'* THE STUDY OF MEDICINE. BY JOHN MASON GOOD, M.D. F.R.S. F.R.S.L. MEM. AM. PHIL. SOC. AND F.L.S. >F PHILADELPHIA. SURGEON QmWM%. *RC£ — > MAY 291900 - /j'0/o'L. IN FIVE VOLmiEO.-------------- VOL. II. FIFTH AMERICAN EDITION. REPRINTED FROM THE LAST LONDON EDITION, GREATLY IMPROVED AND ENLARGED. JWeto*3rotfe: PRINTED BY J. & J. HARPER, FOR COLLINS AND HANNAY, COLLINS AND CO., AND O. A. ROORBACH, —PHILADELPHIA, JOHN GRIGG, TOWER AND HOGAN,--BOSTON, RICHARDSON AND LORD, AND HILLIARD, GRAY, AND CO. 1827. K v-Z _______ I CLASS III. CLASS III. ELEMATICA. DISEASES OF THE SANGUINEOUS FUNCTION* ORDER I. PYRECTICA. FEVERS. II. PHLOGOTICA. INFLAMMATIONS. III. EXANTHEMATICA. ERUPTIVE FEVERS. IV. DYSTHETICA. CACHEXLES. CLASS III PHYSIOLOGICAL PROEM. On treating of the very important and extensive range of diseases cl. lit included under the present class, let us first take a brief survey of fcr°P°sof the sanguineous function which is the immediate theatre of their inquiry. operation, and the means and instruments by which it is maintained. This comprehensive subject may be most conveniently discussed general under the three following divisions :— I. THE MACHINERY OF THE SANGUINEOUS SYSTEM. II. ITS MOVING POWERS. III. THE NATURE OF THE FLUID CONVEYED. I. The importance of the blood to the general health of the animal I. Maehi- system, and its existence in every part of almost every organ, have s,m|uinc-& been known in every country in which medicine has been studied ous system. from the first dawn of its cultivation. It is not necessary to retrace Unsatis- the wild and idle hypotheses that were started in ancient times to ac- hypotheses count for the means by which this universal fluid travels from one of the part to another, and appears in every quarter. It is enough to ob- serve that, till the great and transcendent doctrine of the circulation of the blood was completely established, the acutest physiologists wandered about in darkness and uncertainty, seldom satisfying them- selves, and, still more rarely, the world around them : insomuch that I am not acquainted with a single conjecture that was ever vented upon the subject that is in the least degree worthy of repetition. The opinion, indeed, of a circulation of the blood through the sys- a circu tern was loosely started by various writers even of very early times ; {o„g°"y but under every modification it was found to be accompanied with suspected so many difficulties as always to be dropped almost as soon as it was ancients. revived, and rarely, till the middle of the seventeenth century, to show itself to any effective purpose. Hippocrates guessed at it, Aristotle assented to it, Serveto, who was burnt as a heretic in 1553 imperfectly taught it by pointing out the smaller circulation, or that through the lungs ; and our own illustrious countryman, Harvey, about a century afterwards, gave a finish to the inquiry, by establish- ing the larger circulation, or that over the whole frame. b ix. inuj PHYSIOLOGICAL PROEM. 1. Machi- nery of the sanguine- ous gys torn. Proofs to which it appeals in the present day. Arteries generally terminate in veins: many ol" ' them in exhalants: other* perhaps in lymphatics. Instruments of the san- guiferous machinery. Heart in the more perfect classes of animals. The principal proofs of a circulation of the blood offered by Har- vey, and those, indeed, on which wo chiefly rely in the present da\. are deduced from the disposition of the valves of the heart; the range of the arteries and the veins, and from what occurs when cither tin- arteries or veins are opened, compressed, tied, or injected. Thus. if we open an artery, the blood that jets from the puncture flows in a direction from the heart; and in a direction to the heart, if we open a vein. A compression or ligature upon an artery, puts a stop to the blood that flows from above the ligature ; but the same upon a vein puts a stop to the blood from below it, in which direction the vein immediately becomes distended. In like manner, an acid liquor injected into the veins coagulates the blood in the direction towards the heart, proving that the venous blood is every where travelling hi this course. While an examination by the microscope of the half- transparent vessels of frogs and other cold-blooded animals confirms the view laid open by these phenomena, and shows to us a continual flow of the blood from the heart into the arteries, thence into the veins, and thence to the heart again ; thus completing the circular career. The arteries, therefore, generally speaking, terminate in veins ; but by no means the whole of them, for many are exhalantor secre- tory, and terminate in minute orifices on the surface of membranes and other organs ; which no microscope, however, has yet discover- ed, but whose existence we have every reason to believe, as we per- ceive a perpetual oozing of fluids, whose flow we cannot otherwise account for, into all the cavities of the body ; which keeps their sur- faces moist, and makes motion easy. While, according to M. Ma- gendie, whose experiments, however, seem to want confirmation, other minute arteries terminate in lymphatics, which he makes as much a part of the sanguiferous system as the veins; the lymphatics conveying the more attenuate part of the arterial blood, slightly tinged of an opaline or rose-coloured hue, though sometimes of a madder-red ; such as the fluid which oozes upon puncturing the lymphatics, or the thoracic duct after a long fast. It is not neces- sary to examine into the correctness of this hypothesis in the present place, as we shall have occasion to notice it more at large when treating of the excernent system, which will be found to embrace both the absorbent and secretory vessels. It should, however, be remarked, that in M. Magendie's hypothesis the veins, and not the lymphatics, are the absorbents of the body.* Omitting then for the present the consideration of the lymphatics, the machinery by which the circulation of the blood is principally effected consists of the heart itself, the arteries, and the veins. The heart in the more perfect classes of animals, as mammals, birds, and most, though not all, amphibials, is a very compound organ ; for in all these the blood, when received from the veins, is first sent from this central organ to the lungs to be duly aerated, or, according to Mr. Ellis's hypothesis, to be unloaded of its excess of carbone, and is afterwards returned from the lungs to the same organ before its general circulation over the system commences. * Precis Eleroentaire de Physiologie, Tom. h. PHYSIOLOGICAL PROEM. [cl. m. \ These classes, therefore, are said to possess a double circulation. ne*iaofj"he And as the heart itself consists of four cavities, a pair, composing sanguine- what is called an auricle and a ventricle, belonging to each of the ous system' two circulations ; and as each of these pairs is divided from the other by a strong membrane, these classes are also said to have not only a Hegrt double circulation, but a double heart; a pulmonary and corporeal double, and circulation, and a pulmonary and corporeal heart. double?10" The heart is well known to be situated in the chest, between the Seat and lungs, above the diaphragm, and to be influenced by all the motions "nhe ses of the diaphragm. It is loosely surrounded by a dense and fibrous heart- membrane, named, from its situation, pericardium, possessing little sensibility, closely connected with the substance of the diaphragm, and reflected over the heart and its large vessels. Its use is to con- fine the heart in its proper post; and to lubricate it, in its. state of unceasing activity, with a peculiar fluid, denominated, liquor pericar- dii, supposed to be secrfeted by peculiar glands, but more probably exhaled from the capillary arteries of the internal surface. In a state of health this fluid is small in quantity and of a reddish hue, some portion of the red parts of the blood being intermixed with it; but, in a morbid state of the membrane, it is apt to accumulate, change its properties, and lay a foundation for various complaints.* The power possessed by the pericardium of restraining the heart Restrictive to its proper post, is obvious from the following fact. If, after de- ?