire." The pulse is slow, irregu- lar, and w7eak; at first the tongue is covered with a white fur which becomes rough and brown in the progress of the disease. The bowels are torpid in the beginning, but towards the termi- nation of the disease, diarrhoea almost always occurs in fatal cases. This modification of the complaint seldom runs a pro- tracted course, and frequently proves fatal as early as the se- cond, third, or fourth day. Colliquative haemorrhages from the nose, mouth, and bowels ; petechia? and gangrenous spots are by no means uncommon towards the fatal conclusion of the disease. In this modification the rash from the commencement of its appearance is pale, or of a copperish hue, acquiring at last a purple aspect. The anginose affection is seldom very violent. Dr. Arm- strong thinks that the affection of the throat is rarely the cause of death—its fatal tendency depending chiefly on the " venous congestions of the brain, liver, spleen, lungs, and of the ves- sels of the heart, giving rise to universal collapse and visceral disorganization," and perhaps to a change in the constitution of the blood itself. Seqjjela.—Scarlatina, like measles, is frequently followed SCARLET FEVER. 429 by various troublesome and often dangerous disorders; amongst which, anasarca is by far the most common. There is, in- deed, no acute disease which is so apt to be succeeded by drop- sical effusions as scarlet fever; and this is especially the case with the anginose variety. These swellings seldom occur be- fore the ninth or tenth day after the eruption has gone off, and continue usually two or three weeks. Bateman observes, that " when the anasarca becomes pretty general, a sudden effusion occasionally takes place into the cavity of the chest, or into the ventricles of the brain, occasioning the death of the patient in a few hours." In general, however, the dropsical effusions which occur after scarlatina, are not attended with much in- convenience or danger. The malignant and anginose varieties are sometimes followed by abscess of the tonsils, enlargement of the parotids, inflammation of the testicles, ophthalmia, deaf- ness, and inflammation of the mucous membrane of the ali- mentary canal, otitis, suppuration of the glands about the neck, chronic cough, excoriations about the nates, and bron- chitis, or other slow suppurative inflammations, with hectic fever and its consequences. It is observed by Dr. Armstrong and others, that the hair is very apt to come out on the abate- ment of scarlatina, and that it often never looks or grows well afterwards. Various nervous affections have also been known to occur as sequela of this disease:—such as hysteria, spas- modic asthma, chorea, epilepsy,* and neuraligic pains in the extremities. Strumous affections, chronic cutaneous eruptions, gutta serena, herpes, and rheumatic pains, are occasionally the consequence of the disease. The more perfect and obviously the cuticle desquamates, the less apt are secondary diseases to supervene during convalescence. Diagnosis.—The only diseases with which scarlatina is lia- ble to be confounded are measles and miliary fever; and in the simple and anginose varieties, the diagnosis is indeed some- times attended with very considerable difficulty. There is not a single symptom which can be regarded as absolutely peculiar and characteristic of scarlet fever. The eruption is sometimes wholly or nearly absent, is diffused or in blotches, and occa- sionally papular; and the angina varies from only a slight redness to much tumefaction, with or without ulceration and sloughing. Nevertheless, the following circumstances will al- most always enable us to distinguish scarlatina from measles. In the former the eruption generally comes out within the first forty-eight hours of the fever; whereas in measles the rash rarely appears until the third, and most commonly not until * Kreysig. Abhandlung uber das Scharlachfieber, &c. p. 59. See also Cappel. Abhand. von Scharlachsauschlage, p. 90. Reil. Fieber-lehre. Bd. 5. p. 122. 430 SCARLET FEVER. the fourth day. The eruption in scarlatina appears like a dif- fused erythematous blush of the skin, with innumerable points, intermixed with small papulae, dispersed over the cuticle. The rash of measles, on the contrary, consists of small circular dots like flea-bites, of a deeper red in the centre than at the circumference, so that, in running into each other, the skin presents a less uniform blush than in scarlatina. These red and slightly elevated dots generally appear in clusters or patches, assuming an irregular crescent shape. " The crescent- like form of the patches of measles," says Bateman, " and the more diffuse and irregular shape of those of scarlatina, will be a material diagnostic guide." The colour of the eruption of scarlatina usually resembles that of a boiled lobster shell. In measles it is generally of darker red, inclining slightly to brown. The most prominent diagnostic symptoms between these two affections, however, are the catarrhal phenomena, which are almost invariably very conspicuous in measles, whilst in scarlatina they are either altogether absent, or extremely slight and partial. The inflamed eyes, profuse dis- charge of tears, sneezing, coryza, strong, harsh, and hoarse cough, intolerance of light, and red and swollen edges of the eyelids, so seldom absent in measles, are but very rarely no- ticed in scarlet fever. In the malignant and anginose varieties of scarlatina, the ulceration and sloughs which appear in the fauces are sufficiently characteristic to distinguish this affec- tion from measles. In some instances, simple scarlatina assumes so much the general appearance of miliary fever, that on slight examination it might be readily mistaken for this latter affection. They may be distinguished by the miliary eruption being almost universally attended with considerable perspiration, which is not the case on the appearance of the efflorescence of scarla- tina. The little points or miliary papillae of the rash of scarlet fever rise out of a uniformly erythematous blush of the skin ; whereas those of miliary fever appear to be seated on a skin possessing its natural colour. The coming out of the miliary eruption is generally attended with great anxiety in the prae- cordia; and when it is about declining, a second eruption, si- milar to the first sometimes comes out; and in some instances a third crop ^of.papulae supervenes. Prognosis.—-The prognosis in scarlatina must of course be extremely various, since the disease assumes every grade from the mildest to the most fatal degrees of violence. In the simple variety, little or nothing in general need be apprehended for the safety of the patient, unless dangerous secondary affections supervene during the declension or period of convalescence, from cold or other accidental causes. But the prognosis ought to be cautious, even in cases which appear at first under mild SCARLET FEVER. 431 symptoms ; for the disease will sometimes go on for a few days in a regular and simple form, and then, all at once, assume a highly dangerous grade of violence; and this is more espe- cially apt to be the case when the epidemic generally is of a severe character. The anginose variety of the disease, can never be regarded as free from particular danger ; and the ma- lignant variety is to be accounted among the most fatal mala- dies. It is generally, and perhaps justly, considered that the danger in scarlatina is to be estimated by the character and violence of the affection of the throat. Dr. Armstrong, how- ever, seems to be of a different opinion ; at least, the affection of the throat abstractedly considered, he thinks, is rarely the cause of death—a termination which he refers rather to vio- lent internal venous congestions and visceral disorganizations, which are so common in the more violent grades of this dis- ease. When the eruption is bright red, and uniformly diffused over the whole or the greater part of the body, the prognosis is better than when it is pale or purple or brownish, and ap- pears only here and there in large patches. (Armstrong, Reil.) A variable eruption, being by turns red, pale, and brownish ; appearing now principally in one part, and then in another; going off for a time, and again making its appearance, or final- ly suddenly, and at an early period vanishing entirely, are un- favourable indications. A white streak passing down on both sides of the nose and encircling it below, is said to be a fatal symptom. (Reil.) If on a sudden a strong inclination to pass urine occurs, and a copious flow of crude watery urine takes place, the danger may be considered great. (Richter.) When the inflamed fauces are of a bright red colour, considerably tu- mefied and attended with painful swallowing, the prognosis is better than when the inflamed parts are dark-red or livid, and without swelling and difficult deglutition. White sloughs in the fauces are more favourable than ash-gray or brown ones. The occurrence of gangrenous ulceration is of course of very alarming import. It is scarcely necessary to say that the grade and character of the attending fever has an important bearing on the prog- nosis. A moderately active state of the reaction is favourable; a typhus grade is the reverse; and when the fever is extreme- ly violent at first, with much angina, there is great reason to apprehend early and dangerous collapse. Violent internal venous congestions, by which the development of febrile reac- tion is prevented or much impeded, is always indicative of the utmost danger. The supervention of visceral inflammation is no less alarming. These are generally soon followed by col- lapse, and if death does not take place early, great prostration ensues, with the fatal symptoms of coma, constant delirium, cold extremities, and if to these are added petechiae, colliqua- 432 SCARLET FEVER. tive haemorrhages, and involuntary evacuation of feces, a speedy dissolution may be predicted with certainty. In general, scarlatina is apt to be more mild in children than in adults, except when the former are suffering from painful dentition. The disease is said to be most dangerous when it occurs in persons between the ages of fifteen and twenty-five.* It is also attended with particular danger when it attacks preg- nant women, and especially in the puerperal state. In gene- ral, robust and healthy individuals bear the disease much bet- ter than persons of a weak, lymphatic, and nervous tempera- ment. A regular abatement of the heat and efflorescence of the skin, accompanied with a lateritious sediment in the urine; a subsidence of the swelling, and of the frequency of the pulse; with separation of the sloughs and healthy granulation of the ulcers ; and finally, desquamation of the cuticle, are indicative of a favourable termination of the disease. Cause.—Scarlatina arises from a specific contagious miasm or principle, which like most other febrile contagions, appears to be much under the influence of certain occult atmospheric temperaments, as is manifest from its occasional epidemic pre- valence, as well as from the various grades of violence and di- versity of character which different epidemics have been known to assume. It agrees, moreover, with the contagion of small- pox and measles, in destroying the susceptibility of the sys- tem to its subsequent morbific influence ; although exceptions to this rule have been noticed, the disease having in some in- stances, though extremely rarely, occurred a second time in the same individual. There has been much controversy in re- lation to this latter point. Withering and Willan assert that they never witnessed a second attack of the disease, and they deny the possibility of this occurrence; and Bateman observes, " that this fact is now fully ascertained." Cases of second at- tacks have nevertheless been adduced by authorities equally respectable, and the reality of this occurrence, though rare, appears to me sufficiently established. Bicker,f Neumann Binns, and others, mention instances of this kind ; and Richter observes, that cases of a second, nay even a third attack of scarlatina have been noticed.^ Some in- dividuals are wholly insusceptible to the operation of this con- tagion, and never Jbecome affected with the disease, however frequently they may be exposed to its cause. Accidental pre- * Reil. loc. cit. vol. v. p. 138. t Beschreibung eines Scharlachfiebers.—Rotterdam, in 1778 and 1779, p. 162. X Aufsatze und Beobachtungen fur Aerzte, p. 284, as quoted by Reil. loc. cit. t. v. p. 136. § Specielle Therapie. bd. ii. p. 440. SCARLET FEVER. 433 disposition, age, and idiosyncracy of constitution, have of course a great influence on the activity of this as of other contagions. The period which intervenes between the first impressions of the contagion and the manifest commencement of the disease varies from three to five or six days. It is asserted that the contagion emanating from an individual affected with the dis- ease is most active during the period of desquamation. (Ca- zenave.) Although unequivocally depending on a peculiar con- tagion, yet *' there is abundant evidence that fever attended with scarlet eruption, and possessing all the other characters of this disease, does occasionally arise from exposure to cold."* Scarlatina occurs at all seasons, but it has been observed that warm and damp weather, and the air of low and marshy districts have a tendency to promote the dissemination as well as the violence of the disease. It is also said, (Reil, Richter, Steiglitz,) that this disease is more apt to affect females than males ; and general observation goes to show that nurslings and old persons are much less subject to the influence of its contagion than individuals during the intermediate ages. Some epidemics affect scarcely any but children ; others seize almost exclusively on adolescents and adults. Reil says that he has seen malignant epidemic scarlatina which was almost entirely confined to persons between the ages of fifteen and twenty-five. The progress of epidemic scarlet fever is sometimes very irre- gular. The disease, though very violent and general, some- times suddenly abates so as almost to disappear, and after a while resumes its power and rages with still greater malignity. Occasionally the contagion appears to linger for several years in a certain district, a few patients only becoming, from to time, affected with the disease. Treatment.—From what has been said of the various symp- toms and characters which scarlatina may present, it is at once obvious, that the remediate management of the disease must be greatly modified in the different varieties which it is wont to assume. In the simple form of the disease nothing but the mildest antiphlogistic treatment is necessary. One or two gen- tle aperients, or enemata; a mild unirritating liquid diet; cool or tepid drinks, such as barley-water; toast-water, aci- dulated with lemon-juice, or muriatic acid, or lemonade ; con- finement in a moderate and equable temperature ; with the use of slightly astringent and emollient gargles—such as sage-tea, with a small portion of alum, and sweetened with honey; or an infusion of green tea, is all that it is in general necessary to resort to in cases of this kind. But even the simple form of the disease occurs occasionally under symptoms of very con- * Gregory's Elements of the Theory and Practice of Physic, vol. i. 434 SCARLET FEVER. siderable febrile irritation, and may, by the continuance of the high excitement, assume the severer character of scarlatina anginosa. No regard should, therefore, be paid to the mere de- cision of its being a simple form of the disease ; but where the general excitemeut runs high, it will be prudent to adopt a more active antiphlogistic treatment, and to regulate it in such a manner as to restrain the phlogistic tendency without inter- fering too much with the regular, and we may presume, neces- sary excitement of the heart and arteries. Although it may be true, nay most assuredly is true, that the " nimia diligentia me- dici," has done more harm in simple scarlatina than the dis- ease itself, yet the intelligent and experienced practitioner has a safe and a sure guide in the grade of the existing symptoms to direct him in the application of antiphlogistic measures. It is moreover to be observed, that in the onset of the dis- ease it is not always in our power to decide satisfactorily whether its subsequent course will be simple or complicated, or severe and dangerous. However mild, therefore, the general character of the prevailing epidemic may be, it will be proper, whenever we are called to a case during the forming stage, at- tended with considerable lassitude and oppression, paleness of the face and skin, some headach and nausea, to commence the treatment as if the disease were about assuming an aggravated character. An emetic will under such circumstances frequent- ly do much good by removing internal venous congestions ; and after its operation a brisk mercurial purge may be given with advantage. In cases attended with considerable affection of the head during the forming stage, Dr. Armstrong advises the use of the warm bath strongly impregnated with salt. "This practice," he says, "assisted by a brisk purgative, will in general give immediater elief, and contribute powerful- ly to moderate the subsequent reaction/' When the subsequent febrile excitement becomes strongly developed, it should be moderated by purgatives, tepid affusions, cooling drinks, rest, ventilation, and some of the milder diaphoretic remedies—such as spiritus mindereri, sweet spirits of nitre, or small doses of nitre and antimony.* In the anginose form of the disease, a much more energetic course of treatment is requisite. Almost all writers agree in recommending the use of emetics in the beginning of this, as well indeed as in the other varieties of scarlatina. The earlier they are resorted to, the more beneficial, in general, will be their effects; and it is particularly in the forming stage, or at the very onset of the febrile excitement, that they may be em- ployed with decided usefulness.! When given at this early * Armstrong. Treatise on Scarlatina, Measles, &c. t Numerous authorities, of great weight, might be quoted in evidence * of the good effects of emetics in this disease. They are recommended by SCARLET FEVER. 435 period, they frequently moderate the whole subsequent course of the disease, and in some instances almost completely break up the train of morbid actions. They have indeed been re- commended throughout the whole course of the disease, (Wi- thering,) but general experience goes to show that the com- mencement of the disease is the oniy proper period for their employment. The good effects of an emetic in the beginning of the disease depend, probably, chiefly on the centrifugal di- rection which active vomiting communicates to the circulation, and thereby obviating internal congestions and secondary in- flammations ; and perhaps, also, by weakening the morbid sympathies established by the cause of the disease. Purgatives have of late years been strongly recommended in this affection, and they are, without doubt, often highly useful, although formerly much prejudice existed against their em- ployment. The utility of this class of remedies in scarlatina, is particularly insisted on by Dr. Hamilton ;* and all modern writers speak favourably of this practice. My own experience, though limited in this variety of the disease, has strongly im- pressed me with the utility of repeated moderate purgation in this affection, and with the exception of an antimonial emetic in the commencement, I have in most instances confined myself almost entirely to the employment of aperients, with cooling applications to the surface, an antiphlogistic regimen, and the local applications to be mentioned hereafter. The judicious employment of laxatives in the early periods of the disease, is the most effectual measure for preventing the occurrence of colliquative diarrhoea in the latter stage—an occurrence which is always attended with extreme danger. It is by no means necessary, or, as a general rule, even proper to use active purges. From three to four evacuations in the course of twen- ty-four hours are in general sufficient to procure all the ad- vantages which purgatives can afford,f unless cerebral con- gestion exists, when active catharsis will be very proper.:}: Tissot, (Avis au Peuple); Stoll, (Ratio Medend. torn. ii. p. 248); Wi- thering, (Account of Scarlet Fever and Sore Throat, &c. as it appeared at Birmingham in 1773, and London in 1779, p. 300); Steiglitz, (Versuch einer prufung und verbesserung der yezt gewohnlichen behandlungsart des scharlacbfiebers, p. 241); Richter, (Specielle Therapie. Bd. ii. p. 480); Reil (Fieberlehre, torn. v. p. 166); Armstrong, (on Scarlet Fever, &c); Rush, (Medical Inquiries.) * Treatise on Purgatives. f Bateman, Gregory, Richter, Reil, Willan. Dr. Armstrong, however, recommends active purges in preference to the milder articles of this class, in the anginose variety of the disease. X Rhubarb and calomel; rhubarb and soda in equal parts; calomel with small portions of antimonial powder, (Willan); calomel, followed by a small dose of magnesia; small portions of the sulphates of soda or magnesia; an occasional dose of two or three grains of calomel, with the 436 SCARLET FEVER. With regard to the employment of antimonials and the usual diaphoretic antiphlogistics, experience does not furnish us w ith any satisfactory evidence of their usefulness. " In truth," says Dr. Bateman, " the temperature is too high to admit of a dia- phoresis ; and the only safe and effectual method of producing this effect, consists in reducing the heat of the surface by the application of external cold." Richter, nevertheless, speaks favourably of the internal employment of the muriate of ammo- nia, when the fever is strong, after the bowels have been regu- larly evacuated.* It should be given in union with tart, anti- mon. in the way directed at page 83. If notwithstanding the use of purgatives, and the other remedies already mentioned, the inflammatory condition increases, and the patient becomes anxious and very restless, the use of diluted sulphuric acid, in large and frequent doses, is, according to the experience of Stieglitz, a valuable remedy. (Abhandl. fur Pract. Arzte. B. xxii. p. 307.) The application of cold water to the surface of the body, cannot be too strongly recommended in the higher grades of this affection. " We are possessed of no physical agent," says Bateman, "as far as my experience has taught me, (not excepting even the use of blood-letting in acute in- flammation) by which the functions of the animal economy are controlled with so much certainty, safety, and promptitude, as by the application of cold water to the skin, under the aug- mented heat of scarlatina and of some other fevers. This ex- pedient combines in itself all the medicinal properties which are indicated in this state of disease, and which we should scarcely a priori expect it to possess, for it is not only the most effectual febrifuge (the " febrifugum magnum," as a reverend author—Dr. Hancoke—long ago called it,) but it is in fact the only sudorific or anodyne which will not disappoint the ex- pectation of the practitioner under these circumstances. I have had the satisfaction, in numerous instances, of witnessing the immediate improvement of the symptoms, and the rapid change in the countenance of the patient, produced by washing the skin. Invariably in the course of a few minutes the pulse has been diminished in frequency, the thirst abated, the tongue has become moist, a general free perspiration has broken forth, the skin has become soft and cool, and the eyes have brightened ; and these indications of relief have been speedily followed by a calm and refreshing sleep." The only precaution that it is necessary to observe in the application of cold water to the surface in this and other febrile diseases, is to see that the skin is above the natural temperature, and dry, and that no feeling daily use of a dose of castor oil, or the administration of laxative ene- mata, may be used for this purpose. * Specielle Therapie. B ii p 490. SCARLET FEVER. 