™" °f taching the sternum and opening the chest, an incision be made into cardium. the pericardium of a living animal wide enough for the purpose, the heart will often be found to leap out of its sac through this aperture, and to fall on the right or left side of the thorax. Ana hence the How far the common and colloquial expression derived from common feehng, 0fheaFtleaPs the leaping of the heart for joy—and it might as well be said for grief or terror—is founded on actual fact. The heart, which is loosely confined by its vessels, often leaps as far as its surrounding . sac will allow it. And hence again one cause of the violent palpi- Palpitation tations to which this organ is subject, as we shall hereafter have to ,°f ,he explain more at large. The general structure of the arteries and veins has, till of late years, Arteries been considered as alike, both being supposed to consist of two and veins' separate tunics, an elastic or outer, and a muscular or inner, inde- pendently of the soft and common covering which lines them within. Yet nothing can differ more widely than the relative spissitude and power ascribed to these tunics compared with each other in different parts of the circulating course. As the heart is the salient point of Arterial the circulation, and pours forth about two ounces of blood at every 8tructur* jet, the greatest force is exerted against the arteries that immediately issue from the heart. Here, therefore, we find the greatest resisting power ; for in the aorta and pulmonary artery, the elastic tunic is stronger than the muscular, by which contrivance the arterial canal is never too much dilated in either by the action of the heart in its contraction, or, as the Greeks call it, systole. In like manner this tunic becomes stronger at the bendingof the joints, and continues so through the whole length of the curve ; and the same provision takes * Sec Bostock's Elementary System of Physiology, Vol. i. p. S63, 8vo. 1824. CL. III.] PHYSIOLOGICAL PROEM. I. Machi- nery of the sanguine- ous system. Skilful (djustment 01 the arterial and muscular funics. Cause of collapse on loss of blood. Cause of blushing. Venous structure. Why fur- nished with numerous valves. Whether muscular libred really exist in arteries and veins. Causes of gradual diminution 01 projectile force. place at the sharp angles made by a trunk and its branch, or at an angle formed by the division of one trunk into two. As the arteries, however, recede from the heart, the blood, resisted at every stop by the clastic tunic of the canal it flows through, progressively loses its impetus, and a less clastic power becomes necessary arid is actually provided. At a considerable distance, therefore, from the heart, in whatever direction the arteries ramify, their muscular tunic soon balances their elastic, and gradually becomes superior ; till at length, in the capillary arteries, it is nearly, if not altogether, the only tunic of which the canal consists : whence the case with which these ves- sels collapse on some occasions, as loss of blood, or the exercise of terror, or any other depressing passion ; and the equal facility with which they open in other cases, as in the sudden blush of shame or modesty. In the veins the elastic and muscular jtunics are considerably weaker than in the arteries ; they have, nevertheless, a more diffi- cult task to perform than arteries ; for, with a few exceptions, they have uniformly to force the current of blood upwards to the heart against the power of gravitation. They are hence far more nume- rously furnished with valves than the arteries, by which the ascending columns of blood are prevented from retrograding : and have b\ many physiologists been supposed to possess some degree of con- tractile, and consequently of propulsive power by the joint pressure of the sides of the arteries or muscles that accompany them, and that of the external atmosphere ; to which subject, however, we shall have occasion to return presently. 1 have thus far adverted to the commonly received opinion, and that taught by the most celebrated physiologists of our own country, and especially by Mr. John Hunter Nevertheless it has long been a disputed point, whether, not merely the veins, but even the arte- ries, possess muscular fibres. The physiological arguments of Bi- chat, and the chemical researches of Berzelius, militate so strongly against the affirmative to this proposition, that the existence of such fibres in both classes of vessels has of late been doubted by many, and the contractility of the arteries been ascribed to their elasticity of texture alone ; while the veins are conjectured to be altogether pas- sive in the change of diameter they sustain. Yet whatever doubts may be entertained upon this subject in veins and arteries, the existence of muscular fibres cannot be questioned in the minute ves- sels termed capillaries. I have observed that the force with which the blood is at first projected from the heart,is progressively diminished by the resistance it encounters in the thick and powerfully elastic tunic of the trunks or large arteries into which it is immediately propelled. There are two other causes which co-operate in producing a progressively diminishing force. The first is the short angles against which the blood has to strike at the origin of all the different branches : and the next, and most important, is the larger diameter of the gene- ral mass of the arteries, compared with that of the heart or the arteries from which they immediately proceed ; the range of the diameter augmenting in proportion to the increase of the ramifica- tions. From experiments, indeed, made by Mr. John Hunter on PHYSIOLOGICAL PROEM. [cl. ur. 9 the carotids of camels and swans,* the very same arteries appear J'*1*6^ gradually to widen from the upper end or that nearest the heart to sanguine- the lower or that most remote. From all which he concludes that Diameter'of the aggregate diameter of the arterial system forms a cone whose the arterial apex is at the heart. And he concludes, also, and most correctly, cone. ' that this conic proportion is most obvious, increases most rapidly, Conic and spreads with its broadest base in infants, or rather in the fetus ; vaXTin*"1 for here the main trunks of the arteries are extremely short, while different-. the capillaries are very large, and from the obliteration of many ves- sels in subsequent life, more numerous than at any other period. It- is highly probable indeed that while the aorta in childhood is not a fourth part of the size of the same vessel in an adult, the aggregate of the capillaries of the former possesses a diameter more than four times as large as the aorta in the latter. We may hence, in some degree, account for the difference in the Why the quickness of the pulse at different periods of life. In early infancy different it beats as much as 140 strokes in a minute ; towards the end of the |[L£g1-ffetent second year it is reduced to 100 ; at puberty it is only 80 ; about virility 75 ; and after sixty years of age seldom more than 60 ; in a minute. For reasons connected with the preceding, it is more fre- quent in persons of short stature, those of strong passions of mind, those of great muscular exertion, and in females. From the increas- ing diameter of the blood-vessels as they diverge from the heart, the blood has a greater space for moving forward, and is able to move with more freedom: and hence one reason for the empty state in why the which the arteries are found immediately after death : a second rea- ar,erjes son is that the tunics of the veins possessing little or no elasticity, empty alter readily dilate to the distentive power of the blood as it moves forward: deatl1' a third, and indeed the principal reason, as sufficiently proved by Dr. Carson of Liverpool, is the natural elasticity or resilience of the lungs, which, by keeping them after death in a state of dilatation, allows the blood to accumulate here as in the vacuum. And hence, again, Why blood the reason of the accumulation of blood which is usually found in the lated in the chest after death, as well as the empty state of the vessels. death.aftei This vacuity of the arteries upon death, was one of the objections The above urged very forcibly by the ancients against the circulation of the blood, agaVnst'tb.e or even its following at all the course of the arteries ; and which Dr. d°ct,jne.of Harvey very unsatisfactorily replied to, by asserting, contrary indeed to fact, that the heart continues to contract for some time after death, and even after it has received blood:—for the heart is generally found loaded with blood.t And it is this objection, together with some Circulation others, that has induced Mr. Ker of Aberdeen once more to revive "' *n}e ' the doctrine of the ancients, and deny that of a circulating system altogether, resigning to the arteries the uses the ancients allotted them. It still, however, remains to be ascertained by what means the ul- timate branches of the arteries terminate in those of the veins, and how this communication is conducted. * On Blood, Inflammation, &c. Part. I. Sect. viii. p. 170. t See Dr. Carson " On the Vacuity of the Arteries after Death'." MediCO-Chir. Trans. Vol. xi. Part. i. Voi,. U.—2 10 I. Machi- nery of the sanguine- ous system. Diametor of the aorta and pulmonary artery alike- Balance of arterial and venous blood, how maintained. ..i.. m.] PHYSIOLOGICAL PROEM. Sum total of the blood estimated very differ- ently. II Mot!b» powers of tho san- guineous system. What excites the heart to contract. The pulmonary artery, which receives from the heart the blood re- turned into it from the veins, bears a very close proportion to the di- ameter of the aorta,* which sends the blood from the heart over the whole of the larger circulation. The aorta possesses more strength, but their elasticity is nearly equal, and the measure of each, on being slit, is about 3£ inches : and hence there can be little doubt that the quantity of blood sent back to the heart, is on an exact balance with that which flows from it. It is not, however, at any time the iden- tical blood which is thus returned to the heart, for every organ takes from the general current, as it visits it, such parts and such principles as it stands in need of, to support the wear and tear of its own action ; while another considerable portion is thrown off, as we have already observed, in the form of secretions or exhalations from various emunctorics that open externally or into internal cavities. But the drain which is hereby produced on the arterial blood is compensated by the various fluids collected from every part of the absorbent ves- sels, and by the flow of the chyle from the digestive organs ; both which arc poured into the thoracic duct, and finally intermixed with the returning current of venous blood a short time before it reaches the heart; and in this manner the balance of arterial and venous blood'is maintained. With respect to the actual quantity of blood contained in the entire system, our means of determination are so imprecise, and consequently the calculations, or rather the conjectures that have been offered upon the subject, are so strikingly discrepant, that it is not easy to reach a satisfactory conclusion. It is only necessary to state a few of the different opinions that have been offered to show the absurdity of several of them. Muller and Abeildgaard estimate the weight even in an adult at very little more than eight pounds ;t Borelli at 20; Planch at 28 ; Haller at 30 ; Dr. Young at 40 ;J Hamberger at 80 ; and Keil at 100. Blumenbach states the pro- portion in an adult healthy man to be as 1 to 5 of the entire weight of the body. Yet little reliance can be placed on this last mode of determination, on account of the great diversity in point of bulk and weight of adults, whose aggregate quantity of blood is in all proba- bility nearly alike. The mean numbers, as those of Baron Haller and Dr. Young, making the amount from 301b. to 401b. appear most reasonable; and perhaps fall not far short of the sum intended by Professor Blumenbach. The subject requires further examination, and a nicer estimate. / II. There is another question which has also, in all ages, greatly occupied the attention of physiologists, but upon which we still remain in a very considerable degree of indecision ; and that is, the moving powers employed in the circulation ; or, in other words, the projectile force by which the blood is sent forward. The heart forms the salient point of motion, and with its systole or contraction the circulation commences. But what is it that ex- cites the heart to contract ? One of the most common answers to this question in the writings of physiologists is the flow of the blood * See Hunter on Blood, p. 133* ? Phit. Tran«. ie09, p. ft t Bltrenrenb. Elena. Fbys. p. 4. § 6. PHYSIOLOGICAL PBOEM- [cl. m. 11 mto the ventricles. But this is merely to argue in a circle ; for the ^°u0vfe question still returns, what is it that makes the blood flow into the ^"^ ventricles ? Others have referred the cause to an immediate impulse fyXrnT from the brain. Now in contractions of the voluntary muscles, there is no doubt of the existence of such an impulse, for we are conscious of it, and assent to it; but we are neither conscious of nor assent to any thing of the kind in respect to the contraction of the heart; and are perfectly sure that no such power of the will takes place during sleep. It is a mere assumption ; and an assumption which can only apply to a part of the great animal kingdom even during wakefulness; for, as it is only in mammals and birds that the nerves can be thus influ- enced in their passage to the heart, the postulate does not account for the contraction or dilatation of the heart in other classes of ani- mals.* Mr. John Hunter ascribes this action of the heart, or rather the [^^ of whole career of the circulation, of which he regards the action of the necessify, heart as a single and ordinary link in the general chain, to what he what- calls a stimulus of necessity ; by which he seems to mean an instinc- tive power dependent on the general sympathy of the system which in every part is craving or demanding such an alternation ; or, in other terms, is uneasy without it. His words are as follow : " The alter- ^fhaerdcd nate contraction and relaxation of the heart constitutes a part of the primUm circulation; and the whole takes place in consequence of a necessity, Jjjg^ the constitution demanding it, and becoming the stimulus. It is ra- ther, therefore, the want of repletion, which makes a negative impression on the constitution, which becomes the stimulus, than the immediate impression of something applied to the heart. This we see to be the case, wherever a constant supply of some kind of aid is wanted in consequence of some action. We have as regularly the stimulus for respiration, the moment one is finished an immediate de- mand taking place ; and if prevented, as this action is under the in- fluence of the will, the stimulus of want is increased. We have the stimulus of want of food which takes place regularly in health, and so it is with the circulation. The heart, we find, can rest one stroke, but the constitution feels it; even the mind and the heart is thereby stimulated to action. The constant want in the constitution of this action in the heart, is as much as the constant action of the spring of a clock is to its pendulum, all hanging or depending on each other."! Mr. Hunter's "Treatise on the Blood," is a work of such sterling merit, so rich in its facts, and so valuable in its remarks, that notwith- standing a few nice-spun and chimerical speculations that occasion- ally bewilder it, there is no book on physiology which a student ought to study more assiduously. Yet I am much afraid that the language Li«ie n J-.? read has no great deal of meaning in it; and that it does little JSrSSIhfd more than tell us that the heart contracts because it contracts, or, Jy^* " rather, that the circulation takes place because it takes place. tion. Few physiologists indeed seem to have adopted this opinion : and hence a far more plausible and intelligible hypothesis has been since offered. This consists in supposing the heart to be stimulated by %*$£ from the ChiWTgia Infusoria renoTenda. Aot. -T. M. RVsruwlot. 8vo. LugrJ. Bat. 1779. PHYSIOLOGICAL PROEM. [cl. nr. 13 may be the projectile power of the heart, it must altogether cease I„Je'°vj),fs with the arteries, and cannot reach the veins. the san- And hence arose another hypothesis, which ascribed the propul- fyXrn?8 sive power to a progressive vis d tergo, or a force communicated Uvpoihesis from the ventricles of the heart to the commencement of the arte- tergo. ries, producing a vibration or alternate dilatation and contraction of their tunics, through their whole length to the veins; and thus acting in conjunction with the projectile force of the heart itself. In proof of this auxiliary power afforded by the coats of the arte- Supposed ries, the phaenomenon of pulsation was triumphantly appealed to ; J^ed from which, it was maintained, gave a direct and incontrovertible evidence i,ul8atlon- that an alternate dilatation and contraction, or enlargement and diminution in the diameter of the arteries, is constantly taking place. This, by Bichat, is attributed solely to the locomotion of the arterial Bichat's tubes, propagated to their terminal ramifications, and thence conti- tkm.ana nued to the veins ; but by most, modern physiologists to a joint power compounded of the action of the heart and the arteries. M. Bichat's doctrine has of late been incontrovertibly refuted by one or two very simple experiments of VI. Magen lie.* Besides Arteries which, however, it is now a well-ascertained fact, and one that has cnaoieof been thoroughly elucidated by Dr. Parry of Bath, that no increase ""{J^™ of size, or indeed change of bulk of any kind takes place in arteries during either the systole or diastole of the heart's ventricles in a state of health.t The arteries of animals, to ascertain this point, have been exposed in different parts, and to considerable lengths, without evincing the least apparent increase of size. And hence it is the Pulsation pressure of the finger, or of some other substance, against the side p,"duced of an artery that alone occasions pulsation, in consequence of the J^'^J}];6 resistance hereby made to the regular flow of the blood; the alter- out. nating heat being produced by the greater momentum with which the current strikes against the finger or other cause of obstruction, during the systole than during the diastole of the heart. Professor Dollinger has confirmed the experiments of Dr. Parry by laying bare the carotid of a dog before his pupils which gave to the eye no proof of altered form or motion, though a pulse was dis- tinctly felt by the finger. And in like manner a pulsatory motion is always felt by the fingers when applied to a leaden water-pipe while a pump is at work upon it at one end, and alternately giving a fresh pressure to the column of water it contains by forcing in a fresh supply : yet the pipe is all this time incompressible. It may be still further observed that, in a state of inflammation, the The pulse of pulse of the inflamed part, in consequence of local excitement, is part^arSy much more frequent than that of the heart or of any other organ. n?"ecshJ^*th Thus in a whitlow, the radial artery may give to the finger a hundred that of the pulsations in a minute, while not more than seventy strokes may be th« ne?gh° exhibited in any other part of the system. The rapidity of the pulse bounng is in this case usually in proportion to the degree of the inflammatory par * * Precis Eleraentaire de Physiologic Tom. 11. p. 320. t Experimental Inquiry into the Nature, Cause, and Varieties of the Arterial Pulse, &c. By C. H. Parry, M.D. F.R.S-, *c. Bath, 1816. 14 cl. in.] PHYSIOLOGICAL PROEM. il Movua action •* and hence, if the system should labour at the same time [Tsangu.