437 of chilliness be present. When the arterial excitement is vehe- ment, and the temperature of the surface intense, the water should be applied by pouring or dashing it over the body ; but where this mode of using it is impracticable, or objected to on the part of the patient or his friends, we may obtain our object by washing or sponging the skin with cold water, or vinegar and water, and this should be repeated every hour or two, until the desired reduction of the heat and arterial excitement is ef- fected. Dr. Armstrong observes, that as the disease advances, instead of cold, tepid affusions are to be used ; and, as a gene- ral rule, he thinks it most prudent to resort to the latter after the third day of the stage of excitement. In this, however, we must be governed by the degree of arterial excitement, and of the heat of the surface present; for cold water may be safely and beneficially applied, at any period of the disease, provided the skin be very hot and dry.* (Dr. Stranger.) Purgatives and cold affusions may be employed conjointly. Armstrong, indeed, asserts, that when thus used they do more good than when employed separately, more especially during the first three days of the stage of excitement; and several instances have come under my own observation which strongly favour this opinion. Blisters may sometimes be beneficially used dur- ing the first two or three days of the stage of excitement. When the tonsils are much inflamed and swollen, so as to render swallowing difficult, the application of a blister to the throat will often afford considerable relief. This practice is particu- larly recommended by Willan, Heberden, and Rush. When the disease is complicated with visceral inflammation, little or no relief will be obtained from the application either of cold or tepid water to the surface ; and Armstrong observes, that where these measures in conjunction with purgatives do not afford any advantage, the practitioner may be sure that there is some latent inflammation present. When this is the case, and collapse is not approaching, recourse must be had to sinapisms, blisters, small general or topical abstractions of blood. Should there be manifestations qf much vascular irri- tation, or of incipient inflammation of the brain—that is, should the face become flushed and turgid, with severe pulsating pain in the head, more or less delirium, intolerance of light, and a disposition to somnolency, the patient must be kept in a cool situation, with his head elevated, and blood drawn according to the state of the pulse,\ an active purgative administered, * Willan on Cutaneous Diseases—note at page 360. t Armstrong; Marcus, (Specielle. Therapie. torn. iii. p. 272); Lorry, (Hist.de la Soc. Roy. de Med. t. ii.); P. Frank, (de Curand. Homin. Morbis); Rush; Burserius, (Institut. Med. Pract. vol. ii. p. 72); Heim, (Horn's Archiv. fur Medic. Erfahr. vol iv. h. 1. p. 150.) Richter and other eminent authorities may be adduced in favour of prompt blood- letting in such cases. 438 SCARLET FEVER. warm fomentations, or sinapisms applied to the feet, and cold water to the head, and cups applied to the temples, or blisters to the back of the neck, provided always that collapse is not at hand. Unfortunately, however, internal visceral inflamma- tions supervening in this affection are almost always speedily followed by collapse, and in this state sanguineous and other evacuations are entirely out of the question. Dr. Armstrong observes, that "in such examples the question is simply this— whether, is there greater danger to be apprehended from the inflammation or from the depletion ?" Visceral inflammation, he says, almost invariably terminates fatally, but depletion produces debility only, and debility is rarely the cause of death. He is, therefore, of opinion that an attempt ought to be made to arrest the inflammation by depletion, even in the stage of collapse, wherever it may be seated. It is true, that debility is perhaps rarely the cause of death ; but it may be asked, why is visceral inflammation so fatal in such cases ? The answer would seem to be :—because it is connected with universal de- bility, and the clear inference is, that whatever tends to aug- ment this debility or prostration, must tend also to hasten its fatal termination. Before we adopt so desperate a practice, we should inflect that a small bleeding cannot materially influ- ence or reduce the internal inflammation, and a large one must inevitably precipitate the patient into fatal prostration. Such cases are indeed exceedingly perplexing, for the remedies which are best, and almost alone calculated to remove the inflamma- tion, are also the most certain to increase the prostration. When the brain is the seat of the inflammation, we may apply fomentations to the feet, dry cups to the temples and shaven scalp, and exhibit active purgatives conjointly with carbonate of ammonia, or camphor. In other visceral inflammations at- tended with collapse, I should be disposed to resort to calomel and opium, with dry cupping and large fomenting cataplasms over the region of the affected part. Blisters in such cases are almost as hazardous as bleeding. They produce much general irritation, and the blistered part often speedily becomes gan- grenous. Malignant scarlatina, though generally strongly phlogistic in its commencement, passes so rapidly into a low and typhus state, that formerly physicians placed almost their entire de- pendence in its treatment, on the active and early employment of bark, wine, and other stimulating and tonic remedies. "These'remedies," says Armstrong, "so forcibly, so indiscri- minately, and so fatally recommended by numerous authors, were once the means upon which, unfortunately, I relied for the cure of this modification of scarlet fever; and from repeat- ed trials of them, I can truly affirm that they are the most per- nicious in the first stage, and the most destructive in the se- SCARLET FEVER. 439 cond." However rapidly this form of the disease may pass into a low and malignant state, its onset is often characterized by highly inflammatory symptoms. The attack is vehement, and the febrile excitement at first tumultuous, tending rapidly to consume the vital energies ; and in proportion to the violence of this excited, though transient stage, wrill be the tendency of the disease to assume a putrid character. It is therefore of the utmost importance to break down promptly, by energetic mea- sures, the initial febrile commotion. I have already stated that the exhibition of an emetic, followed by a brisk purgative, in the chilly or forming stage, is often as beneficial in this as in the other modifications of the disease ; and the treatment should always commence with these remedies, if we are called at a suf- ficiently early period. If, after the operation of these evacu- ants, the stage of excitement begins with violent symptoms— such as intense heat of the skin; severe headach ; delirium ; and a frequent, quick, and tense pulse; blood should be promptly and efficiently abstracted, (Burseoius, Lorry, Arm- strong.) As this stage is generally but short, it is of great im- portance to draw blood at once in its onset, to the extent of producing a very decided impression on the system; or, as Armstrong advises, until syncope approaches. By one such bleeding, and the brisk operation of a purgutive, the violence of the disease is often broken down and its subsequent course rendered milder and more manageable. It must not be forgot- ten, however, that these active depletory measures must be en- tirely restricted to the early period of the stage of excitement; for when collapse is approaching, bleeding is wholly out of the question. (Armstrong.) Purgatives are always proper during the stage of excitement in every variety of scarlatina. Calo- mel has been particularly recommended for this purpose both in the mild and the malignant forms of the disease.* Dr. Rush gave this article throughout the whole course of the disease. Seeligf speaks in high terms of a combination of calomel, precipitated sulphuret of antimony, and tart, antimony, ac- cording to the formula below,\ a combination which is said to * " It is somewhat remarkable," says Armstrong, " that calomel, though given in large and frequent doses, will hardly ever produce ptyalism in scarlatina." He states that he has frequently given from six to eight grains of this article to children twice, thrice, and even four times daily, without having in a single instance known it to produce salivation. He considers it the best purgative in every modification of t Hufeland's Journal, bd. 16. 1 st. Reil's Fieber-lehre, vol. v. p. 177. X R. Calomel 9i. Sulphuret. antimon. prgecipit. gr. ii. Tart, antimon. gr. i. M. Divide into twenty equal parts. Dose—one part to be taken every three or four hours by adults. 440 SCARLET FEVER. be particularly useful as a gentle laxative and antiphlogistic alterative in the present variety of the disease. In conjunction with purgatives we may use the ivarm bath with a prospect of advantage, more especially in cases attended with internal in- flammation. When a prompt and energetic antiphlogistic treatment is employed in the onset of the inflammatory form of malignant scarlatina, the system seldom sinks into a very low state of collapse; and when this stage supervenes after such a treatment in the commencement of the disease, we may, in general, give sufficient support to the vital powers by wine-whey, weak so- lutions of ammonia, infusion of serpentaria. a milk diet, quiet- ness, and proper ventilation. (Armstrong.) When from an in- efficient or improper treatment in the beginning, or from a pe- culiar violence of the disease, great and universal collapse en- sues (which is indeed but too frequently the result, both in the inflammatory and congestive modifications of malignant scar- latina) recourse must be had to a more active, stimulating, and tonic treatment. The carbonate of ammonia in frequent and active doses ;* wine; camphor and opium where the brain is not particularly affected ; infusion of serpentaria, with strong doses of elixir of vitriol; quinine and capsicum, are the reme- dies upon which our dependence must be placed. The capsicum appears to be a particularly valuable exciting remedy in this variety of the disease. This article was first employed in ma- lignant scarlatina by Dr. Stephensf in a very fatal epidemic which prevailed at St. Christopher's (West Indies) in 1787, and it has since received the decided approbation of many eminent practioners4 The manner of employing it is as follows: take two table-spoonfuls of small red pepper, or three tea-spoonfuls of common Cayenne pepper, and two tea-spoonfuls of fine salt; beat them into a paste, and pour upon them half a pint of boil- ing water; this is to be strained, and half a pint of good vine- gar added to it. Of this liquor, when cold, a table-spoonful is to be taken every half hour by an adult, and the throat should be frequently gargled with it. Stephens asserts that he em- ployed this remedy in about four hundred cases and with sur- prising success. The ulcers in the fauces soon cast off their * Peart asserts that he has been so successful with the use of carbonate of ammonia, that out of three hundred cases in which he employed it, he lost but three patients. This, however, may well be deemed, ultra rem tendere, in commendation of this remedy, although unquestionably, a highly useful medicine in the stage of collapse, not only of this but of all forms of disease.—Practical Information on the malignant Scarlet Fe- ver, Sfc, by E. Peart, London, 1802. t Edinburgh Medical Commentaries, Dec. 2. vol. ii. p. 75. jCappel, loc. cit. p. 276, Kreisig, loc. cit. p. 113, and Seibert, archiv. fur die Volksarzneikunde, p. 129.—As quoted by Reil, loc. cit., vol.V. p. SCARLET FEVER. 441 sloughs and commenced to heal, a general pleasant warmfh was diffused throughout the system, and the vital powers speed- ily resumed a more active condition. Maifatti* speaks very favourably of the flowers of arnica; and Stieglitz employed them with much advantage in the sinking stage of the com- plaint. Reil strongly recommends large doses of musk, par- ticularly where much restlessness and nervous irritation exists. Stimulating frictions with brandy, camphorated spirits, or tincture of capsicum, have also been found useful in the collapse of this disease. (Reil, Stieglitz.) In the stage of excitement cooling drinks acidulated with lemon-juice, or the sulphuric or muriatic acids should be freely allowed ; but during the subse- quent stages, infusions of sage, balm, or catnep, with sulphuric acid, are more appropriate. In relation to the congestive mo- dification of the disease, it is not necessary to say much in this place ; for the principles of treatment are always the same in all congestive states of febrile diseases, and what has already been said of the treatment of congestive typhus, applies in all respects to the present malady when it assumes this modifica- tion. When the disease commences and proceeds under symp- toms of oppressive internal venous congestions, our first efforts must be to recall the circulation to the surface, and to relieve the internal organs; and for this purpose, our reliance must be placed on the assiduous use of frictions, and warm and stimu- lating applications to the surface; large doses of calomel, (20 grains;) stimulating enemata; warm and gently stimulating ptisans, and small doses of camphor where the stomach is irri- table. Having elicited a moderate degree of febrile reaction by these means, it will in general be most prudent to commence at once with the use of some of the milder stimulating remedies, such as infusions of serpentaria, calamus, wine-whey, or small doses of the carbonate of ammonia; and as the disease ad- vances and the signs of prostration increase, the more active exciting remedies already mentioned must be employed, with an energy corresponding to the degree of prostration present. Local treatment.—Various local applications have been re- commended for the purpose of moderating the tendency to ul- ceration in the fauces, or of checking the progress of the ulcers, favouring the separation of the sloughs, and disposing them to heal. Willan strongly recommends fumigation with nitrous gas ; others speak favourably of the application of a weak so- lution of nitrate of silver to the sores ; and some recommend the sulphate of copper—all of which may, no doubt, be used with benefit. Various gargles also have been employed, and of these the infusion of Cayenne pepper, mentioned above, is perhaps the best. I have seen much good done in putrid sore throat * Hufeland's Journal, Bd. 12, st. 120. 56 442 SCARLET FEVER. by a strong infusion of the root of baptisia tinctoria (indigo plant) and I have also employed the black-wash, (calomel gr. xx. lime-water ^viii.) with excellent effect in several cases of this kind. Barley-water, acidulated with sulphuric or muriatic acid, forms an excellent gargle for washing off the acrid mat- ter from the inflamed and ulcerated fauces. Where there is no visceral inflammation, or collapse has not supervened in the anginose variety, a gentle emetic will often have an excellent effect in cleansing the sores and clearing the fauces from vis- cid and offensive matter. " Emetics," says Armstrong, " are the best gargles, where the throat is much obstructed from an accumulation of tenacious mucus; their operation effectually dislodges that morbid secretion for a time; often greatly re- lieves the respiration ; improves the appearance of the ulcers ; and they may be repeated where no abdominal inflammation exists, at any time, during the continuance of the fever, when- ever the respiration and deglutition become much impeded by an accumulation of phlegm." During convalescence from scarlatina, which is generally very tedious, a light and nourishing diet should be enjoined, and the patient carefully guarded against the injurious influ- ence of cold and variable weather. When there is considerable debility and relaxation present, mild tonic and cordial reme- dies should be prescribed, such as weak infusions of serpen- taria, colomha, gentian, or calamus aromaticus with some of the mineral acids, particularly the sulphuric. In some cases, more or less of an irritated condition of the system remains during the early part of this period. The pulse is quick and frequent, the skin pale and dry, the bowels inactive, the appe- tite weak, and the sleep disturbed. Here tonics and cordials are entirely out of place. Recourse must be had to mild ape- rients, diaphoretics, warm bathing, and a simple and unirri- tating diet. Small doses of calomel in union with ipecacuanha, (one grain of the former to two of the latter) three or four times daily; the muriate of ammonia, digitalis with the nitrate of potash ; spiritus mindereri with minute portions of tartar eme- tic; infusion of eupatorium perfoliatum, or of elder blossoms; acidulated diluents, &c. will generally answer well in cases of this kind. In all instances, the patient should be particularly careful to avoid taking cold ; and as the susceptibility to the injurious effects of low and variable temperature is always es- pecially great immediately after an attack of this disease, he should remain within doors during the whole period of conva- lescence, unless the weather he mild or warm. I have already mentioned dropsy as a very common conse- quence of every modification of scarlatina. This tendency to anasarcous effusion is generally ascribed to improper treat- ment during the febrile stage of the disease, or to errors in SCARLET FEVER. 443 diet, or imprudent exposure to cold during the periods of des- quamation or convalescence. That these causes have a parti- cular influence in this respect cannot be doubted ; but as drop- sy sometimes occurs after the most judicious and careful ma- nagement in all these respects, it would seem that the original disease itself tends ultimately to effusions of this kind, perhaps from not having passed regularly and completely through its specific train of morbid actions—the dropsy or some other dis- order appearing afterwards as a complimental affection.* These dropsical affections are seldom either obstinate in their course or dangerous. In most instances the general state of the system is manifestly phlogistic. The pulse is quick, sharp, tense, frequent, and sometimes full; the skin dry, harsh, and preternaturally warm; the urine small in quantity, high- coloured, and charged with coagulable serum ; and the bowels generally torpid. Here an antiphlogistic course of treatment is evidently indicated. Richter strongly recommends blood- letting, and other eminent writers (and amongst these several recent ones) insist with equal emphasis on the propriety of this measure.j Gregory seems to hesitate concerning the pro- priety of venesection in hydropic affections after scarlatina. He states that he has " met with several cases which appeared to indicate bleeding and purging, but which resisted both, and ultimately yielded to bark and aromatic confection." My own experience leads me to place confidence in this measure, where the diathesis is evidently inflammatory ; not indeed as a sole or even a principal curative means, but as an important pre- paratory step to the employment of diuretics, purgatives, and diaphoretics. The best diuretic in cases of this kind is digita- lis, either alone or in union with small portions of calomel and nitrate of potash. As a purgative and diuretic, I have derived much advantage in this and other varieties of phlogistic drop- sy from the following combination.\ Small doses of tart, an- * Reil. loc. cit. vol. v. p. 186. f Burserius gives an account of an epidemic scarlatina which prevail- ed at Florence in 1717. The disease yielded readily under the plan of treatment recommended by Sydenham. After the twentieth day from the commencement of convalescence, many became affected with a sense of weight in the chest, cough, oedema of the ficeand on the fore-part of the neck. Fever soon followed; the dropsical effusion increased until it became general; the breast felt sore; the abdomen distended and painful; the urine very small in quantity, and in some instances almost entirely suppressed. All who took diuretics died. On dissection, the lungs, kidneys, and intestines were found inflamed. Blood-letting was now freely resorted to in the cases which occurred, and the result was uniformly favourable.—Burserius, Institutiones Med. Pract. vol. ii. p. 81. X R. Crem. tart. l'i- P. sulphat. potassae 3iii. P. scillae 5"- Tart, antimon. gr. iss. M. S.—Give from twenty to thirty grains four or five times daily to an adult. 444 SCARLET FEVER. timon. dissolved in a large portion of some mucilaginous dilu- ent, may also be used with advantage. Richter recommends large doses of calomel, from five to ten grains daily to chil- dren. The occasional use of the tepid bath will often prove beneficial, and the mildest farinaceous diet, writh cooling aci- dulated drinks, and quietude should be enjoined. Sometimes these dropsical effusions are entirely without any febrile irrita- tion, the system being relaxed, torpid, and leucophlegmatic ;— the hydrops frigidus of the German writers (Reil). According to Richter, "the principal remedy in cases of this kind, is ca- lomel in doses sufficiently large to evacuate the bowels free- ly."* The cinchona bark, and the various medicinal prepara- tions of iron, particularly the black sulphuret, are often deci- dedly beneficial in this form of the disease. Among the diuretics, squill, spirits of turpentine,f and the tincture of cantharides, have been especially recommended. (Hufeland, Buchholz). The following mixture is said to have done much good in such cases.:}: Prophylactic measures.—In Germany, and in France, many statements have been published which would seem te prove that the belladonna, when regularly taken by those who are exposed to the contagion of the disease, will be effectively protected from the infection. Hanemann, the author of the homcepathic doctrine, first introduced this narcotic as a preventive of scar- latina, and in conformity to his views, he prescribes it in what may be called infinitesimal doses. He gives but forty drops in seventy-two hours, of a solution of which one drop contains no more than the twenty-millionth part of a grain of the ex- tract! However incredulous we may be in relation to the effi- cacy of such doses, we arc not without respectable authorities in favour of the prophylactic powers of this article when given in small doses. Berndt asserts, that he gave it with unequivo- cal advantage in this respect. Dr.Koreff of Berlin, found it to protect persons completely against this disease when taken for eight or ten days before they were exposed to its contagion. * Kreissig speaks equally favourably of calomel in this and other morbid consequences of scarlet fever. " Against the sequela of scarla- tina," he says, " the powers of calomel are great, and cannot be too highly praised."—Abhandl. uber das Scharlachsfieber, fyc. p. 107. t R. Spir. terebinth. 3i. Tinct. opii gtt. L. M. S.—From ten to twenty drops may be given three times daily to children from five to ten years old. X R. P. cinchon. _ fjss. Aq. fervent, ^xii. coque ad reman. 3vi. dein adde. Rad. polygal. seneg. 3U- Fol. digitalis gi. cala. dein adde. Spir. nitri. dulc. ^ii. Syrup, cort. aurant. §ss. M. S.—Take from a tea, to a ta- ble-spoonful every two hours, according to the age of the patient. SCARLET FEVER. 445 Three grains of the extract are to be dissolved in an ounce of cinnamon water, and given in doses of from two to three drops to children under one year old, and one drop more for every year above this age.