- under ten different inflammations in different parts or organs of a tem'sy8' different structure, as glands, muscles, and membranes, it is possible that it may have so many different seats of pulsation taking place at such different parts at one and the same time, while all of them are at variance with the pulsation of the heart. Even where there is no inflammation such discrepancies in the pulse are occasionally to be met with, insomuch that lleil gives a case in which the heart, the carotids, and the radial arteries all pulsated differently :t and we can hence readily perceive why they should be more frequent and striking under the increased action produced by inflammation, and often, in a debilitated organ, more disposed to irregular action and particularly irregular contractUe action in its capillaries. Capillaries We are, indeed, let a Utile into the mystery of this phenomenon m°oSreCcon- by the curious fact that some of the arteries possess a higher degree u?aCntitheity °f contractile power than others, and that the capillaries possess the larger arte- highest measure allotted to any of them. " Indeed every fact," ob- oonfirmed serves Dr. Bostock, " with which we are acquainted respecting the by Boatock mechanism and functions of the sanguiferous system, lead us to the same conclusion, that the large arteries are to be regarded as canals transmitting the blood from the heart, where it receives its great im- pulse, into the smaller branches; and that it is chiefly in these smaller important branches that it exercises its various functions. "J We may hence this fact on see why the capillaries are, in many cases, so much sooner excited tinn.rama" t*lan tne *arger canals, and exhibit so much more violence of action: a distinction of high importance in explaining the doctrine of in- flammation, though it has been less attended to by pathologists than it deserves. henoCthe** The nyPothesis' therefore, of a via d tergo, whether dependent o?PavuiSa8 upon the heart alone, upon the arteries alone, or upon a combination Batfrfacto* of the two' has bv no means proved sufficiently satisfactory, or been ry, whence- sufficiently supported by evidence in respect to the entire circulation. riveVd.r e Under no modification does it account for the flow of the blood olrrfna of tm*0USn tDe vems. And in regard to the whole of the views which E°Hu°n nave been thus far examined, Mr. John Hunter, as I have already «»• observed, was so extremely discontented that he placed no more stress upon one part or organ of the sanguiferous system than upon another ; upon the heart than upon the arteries ; or upon the arteries than upon the veins; regarding the whole economy as the result of a sort of instinct, to which, as just noticed, he gave the name of a stimulus of necessity; and which opinion he supported by making an appeal to insects which have no proper heart; to worms, most of which have no heart whatever ; and to monsters which have been born without a heart; whilst at the same time he contended that veins, at least the larger, exhibit, under certain circumstances an expansile and contractile power as well as arteries. " I think it probable," says he, " that where there is an universal action of the 8vo.l82S.Siti°n °f the PrinciP,e8 of Pathology, &c. By Daniel Pring, M.D. p. 119. t Memorabilia CUnica. Vol. n. Fasoic. 1-6. Hall. 1792. I Uilementary System of Physiology. Vol. l. v- 402. 8ro. 1824. PHYSIOLOGICAL PROEM. [cl. in. lo vascular system, the action of the arteries and veins is alternate : that "•^Jj'jjj? where the arteries contract, as in many fevers, the veins rather dilate, thesangui- more especially the larger."* And it is hence, again, highly pro- {1eein"B8ys" bable that in this " universal action of the vascular system" the Actions of secernents or extreme arteries take an important part, and, as has since been suggested by Dr. Pring,t operate by a kind of suction, which may be regarded as a vis dfronte. Upon the whole we may conclude with Haller, that the heart exerts a very considerable degree of force in the general economy of the circulation, although it is impossible to estimate its power with mathematical precision. And we may reasonably refer the first, or Moving arterial half of the general circuit of the blood to this force, if not artereiai°cir- alone, in conjunction with the aid contributed by the elastic and Nation. contractile tunics of the arteries themselves, whether pulsation be a result of these powers alternately exercised, or of mere local pressure. It yet remains, however, to account for the second half, or that M°™fS f which consists in the passage of the blood through the veins; and venous co- upon this subject there is one most important and elucidating fact,culatl0n- which, till of late, has never been in any degree brought forward in the course of the inquiry. It is this : that when the heart, by the Vacuum in contraction of its ventricles, has exhausted itself of the blood con- produced tained within it, a comparative vacuum must follow, and the blood |'*jgtB9ys" from the venae cava?, or venous system at large, be sucked up into the right auricle. This ingenious remark seems first to have been thrown out by Dr. Wilson :J and Dr. Carson of Liverpool, taking advantage of it, has constructed a simple and beautiful theory of the projectile powers employed in the circulation, the general principle of which may be expressed in a few words. The heart is supposed General to act at one and the same time in a two-fold capacity. By the con- produced traction of the ventricles, it propels the blood through the arteries ; {j^ £)ewde°u' and by the dilatation of the auricles, it draws it up from the veins, of the It is at once, therefore, a forcing and a suction pump. The con- a^Vorcinf traction of the heart, and consequently its comparative vacuum, are nnd suction supposed to be considerably assisted by the elasticity of the lungs, sist'e5t>yS and the play of the diaphragm which we had occasion to notice at a""°cuy"(,ms some length in our physiological proem to the preceding class, and the great resistance which they jointly afford to the atmospheric pressure; whilst this very pressure, applied on every part of the exterior of the animal frame, contributes in an equal degree to the ascent of the blood in the veins ; for, as the column of venous blood is perpetually girt on all sides, and cannot fall back because of the nu- merous valves with which the veins are furnished, it must necessardy take an opposite or ascending direction. There are, nevertheless, numerous difficulties that yet remain to ™ffcu,ties_ be explained; such as the proportion of projectile power furnished ing to be by the conducting pipes themselves; by what means the want of a exP,a,nc<,• diaphragm is compensated in birds and reptiles which have no such * On Blood, p. 187. t Ubi supra, p. 132.165. t Wilson's Enquiry, &c. pp. 9. 11. 16. &c. 16 cl. ra.] PHYSIOLOGICAL PROEM. II. Moving powers of the sangui- neous sys- tem. Cominuni cation be tween re- mote or- gans dis- tinct from that of the blood. Between the spleen and sto- mach. Between the stomach nnd blad- der. This sub- ject entitled to further inquiry. Doctrine of 'pulsation, and its im- portance. Pulse how influenced. Standard in adult life. Influenced by tempera- ment and idiosyncra- sies. organ ; and what constitutes the projectile power in animals that have no heart, and consequently no double pump to work with.* There is also another curious fact which physiology has pointed out. but has never hitherto been able to explain : and that is, a direct communication between remote or unconnected organs, apparently, by some other channel than the circulation of the blood. Some- thing of this kind seems to exist between the spleen and the stomach, the former of which has been proved by Sir Everard Home to receive fluids from the cardiac portion of the latter, though we can trace no intercourse of vessels : but the most extraordinary example of this kind which at present we seem to possess, is the communication which exists between the stomach and the bladder. For the expe- riments of Sir Everard Honie,t and the still more decisive ones of Dr. Wollaston and Dr. Marcet,| seem to have established, beyond a controversy, that certain substances introduced into the stomach, as rhubarb or prussiate of pot-ash, may pass into the bladder without taking the course of the blood-vessels, and consequently by some other channel ; a channel, indeed, of winch we know nothing. This is a subject well worth studying : for if two organs so remotely situ- ated as the stomach and the bladder be thus capable of maintaining a peculiar intercourse ; so other organs may possess a like intercom- munion ; and by such means lay a foundation for those numerous sympathies between distant parts which so often strike and astonish us. M. Magendie's hypothesis that veins are absorbents will explain the facts in 8ir Everard Home's experiments, but has no bearing upon that of Dr. Wollaston and Dr. Marcet. The discovery of the circulation of the blood has given a great importance to the doctrine of pulsation ; for by the strength or weakness, the slowness or frequency, the hardness or softness, the freedom or oppression, the regularity or irregularity of the beat of the artery against the pressure of the finger, we are now able to determine many momentous facts, relative, not merely to the state of the heart, but of the general system ; and, in many cases, to prognosticate upon grounds which were altogether unknown to the earlier cultivators of medicine. And on this account it is that the Greek physicians took but little notice of the pulse, which, even in the days of Celsus, was regarded as a res fallacissima. The pulse is influenced indirectly by the general state of the body, but directly, by that of the heart, or of the arteries, or of both, or of the quantity of blood which the vessels have to contain. In an adult male of good health, and not too corpulent, the com- mon standard of the pulse may be fixed at seventy strokes in a minute; but it varies in different individuals from sixty to eighty, being greatly affected by the temperament, and partly by the habit of life. In the man of a high sanguine character it rarely sinks below eighty and is often at ninety ; and in the melancholic it seldom rises above sixty, and sometimes sinks to forty. In some idiosyncrasies the n,m^rdineH^^iriC°"Phy8iol0?ica de Stractura atque Vita Venarum : a Medic* Ca™ srue ml rgeDSl Pram,° Pr°p0sit0 °rnata- Auctore Henrico Marx 8?o. t Phil. Trans. 1811, p. 163. J Ibid. p. 96. PHYSIOLOGICAL PROEM. [ex. in. 17 discrepancy is so considerable, and complicated with otlier changes ^w^'"/* than those of frequency and tardiness, that there is no reducing them the sangui to any rule. ,"ec°us *•■ Lizzari tells us of a person whose pulse was not more than ten singular in- beats in a minute.* Dr. Herberden says, he once saw a person whose pulse, as he was told, did not number in the beginning of his illness above twelve or sixteen in a minute ; though he suspects in this and all other instances, where it is below forty, that the artery beats oftener than it can be felt; because such slow pulses are usually unequal in their strength, and some of the beats are so faint as but just to be perceived ; so that others, probably still fainter, arc too weak to make a sensible impression on the finger. He had attended two patients, who, in the best health, had always very unequal pulses, as well in their strength as in the spaces between them, but which constantly became regular as the patient grew ill, and gave a never- failing sign of recovery in their once more returning to a state of irregularity.! In women the pulse is, generally speaking, six or eight Quicker in strokes in a minute quicker than in men, and hence, many women than in of firm health and a lively disposition have a standard pulse ofmen eighty-five. In a weakly frame the pulse is usually rapid ; for debility is almost always accompanied with irritability, and the heart partakes of the general infirmity. In this case, also, from the feebleness with which the heart contracts, the ventricle is but imperfectly emptied, and consequently soon filled again, and sooner stimulated to contraction. Hence, in infancy the pulse is peculiarly quick, and gradually be- Rate in comes slower as the child increases in strength. Dr. Heberden, who m anc>' paid particular attention to this subject, estimates the pulse on the day of his birth, and while asleep, from a hundred and thirty to a hundred and forty ; and fixes it at little less than the same rate, or that of a hundred and twenty strokes, for the first month. During the first year he calculates it at from a hundred and twenty to a hun- dred and eight: during the second, at from a hundred to ninety ; during the third, from a hundred and eight to eighty, at which it continues for the three ensuing years. In the seventh year it is fre- quently reduced to seventy-two; and in the twelfth, to seventy.! In advanced age, from the small quantity of sensorial power secreted, in advan- and the general inertness of the organs, the pulse sinks often con- ced llfe' siderably below sixty strokes in a minute. " I knew one," says Dr. Heberden, " whose chief distemper was the age of fourscore, in whom, for the last two years of his life, I only once counted so many as forty-two pulsations ; but they were seldom above thirty, and sometimes not more than twenty-six. And though he seemed heavy and torpid, yet he could go out in a carriage, and walk about his garden, receive company, and eat with a tolerable appetite." I have at this moment under my care a case of still greater ^"^r anomaly, in which the pulse is never more than thirty, and more commonly even after walking, not more than twenty-seven strokes * Uaccolta d'Opusculi Scientifici, p. 265. t Medic. Trans. Vol. 11. Art, u. ji. 29. t Ibid. Vol. H — 3 1& CL. m.j PHYSIOLOGICAL PllOEM. it. Moving in a minute. Mr. Alexander, the patient I refer tu, is sixty-nvv lir^ui- vears of age; about six years ago, from the bursting of ai pipe«n neous s)s- "he conveyance of coal-gas, he fell down in a fit of asphyxy, ironi which he revived with great difficulty. The reducent plan was carried too far, and though he has recovered from the accident, anu his head is uniformly clear, he is dyspeptic, and subject to palpita- tions of the heart. , , , To what The pulse may be counted with great accuracy up to a hunareu cuiawe'bf and forty or a hundred and fifty in a minute ; and if the stroke be the finger. equa}i and the wrist siender, so that we can take in more than nan the artery by the pressure of two fingers, we can reach a Jmndred and eightv ; Professor Frank gives an instance of two hundred m a case of'complicated carditis ; but beyond this there is great con- fusion and uncertainty : and it is difficult, therefore, to understand by what nice mode of measurement Dr. Wendt could distinguish, as he tells us he has done, a pulse of two hundred and forty-three strokes in a minute.t Uuickened The pulse is quickened by very slight excitements both external c7ta«X&r and internal. The stimulus of the air, of the light, and of sounds, is sufficient to make that of an infant awake fifteen or twenty strokes more frequent than when it is asleep, and beyond their control. The pulse of an adult is usually quickened eight or ten strokes during the digestion of a meal ; and running, or any sudden and in like man- rapturous emotion of the mind will double the ordinary scale. The checked, depressing passions, on the contrary, check it, and have, sometimes, put a total stop to the heart's motion, with a deadly shock, and killed the patient in a moment. There are many drugs that have a like tendency, of which all the simple narcotic poisons afford exam- ples. The digitalis and hyoscyamus are expressly used on account of this property: the prussic acid, and the plants that contain it, as bitter almonds and the leaves of the prunus Lauro-cerasus, when given in free doses, destroy the irritability, and extinguish the pulse Sometimes instantly: and this so effectually that the heart, when immediately- •tant£. m examined, has been insensible, not only to puncture, but to con- centrated acids. How quick- As the excitement of the stomach during the natural process of morbid'ex- digestion is capable of accelerating the pulse eight or ten strokes in ntemenis. a mmute, there can be no difficulty in conceiving that it may be still more accelerated by a morbid excitement of any other large organ, and particularly where the primary seat of excitement is in Hence the the sanguiferous system itself. And as, generally speaking;, the pulse a no- c ° c ., , J . . . . ., i J A ■ & aometer. frequency or the beat is m proportion to the degree of excitement, the pulse becomes a sort of nosometer, or measurer of the violence and danger of the disease: and it measures it equally, whether the return of the beat be below the standard of health or above it. other cir- How far, in either case, the pulse may vary from its natural num- to'be'no't? Der without great danger, depends upon a multitude of collateral V&2 whh circumstances, as the age of the patient, his idiosyncrasy, the pecu- its quick- ness. * De Cur. Horn. Morb. Epit. Tom. n. p. 175. 8vo. Manhem 1792. + De Mutatione quadam Pulsus insigni. EHanir. 1778. V. Bald. Syll. r PHYSIOLOGICAL PROEM. |cl. in. 19 linr disease he is labouring under, and the strenglh or weakness of "\vvlovJJJs the system. And hence, in addition to the number of the pulse, thesangui- we should also attend to its degree of fulness, softness, firmness, "el""8"78 freedom, and regularity ; a critical knowledge of which can only be learnt by experience and a nice discrimination. It has been highly injurious, however, to the study of medicine, £hnee ^"n that this subject has been often too finely elaborated, and the varia- rendered tions of the pulse been ramified into so many divisions and subdi- pleated. visions, and nice unnecessary distinctions, as to puzzle the young and be of no use to the old. And hence, some of the best patholo- gists of modern times have been too much disposed to shake off nearly the whole of the encumbrance, and pay no attention what- ever to the pulse except in regard to its frequency. Among this number was Dr. Heberden : " Such minute distinctions of the seve- ral pulses," ?ays he, " exist chiefly in the imagination of the makers, or, at least, have little place in the knowledge and cure of diseases. Time, indeed, has so fully set them aside, that most of these names of pulses are now as unheard of in practice as if they had never been given."