* Seclusion of the sick, free ventilation, frequent changes of the linen, and other similar precautions, have been found com- pletely effectual in preventing the communication of the disease to other members of the family. It does not appear that the con- tagious miasm of this disease is capable of attaching itself to clothes like some of the other exanthematous contagions. The breath of patients in the malignant form of the disease is said to be powerfully infectious; and the same has been observed with regard to matter discharged from the fauces. CHAPTER XXIV. ERYSIPELAS. Erysipelas is a febrile disease attended with diffusive cu- taneous inflammation on some part of the body, characterized by redness, burning heat, swelling, and vesication. In the majority of instances, various symptoms of deranged health precede the appearance of the erysipelatous inflamma- tion—such as lassitude; slight headach; loss of appetite; nausea; general depression; furred tongue; and a disagreea- ble feeling of weight in the epigastrium. The symptoms usual- ly terminate in febrile reaction before the cutaneous inflammation commences; but in some instances the local and general affec- tions come on simultaneously ; and occasionally the inflamma- tion appears before the febrile irritation is developed. Syden- ham speaks of an erysipelas, in which the affection of the face preceded the fever. The inflammation comes out in the form of an irregularly circumscribed stain or blotch, which soon spreads over a greater or less extent of the contiguous surface. When the in- flammation is very superficial, the redness of the skin disap- pears, for a moment, when pressure is made with the point of the finger; but where the inflammation extends deeper, no white spot is left after pressure. A sense of burning and stinging pain, but neither pulsation nor tension is felt in the * Ed. Med. and Surg. Journ. Jan. 1825. 446 ERYSIPELAS. inflamed part. Some degree of tumefaction always attends from the beginning, and increases often to a very considerable extent in the progress of the disease. After the inflammation has continued for an uncertain time, though usually about the third day, small vesicles or blisters of various sizes, filled with a lympid or yellowish serum, make their appearance. On the succeeding day, and sometimes not until two or three days after, these vesicles break and discharge a viscid fluid, which occasionally form crusts or large scabs. When the inflammation is about terminating in resolution, which usually takes place between the fourth and sixth days, the redness of the affected part diminishes, and assumes a pale or brownish yellow co- lour ; the swelling also begins to subside; the skin acquires a rough and rugose appearance; and on the following day des- quamation takes place. The general or febrile symptoms com- monly follow the progress of the local erysipelatous affection, both increasing and declining together; yet in their respective grades of violence there is often no direct proportion between them, the fever being sometimes severe, with but a moderate local inflammation, and vice versa. In some instances the inflammation gradually passes along the skin, without increasing much in the extent of its surface, disappearing from the parts first affected in proportion as it encroaches on the adjoining sound skin. La Motte gives the history of a case which commenced on the scalp, and in the course of three weeks gradually travelled over the whole sur- face of the body.* Similar cases are related by other observ- ers.! (Reil.) Occasionally, whilst it retains possession of the part first seized, it spreads more and more, until a large ex- tent of skin, and in some rare instances the whole surface of the body is erysipelatous. Salmuth, (cent. i. obser. 3,) relates a case of universal erysipelas. Sometimes the inflammation dis- appears from its original seat, and comes out on some other and often remote part of the body. Such are the general phenomena of erysipelas. It is subject, however, to several prominent modifications, exhibiting import- ant peculiarities both in relation to the character of the local affection and the nature of the attending fever. The true seat of erysipelatous inflammation appears to be in the cutis or the dermoid system generally; and in its simple and regular form, it is in a great measure if not wholly con- fined to this structure. When the inflammation is very active, and extends itself to the subcutaneous and intermuscular cellu- lar structure it assumes somewhat of the character of common phlegmonous inflammation, constituting the erysipelas phleg- * Chirurg. t. i. observ. p. 92. t Ephem. Nat. Curios. Dec. ii. Ann. iii. ob. p. 171. ERYSIPELAS. 447 monodes of authors. This state of the disease is characterized by a decidedly synochal grade of fever ; the pulse being hard, tense, and frequent; a vividly red appearance and an extreme- ly distressing burning heat and prickling pain of the inflamed part; a dry tongue, with urgent thirst; and a tendency to pro- fuse sweats. The swelling usually commences about the second day of the fever; and in a few days more, small vesicles ap- pear on the inflamed skin. When the disease tends to resolu- tion, these vesicles break or subside about the fifth or sixth day; the redness assumes a yellowish hue ; the tumefaction and fever gradually decline, and by the eighth day the old cu- ticle begins to desquamate. Frequently, however, instead of taking a turn to resolution, the pain becomes throbbing, at the same time that the redness diminishes, and more or less exten- sive suppuration of the ordinary phlegmonous character takes place. Sometimes the inflammation extends deeply into the cellular tissue, and appears to commence simultaneously with the ex- ternal or dermoid affection. In cases of this kind, the pain is always extremely severe; the skin tense, and exceedingly pain- ful on the slightest pressure; and the general phlogistic irrita- tion vehement. " The termination, except from energetic treat- ment, is seldom in resolution; the suppuration, which takes place from the fifth to the seventh day, though sometimes sooner, is accompanied with irregular chills ; the redness of the skin and the pain diminish, but the swelling increases; there is much doughiness, and the part remains in that state for some time; in some cases, the pus remains for a long time before an opening is formed in the skin to give it vent, but in general it escapes either by a natural or artificial orifice, mingled with shreds of gangrenous cellular tissue. In these cases the course of the disease is ordinarily tedious, sinuses are formed, some- times sloughing of the skin takes place to a considerable extent, and colliquative diarrhoea often carries off the patient, exhaust- ed by the slow fever and great suppuration." (Cazenave.) In some instances, where cellular inflammation and suppuration takes place beneath aponeurotic membranes, the symptoms be- come still more violent and distressing. In cases of this kind, " violet spots appear on the inflamed skin about the second or third day; these spots increase rapidly, and become covered with vesications ; finally, small eschars are formed which gra- dually fall off, and convalescence takes place under a greater or less degree of suppuration." Thisvariety of the disease is sometimes attended with strong symptoms of disorder of the biliary system, constituting the erysipelas phlegmonodes biliosum of some of the continental writers. Although not an uncommon modification, it has been but little noticed by the English writers. Mr. Copeland Hut- 448 ERYSIPELAS. chinson is, I believe, the only one who has given a particular account of it in the English language. There is, generally, much bilious vomiting in the commencement of this variety of the disease, and throughout its whole course the symptoms of biliary disorder are very conspicuous; the tongue is covered with a brown fur; the tunica albuginea is tinged with bile; and the skin generally exhibits a more or less icterode hue. The fever is of the synochus grade, and suffers very distinct evening exacerbations and morning remissions. The urine is small in quantity, and highly charged with bile; and in many instances bilious diarrhoea attends. Phlegmonous erysipelas may occur on any part of the body, but it most commonly appears on the extremities and face. Bateman says that it most frequently occurs in the face; but Cazenave states that it is most frequently observed on the ex- tremities, and this accords entirely with my own observations. In some cases, the erysipelatous inflammation is early ac- companied by an cedematous state of the affected part, and this is more particularly apt to be the case when the disease attacks persons of a relaxed and Ieucophlegmatic habit, or in such as have suffered much from chronic disorders, or are habitually intemperate. It would seem that in cases of this kind the ca- pillary vessels of the cellular tissue are at first in a highly congested, but not inflamed condition, and that these vessels soon relieve themselves by pouring out serum into the cellular structure. This modification makes its attack more mildly, and is upon the whole less dangerous and distressing than the preceding variety; although sometimes attended with consider- able danger when it attacks the face. The inflamed skin is pale-red, or yellowish-brown, and is attended with but a mode- rate degree of heat and burning pain. The tumefaction does not increase so rapidly as in the phlegmonous state of the dis- ease, and exhibits a smooth and polished surface, and pits when pressure is made with the finger. The vesicles are very minute, numerous, and but little elevated. On the second or third day after their appearance they break and give rise to thin dark-coloured scabs. When the disease attacks the face the swelling often becomes so great as to close the eyes and render the whole face exceedingly bloated, giving it the ap- pearance, as Willan observes, " of a bladder distended with wra- ter." In this case, too, considerable vomiting sometimes oc- curs at an early period, and in the height of the inflammation delirium and coma occasionally supervene, and death takes place under symptoms of cerebral oppression. This modifica- tion of the disease is usually denominated erysipelas cedema- todes. When the disease occurs in weak and nervous individuals, it is apt to assume a typhoid character, and is generally ac- ERYSIPELAS. 449 Companied with low delirium throughout the greater part of its course. In instances of this kind the inflamed part is of a dark or livid colour; the vesicles are not numerous but large, and frequently terminate in gangrenous ulceration. Suppura- tion and sloughing of the cellular tissue usually takes place, " producing little caverns aid sinuses which contain an ill- conditioned pus." This constitutes what is termed by authors erysipelas gangrenosum. In the year 1716, gangrenous ery- sipelas prevailed epidemically at Toulouse; and a similar epi- demic is said to have prevailed in France in 1150. (Reil.) Infants are subject to a modification of erysipelas (E. nea- natorum) of a very obstinate and dangerous character. It usually occurs soon after birth, and instances are related of children having been born with blotches of erysipelatous in- flammation so far advanced as to exhibit vesications and spots of gangrene. (Richter, Bateman.) The inflammation almost always commences on the lower part of the body—particularly about the genitals, nates, and umbilicus, and gradually spreads over the abdomen and along the back and inside of the thighs. In some instances several parts are affected at the same time, without any confluence of the inflamed blotches. The inflam- mation begins by a small red spot, which rapidly spreads irre- gularly over a greater or less extent of the skin. The inflamed part swells considerably, is firm and extremely painful to the touch, and of a dark red or purplish colour. Large but thinly scattered vessels appear, having inflamed livid bases, tending often rapidly to sphacelus. The disposition to gangrene is in- deed always very considerable in this variety of erysipelas, particularly on the abdomen; when it affects the extremities, ulcerative suppuration is apt to ensue. Symptoms of intestinal and hepatic disorder are scarcely ever wholly absent. The alvine discharges are usually frequent, painful, and grass-green; in some cases there is constipation with colicky affections. A jaundiced appearance of the skin, aphtha in the mouth, and acid ejections from the stomach, are very common in this dis- ease. Its course varies from about seven days to three weeks. When deep incisions are made into the affected parts after death, a large portion of thin serous fluid issues,* and the skin exhibits a firmer and thicker structure than in the natural state. Meckel found the umbilical vein, together with the peritoneum inflamed, and he wTas led by this fact to believe, that inflamma- tion of this vein, occasioned by rude management in cutting and tying the umbilical cord constituted the primary disease. This opinion has since been adopted by many, but its correct- ness as yet is by no means established. (Reil, Fieber-lehre, * Osiander. Denkwurdigkeiten, b. ii. st. 2, s. 370.—Neue Denkwur- digk. b. i. s. 56. 450 ERYSIPELAS. b. ii. kap. 5, s. S29.) Richter observes, that this disease in its general character is never purely inflammatory, but always manifestly gastric and irritative. There is another affection which appears to be very closely allied to the present one, if not in reality the same disease, and which is equally confined to new-born infants. This is the induratio telse cellular is, an affection characterized by a pecu» liar hardening, consolidation, or induration of the cellular tis- sue. It is not often met with in private practice, but in some of the foundling hospitals of Europe it has been abundantly observed. The affected part becomes hard, incompressible, and tense; the skin so firmly adherent to the subjacent parts that it cannot be pinched up, or in any way moved from its fixed position. Its colour is violet, pale red, yellowish red, or yellow. It generally commences on the trunk, and gra- dually extends its circle until, in some instances, the whole body becomes affected. The little patient cannot cry out; de- glutition is often difficult, spasmodic, and occasionally impos- sible; the jaws are sometimes closed as in trismus; and inmost cases, convulsive or tetanic spasms ultimately come on. Its course is always rapid—terminating often by the third day, and seldom continuing beyond the seventh. It is a most fatal ma- lady. I have seen five or six cases, but no recovery. There is also an habitual and non-febrile form of erysipelas. It occurs in cachectic persons, in women of a leucophlegmatic habit labouring under menstrual irregularities, and especially in individuals affected with chronic visceral disease, more par- ticularly of the liver. Habitual drunkards also are very liable to this form of the disease, no doubt from the hepatic disorder which is almost always ultimately produced by habitual intem- perance. Although erysipelous inflammation most commonly termi- nates in resolution, yet suppuration and gangrene frequently occur in the more violent grades of the disease. There is some- thing very peculiar, however, in erysipelous suppuration, both with regard to the seat of this process and the character of the pus which is formed. It always commences in the subcutaneous cellular tissue, and the pus generated is very rarely thick, and yellowish like that in common phlegmonous suppuration, but thin, grayish or whitish, somewhat acrid and sanious. The matter is never collected in circumscribed cavities ; it travels along the cellular tissue, under the skin, and between the mus- cles until this structure (cellular) is almost entirely destroyed in the affected part. Small openings finally ulcerate through the skin, and the matter mixed with shreds of sphacelated cel- lular membrane is discharged. Through these orifices large portions of deadened cellular structure may be drawn "resem- bling pieces of wet tow." I have in two instances known this tissue so completely destroyed in the forearm that the skin hung ERYSIPELAS. 451 loose like a bag round the muscles, and the muscles themselves were completely separated as if they had been dissected from each other. Both cases terminated fatally. In instances of this kind, that finally get well, the skin grows fast to the mus- cles, and even the muscles themselves adhere to each other, rendering their action very difficult, and sometimes destroying the free use of the limb entirely. Erysipelas, of whatever variety it may be, is always more dangerous when it attacks the head than when it occurs on the body or the extremities. This arises chiefly from the brain being apt to become oppressed or inflamed in severe cases of the face. Instances occur in which the inflammation passes down into the fauces and along the alimentary canal, giving rise to severe and exhausting diarrhoea. Visceral inflammations of various kinds have been known to supervene during the pro- gress of severe erysipelatous affections. I have seen a case in which pneumonia came on during the height of the disease; and instances are related, in which the inflammation extended along the vagina into the uterus, as well as along the urinary passages to the kidneys.* (Frank.) The brain, however, is by far the most frequently affected in this disease. Does this arise from metastasis of the external inflammation ? This point has been much disputed. Cullen ascribes the cerebral affection to the mere extension of the inflammation from the external part to the brain. This I believe to be correct. I have seen at least half a dozen cases in which symptoms of cerebral inflammation came on; but in no instance was the external inflammation in the smallest degree lessened by this occurrence. It is from the state of the brain, when the disease attacks the face, that we chiefly collect the prognosis. When neither delirium nor coma supervene, either before or during the presence of the inflam- mation, there is generally no cause to apprehend particular danger; but when these symptoms come on the hazard is al- ways great. I am by no means disposed to deny that erysipe- las sometimes passes, by metastasis, from the external to in- ternal parts—or perhaps, more correctly speaking, that visceral inflammation sometimes supervenes at the same time that the erysipelatous affection disappears. I have myself recently seen an instance of this kind. A lady became affected with erysi- pelas on both arms, occupying the whole surface from the hands to the elbows. On the third day the inflammation rapidly sub- sided, and on the following morning she was seized with alarm- ing hsemoptisis. Richter observes that the cedematous and what he calls nervous\ modifications of erysipelas are the most liable to pass upon internal organs. * Reil, loc. cit., vol. ii. p. 372. t He designates those cases by the term nervous, that are attended with a typhoid or typhus grade of fever. They are generally connect- ed with manifest gastric derangements. 452 ERYSIPELAS. What I have hitherto said has a reference chiefly to the local erysipelatous affection. In relation to the character of the at- tending fever important diversities occur, which it maybe pro- per to notice more particularly than has already been done. The most common grade of erysipelatous fever is the syno- chal or strictly inflammatory. In some instances the fever in its onset manifests a typhoid tendency, but as soon as the inflammation appears, its synochal character becomes develop- ed. More commonly, however, the fever begins at once in the character of a well characterized synocha, and this is more particularly apt to be the case in the phlegmonoid variety of the disease. In nearly all instances in which the inflammation attacks the face, the attending fever is of this grade, and it is of course alw7ays more apt to assume this grade in the young, plethoric, and robust, than in aged, infirm, and relaxed indi- viduals. When the fever is synochal it always increases in violence when the inflammation appears. Not unfrequently the attending fever is typhoid, ab initio, and throughout. This is most apt to be tbe case in weak, nerv- ous, and irritable subjects, and particularly in those who are affected with derangement of the digestive organs. Cases of this kind are always much more dangerous than where the fever is of a more active grade; for they are equally liable to the supervention of internal inflammations, and the occurrence of gangrenous suppuration is much more common in the former than in the latter, and of course the system less capable of sus- taining the effects of the disease. Typhus, or as it has been called malignant erysipelas, has occasionally prevailed epidemically. De Haen and Bartholini mention epidemics of this kind, and I have already referred to the epidemic which prevailed at Toulouse in 1716, which is said to have been hut little less fatal than the plague.* Cause.—In relation to the cause of erysipelas nothing very definite can be said. Some individuals appear to be constitu- tionally predisposed to this affection; and Richter supposes that this predisposition depends on a peculiarly irritable and delicate condition of the dermoid system. In some persons, bruises, wounds, and other local irritating causes are particu- larly apt to %ive rise to erysipelous inflammation, and this is more especially the case in injuries of the scalp. The inflam- mation which is produced by the recent leaves of the rhus tox- icodendron is strictly of an erysipelous character. Individuals of a cachectic habit; the habitually intemperate in diet and spirituous drinks; the leucophlegmatic ; and persons labour- * Hippocrates mentions an erysipelas which spread among the people, and proved exceedingly fatal. The whole arm, leg, &c. had their soft parts in some instances almost entirely destroyed by gangrenous ulcer- ation.— Van Swieten's Comment, vol. v. p. 181. ERYSIPELAS. 453 ing under chronic visceral affections, particularly induration of the liver or spleen or mesenteric glands, are most liable to this disease. Strong and sudden mental emotion has been known to produce erysipelas. Richter observes that he has known individuals who always became affected with erysipelas of the face after they had been thrown into a violent fit of an- ger. (Therapie. bd. ii. p. 210.) In some individuals, erysi- pelas returns periodically. (Reil.) These cases are generally slight and soon go off, and are usually dependent on some dis- order of the liver or alimentary canal. Erysipelas seems at times to depend on some peculiar atmospheric constitution or miasm, for it is only to a cause of this general character that we can ascribe its occasional epidemic prevalence. Some wri- ters of eminence assert that the disease is sometimes propagat- ed by contagion ; and there are many facts recorded, which strongly favour this opinion. The disease has, for instance, been known to prevail to a great degree in certain wards of hospitals;* and Dr. Wells has brought forward some exam- ples which occurred in private families, that appear to demon- strate its occasional contagious character.! Its occasional ap- parent contagious character in hospitals may depend, however, merely on a general depraved habit of body produced by the foul air to which the inmates of hospitals are at times exposed from deficient cleanliness and ventilation. Bateman states that this disease has been banished from the Royal Infirmary of Edin- burg, by ventilation and other means of purification. Erysipelas occurs sometimes in the course of fevers, appa- rently from a critical effort of the system to relieve itself from some internal irritation. I have lately witnessed an interesting example of this kind. A person was seized with fever of a re- mitting synochus form. The disease w7as attended with symp- toms of much gastric and biliary derangement. It continued without any amendment for nearly two weeks. At last a vio- lent erysipelous inflammation occurred on the face, which in the course of six days subsided regularly, and left the patient in a state of convalescence. This disease appears also at times on the suppression of some habitual evacuation. I know a gentleman in this city who has been affected, for thirty years past, with an extensive superficial ulceration on one of his legs. Whenever the ulcer becomes dry, which generally occurs seve- ral times during the year, either an erysipelous inflammation occurs on the face or the forearms, or lie is seized with a vio- * " The occasional contagious character which erysipelas assumes is well known to all who have paid any attention to the complaint in the wards of hospitals."—Dr. Johnson, Med. Chir. Rev. October, 1826, p. 404. ■f Transactions of a Society for the Improvement of Medical and Chi- rurgical Knowledge, vol. ii. 1800. (Bateman.) 454 ERYSIPELAS. lent fit of asthma. On the application of a blister to the leg these affections speedily go off. Treatment.—With regard to the general treatment of this disease, it is obvious that it must be modified according to the character of the attending fever; and that a course of reme- diate management which might be very proper in one modifi- cation of the malady, would probably be very injurious in an- other. When the fever is of a high grade of reaction, the treatment should be antiphlogistic. It is not, however, often necessary even in cases of this kind to make frequent and co- pious abstractions of blood—unless symptoms of cerebral in- flammation supervene, with an active state of the circulation. Under such circumstances blood should be promptly and freely drawn, in order to relieve the brain. It does not appear, how- ever, that any particular impression is often made on the pro- gress of the erysipelatous affection itself—at least not on its obvious condition—by venesection ; although unquestionably frequently very useful in obviating some of the unfavourable consequences of the inflammation. When the pulse is frequent, tense, and hard, bleeding ought by all means to be practised, and carried to the extent which may be indicated by the state of the circulation, without any regard to the appearances or character of the local affection. With regard to the propriety of local bleeding by leeches, very discrepant sentiments'are expressed by authors. Willan, Thomson, Richter, and others speak decidedly against this practice, and from what I have myself seen of it, there appears to me much foundation for rejecting^. In the only case in which I have employed leeches, several very obstinate ulcera- tions occurred, apparently in consequence of the leech-bites. Cazenave speaks favourably of this mode of depletion ; but he very properly cautions against applying the leeches to the in- flamed surface. It must be observed, however, that although some advantage may be derived from the application of leeches a small distance from the eruption, yet as the inflammation is apt to spread, this will not always obviate the evil consequences which are apt to result when they are used on the inflamed part. Purgatives are useful in every variety of the disease. When the disease attacks the face they are particularly serviceable. In the ordinary phlegmonoid form, the saline purgatives are in general the best; but where symptoms of gastric derange- ment attend, calomel in small and repeated doses, assisted by an occasional saline aperient, is preferable. In the bilious modification, the exhibition of an emetic will often prove par- ticularly useful. After the operation of an emetic in this va- riety of the disease, large doses of calomel should be given until the bowels are freely moved. Reil says that in cases at- ERYSIPELAS. 455 tended with fever of a synochus, inclining to the typhoid grade, emetics are highly serviceable. "If the disease has continued for some days, and the more direct antiphlogistic remedies may no longer be deemed proper, and the inflamed part assumes a pale yellowish hue and is somewhat cedematous, with but a moderate degree of heat and pain, emetics will ge- nerally arrest the progress of the disease effectively."* The regular action of the cutaneous exhalents should be sup- ported by diaphoretics of the refrigerent kind. The saline mixture with a small portion of tart, emetic; spiritus minde- reri, according to the formula mentioned at page 132; or the sal ammoniac mixture mentioned at page 83, will answer well for this purpose. Small portions of calomel and ipecacuanha in union are peculiarly beneficial in this disease,! more espe- cially in the erysipelas of infants. Throughout the whole course of infantile erysipelas, our principal aim should be to restore the regular action of the liver, alimentary canal, and the cutaneous function ; and hence calomel and ipecacuanha in the proportions just mentioned, with an occasional dose of magnesia or castor oil, and warm bathing constitute, so far as my own experience enables me to judge, the most useful course of internal treatment in this variety of the disease. When the attending fever is typhoid, direct depletion will of course be improper. In cases of this kind bark and wine have been much recommended ; and where the symptoms of pros- tration are great, it will be necessary to employ them actively. I have used cinchona in conjunction with the carbonate of am- monia with much advantage in a few cases of this kind. The quinine, however, would appear to be the best tonic in this modification of the disease. I have had occasion to prescribe it in but one instance of this kind, and its effects in this case were highly gratifying. But although tonics and stimulants are essential in cases of this low grade of reaction, mild laxatives are almost equally necessary. The bowels are almost invariably loaded with ir- ritating matters, which, if not removed, tend strongly to op- press and prostrate the powers of the system. In instances of this character, it will be proper to exhibit laxatives conjointly with stimulants, and to continue the use of the latter during as well as after the operation of the former. In what is called the gangrenose modification of the disease, the fever always assumes a low grade in its progress, however active it may have been in its early stage. Where manifestations of ap- * Fieber-lehre, bd. ii. p. 398. f R. Calomel gr. ii. Pulv. ipecac, gr. iii. Sacch. albi. gr. xii. M. Divide into twelve equal parts. S. One to be taken every four hours by an infant. 456 ERYSIPELAS. proaching gangrene come on, or where this process has already commenced, wine, opium, camphor, quinine,* and the mineral acids are the remedies upon which our reliance must be placed. Free purging with active doses of calomel in the early period of the disease will, however, always p< rhaps render the ne- cessity of tonics and stimulants in the latter stages much less urgent than when this evacuation has not been sufficiently ef- fected. It should always be recollected in prescribing for fe- brile diseases, that intestinal irritation, from whatever cause it may proceed, has a powerful tendency to oppress or pros- trate the vital powers; and that, under due precautions, the debilitating effects of purgatives are greatly exceeded by the increased energy imparted by the removal or diminution of such sources of irritation. Should the inflammation terminate in suppuration and slough- ing, opium and camphor with quinine or cinchona are indis- pensable in all cases. Opium is particularly valuable under circumstances of this kind, by allaying general irritation and supporting the action of the heart and arteries. Opium may be given advantageously in combination with quinine; and in several instances of extensive suppurative ulceration in this disease, I have known much benefit derived from the extract of conium in union with camphor given at short intervals in full doses. Upon the whole, however, bark or quinine in large doses, and opium may be regarded as the most useful support- ers in such cases. Where the pain and irritation are great, opium after proper evacuation, seldom fails to procure much relief. It should be given in full doses, at the same time that cold applications are made to the scalp and forehead. When secondary inflammation occurs in some internal or- gan, recourse must be had to local and general bleeding if the pulse remains sufficiently active, and in all such cases, cupping, sinapisms, blisters, and the other usual revulsives are indis- pensable. In cases attended with prominent cerebral disorder, such as delirium, coma, or insensibility, active purgatives and stimu- lating enemata are indispensable. For this purpose the ol. te- rebinth, has been found especially efficacious. Mr. Cox has given an account of a case where erysipelas of the scalp, face, and breast, attended with delirium, succeeded by coma and in- * This article has of late years been much recommended, and deserv- edly so, in erysipelas of a typhoid tendency. Sir Astley Cooper in his Lectures gives the following, as, in general, the most successful mode of remediate management. " At first, give calomel for the purpose of restoring the secretions of the liver and intestines, and the liquor am- moniae acetatis with antimony to act upon the secretion of the skin, and then give the sulphate of quinine." ERYSIPELAS. 457 sensibility, with other symptoms portending a fatal termination, which was successfully treated by the daily use of the turpen- tine combined with castor-oil both by .the mouth and per anum. This medicine brought away large offensive stools, and from the first dose the symptoms gradually subsided.* Some diversity of opinion exists with regard to the proprie- ty or usefulness of local applications to the affected part. Bate- man observes, "that with respect to external applications in the early stages of erysipelas, experience seems to have decided that they are generally unnecessary, if not prejudicial;" and the same observation is made by Cazenave and Schedel. My own experience has led me to a different conclusion. I have certainly never seen the least injury done by suitable applica- tions of this kind; but, on the contrary, often the most decided benefit. Formerly physicians were much in tbe habit of ap- plying cooling or relaxing remedies to the inflamed surface— such as lead-water, cold water, emollient poultices, fomenta- tions, &c. That such applications should prove useless, and often injurious, may be readily admitted. There exists a close analogy between the inflammation of erysipelas and that pro- duced by a scald or slight burn. In both, the capillaries of the inflamed part are debilitated, congested, and passively distend- ed, and in both, therefore, the best applications are such as are capable of exciting or stimulating these vessels to increased tone and activity. For a number of years I was in the habit of using a solution of corrosive sublimate in the proportion of about four grains to the ounce of water, and generally with a satisfactory result, f Pieces of linen or flannel moistened with this solution should be laid over the inflamed part, and renew- ed until the inflammation begins to subside. During the last four years, however, I have invariably used the nitrate of sil- ver in solution, in the proportion of five or six grains to the ounce of water, and uniformly with prompt and complete suc- cess. This solution is to be applied in the manner just men- tioned for the sublimate wash. The mercurial ointment has been a good deal used in this country as an application to ery- sipelous inflammation.^ I have myself employed it in several cases; in one, it proved very useful, but in the others, it afford- ed little or no advantage. It is to be applied by spreading it on pieces of linen and laying them on the inflamed part. Dr. Brodie of London, from some experiments he made with this * Lond. Med. Repository, April, 1825. f I learned the use of this remedy in erysipelas from Dr. Schott of this city. X This remedy was first introduced to the notice of the profession by Dr. Dean of Harrisburg, although I have learned, that in the interior of this state, it was long before used in this affection by several respecta- ble practitioners. Drs. M'Lellan and Lewis employed it before Dr. Dean became acquainted with its use 58 458 ERYSIPELAS. ointment, came to the conclusion that its good effects depended more on the adepose substance, than on the mercurial oxide combined with it, and in subsequent trials, he used only simple ointment, which in some instances, he says, proved quite as useful as the mercurial unguent. Lard has also been used in this city, and it is said, with considerable benefit. Brodie ob- jects, and with justice, to the mercurial ointment on account of its tendency to produce salivation; for in other respects, " its utility seemed unquestionable." Dr. Dewees also speaks highly of this ointment, but makes the same objection to its use. Blisters applied to the inflamed surface will often promptly arrest the progress of the inflammation. Dupuytren speaks very favourably of this practice, and it has long since been a favourite remedy with many practitioners both in this country and in France. My own experience enables me to say very little of this application. I have resorted to it only in two cases; one of these terminated in extensive suppurative ulcera- tion ; the other was benefited by it. Blistering is said to be most useful where there is but a moderate degree of febrile re- action, with a moist and slightly red tongue, and a somewhat hot and tense skin. The blister must be laid directly oyer the inflamed part, and be large enough to extend a small distance on the sound skin. Velpeau and Bretonneau speak highly of the efficacy of compression by bandages in phlegmonous erysipelas; and their statements do not permit us to doubt that, in some instances at least, much benefit may be derived from this practice. When the disease affects one of tbe extremities, compression may be easily made; but in the face it is impracticable. It is only in the early stage of the complaint, before vesication occurs, that this practice can be advantageously or safely adopted. In a case which I have attended within the last eight days, I had a satisfactory illustration of the usefulness of this measure. Ne- vertheless, statements have been published unfavourable to this practice; and Cazenave apprehends, though apparently not from any experience, much mischief from it. Several late English writers strongly recommend making incisions into the affected part. Mr. Lawrence says, they are most useful when made soon after the commencement of the in- flammation; and he recommends that they should be extensive- ly used. Mr. Hutchinson also is in favour of free incisions; but other writers speak more favourably of small ones. It is only in the phlegmonode variety of the disease, that this prac- tice has been found useful. Mr. James speaks in doubtful terms of the utility of this practice. He states, that in the cases in which he tried incisions, he did not obtain all the advantage which he was led to expect from Mr. Hutchinson's report of ERYSIPELAS. 459 this practice. Several writers strongly protest against this measure, affirming that the wounds are apt to run into morti- fication. Mr. James did not find this tendency to mortifica- tion so great as some appear to apprehend. MINOR EXANTHEMATA. Herpes. The term herpes, was formerly applied in a very vague man- ner, and the German writers still include under its head vari- ous chronic affections of the skin, which by the late English and French writers, are regarded as wholly diverse from each other.* Willan first employed it in a definite manner, and restricted its application to a distinct class of cutane- ous affections, characterized by an eruption of vesicles, ap- pearing in groups or clusters on an inflamed surface, "so as to present one or more distinct spots separated from each other by intervals Of sound skin." In most instances, manifest constitutional disorder, such as langour, loss of appetite, rest- lessness, and occasionally febrile symptoms, with a burning or stinging sensation, or deep-seated aching pain in the affected parts, precede the appearance of the eruption. There is a regular increase, maturation, and decline in the progress of the eruption, but the duration of its course varies from one to three weeks. The fluid in the vesicles is at first limpid, be- coming opake or whey-like and more viscid as the disease advances, and at last either concretes into brown crusts, or the vesicles break, and suffer it to escape, in which case disagree- able and unmanageable ulcerations often ensue—(Bateman.) The diagnosis of herpes is founded on the assemblage of the vesicles in separate clusters ; the red or inflamed state of the skin upon which they are seated, and the natural colour of the intermediate spaces of skin. These characteristics distinguish it sufficiently from erysipelas. From tetter (impetigo,) eczema, * Richter arranges ptyriasis, psoriasis, ecthyma, and various species of impetigo with the herpetic affections His fourth species, herpes pustu- losus, comprehends the five varieties of herpes of Willan. The minute splitting of diseases, so common of late, may be regarded of very doubt- ful advantage, both in a scientific and practical point of view. A care- ful comparison of many of these species—their variable character, and their frequent conversion into each other—shows at once the little found- ation there exists for at least some of these subdivisions. The affections arranged under the term herpes, by Willan and others, are however sufficiently distinct in their character, and diverse from other analogous disorders, to require separate consideration; and it is of little conse- quence what name they bear, provided they are properly described and understood. 460 HERPES PHLYCTENODES. and other forms of chronic eruptions, it differs in its purely vesicular form, its more acute character, and particularly in the regular progress of the vesicles from their incipient trans- parent state to maturation, and finally scabbing. Herpes admits of being divided into different varieties, ac- cording to the particular form of the vesicular clusters, and the part of the body upon wliich they appear. HERPES PHLYCTENODES. This variety of herpes may occur on all parts of the body, having no determined form or seat. The appearance of the eruption is usually preceded, for several days, by slight febrile symptoms, and these sometimes continue after the vesicles have come out. On the part which is about to be the seat of the eruption, we may at first notice a multitude of very minute red points. In the course of twenty or twenty-four hours more, the skin upon which these points appear, becomes uniformly red; and small transparent vesicles make their appearance. The cutaneous efflorescence extends a few lines beyond the margin of the vesicular group; and the vesicles themselves are firm and resisting to the touch during the first day. A sense of smarting, and occasionally a dull and severe pain accompanies the appearance of the eruption—(Cazenave.) The eruption most commonly occurs on the upper parts of the body, particularly on the neck, breast, arms, and cheeks. It consists of small transparent vesicles, aggregated into irregular clusters of various sizes, from a few to nine or ten inches in circumference. These vesicles are sometimes very minute, and at others they are as large as a small cherry. In some instances they come out at first on the neck or breast, *' and gradually extend over the trunk to the lower extremities, new clusters successively appearing for nearly the space of a week." This gradual extension of the eruption occurs very rarely, however, except in cases where the vesicles are very minute. In general the eruption is confined to one or two groups when the vesicles are pretty large. About the fourth or fifth day the vesicles either burst and give exit to the included fluid, or they begin to wither and concrete into yellowish scabs, which usually fall off about the eighth or tenth day, and leave a red and irrita- ble surface. When the eruption appears in successive groups on different parts, the disease will of course be pro portion ably prolonged ; for each cluster passes regularly through its stages of maturation and scabbing. However contiguous the groups of vesicles may be to each other, the intervening skin always retains its healthy appearance—(Bateman.) HERPES PHLYCTENODES. 461 Diagnosis.—The only affection with which the present form of herpes is particularly liable to be confounded is pemphigus; but an attention to the circumstance that tbe vesicles in pem- phigus are usually large, and always isolated—or at least not aggregated in clusters; and that they are very rarely attended with a red or inflamed basis, (unless where the bullae are nearly in contact with each other) will enable us without difficulty to distinguish these affections. Causes.—Children, and young and robust persons appear to be most liable to this affection ; but of its predisposing and ex- citing causes we have no definite knowledge. Cold, improper nourishment, or an excess of food, grief, watching, and irrita- tion in the primse vise have been supposed to exercise an agency in its development. HERPES ZOSTER Shingles, Zona. This disease bears a very close resemblance to erysipelas, and was generally regarded as a mere variety of this affection, until Willan pointed out its distinctive characters, and placed it with the herpetic eruptions. This form of herpes is charac- terized by a band of vesicles, seated on a red or inflamed sur- face, commencing usually either in the right hypochondrium or lumbar region, and extending like a belt towards the fore part of the abdomen, without however crossing the median line. In some instances this band of vesicles passes down to the groin ; in others it passes upwards to the inferior angle of the scapula, and sometimes extends to the internal part of the arm, "running down occasionally to the cubital border of the hand." We rarely find this eruption on the left side of the body; indeed I have never seen an instance of its location on this side. It has never been found to occur on both sides at the same time. These vesicular zones are composed of irre- gular groups from one to two or three inches in diameter; and where the clusters are not very close to each other, the inter- mediate skin retains its healthy colour. The extension of the band does not occur by a regular succession of vesicles, but by successive new clusters coming out nearly in a line with the first. This, like the preceding variety of herpes, is generally preceded for a few days with loss of appetite, lassitude, slight headach, nausea, more or less febrile irritation, " together with a scalding heat and tingling in the skin, and shooting pains through the chest and epigastrium." In some instances, however, little or no constitutional symptoms can be perceiv- 462 HERPES ZOSTER. ed.* At first vividly red blotches appear arranged into an ir- regular belt, a short distance from each other. Upon these inflamed surfaces, a number of small whitish points appear, which soon increase in size, and become distinct transparent vesicles "of the size and appearance of small pearls." These vesicles increase in magnitude until the third or fourth day, when they acquire a yellowish or milky appearance, and on the following day begin to shrivel, at the same time that their bases acquire a darker red, or bluish colour. The vesicles about this time break and discharge a viscid serous fluid which dries into brownish crusts, which fall off about the tenth or twelfth day. Sometimes excoriations and occasionally super- ficial ulcerations occur, leaving strongly marked cicatrices. The disease does not, however, always pursue this regular course. In some instances the vesicles dry up about the fifth or sixth day—the fluid in them being absorbed—and terminate without scabbing, by desquamation. In old and enfeebled sub- jects the eruption has been known to terminate in gangrenous ulceration of the skin. Causes.—Zona is most apt to attack young persons ;f and it is said to occur more frequently in males than females. (Bateman, Cazenave.) Reil asserts that this affection has ne- ver been observed in children under three years old. It seems occasionally to arise from the influence of bold ; and some have ascribed its occurrence to irritation of the urinary or- gans. (Reil.) Disorder or irritation of the pritnse vise, and perhaps of the biliary organs has appeared to me in some in- stances to be at the root of the disease. It is said to have pre- vailed epidemically. (Cazenave.) Prognosis.