* And in forming, therefore, his prognostic of a dis- ease, while he appeals to the pulse merely in respect to its number, he draws his other grounds of decision from the nature of the malady, and the violence of its specific signs. But this is to limit the subject to too strict a boundary ; and to Sometimes , , 1,. , • • i , to° rnuch exclude ourselves from what, m many instances, are clear and even simplified leading diagnostics. There are some practitioners, and of very high merit too, whose fingers are no more capable of catching the finer distinctions of the pulse than the ears of other persons are the niceties of musical sounds. I suspect this was the case with Dr. Heberden. as it was also with the late Dr. Hunter ; of whom Mr. John Hunter observes, that, " though he was extremely accurate in most things, he could never feel that nice distinction in the pulse that many others did, and was ready to suspect more nicety of discrimination than can really be found. Frequency of pulsation in a given time is measura- ble by instruments; smartness or quickness in the stroke, with a pause, is measurable by the touch, but the nicer peculiarities in the pulse are only sensations in the mind. " I think," continues this distinguished physiologist, " I have been certain of the pulse having a disagreeable jar in it when others did not perceive it, when they were only sensible of its frequency and strength : and it is, perhaps, this jar that is the specific distinction between constitutional dis- ease or irritation and health. Frequency of pulsation may often arise from stimulus, but the stroke will then be soft ; yet softness is not to be depended on as a mark of health, it is often a sign of dis- solution ; but then there must be other attending symptoms."! Dr. Fordyce's table of the pulse is, perhaps, unnecessarily compli- cated ; but the strength or weakness, fulness or smallness, hardness or softness, regularity or irregularity of the pulse, are indications nearly as clear as its frequency or slowness, and, in many cases. quite as diagnostic of the general nature of the disease. Frequency * Med. Trans. Vol. n. p. 20. f On Blood, Part 11. CL. iii. p. 3IP, 20 *■■•• nr.j PHYSIOLOGIC AL PROEM. II. Moving powers of the eun- guincous system. Strength nnd regu- larity, or weakness and irregu- larity ol the pulse. Full and small pulse, Hard and |i>ft pulse. Obstructed and free pulso. Examples of the doc- trine carried to an ex- treme Pulse of Solano. Organic pulses of Dc Bordeu. On what founded. and slowness of the pulse taken bv themselves*, indicate little more than the degree of irritability of the heart, or the force of the stimu- lus that is operating upon it. The strength and regularity, or weak- ness and irregularity of the pulse are as palpable to the finger as the preceding signs, and show, in characters nearly as decisive, the degree of vigour or debility of the heart; and hereby, except where this organ is labouring under some local affection, the vigour or debility of the system, which a mere variation in the state of the frequency of the pulse will not tell us. A full and a small pulse may be distinguished with almost as much ease as any other pro- perty it possesses ; this Mr. John Hunter ascribes to the state of (he arteries : but, if I mistake not, it gives us rather a measure of the quantity of blood circulating through the system, than of the muscular strength of the arteries, or of the heart itself; which is often a very important indication, and especially when combined with the preceding signs ; as it will then be our best guide in cases where we have determined upon emptying the vessels as far as we can do it without danger. Hardness and softness of the pulse, together with that vibratory thrill which has been called wireness, are not quite so easily learnt as its fulness and smallness, but a nice finger will readily discriminate them, and practice will point out the difference to every one. These characters Dr. Fordyce makes dependent, and I think with great reason, on the state of the arteries rather than on that of the heart, or on the quantity of the circulating fluid ; and Mr. John Hunter concurs in the same view. They measure the degree of vascular tone, or power of resistance ; and when the same effect, whether above or below the natural standard, takes place in the capillary arteries, it produces that change in the pulse which he distinguished by the names of obstruction and free- dom, but which it is not always easy to discriminate from several of the preceding qualities ; nor is it of great importance, as we have in such cases other symptoms that more strikingly manifest the same fact. Thus far, perhaps, the doctrine of pulsation may be studied to advantage : but when, beyond this, we come to a distinction between the free and dilated pulse, as proposed also by Dr. Fordyce; the quick and the frequent, as proposed by Stahl ;* and the dicrotic, co- turnizing, and inciduous, proposed by Solano,f as mere subvarieties of the rebounding, or redoubling, itself a variety of the irregular pulse, we perplex pathology with a labyrinth in which the student is lost, and the master wanders to no purpose. " lnfida," says Professor Frank, " arbitraria et jequivoca est multorum de pulsibus criticis doctrina "t De Bordeu acquired great reputation in the middle of the last century, for applying the doctrine of pulsation as an index to the diseases of every distinct organ of the body ; whence he not only adopted most of the subdivisions of Solano, but added others, and subdivided them still further. He started it as a new hypothesis + 5e Di£e,_rentia Pulsus ceteris et freqnentis. T Novas Obaervationes circa Crisinm Praedictiones ex Pulsii. ex pulsu. Vind. 1770. Vienn. 1753. t De Gurandis Horn. Morbis Epitome. Tom. i. p. SO. Wetscb. Medicinw PHYSIOLOGICAL PROEM. |cl. ni. 21 winch he endeavoured to support by facts and arguments, that every IX- Moving separate organ possesses a principle of life in some measure pecu- the san- liar to itself, and independent of the rest of the frame ; that each is ^tDe"°' endowed with a proper function, and susceptible of proper sensa- tions and movements; and that, by the agreement and co-operation of all these distinctive powers, the life and health of the entire sys- tem are budt up and maintained. These principles are developed and defended in his thesis " De Sensu generice considerate," pub- lished at Montpellier in 1742. Though arrogating the merit of originality, they are, however, little more than a revival of the ancient doctrine of harmony invented by Aristoxenus, and at one time very popular in Greece, as we learn from Lucretius : —Multa quidem sapientum turba putarunt Sensum animi certa non esse in parte locatum ; Verum habitum quemdatn vitalem corporis esse, 'apmonian Graiei qnarn dicunt.* M. De Bordeu, in adopting this hypothesis, supposed farther, that How ap an affection of any particular organ will occasion a peculiar varia- p ie< tion in the pulse from its natural state ; and, by a careful attention to these changes, he conceived himself capable of ascertaining the seat of the disease, and the channel through which nature was aiming at a crisis. He describes, in consequence, an overwhelming multipli- city of organic pulses; but his general division is into superior and inferior pulses : and this he founds on an observation that the actions of the parts seated above the diaphragm, and of those below, excite very different impressions on the circulatory system. These views are chiefly given in the most famous of all his publications, entitled " Recherches sur le Pouls par rapport aux crises."! This hypothesis became extremely popular in France and Germany, and excited a considerable degree of attention at Edinburgh. It is now. however, little heard of, and is by no means worth reviving. In effect, a voluminous and complicated classification of pulses is rather a proof of an active fancy than of a sound judgment: and though Dr. Heberden and Dr. Hunter may have thought too lightly of this branch of pathognomy, it is better to adopt their simplicity than the puerile conceits of many more elaborate pulse-makers. The Chinese have a more operose system of pulsations than any that have appeared in Europe; but nothing can be more whim- sical than their divisions. Avicenna treated of the pulse musi- cally ; and Hoffenuffer, pursuing his principles, drew up, in 1641, a musical scale of the pulse, dividing it into musical time, and mark- ing the different beats by semibreves, minims, and crotchets, semi- quavers, and demisemiquavers ; thus reducing his patient to a harp- sichord, and his profession to a chapter on thorough-bass. III. To speak minutely of the constituent principles of the iii intrin- blood, would carry us too far into the regions of animal chemistry ; tiesPorf Uie and I shall hence limit myself to a very brief analysis of those that blood- * De Rer. Nat. Lib. III. 98. See the author's examination of this hypothesis, and it* resemblance to others of later date, in the notes to his Translation of Lucretius, Book V. 100 and 104. + Paris 1756, 8to. 22 CL. m.] PHYSIOLOGICAL PROEM. m intrin- are fiXe(i or confinable, having already paid some attention to the tiesPofIthe gases in the physiological proem to the preceding class. An°iy«.iS of For the first judicious account of these principles, we are indebted Parmentier to an elaborate memoir of MM. Parmentier and Deyeux, who andDeyeux. arranged them under the followinD. heads :—1. A peculiar aroma, or odour of which every one must be sensible who has been present at a slaughter-house, on cutting up the fresh bodies of oxen. 2. Fi- brin, or fibrous matter, frequently also called coagulable lymph, and gluten. 