—This form of herpes is but rarely attended with severe symptoms. When it terminates in ulceration it may * Cazenave and Schedel observe," We have seen a great number of in- stances of zona in the Hospital St. Louis, and have never seen it accom- panied with those general symptoms, and particularly of a gastric nature, with which it has been asserted it is always attended; a state of uneasi- ness, in some rare cases a slight excitement of pulse, heat of the skin, a sensation of tension which is generally painful about the seat of the eruption, acute pain in those parts where the disease terminates in ulcer- ation, and finally a slight local pain remaining some time after the eruption has disappeared (not acute as has been said) are the only phe- nomena which, in a majority of cases at least, accompany this variety of herpes."—Practical Synopsis, p. 104. t We often meet with perplexing discrepancies in the statements of different writers, on points too which are matters of mere observation. Thus, in the present instance, Reil's observations are directly opposed to those of Willan, Bateman, Cazenave and others. " Of the causes of zona, we know at least that those who are most subject to it are old and cachectic persons, with a relaxed skin and visceral disorders." Fieber- lehre, bd. v. p. 399. My own observations, however, lead me to the opinion expressed in the text upon this point. HERPES ZOSTER. 463 become troublesome; and the occurrence of gangrene, which, however, is very uncommon, will of course be attended with more or less danger, according to its extent and the patient's constitutional vigour.* Treatment.—The treatment of herpes phlyctenodes and zona, is to be conducted on the same principles. Gentle aperients, a simple and unirritating diet, and rest will, in general, suf- fice for the constitutional treatment. When there is consider- able restlessness, and some degree of febrile irritation, we may prescribe mild diaphoretics and cooling acidulated diluents. Where there is reason to suspect gastric or biliary irritation, minute portions of calomel and ipecacuanha will be proper. The warm bath will also be useful to allay restlessness and dispose to a regular action of the skin. Occasionally the arterial ex- citement is such as to warrant small abstractions of blood by venesection or leeching. Reil recommends particular attention to the renal functions, and advises diuretics where the urinary secretion is scanty. Where there is much deep-seated pain, we may use full doses of Dover's powder with benefit. Bateman considers external applications unnecessary during its vesicular state ; and Cazenave asserts that " they are use- less." My own experience has led me to a different conclusion. It is indeed true, that "saturnine and other similar astringent lotions" are of little or no service. I have, however, uniformly found the application of a solution of lunar caustic, in the pro- portion of six grains to an ounce of wrater, when employed soon after the vesicles appear, to arrest the progress of the eruption, and cause desquamation in the course of three or four days at furthest; and sometimes much earlier. I have never known the slightest inconvenience to result from this practice. I keep this solution constantly applied to the affected part, by strips of linen or flannel saturated with it.f HERPES CIRCINATUS. Ring-worm. This form of herpes is easily recognized by the annular ar- rangement of its small vesicles. It commences with slight red- * In relation to the prognosis of this affection we find very different sentiments expressed by the old writers. Pliny, Lannge, Dr. Hoffmann, and Shulze considered it as a dangerous disease; whereas Bursirius, Vo- gel, Lorry, and Diel assert the contrary opinion.—Reil, loc. cit. vol. v. + The lunar caustic was, I believe, first used as a local application in this affection, by M. Geoffroy.—Revue Medicale, April, 1820. 464 HERPES CIRCINATUS. ness and itching, succeeded by a circle of minute globular vesicles closely set together, which when closely examined are found to contain a colourless fluid. These coronse of vesicles vary from an eighth of an inch to two inches and upwards in diameter, and the larger ones leave the central portion of the skin apparently in a natural state. The vesicles break in four or five days after their appearance, and are succeeded by little prominent, brownish, and thin crusts or scales, which in the majority of cases fall off about the eighth or ninth day, leaving a red surface which gradually disappears. Occasionally the whole disk of the circle is somewhat inflamed, "and a slight desquamation occurs without the formation of vesicles." When the circles are very small the eruption withers, and gradually exfoliates without the formation of crusts or scales. Although the eruption is seldom protracted beyond the tenth day, yet in many instances new circles of vesicles appear, in succession, so as to prolong the whole course of the disease for several weeks. The eruption is always attended with a troublesome itching and tingling sensation. This variety of herpes is most frequently met with in chil- dren, and occurs generally on the arms, shoulders, breast, and especially on the neck and face. This disease must not be confounded with a somewhat simi- lar affection which occurs only on the scalp, (porrigo scutula- ta,) and which is familiarly known by tbe term hair-ioorm. This disease is contagious, destroys the hair, and is pustular. Its duration is indefinite and long, and it gives rise to the for- mation of thick adherent scabs. There is a variety of ring-worm, not noticed in the work of Cazenave, though described by Bateman, wliich is by no means uncommon in this country, and which often continues for many months, and at last takes up a large extent of sur- face. It commences with a small circle of vesicles, like the form just described. This circle, however, gradually enlarges its circumference, by the successive appearance of new vesi- cles around the external margin of the ring, whilst those situa- ted on its internal margin heal and desquamate. Treatment.—The treatment is almost exclusively local. Alkaline washes, such as a lotion of from one to two drachms of subcarbonate of potash or soda to a pint of water; or solu- tions of nitrate of silver, sulphate of zinc, or of copper. One of the best applications I have met with in this affection, is an ointment made of the root of the common narrow-leafed dock, {rhumex crispa) by boiling the grated root in lard. Mild lax- atives should be used if the eruption is extensive. HERPES LABIALIS. 465 HERPES LABIALIS. This is a vesicular eruption which occurs on the upper and under lips, and particularly at the outer angle of the lips, ex- tending sometimes nearly round the mouth, and occasionally to the cheeks, alee nasi, and chin. In some instances this erup- tion appears almost suddenly without any previous redness or disagreeable sensation in the part; and at others it is preceded by slight tenderness or pain, inflammation, and swelling of the skin, for three or four hours. The lip generally becomes some- what swollen, hard, stiff, and tender. The vesicles sometimes "attain the size of a small pea, and are filled with a transpa- rent fluid," which soon becomes opake, acquiring a straw-co- lour, or sero-purulent appearance during the third or fourth day. In the course of a day more they shrivel, and are suc- ceeded by light-brown scabs, which usually separate on the seventh or eighth day. This eruption is always attended with very considerable heat and smarting, and great soreness to the touch. This variety of herpes does not often occur as an idiopathic affection. It generally appears on the subsidence of slight fe- brile affections from cold, as well as on the declension of other acute diseases, more especially such as are connected with vis- ceral affections. It may in fact be considered, in cases of this kind, as a phenomenon of crisis, for it is a common, and in ge- neral not an incorrect observation, that the occurrence of this eruption indicates the near approach of convalescence. In many instances it is accompanied by coryza, and pain or ten- derness in the fauces. It may be produced by irritating appli- cations to the lips. The only remediate applications necessary in this affection are such as palliate the burning heat and pain, when these are troublesome. For this purpose, fomentations, with a decoction of white poppy heads; or cold water, with a small portion of acetate of lead dissolved in it, may be used. HERPES PREPUTIALIS. This variety of herpetic disease, occurs on the prepuce and may readily be mistaken for chancre, to which indeed it some- times bears a very close resemblance. It begins with one or more red spots, attended by itching, and a sense of slight heat in the part. Small vesicular elevations soon appear on these inflamed surfaces. When the eruption occurs on the external 59 466 PEMPHIGUS. surface of the prepuce, the vesicles dry up about the sixth day, and are converted into small, firm scabs, which usually fall off by the end of the ninth or tenth day, and leave the skin un- derneath sound. When the eruption occurs on the internal surface of the pre- puce, they generally break about the third or fourth day, and form small scales, which soon separate and leave excoriations, passing sometimes into superficial ulcerations, with white bases, and slightly elevated edges. If left to themselves, or not irritated, these sores continue nine or ten days before they begin to heal, but when they once commence this process they usually cicatrize rapidly. This affection may arise from the prepuce being chafed by woollen clothing; from the irritation of morbid vaginal dis- charges; and particularly from suffering the natural secre- tions of the part to remain between the glands and prepuce. Treatment.—I have generally employed a solution of borax with much advantage in this affection. When the excoriations are slow in healing a very weak solution of the nitrate of sil- ver is perhaps the best application. I have used this solution in a number of cases with prompt benefit. The chlorite of soda in solution is likewise a very efficacious application in cases of this kind. I have lately employed this lotion in two obstinate cases with marked success. It was first recommend- ed by Lisfranc. I used this article in the proportion of twenty grains to an ounce of water, and applied it five or six times daily. CHAPTER XXV. PEMPHIGUS.* The term pemphigus is used to designate a peculiar exan- thematous affection, characterized by fever, followed in the * The first distinct account that was given of this disease is to be found in the writings of Piso (observ. 149) and Morton (tract, de morb. acut.) It has since been described under a great variety of names—such as, febris catarrhalis vesicularis, (Delius. amaenitat. med. dec. 1;) febris vesicularis, (Macbride and Selle, prax medic. 1.11. c. 18;) febris pemphy- godes, (Seeliger, Ephemer. N. C. dec. 1, ann. viii. ob. 56;) febris phlycte- nodes, (Bursirius;) hydatides, (de morbis a colluvie serosa ott^;) febris bullosa, (Brugmann.) PEMPHIGUS. 467 course of from one to three days with large transparent vesi- cles, having red and inflamed bases. The occurrence of such a disease, as an independent or idiopathic affection, has been much doubted by many writers, and some have even denied its existence altogether. Willan, Bateman, Plumbe, Reil, and a number of other writers contend that the cases which are described by the earlier writers as acute idiopathic pemphigus were—typhus, pestilential, or other milder forms of fever, at- tended by bulla?, as mere casual symptomatic and unessential eruptions. Gilbert,* and Biett,f on the other hand, admit the occasional appearance of acute pemphigus, as an idiopathic ma- lady. There can exist but little doubt that many of the cases described by authors as pemphigus, were in relation to their vesicular character purely symptomatic; for bullse entirely similar to those which are ascribed to this affection have been known to occur in diseases obviously diverse in their general essential characters. They have occurred in intermitting fever ;\ in bilious remittents ;§ in dysentery ;|| in typhus ;f[ in various modifications of malignant as well as in arthritic fevers ;** in hysteric affections ;ff and in the ordinary ca- tarrhal fevers, as well as in various other dissimilar febrile diseases. Cazenave states that he saw a case in the Hospital of St. Louis, in which " this eruption was attended not only with gastro-intestinal irritation, but also with a pulmonary catarrh, an ophthalmia, and a very acute inflammation of the urethra. All these symptoms, together with the eruption, dis- appeared in the course of a month." It is difficult to conceive upon what grounds he regards this as a case of idiopathic pem- phigus ; for in its general course and phenomena it is greatly at variance with his previous description of this affection. Most assuredly if this case deserves to be regarded as an instance of pemphigus, we may with little hesitation admit the many sup- posed examples of this disease, which have been reported by different writers (but rejected by Cullen, Willan, Bateman, and Reil) as genuine, though modified instances of this affec- tion. Under this perplexing contrariety of statements and opinions, it is no easy matter to come to any satisfactory con- clusion on this head. That the appearance of bullse or large distinct vesicles in febrile affections is often casual or symp- * Monographic sur le Pemphigus. t Cazenave and Schedel. Pract. Synop. of Cutan. Diseases. X Braune. Versuch uber den Pemphigus, &c. Leipzig, 1795. § Salabert. Abhandl. fur pract. arzte, vol. xiii. II Bontius. De Medic. ^Egyptiorum. Rengger. Museum der Heib- kunde, Zurich, 1794. 1T Medecine Experimentale. ** Hufeland's Journal, vol. xi. p. 138. tt Frank. Epitome, torn. iii. p. 269. 468 PEMPHIGUS. tomatic, and sometimes apparently critical, is unquestionable ;* but it is nevertheless difficult to deny, merely from this gene- ral fact, that they may appear in an acute form as an idiopa- thic or independent malady. Whether, however, this eruption be always, or only generally symptomatic, I shall now describe it, as it has been observed and recognised for genuine acute pemphigus by several recent writers who must have been fully acquainted with the doubts expressed on this subject by Cul- len, Willan, and others, and who, we may therefore presume, were better prepared to estimate the character of the disease than the earlier writers. Pemphigus appears under two distinct forms: the acute and the chronic. The latter form is described by Willan, Bate- man, and other late writers under tbe name of pompholix. Symptoms of acute pemphigus.—The disease commences with symptoms of general indisposition, or more or less strong- ly developed febrile irritation. In some cases, these precur- sory symptoms amount only to a feeling of general languor and uneasiness, with slight acceleration of the pulse, and itch- ing of the skin. In others, nausea, loss of appetite, slight chills, increased thirst, and great frequency of the pulse, with a hot and burning skin precede the eruption. At an indefinite period from the commencement of these symptoms—varying from one to four days—the eruption makes its appearance. At first, small red circular spots come out, which speedily increase in size, each one becoming covered with a transparent vesicle. These vesicles or bullse are of a circular form, and vary from the size of a pea to that of a large hazelnut. Sometimes the bullse are much smaller than the red spots upon which they are seated, leaving a considerable inflamed margin around their bases; at others, they cover nearly the whole surface of the circular spots, with only a very narrow line of red border. Cazenave and Schedel seem to regard these red areola? or bases as invariably present and strongly characteristic of acute pemphigus. Richter, however, observes that the bullse some- times appear to rise out of a sound skin without the least red- ness around their bases. Some spots occasionally appear on the skin which do not vesicate; but to the touch they will be found slightly elevated, " and when they are rubbed for a short time, the cuticle becomes detached, and a slight exudation of serous fluid takes place under it." The bulla? increase in size during the first twenty-four hours, and the contained fluid, at first limpid, becomes yellowish and * Frank saw an instance of an inflammatory fever, in which after the fifteenth venesection a critical pemphigus broke out.—De Curandis, Horn. Morb. L. Ill, p. 265. PEMPHIGUS. 469 finally turgid.* They sometimes break on the second day; but much more commonly they remain in a turgid state to the end of the third or beginning of the fourth day, when the fluid begins to be absorbed, and th evesicles shrivel, leaving either thin brownish crusts, or only "small dry white epidermic lamellse," which in a few days longer separate, exposing pale red sur- faces, f If the bullse are broke at an early period, they some- times rise again, but more frequently superficial suppurative ulcerations ensue. (Richter.) The occurrence of the eruption has no manifest influence on the general symptoms, the fever continuing usually without any particular change until the bullse begin to wither. (Rich- ter.) The eruption may come out on any part of the body, and either occupy only a particular region, or appear scatter- ed over the greater part or the whole surface of the body. In most instances, however, the bullse are confined at first to a single part; and when these begin to disappear, another crop comes out on some other portion of the body ; and in this way, two or three successive eruptions may take place, so as to pro- tract the whole course of the disease sometimes to the period of between two and three weeks. The internal mucous sur- faces also are liable to become affected, particularly the mouth, fauces, and cesophagus, and probably the mucous membrane of the alimentary canal. The pompholix solitarius of Willan, is according to Cazenave and Schedel a mere variety of acute pemphigus. This is an extremely uncommon form of the disease, and may assume a more or less chronic character, although its usual duration is from eight to ten days4 Willan says that it seems to be en- tirely confined to females. A sensation of tingling of some portion of the skin is at first felt, which is succeeded by one large vesication (appearing usually at night,) which is rapidly filled with a transparent colourless lymph. This large bulla breaks in the course of forty-eight hours, and leaves a superfi- cial ulceration. In a day or two a second vesication occurs near the first one, which runs through the same course; and a third or even a fourth one may rise in succession, so as to pro- tract the disease to the ninth or tenth day. (Bateman.) * This fluid has been noticed acrid or irritating, like the tears in vio- lent catarrh. Occasionally it is reddish, as if a small portion of blood were mixed with it. Very generally, however, it is perfectly bland and unirritating, at least in the early period of the eruption.—Richter, Spe- cielle Therapie, bd. ii. p. 604. j The spots left by this eruption are said to be peculiar. " We have several times seen M. Biett draw a diagnosis from them as to the pre- vious existence of bullar eruption, which had been cured some time be- fore. They are of a dull red colour, separated from each other, of an irregular form, of variable size, and form slight exfoliations from time to time.»—Cazenave and Schedel, I. c. p. 129. X Cazenave, Synopsis, &c. p. 124. 470 PEMPHIGUS. Chronic pemphigus.—Willan and others who deny the exist- ence of acute idiopathic pemphigus, describe the present va- riety of the disease as a distinct affection, under the term pom- pholix. They assert that the bullse appear " without any inflammation around them and without fever." This, says Richter, is not entirely incorrect. In many cases the disease commences with distinct febrile symptoms, which continues occasionally until the first eruption is completed; and in some instances the slight fever reappears afterwards whenever a new and numerous eruption of bullae is about to take place.* In almost all cases the patient experiences a slight degree of lassi- tude, pain in the limbs, and languor, for several days previous to the appearance of the eruption. Nor does the observation that the bullse are always " without any inflammation around them" appear to be correct, for in some instances " the secon- dary eruptions have erythematous areolse." (Cazenave.) The bullse begin by small red elevated points, on the centre of which the epidermis becomes speedily raised. These rapidly enlarge " into irregular vesications, acquiring often in a few hours the size of a hazelnut or even a walnut." If they do not break they begin to shrivel about the third or fourth day, the fluid contained acquiring a reddish and opake appearance. In a few more the withered and macerated cuticle dries into thin brownish crusts. If the bullse break at an early period " the cuticle shrivels, or becoming partly detached rolls up and lays bare a portion of the inflamed surface," or separates entirely and exposes a painful superficial ulceration. (Cazenave.) This affection is generally very tedious in its course, and may continue for several years. A continual succession of bullse break out on different parts of the body, sometimes in successive crops, and at others in such a manner that, at the same time, some will be just appearing, others will be large and distended with a straw-coloured lymph, and others again shrivelling, or already converted into small crusts. Occa- sionally the eruption is so numerous that many of the bullae run into each other, and in this case some of them usually be- come purulent, and on drying up leave thin yellowish crusts extending over a considerable portion of the body. When the eruption is moderate, the patient does not in ge- neral experience much inconvenience from the disease; but in cases attended with numerous vesications, and particularly where the lymph is somewhat irritating, a burning and ex- tremely distressing itching is experienced, which in violent cases sometimes obliges the patient to keep to his bed. * Specielle Therapie. bd. ii. p. 613. Reil says that in some cases the febrile symptoms are conspicuous in the commencement, but that these gradually subside, leaving only a chronic bullar eruption, which conti- nues often for many months, and even years. Loc. cit. p. 428. PEMPHIGUS. 471 In some instances the vesicles are early attended with severe burning pain, become filled with a red acrid humour, and ter- minate in superficial suppurative ulcers which heal very slow- ly. Reil observes that bullse of this kind, containing bloody lymph, occur only about the ears, where previous vesicles have already occurred.* Wichmann relates a case in which nine months after the commencement of the disease he found the patient extremely tormented and debilitated by a great num- ber of large ill-conditioned ulcerations on the lower extremi- ties and sacral region. The ulcers appeared red, and the sur- rounding skin as if it had been scalded with hot water, j A somewhat similar case is mentioned by Cazenave and Schedel. This affection may occur simultaneously on every part of the body; but in most instances the vesications are confined to a particular space. In the palms of the hands and soles of the feet they occur but very rarely. They have been observed on the internal surface of the mouth, the fauces, oesophagus, and the alimentary canal; in these situations they soon assume the appearance of aphthse. The tongue and fauces occasionally be- come excoriated in cases of this kind. Colic ; constipation ; bloody and mucous alvine discharges; nausea; vomiting, or hsematemesis, have been known to supervene in cases where the disease affected the alimentary canal. (Wichmann, Reil.) " At times it would seem as if the eruption on the external and internal surfaces alternated—the symptoms of the latter in- creasing as those of the former decrease and vice versa.\" Both Wichmann and Braune relate cases in which the mucous mem- brane of the bronchia became affected during the progress of this malady. Several instances are mentioned in which cough and purulent expectoration came on. Cause.—Of the etiology of pemphigus there is as yet but lit- tle known of a satisfactory or definite character. It is said to be more common in old than in very young individuals, and in women than in men.§ Braune supposes that this affection is frequently dependent on deficient or disordered urinary secre- tion ; (I. c. p. 59.) Habitual deficiency of this secretion, and obstinate chronic cutaneous disorders, are indeed not unfre- quently associated affections. In one of the instances of chro- nic pemphigus mentioned by Braune, the intimate connexion between the action of the kidneys and the cutaneous affections was manifested in the clearest manner. Whenever the urine * Fieberlehre, bd. v. p. 418. | Beitrag zur Kenntniss des Pemphigus. t Braune. Versuch uber den Pemphigus und das Blasenfieber. Reil, 1. c. p. 420. § This at least is in conformity with the observations of Reil and others. Cazenave, on the contrary, says that the chronic form of the disease " rarely occurs in women." 472 PEMPHIGUS. flowed freely the bullse disappeared; but they invariably re-ap- peared when this secretion became scanty, watery, and muddy. Renal calculi were discharged from time to time with the urine. Richter, Wichmann, and Reil, also admit the frequent occurrence of renal disorder in pemphigus. It would seem also that disorder of the liver is a frequent attendant on this disease, whether as cause or effect is not known. Biett, in his dissections in the Hospital St. Louis, several times met with structural disease of the liver in persons who had died under this disease. (Cazenave.) The irritation of dentition; neglect of personal cleanliness ; a deficient and coarse diet; habitual exposure to a damp at- mosphere ; and chronic visceral affections, would seem some- times to favour the development of the disease. It arises, how- ever, often without any perceptible cause, either predisposing or exciting. It is said to have occurred endemically. The same individual may be affected with it several times, at dis- tant intervals. This disease is not contagious. Hall inoculated with lymph taken from the bullse without effect.* Diagnosis.—Acute pemphigus is liable to be confounded with rupia simplex, ecthyma, and herpes phlyctenodes. From the first of these affections it differs, by the bullse in rupia being few in number, and followed by ulcerations, upon which thick and projecting scabs are formed. It is distinguished from the se- cond by the bullse in ecthyma being less elevated, and filled with a purulent fluid, having a brownish spot in the centre of each. From the last disease it may be distinguished by the vesicles in herpes always appearing in clusters seated on a dif- fused red and inflamed surface. Although several bullse in pemphigus are occasionally found collected in one or more groups, yet distinct bullse appear elsewhere on the body, which is not the case in herpes. Prognosis.—The acute form never terminates fatally unless dangerous secondary affections supervene. In relation to the probable duration, ultimate violence, and obstinacy of the chro- nic form of the disease, the prognosis is in general very uncer- tain. Some cases continue moderately for eight or ten weeks, and terminate; others apparently equally mild during the first four or five weeks, gradually acquire more and more severity, and continue for many months in an aggravated and very dis- tressing form, and may even terminate fatally. The degree of danger depends, of course, in a great measure on the extent of the eruption, the obstinacy of its progress, the nature of the visceral affections with which it may be complicated, and the degree of constitutional vigour of the patient. When the vesi- cations assume a livid or bluish appearance, there is much rea- * Duncan's Annals of Medicine, for the year 1799. PEMPHIGUS. 473 son to apprehend unfavourable consequences. (Reil.) Old worn down, relaxed, arthritic, and nephritic subjects are most apt to suffer severely from this affection. Treatment.—In the acute form of the disease it will in ge- neral be sufficient to put tbe patient on a simple and unirritat- ing diet; to prescribe an occasional mild laxative; cool acidu- lated diluents; rest; and to avoid a humid and variable atmosphere. If inflammatory symptoms supervene, or the eruption is very extensive, a more active antiphlogistic treat- ment is required. Gentle purgatives ; the ordinary saline dia- phoretics, particularly the alkaline effervescing draught (potio Riverii ;) tepid bathing; and venesection, must be used with an energy corresponding to the degree of general and local in- flammatory excitement present. Richter recommends calomel in such cases above all other aperients. He also advises the use of diuretics, if the disease manifests a disposition to conti- nue beyond its ordinary course—and of these, he says, digitalis is the best, squills being according to his experience objection- able. All local applications must be avoided, nor should the vesicles be disturbed or opened. Cazenave recommends the application of leeches to the anus. In chronic pemphigus, (pompholix,) we should in the first place endeavour to ascertain whether any visceral or other ge- neral disorders co-exist, or preceded the eruption. Should there be grounds for presuming the presence of a syphilitic taint, or of an arthritic or calculous diathesis, or finally of hepatic or some other visceral affection, recourse should be had to reme- dies suited to counteract the lurking affection. (Richter.) In general, a moderately antiphlogistic treatment—such as acidu- lated diluents, mild aperients, and tepid baths, will be proper in the commencement. The German writers speak very fa- vourably of the employment of diuretics in this variety of the disease. They are particularly indicated where the urinary se- cretion is scanty or unnatural. Richter says that he cured an inveterate case in a short time by the following mixture,* in conjunction with the free use of an infusion of juniper berries. The same writer recommends dulcamara, in union with anti- mony.X Lime-water in large portions; infusions of herba * R. Extract, digital, purpur. gr. iii.—iv.—vi. Submuriat. hydrarg. mitis gr. i. Opii puriss. gr. ss. Sacch. albi gr. xv. M. Divide into twelve equal parts. S. Take one three times daily. The proportion of digitalis should be gradually increased. If the gums become affected, the use of the medicine must be suspended for a while.—Loc. cit. p. 615. X R. Antimon. crud. nigri. Pulv. stipit. dulcamar. aa gi. Extract, trifol. aquat. gii. M Divide into two grain pills. S. Take ten three times daily. fin 474 PEMPHIGUS. jacea; sarsaparilla; precipitated milk of sulphur; bella- donna ; and opium, have all been mentioned as remedies in this affection. I have met with but one case of chronic pem- phigus. It continued for six months under various modes of treatment, and at last disappeared under the use of Fowler's ar- senical solution. When diarrhoea, with more or less obtuse abdo- minal pain supervenes, opium is particularly serviceable. When pulmonary irritation occurs, attended with frequent and vio- lent cough, spitting of blood, and oppressed respiration, local and general bleeding becomes necessary, after which opium and calomel may be administered with benefit. When by the long continuance and severity of the disease, the strength of the patient is exhausted, or when the disease occurs violently in old, relaxed, and worn down subjects, quinine, with the sul- phuric acid; a nourishing diet; occasional opiates; chaly- beate preparations; and other supporting remedies should be employed. Cazenave and Schedel state that they have observed several examples in the Hospital St. Louis, of the very good effects of tonic remedies even in young subjects, where the eruption was of long continuance. CHAPTER XXVI. URTICARIA. Nettle-rash. The Nettle-rash, a very common cutaneous affection, is cha- racterized by hard elevations of the cuticle, of irregular forms, with a pale or whitish centre, and generally a diffuse redness round their margins, attended with intolerable itching, and a stinging or smarting pain. Its course is often very rapid, the eruption appearing sud- denly, and vanishing again in the course of a few hours; al- though in such cases, it usually reappears for several days in succession. It may also assume a chronic character, and con- tinue with occasional transient intermissions or remissions for many months, or even years. Urticaria febrilis.—Symptoms of general indisposition, such as, nausea, languor, drowsiness, slight chills, headach, ano- rexia, pain and anxiety in the epigastrium, with an accelerat- ed pulse, precede the appearance of the eruption. At first, a general itching with a feeling of tingling heat is felt over the whole body; to relieve which, the patient is apt to rub or scratch URTICARIA. 475 the skin, which never fails to bring out almost instantaneously large patches of red elevations or wheals with whitish central disks, and irregular crimson areola? attended with an extreme degree of itching and tingling. The eruption speedily becomes more or less extensively diffused over the surface, particularly on the palmar aspect of the forearms, around the knees, along the loins, on the inner part of the thighs, and on the shoulders. The eruption vanishes irregularly on different parts of the bo- dy, but is almost immediately recalled " on any part of the skin by strong friction or scratching." During the day the eruption subsides, but as the evening approaches, it returns together with slight febrile irritation; and in this manner the disease is usually protracted to the sixth or seventh day before it finally subsides. The parts principally affected become swollen and uniformly red ; but the swelling always soon sub- sides after the eruption disappears. More or less languor and febrile irritation accompany the disease throughout; " the dis- order of the stomach, however, is relieved by the appearance of the eruption, but returns whenever the eruption reappears." (Bateman.) Urticaria evanida.—This variety of the disease is unattend- ed by fever, and often continues for many months under a suc- cession of transient wheals appearing here and there on the body and vanishing again in a few hours at short and irregu- lar intervals. An eruption will perhaps appear on one arm in the morning, and disappear again in a few hours; in the af- noon, the wheals may come out on the legs and remain for a short time ; and after a short interval, or only on the follow- ing morning, they may appear on the body. In this way the disease may go on to a very protracted period—the eruption appearing and disappeaing frequently, "according to the tem- perature of the air or the exposure of the patient, and the degree and kind of exercise which he uses." The slightest friction or scratching will almost immediately bring out the wheals on any part of the body ; but when thus excited they usually re- cede again in a very short time. The eruption consists of ir- regular patches slightly raised and firm to the touch, or of elongated wheals, "like those produced by the stroke of the whip, or they are round, resembling the firm, elevated tumors produced by the bite of a mosquito. These wheals are not surrounded by an erythematous areola, although sometimes en- circled by a very narrow and faint streak of red. They are always attended with violent itching, and a sensation of ting- ling or stinging pain, more particularly "on undressing and gettin0- into bed. Languor, headach, transient pains, and derangement of the digestive functions, are apt to occur during the course of the disease ; but in some instances scarcely any symptoms of constitutional or sympathetic disorder, except the cutaneous affection, attend. Its course varies from a few days to many months and even years." (Bateman.) 476 URTICARIA. Urticaria tuberosa.—This rare variety of the disease is characterized by hard, prominent wheals, or tuberosities, at- tended with deep-seated pain, tension, and difficulty of motion. The eruption occurs chiefly on the loins and on the extremities. It generally comes out at night and disappears before morning, leaving the patient, " weak, languid, and sore as if he had been bruised or much fatigued." Cazenave and Schedel state that they saw at the hospital St. Louis, an instance accompanying a quotidian fever, which, after having lasted for four years, finally terminated "in swellings, great distention, ecchymo- sis, ruptures, and ulcerations." Some paroxysms were at- tended with so much general tumefaction, as to produce op- pressed and hurried respiration, a livid and puffed face, weak and intermitting pulsation of the heart, and other very alarm- ing symptoms. Urticaria subcutanea.—In this variety the wheals seem, as it were, to lurk beneath the skin, and make, their appearance only at distant intervals. An almost constant tingling sensa- tion, however, is felt in the skin, with occasional severe prick- ing sensations as if needles were thrust into the surface, limit- ed at first to a single part, but extending afterwards to others. Individuals affected with this variety of the disease arc apt to suffer frequent pain in the stomach and cramps in the muscles of the legs. (Bateman.) Causes.—Urticaria is most commonly met with in children, young females, and in persons of a sanguine and nervous tem- perament. The seasons most favourable to its occurrence arc spring and summer. Some individuals are so strongly pre- disposed to the disease, that the least friction or scratching al- most immediately brings out large wheals. The irritation of dentition, mental excitement, and various ingesta or articles of food, such as strawberries, raspberries, mushrooms, honey, oatmeal, green cucumbers, almonds, dried or smoked fish, lob- sters, shrimps, crabs, and particularly muscles, are apt to pro- duce febrile urticaria in some individuals. The internal use of valerian and balsam copaiba produce extensive urticaria in some persons. Chronic urticaria is frequently connected with an irritable and deranged state of the digestive functions. The tuberous variety " seems to be excited by excess in diet, over- heating by exercise, and the too free use of spirits." Urtica- ria is also produced by direct irritating applications to the skin, particularly by the leaves of the common nettle {urtica dioica) and by the contact of certain caterpillars, as the pha- laena processionaca. It occurs sometimes in the course of va- rious febrile diseases, and is occasionally speedily produced by taking a draught of cold water after the body has been excited or heated by exercise. In many instances, however, the dis- ease makes its appearance without any manifest exciting cause; URTICARIA. 477 and its frequent dependance on peculiar idiosyncracy or con- stitutional habit is unquestionable. In children it often occurs during the process of dentition, or apparently from acidity in the primse vise, and is in them usually called hives. Prognosis.—Although often an extremely tormenting affec- tion, from the intolerable itching and stinging pain which usu- ally attend, urticaria is almost universally wholly devoid of dangerous consequences. Werlholf indeed, observes that it has in a few instances terminated fatally ; but death probably oc- curs only where the eruption is secondary and associated with some other more serious malady. Richter says that in children the disease is sometimes accompanied with great difficulty of breathing. The sudden recession of the eruption does not ap- pear to give rise to any unfavourable consequences. Treatment.—In the febrile variety of the disease, advantage may sometimes be obtained from an emetic of ipecacuanha. Richter states that the operation of an emetic will occasionally put a speedy stop to the progress of the disease. In general, however, one or two mild laxatives, rest, simple diet, cooling drinks, and the occasional use of the tepid bath will be suffi- cient. Where there are symptoms of acidity in the primse vise, magnesia or alkaline remedies, particularly lime-water, will be proper. When the disease occurs in irritable and debilitat- ed subjects, or in persons of weak and disordered digestive powers, benefit may be derived from moderate doses of quinine, sulphuric acid, and the usual preparations of iron, after the alimentary canal has been evacuated by emetic and laxative remedies. Reil says copious draughts of cold water often pro- duce a very good effect. In the chronic variety of urticaria particular attention should be paid to the diet; for, in some instances, it would seem to depend on some article of food rendered oppressive or irritat- ing to the stomach by constitutional habit or idiosyncracy. "I have," says Willan, "desired several persons affected with chronic urticaria, to omit first one and then another article of food or drink, and have thus been frequently able to trace the cause of the symptoms. This appeared to be different in dif- ferent persons. In some, it was malt liquor; in others, spirit or spirit and water; in some, white wine; in others, vinegar; in some, fruit; in others, sugar; in some, fish; in others, un- prepared vegetables." Almost all the usual diaphoretic alter- ative remedies, such as sarsaparilla, the root of burdock, the golden sulphuret of antimony, dulcamara, Lisbon diet drink, &c. have been at times recommended, but they rarely appear to afford any particular advantage. Fowler's solution, how- ever, is a very efficacious remedy in the chronic form of the disease. It is mentioned by Cazenave as having been suc- cessfully used in a very obstinate and distressing case of this 478 URTICARIA. kind. Dr. Dewees has used it frequently with success, and I have myself employed it in a few obstinate cases with the hap- piest effect. To relieve the extreme itching various external applications have been recommended. Vinegar and water, or lemon juice diluted with water, will sometimes procure considerable relief. The tepid bath also, may be used as a palliative for this pur- pose. Sea-bathing, or washing with salt water, has been used with good effect, both as a palliative and a curative means. Dusting the affected part with rye-meal or hair powder, gives some relief from the itching and tingling. CHAPTER XXVII. MILIARIA. Miliary Fever. This is a febrile affection characterized by an eruption of accuminated vesicles, of the shape and size of millet seed, more or less thickly scattered over the surface of the body. These minute vesicles are at first red, and surrounded with erythe- matous areolse, which run into each other when the eruption is copious, and give a uniform vivid redness to the surface, (miliaria rubra.) In the course of from twenty-four to forty- eight hours they enlarge, and the contained fluid becomes whey-like, giving them a white or pearly appearance, {miliaria alba.) When the vesicles are very numerous, some of them unite, and form here and there vesicles of the size of a pea; and on some parts they are closely grouped into irregular patches of various sizes. In a fewr instances some of these confluent vesicles become filled with a purulent fluid, (milia- ria purulenta.) In some cases the eruption retains its red co- lour throughout; and occasionally the vesicles are white from the commencement. The miliary eruption appears in general as a symptomatic exantheme in various forms of fever; "in continued, remit- tent, inflammatory, and contagious, as well as other diseases;" and it has been much doubted whether it ever occurs as an idiopathic or independent malady. Bateman says that " it is perhaps invariably symptomatic ;" and this would seem to be the general sentiment at the present day. Cazenave never- MILIARIA. 479 theless asserts, "that there are instances where it is idiopa- thic, as when it occurs in persons in good health, after violent exercise during the heat of the summer;" and Richter ex- presses the same opinion. The appearance of the eruption is almost always preceded by premonitory symptoms; such as a sense of anxiety in the epigastrium; weight and oppression in the breast, accompa- nied with a short dry cough ; pains in the loins and extremi- ties; a benumbed prickling sensation in the fingers ; stinging, itching, and burning pain in the skin ; a small, frequent, con- tracted, and tense pulse ; cephalagia ; vertigo ; ringing in the ears; and a feeling of heaviness in the head ; creeping chills; disposition to syncope; palpitation; twitching of the tendons; delirium. The most characteristic phenomenon, however, is the profuse sour rank sweat, which is said almost invariably to occur just before and during the appearance of eruption. Sometimes, however, the miliary vesicles come out without any precursory symptoms whatever.* The eruption alwrays appears first on the neck, breast, and on the inner sur- face of the arms; and then successively on the abdomen, back, and inferior extremities. The duration of the eruption is very variable. In some instances it disappears as early as the fifth or sixth day; but in the majority of cases desquamation does not take place until the ninth or tenth day, and occasion- ally not until a still later period. Not unfrequently the eruption of vesicles is repeated twice, thrice, and even a fourth time, so as to protract the whole course of the disease to the sixth or seventh week. In most instances new vesicles appear daily for five or six days, and longer. This eruption appears to be peculiarly liable to recede from the slightest causes; and the con- sequences of a sudden retrocession areoften extremely alarming. Great anxiety in the precordial region ; extreme restlessness ; increased febrile irritation; violent delirium ; coma; or strong pulmonary congestion with distressing dyspnoea, are among the consequences which are apt to result from this accident If under these symptoms the eruption does not re-appear, or copious diarrhoea, or some other evacuation, does not ensue, a fatal termination is almost inevitable. (Richter.) This eruption does not appear to be the effect of critical ef- fort in the system, or in any degree to diminish the general symptoms, if we except those miliary vesicles which some- times occur towards the termination of rheumatic fever and gout.f Causes.'—That the miliary eruption is generally an artifi- * Richter, Specielle Therapie. Bd. ii. 541. X Stoerk, Barretta, Dissert, de Miliaris Natura, &c. as quoted by Richter. 480 MILIARIA. cial disease has been long ago fully established. In the latter part of the seventeenth, and the commencement of the eighteenth century, when the alexipharmic or heating and sweating plan of treatment was so much in vogue on the continent, miliary fevers of the most fatal character were among the most fre- quent diseases. As soon as the antiphlogistic and cooling me- thod of treating febrile affections became more universally adopted, the miliary disease was but rarely observed ; and it is now almost an unknown affection, except in its mildest form. By a stimulating, sweating, and heating treatment, miliary vesicles may be produced in every variety of febrile disease; and as such a plan of treatment is peculiarly apt to render even mild and manageable fevers dangerous and malignant, we may readily conceive how fatal the diseases must have been which were thus fomented into the miliary eruption. Some- times, however, miliary vesicles make their appearance in acute diseases under the best regulated antiphlogistic treat- ment ; and there can, 1 think, exist but little doubt that an erup- tion of this kind appears at times as an idiopathic disease. I have seen but few instances of this kind ; but one case which came under my notice within the present year was apparently of this nature. The patient, a child, complained a few days of slight indisposition, which was followed by an eruption of innumerable red points or vesicles. On the second day they became more distinctly vesicular and whitish, and continued until the fourth day before desquamation began. There was throughout the disease a constant moderate perspiration. Cazenave and Schedel observe, that "in certain cases of violent entero-colitis, accompanied with general debility, the miliary eruptions, which often occur at night during the paroxysms, present the next day a complete vesicular appear- ance, and the portion of skin which they cover is destitute of redness, and appears as if a multitude of minute drops of limpid water had been sprinkled over its surface." The affections in which the miliary eruption is most apt to occur, are: puerperal fever ; gastro-intestinal irritation or in- flammation ; inflammation of the serous membranes; rheuma- tism ; and Richter says that females affected with severe leu- corrhoea are particularly liable to this affection on the occur- rence of febrile irritation. The occurrence of this eruption is said to be favoured by a confined and damp atmosphere, exces- sive sanguineous and mucous discharges; insufficient and in- nutritious diet; acid and other irritating substances in the ali- mentary canal; and intemperance. Treatment.