3. Gelatine. 4. Albumen. 5. Red colouring matter. 6. Iron. 7. Sulphur. 8. Soda. 9. Water. b°"aete^ex- Still minuter and more exact experiments have since been made pfrimen " upon particular portions or the whole of the blood, especially by Dr. Marcet,* Dr. Bostock,t and Professor Berzelius4 which confirm the greater part of the preceding results, but have detected a few errors which it is necessary to notice. No gelatine Neither the blood of man nor of quadrupeds, so far as they have Wood! been examined, contain any gelatine. " The mistake," says M. Berzelius, " arises from the gelatinous appearance of the albumen ; I have never been able to detect a particle of gelatine in blood, and, as far as my researches extend, I have found gelatine to be a sub- stance altogether unknown to the economy of the living body, and to be produced by the action of boiling water on cartilage, skin, and cellular membrane; substances which are totally distinct from fibrin and albumen." It follows, therefore, that wherever gelatine is found in the animal frame, it is produced by a decomposition and recombination of the particles of the blood by the action of the Uncoaguia- secernents. But instead of the gelatine, Dr. Bostock has since of BOTtock. discovered in the serosity, or that part which remains when the lymph or serum has parted with its albumen by heat, a distinct sub- stance which he has denominated from its quality, uncoagulable matter,§ and which Dr. Marcet has called muco-extractive matter. Berzelius has affirmed it to be impure lactate of soda. Sulphur of The sulphur detected in the blood by Parmentier and Deyeux the blood a , *. . „ . ■> „ . J component does not exist in a free state, but is a component part ot its albu- aiburnenhe meni as is also its carbone and hydrogene, which, in consequence, alone. have as strong a claim to be considered as constituent principles as sulphur. It is by means of its constituent sulphur that the albumen of blood or of an egg, becomes capable of blackening a silver instru- Chiefsoi- ment employed to stir it. And as it is the albumen that is now taUic°ox™e known to dissolve the oxydes of mercury introduced into the blood ?*e*' in the cure of syphilis, it is probably owing to the sulphur of the albumen that this effect is produced ; or that the oxydes of any metals introduced as medicines into the blood are dissolved ; since the albumen of the serum is also discovered to be a powerful men- struum in dissolving iron, copper, and other metallic preparations. blood0!1118 —e ir°n traced m the blood is> in like manner, a constituent cr°n°=tituent principle of the red colouring matter, and exists in so intimate an °ofurinegCO" Union with k that U cannot be detected by the best re-agents we matter. * Trans. Medico-Chirurg. Soc. Vol. u. p. 370. t Id. Vol. i. | id. Vol. in. 5 Elementary System of Physiology, Vol. i. p. 476, 8vo. 1824. PHYSIOLOGICAL PROEM. [cl. m. 83 possess, till the composition of the colouring matter is totally de- j.11- ^'y^- stroyed by heat, or some other means. tie* of the With these explanations we are now able to proceed to a clear Anaiysia of comprehension of the following brief analysis of the blood, as cor- Berzelius. rected by the later experiments of M. Berzelius, supported by those I have just adverted to of Dr. Marcet and Dr. Bostock. Blood is composed of two parts, one homogeneous and liquid, Bloo(r the real difference between that of any one species of animal and once be- '" any other. M. Berzelius observes that "the great agreement m w«Sdof" the composition of human and ox blood is remarkable, and ex- dinerent piams to us ^{j possibility of the phenomena observed in the ex- de^edT penments in transfusion." But we have a clear proof that the blood of one species of animals differs so much from that of an- other, either in its principles or their modification, that no benefit can result from transfusion, unless from like kinds to like kinds. Thus, according to several interesting experiments of Dr. Blundell, a dog, asphyxiated by hemorrhage, may easily be recovered by a transfusion of blood from another dog, but is little or not at all re- lieved if the blood be taken from man ;* and the experiments of MM. Prevost and Dumas precisely coincide with this doctrine. Blood, in Upon the whole, however, we cannot but regard the blood as in "ecu,'the many respects the most important fluid of the animal machine: unTnuXrf fr°m li au *'ie souds are derived and nourished, and all the other the animal fluids are secreted ; and it is hence the basis or common pabulum frame: Qf eyery part And ag ■ t jg the source 0f general health so it is acted upon also of general disease. In inflammation it takes a considerable bod?es?vo- share, and evinces a peculiar appearance. The miasms of fevers latiie and ami exanthems, are harmless to every other part of the system, and only become mischievous when they reach the blood : and emetic tartar, when introduced into the jugular vein, will vomit in one or two minutes, although it might require, perhaps, half an hour if thrown into the stomach, and in fact does not vomit till it has reached the circulation. And the same is true of opium, jalap, when im- and most of the poisons, animal, mineral, and vegetable. If im- ereatsource perfectly elaborated, or with a disproportion of some of its consti- of morbid tuent principles to the rest, the whole system partakes of the evil, and a dysthesis or morbid habit is the certain consequence ; whence Transmits tabes, atrophy, scurvy, and various species of gangrene. And if it corporea" become once impregnated with a peculiar taint, it is wonderful to subsequent remar^ ^ie tenacity with which it retains it, though often in a state generations, of dormancy or inactivity, for years or even entire generations. For as every germ and fibre of every other part is formed and regene- rated from the blood, there is no other p*art of the system that we can so well look to as the seat of such taints, or the predisposing cause of the disorders I am now alluding to ; often corporeal, as gout, struma, phthisis ; sometimes mental, as madness, and occa- sionally both, as cretinism. Hence sup- It is hence the blood has been supposed to be alive : a belief of posed to'be very high antiquity, and which has been warmly embraced by Dr. Harvey and many others of the first physiologists of modern times. It was a favourite opinion of Mr. John Hunter, and runs through As taught, the whole of his doctrines. "That the blood," says he, "has life r»yPMCra.i'.y is an opinion 1 have started above thirty years, and have taught it Hunter. for near twenty of that time in my lectures. It does not, therefore, * Trans. MedioChir. Soc. Vol. ix. p. 86 PHYSIOLOGICAL PROEM. Lcl. hi. 27 come out at present as a new doctrine ; but has had time to meet p"'p£r\"engs*Q with considerable opposition, and acquire its advocates. To con- of the Wood. ceive that blood is endowed with life while circulating, is, perhaps, carrying the imagination as far as it well can go; but the difficulty arises merely from its being a fluid, the mind not being accustomed to the idea of a living fluid."* The experiments and train of reasoning he urges in favour of this opinion are highly ingenious and peculiarly strong. And, though they may not be demonstrative of a vital and energetic essence separate from the blood itself, but inherent in its substance, and controlling its motions, they seem very clearly to show that the blood is endowed with peculiar powers; and that, as matter at Dnfl^neenf^i large is subject to the laws of gravitation, so the matter of the of instinct. blood is subject to the law's of instinct. We may here add, in favour of Mr. Hunter's opinion, the following two corollaries of Dr. Philip, deduced from a large field of experiments. " The power of the blood-vessels, like that of the heart, is independent of the nervous system.—The blood-vessels can support the motion of the blood after the heart is removed."! Admitting these deductions to be established, the power here IPsti"ct'.,. referred to, and capable of influencing the blood or the blood- operating by vessels, separately from that of the heart, and of the nervous sys- onts^w'rT tem, must be the power of simple life, or of instinct, which is simple la"s- life operating by the exercise of its own laws. This view of the subject has of late, however, been carried by d'^P"11* Dr. Pring to an extent far beyond what Mr. Hunter at any time cording to contemplated. For Dr. Pring not only supposes the blood to be morbi'dse- alive, and to communicate life to the sentient and healthful parts cretion* and Of the system, but to its insentient and diseased elemenk as well ; poisons. and that the matter of animal poisons, derived from the blood, are themselves also living bodies, acting specifically by the vital but discrepant properties they are endowed with. And he thinks that hereby " a distinction may be furnished between the contagious and infectious diseases."! • On Blood, p. 77. t Phil- Trans. 