—The attending fever must be treated according to its character and symptoms, without any regard to the mili- ary exantheme. In general the febrile irritation is sthenic, and requires an antiphlogistic treatment, and cooling regimen. In MILIARIA. 4S1 short where the eruption is symptomatic we must prescribe for the original malady, and not for the cutaneous affection. The idiopathic cases are mild, and require little more than gentle aperients, cooling drinks, and free ventilation, with- out, however, exposing the patient to a cold or humid air. The diet, of course, must be mild and unirritating ; and in instances which manifest much gastric derangement, a gentle ipecacuanha emetic may be given with advantage. When the eruption recedes, and unfavourable symptoms ensue, we should endeavour to recall it to the surface by warm bathing and mild diaphoretics—such as Dover's powder ; and where the arterial action is low, by the internal use of carbonate of am- monia, infusion of serpentaria, camphor, and opiates. CHAPTER XXVIII. LICHEN. This affection is characterized by minute firm elevations or pimples, (papulse,) generally appearing in clusters, usually of a white colour, sometimes red, and attended with considerable itching. Systematic writers describe many varieties of the disease. Lichen simplex.—The disease almost invariably commences with transient flushes of heat in the face ; lassitude ; a slight- ly accelerated pulse, and occasionally severe headach ; weak- ness ; painful sensations in the stomach, and general febrile irritation. The eruption consists of red and inflamed miliary pimples, attended with heat and itching. In three or four days the redness begins to fade, and on the following day desquama- tion commences, which is usually completed in three or four days more, unless successive crops of papulse appear, which sometimes occurs. In the chronic variety of simple lichen, the pimples are usually white, and but slightly or not at all inflam- ed. The eruption is preceded by moderate itching. The pa- pulse are often not very perceptible, but in passing the hand over the skin it receives the sensation of a slight roughness from the small firm elevations on the surface. Its course is tedious, and of uncertain duration, lasting often several months. The skin becomes thickened, and at last exfoliates in large scales. Acute lichen occurs most commonly on the face and body; the 61 482 LICHEN. chronic, on the extremities, more especially on the back of the hands. In irritable habits it sometimes returns every summer. Per- sons subject to gastric pains and headach, are sometimes af- fected with this eruption, when these affections go off, as if by crisis. (Bateman.) Sometimes the pimples occupy the roots of the hairs of the skin. (L. pilaris.) And in this case the disease generally continues long. In some instances the pa- pulse appear in patches or groups, well defined, and approach- ing to the circular form. (L. circumscriptus.) These spread, at the same time that the central part heals and exfoliates, re- maining, however, slightly red and scurfy. Occasionally the patches are livid, the pimples being soft and flat. {L. lividus.) These are sometimes mixed with dark red or purple maculse from sanguineous extravasation, occurring most commonly on the lower extremities of relaxed debilitated subjects. The erup- tion is sometimes disposed into the form of a long stripe or band, extending in a spiral manner round an extremity. (L. gyratus, Biett, Cazenave.) At times the eruption consists of larger pimples than the usual size. {L. urticatus.) They are inflamed, prominent, large, confluent, " and resemble the stings of a nettle." They come out suddenly on the face or neck, particularly in young persons and females in the sum- mer. A burning pain and considerable itching attends. They usually disappear in a short time, but often return at irregular intervals. (Cazenave and Schedel.) Infants at the breast are sub- ject to a modification of this eruption, (L. strophulus,) in wliich the papulse are "either redder or whiter than the skin, and attended with great itching, which is much increased by the heat of the bed." It is acute in its character and subject to distinct exacerbations. (Cazenave.) Lichen agrius.—This is conspicuously febrile; the eruption consists of a multitude of vividly red miliary pimples, aggre- gated into large patches, seated on a diffused erythematous surface. Itching, heat, and a sense of painful tingling, greatly increased by the heat of the bed, by active exercise, and sti- mulating ingesta, are experienced. Morning remissions and evening exacerbations occur. The skin around the patches is generally painful and somewhat swollen. The eruption and general symptoms usually increase until about the fourth or fifth day, when small ulcerations appear on the summit of the pimples, discharging a sero-purulent fluid, which concretes into small, yellow, prominent crusts. These finally fall off, and are succeeded by thin scales. The disease usually conti- nues from twelve to fifteen days. The itching and stinging sensation in this variety of the disease is often extremely vio- lent. In many instances the eruption appears and disappears several times before it finally goes off. The skin of the affect- LICHEN. 483 ed parf s generally, at last, becomes harsh, chappy, and ex- tremely painful when rubbed. This variety may terminate in impetigo, a chronic pustular affection. (Bateman). When the eruption recedes, from exposure to cold, it is apt to be fol- lowed by an increase of fever, headach, vomiting, and colic pains. Simple lichen may assume this form of the disease. L. agrius is most apt to occur in young persons of vigorous and sanguineous habits. (Cazenave.) Lichen may also acquire a chronic character. In this case the cuticle becomes harsh, hard, full of fissures, dry, and rough, particularly in the hol- low of the articulations. Causes.—Lichen occurs in persons of all ages, and in both sexes. Summer and spring are the seasons most favourable to its occurrence. High temperature, particularly the heat of the sun, is apt to excite it. Mental affections, stimulating po- tations habitually indulged in, gastro-intestinal irritation, and internal inflammations, are mentioned among its most obvious causes. Diagnosis.—Simple lichen may be distinguished from eczema by its acuminated, solid, and very prurient pimples; the eruption of eczema consisting of transparent vesicles, attended only with slight smarting pain. From scabies, lichen may be known by the distinct vesicular character of the former, and its usual location on the bends of the joints and between the fingers. The vesicles of lichen are aggregated in clusters. From prurigo, lichen is distinguished by the flat, irregular appearance of the papulse in the former, and their being usually lacerated, and covered with small blackish crusts. The itch- ing and burning of prurigo is always extremely distressing; in simple lichen it is generally slight. (Cazenave.) Lichen circumscriptus sometimes resembles herpes circinatus; but may be known from it by the red, or more strongly inflamed state of the skin surrounding the margin of the latter; and the distinct papular character of the former, both in the centre and at the border of the patches ; whilst in herpes the central disk is free from vesicles. Lichen urticatus may be mistaken for erythema papulatum, or syphilitic lichen. The diagnosis be- tween them consists in the large size of the erythematous patches, their pale-red colour, the almost entire absence of itching, their less prominence, and their not appearing and disappearing several times in succession. The copper colour of the papulse of syphilitic lichen, their freedom from inflamma- tion and much itching, and their slow progress and long con- tinuance, distinguish it from L. urticatus. From chronic eczema lichen agrius is often not easily distinguished. The presence ef lichen, however, may be known by the great itch- ing, roughness and thickening of the skin, and the appearance here and there of distinct pimples. 484 LICHEN. Prognosis.—Lichen is never a dangerous, but sometimes an extremely troublesome and disagreeable affection. The pre- cursory fever is seldom so great as to keep the patient confined, and in the majority of instances it is wholly absent. By vio- lent friction and scratching, and sometimes spontaneously severe excoriations and burning pain occasionally occur, which are almost always difficult to remove. When the eruption is repelled by improper applications, or by other injurious influences, as cold, severe fever, internal inflamma- tions, great heat, thirst, fixed pains in the abdomen, vomiting, &c. sometimes ensue. Treatment.—In the simple variety, tepid bathing; mild aperients ; diluent acidulated drinks ; abstinence from heating drinks, food and exercise; are all that is necessary to pre- scribe. Dry, irritating applications are improper—particu- larly sulphur, and the metallic oxydes. To relieve the severe itching and burning in the affected parts, we may apply cream, or wash the part with flaxseed tea, or some other mucilaginous fluid. When the affected parts become very red and irritated, attended with constant stinging pain and itching, a laxative dose of calomel may be given occasionally, and fresh, unsalted butter applied. In the chronic forms of the disease, alkaline and sulphurous baths, mild laxatives,* tepid bathing, at first with the water of scalded bran, "and afterwards with water rendered alkaline by adding subcarbonate of potash, in the proportion of half an ounce or an ounce to four or five pounds of water." Cazenave advises, in severe cases of this kind, anointing the eruption with one of the following ointments.} During desquamation the internal use of the diluted sulphuric acid is often beneficial. The treatment must be more active, however, in lichen agrius. Here sanguineous evacuations, both topical and gene- ral, are often necessary in the beginning of the complaint; but when blood is drawn by topical means, it must be taken from a sound part of the skin. (Cazenave.) Low diet, laxatives, diluted nitric or sulphuric acid taken internally, laxative doses * R. Calomel gr. xii. Hydrarg. sulphur, nigr. gr. xxxvi. M. Divide into 12 equal parts. S. Give one every other evening to a child of from 2 to 7 years old, with a small dose of ol. ricine on the following morning. t R. Calomel ^ss. P. camph. gr. xii. Axungise 3L M. f. Or— R. Protoioduret hydrarg. gr. xii to $i. Axungiae 5i. M. f. LICHEN. 4S5 of calomel, alkaline sulphurous baths in the decline of the malady, the internal use of Fowler's solution, with a gradual increase of the dose, until it produces gastric disturbance, are the means generally relied on in cases of this kind. CHAPTER XX;iX. ECZEMA. Eczema is a vesicular eruption, which occurs both in ara acute and chronic form. Cazenave and Schedel divide acute eczema into three varieties, namely, E. simplex, E. rubrum, and E. impetigionodes. 1. E. simplex.—The eruption consists of innumerable small, closely approximated, transparent vesicles, without any sur- rounding inflammation, distributed over a greater or less extent of the surface—the skin every where retaining its na- tural colour. No premonitory symptoms, but only a slight itching precede the eruption. The fluid in the vesicles soon becomes opake, and after a short period is absorbed; the vesi- cles then shrivel, and the cuticle desquamates slowly. It never spontaneously gives rise to inflamed surfaces. This eruption is usually local, or confined to certain parts—commonly the arms and between the fingers, and being attended with severe pruritus may be mistaken for the itch. Heating and irritating applications to the skin often produce this affection. "It often appears between the fingers of women in child-bed;" and in persons who are much exposed to the heat of a fire. It is sometimes associated with itch, and appears to be excited by the irritating remedies usually employed for the cure of that affection. Eczema rubrum.—Heat, stiffness, and some tingling in the skin, precede the eruption in this variety. The affected sur- face is inflamed and vividly red, covered with very minute acuminated pimples, of a shining white or pearly hue. After some time, vesicles of the size of a pin's head, surrounded with distinct red areola?, appear on the affected parts. In the course of six or seven days the contained fluid is absorbed, the vesi- cles shrivel and desquamate, leaving a pale red surface, sprinkled with minute rounded papulse, each rising from a small whitish disk. In some instances the cutaneous inflam- 486 ECZEMA. mation increases, and continues beyond its ordinary duration; the vesicles become confluent, break, and discharge an irritat- ing fluid, which causes superficial excoriations; and at last, concrete into large, thin, pliant scales, leaving inflamed sur- faces on falling off. Eczema impetiginodes.—Violent inflammation, swelling of the affected parts, and vesicles generally congregated or con- fluent, filled with a sero-purulent fluid, are the principal cha- racteristics of this variety of the aisease. These purulent ve- sicles soon break, and the fluid concretes into soft, yellowish, and often extensive scales, or thin crusts. When these fall off they leave red surfaces, exuding a reddish fluid, which dries into thin laminse. The eruption is commonly confined to a particular part, or even a single spot. Occasionally, how- ever, it occurs over the whole body, and is attended with con- siderable fever. The disease may continue from ten to twenty days, and upwards. The vesicles are generally transparent at first, and become pustular afterwards. This variety also sometimes assumes a chronic character, resembling then the chronic state of eczema rubrum. Chronic eczema.—When acute eczema is very severe, it often terminates in chronic excoriations and fissures of the skin on different parts of the body, particularly in the bends of the knees and elbows, and about the axillse. The parts thus irritated and inflamed, exude an abundance of serous fluid wdiich causes the linen to adhere to them. In this state it usually remains for several months, the discharge continuing undiminished. In some instances, the exuded serum dries into soft, yellowish, and thin crusts, leaving an inflamed and nearly dry surface when they fall off. "These crusts form at greater intervals; they become drier and the disease seems on the point of disap- pearing, when on a sudden, and without any assignable cause, the inflammation acquires greater intensity." New vesicles arise, which like the former soon break and discharge their fluid; " and the affection goes through the same course, and the disease may thus last for years." (Cazenave.) Sometimes, the thickened, red, fissured skin remains dry, and the crusts are drier, more firmly attached, and of a brownish yellow hue, leaving but a slightly red surface when they separate. Occa- sionally indeed, the skin for a long time remains vividly red, cracked, with dry scales of altered cuticle thinly scattered over the surface. Chronic eczema commences on a limited portion of skin, often not above a few inches in diameter, and spreads afterwards over a greater or less extent of the sur- face. The itching is always very great and returns by spells, causing an irresistible desire to scratch. The parts furnished with hair, the region of the pubis, the arm-pits, groin, scrotum, pudendum, and the bends of the joints ECZEMA. 487 are most apt to become the seat of eczema, although every part of the body may become affected with it. Causes.—Though not contagious, yet instances do occasion- ally occur in which this disease is communicated from one to another by protracted contact. (Biett, Cazenave.) It occcurs more frequently in women than in men, and in the warm than the cold seasons. Its general cause is unknown. It may be excited by direct irritating applications to the skin, as a blis- ter, sinapisms, turpentine, valerian root, the rays of the sun,* dry frictions, and irritating ointments, lime, and sugar. | The use of mercury when long continued sometimes produces a ve- ry severe variety of eczema. Diagnosis.—Simple eczema often greatly resembles itch. They may be distinguished by the following circumstances. In eczema, the vesicles are flat or rounded; in itch, pointed; in the former, they are nearly or entirely in contact with each other; in the latter, they are single and considerably separat- ed. The itching of eczema is attended with smarting pain; in itch, the pruritus "is rather agreeable than "painful." The impetiginode variety of eczema has been confounded with impetigo. The former, however, occupies large spaces, the latter usually small ones. The eruption in impetigo is strictly pustular from the beginning. In eczema impetigi- nodes, it is vesicular at first, the vesicles being generally trans- parent, and never contain genuine pus, as they do in impetigo. In the latter, desiccation gives rise to thick, yellowish, uneven scabs; in eczema, only thin pliant scales are formed. Vesi- cles of eczema rubrum surround the latter, but they never ap- pear in impetigo. Chronic eczema is very liable to be confounded with lichen and psoriasis. Lichen agrius, the variety most apt to be mistaken for chronic eczema, differs from this affection, in the thick, small, and yellow appearance of the scales or scabs, and the papular appearance of the surface which they leave on fall- ing off; whereas, the. surfaces left by the separation of the thin lamina in eczema, are smooth, red, often shining, and gene- rally slightly excoriated. In lichen, small hard papillse may be seen around the eruption; in eczema, vesicles only appear in the neighbourhood of the eruption. Treatment.—Diluents, acidulated with sulphuric, or nitric acid ; a light and simple diet; occasional tepid bathing ; gen- tle laxatives; and where the eruption is extensive, alkaline * The prickly-heat or heat-spots are classed with this variety of erup- tions. (Willan.) X Persons who are in the habit of handling or working in sugar are liable to an eruption of this kind on the hands, called the grocer's itch. (Bateman.) And brick-layers are subject to a similar affection from the irritation of lime. 488 ECZEMA. and sulphurous baths ;* with some of the milder vegetable to- nics, such as infusions of cinchona, serpentaria, or colomha when languor or debility exists, are the principal useful mea- sures in this variety of the complaint. When the eruption continues long, advantage may be obtained from rubbing the affected parts with sulphur ointment. In eczema rubrum and impetiginodes, frequent bathing or emollient fomentations of the affected parts will generally mo- derate very considerably the itching pain and tenderness of the eruption.f Emollient poultices also often answer well as a palliative application. After exfoliation, the following oint- ment may be beneficially applied to the tender and half-exco- riated surface^: by means of linen rollers renewed twice daily. Mild laxatives should be regularly given; and a simple, unir- ritating diet, as well as total abstinence from all kinds of sti- mulating drinks enjoined. It will also be useful to administer refrigerent diaphoretics, such as sweet spirits of nitre, small portions of nitrate of potash with tart, emetic, spiritus minde- reri, and to allay nervous irritation and procure rest at night, full doses of Dover's powder with a few grains of calomel in the evening. The diluted mineral acids with tonic bitter in- fusions will at times be proper during the subsidence of the disease. All kinds of irritating applications must be avoided. When the exciting cause is obvious, and of such a nature as to enable us to remove it, the first step in the treatment must of course be to obviate its influence. In chronic eczema, emollient baths of about the temperature of 90° Fahr.; the internal use of nitric or sulphuric acid ; oc- casional laxatives; alkaline solutions internally, and when the itching is great externally,^ are among the principal remedies * The alkaline bath is made by dissolving five or six ounces, or more of the subcarbonate of potash or soda in a bath. The sulphurous bath is made by adding about four ounces of sulphuret of potash to a bath. (Cazenave.) X The French are in the habit of using a decoction of bran, or the water of scalded bran for this purpose. Cazenave and Schedel recom- mend cataplasms made of potatoes and some emollient decoction. X R. Emplast. plumbi K". Cerae flavse §ss. Olei amydal. dulc. ?iss. Melt the plaster with the wax, then add the oil and stir the mixture until it has entirely cooled. This ointment is particularly recommend- ed by Dr. Pearson.—See Bateman's Synopsis, &c. p. 12. § " Half a drachm of the subcarbonate of potash dissolved in a pint of infusion of chicory may be given internally." Washing the affected parts with a solution of the subcarbonate of potash or soda before go- ing to bed will generally afford much relief. (Cazenave.) ECZEMA. 489 in this form of the disease. One or two of Plummer's pills* given twice daily have been found very useful in chronic ecze- ma. Benefit may also be derived from laxative doses of calo- mel and pulvis antimonialis, with an occasional dose of sul- phate of magnesia or soda. Sulphurous waters employed both externally and internally will, in general, contribute material- ly towards the removal of the disease. Infusions of sarsapa- rilla, chimaphila, or of the slippery-elm bark, with small por- tions of antimony, may also be usefully employed. In a very severe and inveterate case of chronic eczema, I prescribed the following pills in conjunction with sarsaparilla syrup with complete success.f In the dry, scaly, cracked form of local eczema, "as it occurs in the hands," Cazenave recommends frictions on the part, with an ointment made by mixing half a drachm of proto-nitrate of mercury with an ounce of lard; or of twenty grains of proto-ioduret of mercury rubbed up with an ounce of axunge. I have known a case of this kind cured by the following application,^ first recommended, I believe, by Alyon. (Essai sur les Proprietes Med. de VOxygene.) Washing the affected parts with an infusion of stramonium leaves, or of solanum nigrum, or hyoscyamus, will generally greatly allay the itching and painful irritation. When the eruption is confined to a limited surface, solutions of borax, lime-water and milk, or an ointment made by mixing half a drachm of calomel with an ounce of lard, may be occasionally applied with benefit. The best local application, according to my own experience, however, is stramonium ointment inti- mately mixed with a portion of calomel, in the proportion of thirty grains of the latter to an ounce of the former. The tincture of cantharides is sometimes very efficacious in obsti- nate cases of this affection. Cazenave states that it is parti- cularly useful in the eczema of women.§ Arsenic also has been used with complete success in inveterate instances of * R. Calomel. Antimon. sulph. praecipitat. U 3ii. Pulv. g. guaiac. 3jy- Sapo. venet. 5"- Mf. pi. »a gr. iii. t Muriat. hydrar. corosiv. gr. m. G. opii Sr- x- G. camphor. 8r- xx- Conserv. rosar. r 520 HEMOPTYSIS. hsemorrhoidal discharge, there is usually no reason to apprehend any very serious consequences, if the predisposition to con- sumption does not exist. In general, haemoptysis, result- ing from causes which suddenly produce strong pulmonary congestion, or general arterial excitement—such as lifting heavy weights, or other violent bodily exertions ; loud singing or declaiming; playing on wind instruments; over-distention of the stomach; stimulating drinks, &c. is much less apt to lead to dangerous consequences than cases that occur sponta- neously. Treatment.—The remediate management of hsemoptysis di- vides itself into that which is proper during the actual exis- tence of the hsemorrhage, and that which should be pursued af- ter the bleeding is arrested. When the pulse is frequent, tense, or hard, the momentum of the circulation should be immediately reduced by venesection; and to effect this purpose adequately, it is often necessary to abstract blood very copiously. In some instances, the pulse will be found very small, but tense and firm to the touch ; and in such cases it is particularly important to resort to prompt and very free venesection. At the same time that this step is taken, large portions of common salt,* or small doses of su- gar of lead, should be administered at short intervals, until the hsemorrhage is checked. A large sinapism may also be applied over the breast, as soon as the activity of the pulse is reduced. Perfect rest and cooling drinks should be rigidly enjoined. If the feet are cold, warm applications or sinapisms ought to be applied to them; and the patient may take an oc- casional draught of cold water.] If the bowels are constipated, the rectum should be emptied by laxative enemata. In cases of this kind, large doses of the nitrate of potash will often promptly arrest the haemorrhage; and in a manifestly phlogis- tic state of the system, it is decidedly the best internal remedy we possess in this affection. This article was long ago strong- ly recommended by Selle ;\ and Richter speaks very favoura- bly of its powers in this disease. Dickson also gave it in very large portions, dissolved in mucilaginous fluid, in this affection, * This article was first introduced to the notice of the profession, as a prompt and efficient remedy in haemoptysis, by Dr. Ruch. It would seem, however, from Schopf's account of his Travels in the United States, (Bd. i. p. 116,) that the knowledge of its powers in this way was first brought to this country from Ireland by Schiel. F. Hoffman and Fordyce assert, that a solution of sulphate of soda will often do more good in haemoptysis than any other remedy. t Burserius (Inst. Med. Pract., vol. iv. p. 33,) says much in favour of the use of frequent draughts of cold water, (the temperature of which is to be lessened from time to time, until it is at last taken as cold as ice,) in this variety of haemorrhage. J Medicina Clinica. Berlin, 1797. p. 147. HEMOPTYSIS. 521 with much benefit ;* and we may likewise cite the experience of Gibbon,f anu< Hartmann4 in favour of its excellent effect*. In Italy it has of late years been greatly extolled as a remedy in hsemoptysis, and, according to my own experience, not more than it deserves. Recamier has within a few years re- ported some cases illustrative of its beneficial effects in this variety of haemorrhage. He gave half an ounce of nitre, dis- solved in a mucilaginous mixture, in the course of twenty-four hours, and in this way three cases were promptly relieved af- ter bleeding and other remedies had been used ineffectually.§ From fifteen to twenty grains of this article, dissolved in a small cup of barley-water or some other mucilaginous fluid, may be taken every half hour or hour, until the bleeding is checked. A great variety of internal astringent remedies have been recommended in this affection—such as alum, colcothar of vitriol, sulphate of copper, sulphuric acid, &c; but they are all so decidedly inferior, in efficacy, to the sugar of lead, that they deserve little or no attention in this respect. It may be given in doses of from one to five grains every half hour or at longer intervals, according to the rapidity of the hsemorrhage. It appears to be equally applicable in cases attended with an active or debilitated state of the circulation. I have generally given it in union with calomel, where the diathesis was phlo- gistic ; but in cases attended with a nervous or spasmodic con- dition, opium is the best adjuvant. In cases attended with an irritated, small, frequent pulse, with a pale and contracted countenance, cold extremities, and a dry skin, small doses of sugar of lead, in combination with opium and calomel,|] will generally procure prompt relief. Richter and Meza^J recommend ipecacuanha in such cases. The former writer states that he has often promptly arrested haemoptysis, attended with cold extremities, alternate flushing and paleness of the face, limpid urine, small and hard pulse, and much anxiety in the chest, by exhibiting a quarter of a grain of ipecacuanha every fifteen minutes. {Specielle Thera- pie.) It is in instances of this kind, that emetics may be given with advantage. Whenever a congestive state of the pulmo- * Lond. Med. Obser. vol. vi. No. XVI. t Medical Cases and Remarks. Lond. 1800. *..„., t Nova Act. R. Soc. Scient. Upsal. vol. i. p. 109, as quoted in Rich- ter's Ausfuhrliche Arzneimittellehre, vol. iv. p. 242. 6 Med. Chir. Rev. January, 1826. IIR. Calomel gr. vi. Pulv. acetat. plumbi. gr. xii. ---- opii gr. hi- M. Divide into 12 equal parts. Give one every thirty minutes if the haemorrhage is considerable, or every two hours in less rapid cases. H Reil. Fieberlehre. Bd. iii. p. 107. 66 522 HEMOPTYSIS. nary system is present in this affection, with deficient action of the cutaneous capillaries, vomits will be likely to prove serviceable. They were formerly much, and too indiscrimi- nately recommended by some practitioners. (Brian Robinson.) In ordinary cases, attended with a plethoric and excited state of the system, they are unquestionably hazardous. In the spasmodic and nervous cases just mentioned, Harles,* Stork, Richter, Plater, and others, speak very favourably of hyoscyamus. ^Harles particularly recommends an oil pre- pared by boiling the leaves of this plant in flaxseed oil; and F. Hoffman considers the extract, given in doses of from one to three grains every hour, as one of our best remedies in such cases. According to Dr. Miner's experience, the powdered capsicum, given in doses of from three to five grains every ten minutes, is a most efficient remedy in hsemoptysis. I have had occasion to prescribe this article in one instance lately, and the result has given me a very favourable impression of its powers in this respect. When spitting of blood assumes a chronic character, and is attended with an irritated state of the pulse, digitalis some- times does much good. From one-fourth to half a grain of the powdered leaves, or from fifteen to twenty drops of the tinc- ture, may be taken every four hours, until a manifest impres- sion is made on the pulse. It will be proper to keep the sys- tem moderately under its influence for ten or twelve days. In cases of this kind, much advantage will, in general, result from blistering the breast—or, what is still better, pustulat- ing this part with tartar emetic ointment, or establishing a more permanent discharge by a caustic issue or seton. The nature of the occasional cause should be particularly kept in view in regulating the treatment of haemorrhage, and especially for the prevention of its recurrence. When haemoptysis supervenes in consequence of suppressed hsemorrhoidal discharge, advantage may be obtained from the use of small doses of aloes, and particularly from the applica- tion of leeches to the anus. These measures are particularly useful in conjunction with a light diet, moderate exercise, and an occasional general bleeding, to obviate the return of the hse- morrhage from the lungs. When the disease appears to arise from general plethora, in consequence of a free indulgence in the pleasures of the table, and an indolent course of life, or sedentary habits, it will be particularly necessary to enjoin a simple, unirritating, and moderate diet, cooling drinks, moderate exercise, and the avoidance of all kinds of stimulating beverages. Should the hsemoptysis be dependent on irregular, gouty * Hufeland's Journal der Pract. Heilkund. B. ix. s. ii. p. 47. HEMOPTYSIS. 523 irritation, or rheumatism, especial advantage may be gained from setons or issues on the inferior extremities, and a course of treatment calculated to counteract these affections. When abdominal indurations exist, or intestinal irritation from a loaded state of the bowels, or acrid secretions, a gentle course of mercurial and aperient remedies, the extract of tarax- acum, and other deobstruents, with a regulated diet and exer- cise, will be most likely to insure exemption from a subsequent attack of the haemorrhage. If the bleeding appears to be excited by a violent cough, at- tended with irritation of the respiratory passages, expectorants, demulcents, leeching and cupping on the chest, venesection, and opiates are particularly indicated. In such cases frequent doses of flaxseed oil are said to be very beneficial.* When the cough is violent and spasmodic, and the pulse contracted and small, with a dry skin, small doses of camphor and ipecacuan- ha, with mucilaginous drinks, often procure great and speedy relief. (Richter, Specielle Therapie. Bd. iii. p. 297.) When hsemoptysis occurs in young females from menstrual irregularities, we may resort to the tincture of cantharides, venesection, blisters to the sacrum, riding on horseback, and the warm hip-bath ; but the ordinary stimulating emmenagogues must be carefully avoided. When cases of this kind are at- tended with a chlorotic, or sluggish and relaxed state of the system, the ferruginous preparations, exercise by gestation, a nourishing and digestible diet, with aloetic aperients, &c. may be properly used. I have employed the following pills with obvious benefit in two instances of this kind.f MENORRHAGIA. Uterine hsemorrhage appears under a great variety of modi- fications both in relation to its phenomena and causes. Under the present head, however, I shall treat only ef those hemorr- hagic discharges which occur in the unimpregnated state of the uterus—excluding also such as depend on organic or struc- tural disease of the womb. In some instances the menstrual secretion becomes so copious * Journal de Med. torn. xxx. p. 85. X R. Prussiat. ferri. 3i. G. aloes soce. gr. viii. Tart, antimon. gr. ii. Conserv. rosar. q. s. M. Divide into thirty pills. S. Take two every morning, noon, and evening. 524 MENORRHAGIA. as to cause much debility and exhaustion, and to require reme- diate interference. In many females the flow of menses is always \ery large, who nevertheless enjoy a state of vigorous health. In instances of this kind the discharge must not be regarded as morbid, or immoderate, however copious it may be; for if the system sustains no inconvenience from it, it is to be viewed as natural, or consistent with the constitutional habit of the individual in whom it occurs. So long, therefore, as the health of the female continues unmolested by copious menstrua- tion, it cannot be accounted immoderate, or a proper object of medical attention; but when this evacuation gives rise to de- bility, exhaustion, and other symptoms of ill health, it amounts to a morbid discharge, and requires remediate measures. Immoderate flow of the menses must not be confounded with menorrhagia. This latter is, strictly speaking, a hemorrhage, whilst the former consists in a mere superabundant secretion of the natural or healthy menstrual evacuation. In menorrha- gia the effused blood retains its power of coagulation, or at least shows a tendency to coagulate ; but in immoderate men- strual discharge it remains liquid and entirely free from co- agula. Menorrhagia is sometime preceded by various premonitory symptoms ; such as pain and tension in the loins and pubic region ; a feeling of fulness and pressing down in the uterus; frequent desire to pass urine; a small, contracted, and fre- quent—or a full, wave-like, or rebounding pulse ; heaviness of the head ; ringing and noise in the ears ; slight creeping chills, transient flushes, and sense of weight in the feet. In many instances, however, the haemorrhage commences without any indications of its approach. Sometimes a sudden gush of blood takes place, which continues to flow very copiously for a few hours, and then ceases. More commonly, however, the dis- charge continues for four or five days, and in some instances several weeks, and goes off very gradually. When it occurs about the period of the final cessation of the menses, it is apt to become very protracted in its duration, more especially in females of plethoric and relaxed habits of body. When menorrhagia is copious, and prolonged in its course, or recurs frequently at short intervals, it seldom fails to pro- duce great relaxation and debility, and to lead ultimately to a train of very distressing, and even dangerous affections. Fe- males who are much affected with this hsemorrhage, become pale, sallow, weak, and dyspeptic ; and in phlegmatic habits, cedema of the feet, or general anasarcous effusion, pains in the stomach, with great muscular prostration, are apt to ensue. Leucorrhoea often extremely copious, almost universally occurs during the intervals of the hsemorrhages, and contributes greatly to the general debility and relaxation. MENORRHAGIA. 525 Menorrhagia may with much propriety be divided into active and passive.* The former variety occurs in sanguine- ous, robust, florid, and healthy females, and is almost inva- riably preceded for a short time by the natural menstrual se- cretion. These cases rarely continue more than seven or eight days, and are often attended with considerable pain in the lower part of the abdomen, with a frequent and tense pulse, and a dry and feverish state of the skin. Passive menorrha- gia is almost entirely confined to the period when the uterus is about losing its functions—and is met with only in such as have been much debilitated and relaxed by privations or pre- vious diseases, particularly protracted and profuse leucorrhoea; or in individuals of a nervous or phlegmatic temperament, who have been subject to profuse catamenial or nienorrhagic discharges. The pulse, in cases of this kind, is small and weak ; the muscular system relaxed and debilitated ; the skin cool and pale; the countenance exanguious, and expressive of anxiety and languor; the urine generally pale; and the sto- mach disturbed with frequent nausea, and other unpleasant sen- sations. The discharge is apt to continue for three or four weeks, and sometimes much longer. When in bed the hsemorrhage is usually moderate; but on rising, or making the least bodily exertion, the flow of blood is often suddenly increased. If the hsemorrhage ceases, it is succeeded by a profuse, leucorrhoeal discharge, which is quite thin or watery. Causes.—Females of vigorous and sanguineous habits are more subject to menorrhagia than the feeble. The predispo- sition to this hsemorrhage is much favoured by whatever has a tendency to produce general plethora, and an irritable and re- * Dr. Dewees thinks there is good reason to doubt the propriety of this " mechanical distinction." He adopts the doctrine of Broussais, that all haemorrhages are active, and quotes Dr. Caldwell in support of this opinion. Strictly speaking, there is, perhaps, no haemorrhage, ab- solutely passive, and in which the vessels that furnish the blood do not co-operate in the'production of the haemorrhage by some kind of action In a practical point of view, however, this distinction is unquestionably both proper and useful. Would Dr. Dewees not con- sider aloes a very improper remedy in the menorrhagia of young, sanguineous, and robust females] He no doubt would. And why? Because experience has shown that this article, is among our most efficient means for exciting the uterine vessels, and directing the afflux of blood to them. Yet this article, given in small, but frequent doses, deserves to be accounted the best remedy we possess for those pro- tracted exhausting, and obstinate uterine haemorrhages which occur in relaxed nervous, and phlegmatic habits, about the critical period of life. When, therefore, we see a particular modification of this discharge arrested by a remedy which we are accustomed to regard as decidedly calculated to stimulate the vessels from which it occurs— in other words, when we cure the haemorrhage by exciting applications, we have good grounds for distinguishing it from those cases of the same affection which are invariably increased by its operation. 526 MENORRHAGIA. I axed state of the system. A luxurious and indolent life; the free use of high-seasoned and nourishing diet, wines, and cor- dials; tightly laced corsets; frequent and long indulgence in the warm bath; habitual costiveness; and inordinate sexual indulgence, are among the most common and influential pre- disposing causes of active menorrhagia. Copious and protract- ed leucorrhcea; mental depression; deficient and unwholesome nourishment; habitual exposure to a cold or humid atmos- phere; in short, every thing which is capable of relaxing and debilitating the general as well as the uterine system, may fa- vour the occurrence of passive menorrhagia. Whatever tends to produce sanguineous congestion in the uterus may excite this haemorrhage; such as riding on horse- back ; dancing ; active purgating; the use of emmenagogues; immoderate venereal indulgence; long and rapid walking; a fall on the hips; stimulating diet and drinks; a loaded and constipated state of the bowels; suppressed haemorrhoidal dis- charge ; induration of the liver or spleen ; and reading volup- tuous novels, &c. Treatment.—The indications in this, as in the other varie- ties of haemorrhage are, to remove the predisposing and excit- ing causes if practicable; to lessen the momentum of the ge- neral circulation, if it be not below the natural standard; to derive the circulation from the uterine system; and finally, to constringe the bleeding vessels. If the pulse be active or tense and quick, venesection will be proper; and every thing which has a tendency to excite the action of the heart and arteries must be removed. The patient should lie on a mattress, avoid getting up or walking about, and take only the lightest kinds of liquid farinaceous nourishment and cooling acidulated drinks. Having diminish- ed the momentum of the circulation, recourse must next be had to such remedies as experience has shown to be capable of con- stringing, or in some way or other checking the haemorrhagic action of the bleeding vessels. Among these, the sugar of lead holds the first rank, and will seldom disappoint our expecta- tions entirely, in the active variety of the disease. From two to three grains, either alone or with a grain of ipecacuanha, may be given every half hour or hour, or at longer intervals, according to the rapidity of the haemorrhage. When the pulse is contracted and quick, it should be given in union with mo- derate doses of opium or Dover's powder. I have been in the habit of giving it in such cases with about a grain of camphor and the same quantity of ipecacuanha in each dose, with the view of exciting a gentle diaphoresis. The tincture of cinnamon is, perhaps, more frequently used by the German physicians in menorrhagia than any other re- medy ; and my own experience enables me to speak with much MENORRHAGIA. 527 confidence of its usefulness in cases unattended with considera- ble arterial excitement. From thirty to sixty drops of it may be given every hour or two. I have, in some instances, known tne discharge very promptly moderated by this medicine alone. 1 ^re?u vanety of other astringent remedies are recommend- ed in the books for the treatment of this haemorrhage. Alum the extract of rhatany, kino, the sulphate of copper, &c. may, no doubt, be used with occasional advantage ; but they are not equal to the sugar of lead for arresting sudden and rapid me- norrhagic discharges. In cases attended with a moderate and protracted flow of blood, the extract of rhatany will often af- ford much advantage; and in instances of this kind, I have also used alum, in union with ipecacuanha, with marked bene- fit.* In cases accompanied with increased arterial excite- ment, the nitrate of potash, given in large doses, will often af- ford prompt relief. When the haemorrhage is profuse and ra- pid, cold applications to the vulva and region of the pubis should be made. We may also resort to cold and astringent injections into the vagina. When the violence of the discharge has been in some degree checked, and it continues in a mode- rate degree, the elixir of vitriol, diluted in cold water, may be taken at short intervals with advantage. Should the measures already indicated fail to arrest or sufficiently to moderate the hsemorrhage, recourse must be had to the tampon. A strip of soft linen should be introduced by pushing it gradually into the vagina on the point of the finger until the exit of the blood is obstructed. This will cause the formation of a coagulum, which, being immediately in contact with the bleeding surface, prevents the further progress of the effusion. Emetics also have been recommended for the suppression of uterine hsemorr- hage ; and in active cases of a protracted character, attended with symptoms of gastric disorder, an emetic dose of ipecacu- anha will occasionally do much good.f Perfect rest, a light simple diet, and cooling drinks must be enjoined, and all men- tal agitation carefully avoided. In passive and protracted haemorrhage from the womb, attended with the symptoms mentioned above, as indicative of this variety of menorrhagia, little or no permanent advantage can be obtained from astringent and cooling remedies. These haemorrhages are, indeed, often extremely obstinate in their course. From much attention to cases of this kind, I am sa- tisfied that the appropriate remedies are such as tend to invi- gorate the uterine vessels. Blisters to the sacrum will, in * R. Pulv. sulph. aluminis gi. Pulv. ipecac. gr. xii. M. Divide into six equal parts. Give one every three or four hours. t Eberle'a Mat. Med., vol. i. p. 27. Second edition. 528 MENORRHAGIA. some instances, do much good; but the remedy which has most frequently succeeded in my hands, is a combination of aloes and the prussiat of iron,* in conjunction with the tinc- ture of cinnamon. With these medicines I have often succeed- ed promptly in arresting such haemorrhages. Dr. Dewees recommends small doses of hiera picra, a combination which I have known very effectual in several cases. Aloes is an old remedy in this variety of haemorrhage. Burdach in his Materia Medica, mentions its usefulness in such cases. Ergot may also be used with a prospect of advantage; and I have even resorted to the more active emmenagogues, such as the extract of savin, with evident benefit; and in no instance with disadvantage. The prussiat of iron, in doses of from ten to fifteen grains, has been employed by some practitioners with much success; and I do not doubt, from what I have seen of its powers, that it may be very beneficially given in this form of passive haemorrhage. We may also resort to the muriated tincture of iron in cases of this kind. I have lately succeeded in putting a stop to a protracted hsemorrhage of this kind, by a mixture of the compound tincture of aloes and the muriated tincture of iron, according to the following prescription. R. Tinct. aloes compos. ------ferri. muriat. aa fss. M. Take 20 drops four times daily. * R. Prussiat ferri 3ji. G. aloes gr. v. Conserv. rosar. q. s. M. Divide into 20 pills. S. Take one three times daily. END OF VOLUME I. NLM032068173