1815, p. 445. J Principles of Pathology and Therapeutics, &c. By Daniel Print;, M.D. 8vo. 1823. CLASS III. H IE M A TIC A, ORDER I. PYRECTICA. FEVERS. HEAT AND NUMBER OF THE PULSE PRETERNATURALLY AUGMENTED ; USUALLY PRECEDED BY RIGOR, AND FOLLOWED BY PERSPIRATION I DURING THE RIGOR, PAINS FIXED OR WANDERING : LASSITUDE : DEBILITY OF MIND AND VOLUNTARY MUSCLES. Class III. There is no complaint so common as fever ; none in which Difficult1 of mankind, whether professional or laical, are so little likely to be defining mistaken, and yet none so difficult to be defined. In reality, no- writer seems to have been fully satisfied with his own definition ; and it is not extraordinary, therefore, that he should seldom have given satisfaction to others. The difficulty proceeds from the com- plexity of thf symptoms thai enrar into the character of a fever; the contrariety of many of them to each other in different stages of it; and the occasional absence of some that, in other instances, appear to constitute its leading features. " Febris," says Professor Frank, " certorum potius morborum umbra quam ipse morbus est."* Difficulty There are also two other difficulties of considerable magnitude division! that the nosologist has to contend with in laying down a clear and SamIse.nenC Perspicuous survey of fevers; and that is, their division or colloca- tion, and their generic names. But as I have already pointed out these difficulties, and the means by which they are attempted to be remedied under the present arrangement and nomenclature, in the running commentary to the order before us in the volume of JWoso- logy, I shall beg to refer the reader to the observations there laid down, and shall subjoin only one or two additional remarks, upon the same subject. Huise nodt Although the number of the pulse as well as the heat is preter- LTways01 naturally augmented in almost every case of fever, an extraordinary fnTvenr!ed ».nstance is sometimes to be met with that opposes the general law, for the most part dependent, I believe, on a great and sudden op- pression of the brain; an explanation which withdraws the ano- * De Cur.ind. Horn. Morb. Epit. i. p. 2. 4 Torn. 870. Mannh. 1793. wl. in.] SANGUINEOUS FUNCTION. [ord. i. 29 maly, and accounts for the ordinary increase of pulsation as soon Order !• as such oppression is removed. Thus, in the yellow fever of Fevers.0*" Antigua in 1816, the pulse, as Dr. Musgrave informs us, was, in one instance, under forty-four. " We almost fancied," says he, " this unusual softness might be constitutional: but, on opening a vein, it greatly increased in frequency ; and, after the loss of a considerable quantity of blood, it numbered eighty, with nearly complete relief from every uneasy sensation."* In such cases, the heat of the system usually exhibits as little febrile augmentation as the pulse : for as the former is the result of increased action, till such increased action takes place, the heat, as in the first stage of the paroxysm, may continue even below the natural standard. Ordinarily, however, the heat is considerably heightened, insomuch as in some instances to reach 108° Fahren- heit, which however is the utmost point it has ever been known to attain in fever. There is a still more curious variation from the general law, nnstta;"cer0f which is sometimes, though very rarely, found to take place, of ceding cold. which Schenck gives a single example that occurred in his own practice; I mean, a reversed order of the symptoms of the febrile paroxysm, and an appearance of the sweating stage before the shivering and hot fit.f To provide for these extraordinary and anomalous incidents by any definition whatever, is beyond the power of language. They must be left to themseives, and will rather confirm than disturb the definition now offered, agreeably to the maxim of the Schools— exceptio probat regulam. In dividing fevers into distinct genera I have taken the line of p'inc'P|eh demarcation from the character of their duration, as limited to a the author single paroxysm ; as composed of numerous paroxysms, with J^n'the intervals of intermission or perfect apyrexy; as composed of genera of numerous exacerbations, with intervals of remission, or imperfect eveTS" apyrexy ; and as composed of a single series of increase and de- crease, with a mere tendency to intervals of remission, without perfect apyrexy at any time. Other nosologists have drawn their Comparfd generic distinctions from other circumstances ; as their disposition principles. or indisposition to putridity ; their inclination to a sporadic or an epidemic character; the vigour and violence, or weakness and debility, of their action ; or, in the language of Dr. Darwin, the nature of their influence on the sensitive or irritative fibres of the animal frame. The most obvious mark, however, and that which has been most generally approved, is the character of duration assumed in the arrangement before us. To all the rest there are greater or less objections, which, as I have already examined them in the comment just referred to, need not be repeated in the present place. Regulated, therefore, by the principle before us, fever admits of the four following genera :— * Trans. Med. Chir. Soc. Vol. ix. p. 133. t l.ib. vi. Obn. 34 so cl. 111.] HiEMATICA. 1°™' Order I. I. EPHEMERA. DAIRY FEVER. F&c6™'3" H. ANETUS. INTERMITTENT FEVER. III. EPANETUS. REMITTENT FEVER. IV. ENECIA. CONTINUED FEVER. To each of these belong several species, and to most of the species several varieties, as will be noticed in their respective order. ordinary Some slight deviation from the ordinary nomenclature may be tuTs^ghtiy observed in the generic names above : but the reader can have no frornated difficulty upon this head, as he will find the changes that have hereby been occasioned are in every instance founded upon a prm- ciple of correctness and simplification ; and consequently calculated to disentangle rather than to add to his encumbrances, and to facilitate his progress in the labyrinth before him. The term Ephe- mera, is, indeed, well known to every one. Anetus and Epanetus are Greek terms, importing intermittent and remittent, from muifu and tiravniM. Enecia, from the same tongue, denotes continued action, and is a derivation from mwius, " deserves the name of a causes physical cause which so constitutes the disease, that, when present the disease exists ; while it continues, the disease continues; when "hanged or removed, the disease is altered or destroyed." It is this cl. in.] SANGUINEOUS FUNCTION. [ord. i. 31 which constitutes the proximate cause, and is, in fact, the essence Order !• of the disease, the actual source of all its effects. The remote Fevers.0*' cause is that which directly produces the proximate; as a spe- cific virus in syphilis, or a specific miasm in influenza, or epidemic catarrh. In fever we can often trace the remote causes ; though we are still too little acquainted with the nature of several of them to be able to restrict them to a specific mode of action; of the proxi- mate cause, we know but very little at present, and it will probably be long before we shall know much more. Let us, however, begin with the proximate cause as that which r-roxiinata ■ • 1 i ■ /> i • • • n tt i_- cause has has most excited ihe attention of physicians m all ages. Upon this given rise subject, indeed, a great deal of learned dust has been raised, and a 8°*"';°.!" great deal of valuable time consumed. Ancient speculations, for tions. they are not entitled to the name of theories, have been over- thrown : and modern speculations, in vast abundance, erected upon their ruins ; which, in rapid succession, have also had their day and expired. It is an inquiry, therefore, not likely to prove very pro- ductive ; yet, as forming a part of medical science of which no student should be altogether ignorant, it seems nar essary to carry it into a brief survey of the most popular doctrines which have been advanced upon the subject in different ages. Fevers, then, in respect to their proximate cause, have been con- Humoral , . . K. , T, , . , . , .and nervous jectured to originate from a morbid change, either in the composi- pathology. tion of the blood, or in the tone or power of the living fibre. The first view has given rise to various hypotheses, that rank under the common division of the humoral pathology. The second has given rise to other hypotheses appertaining to the common division of the fibrous or nervous pathology. The hypotheses derived from the one or the other of these sources, hjj'p!'he9e9 that are chiefly entitled to attention, are the following: of which that have the first two belong to the former division, and the remainder to the Upon°theere latter. subject of a I. That of the Greek schools, founded on the doctrine of a con- cause. coction and critical evacuation of morbific matter. II. That of Boerhaave, founded on the doctrine of a peculiar viscosity, or lentor of the blood. III. That of Stahl, Hoffman, and Cullen, founded on the doc- trine of a spasm on the extremities of the solidum vivum, or living fibre. IV. That of Brown and Darwin, founded on the doctrine of accumulated and exhausted excitability, or sensorial power. V. To which we may add that fevers have, by some physiologist*. as Dr. Clutterbuck and Professor Marcus, been identified with in- flammation ; and their proximate cause been ascribed to increased action in some particular organ. I. It was the opinion of Hippocrates that fever is an effort of tLh^ysp°t: nature to expel something hurtful from the body, either ingenerated, concoction. or introduced from without. Beholding a violent commotion in the'Grec0' the system, followed by an evacuation from the skin and kidneys, school? with which the paroxysm terminated, he ascribed the commotion to 32 Order I. Pyrecuca. Fevers. Proximate cause. I. Doctrine of concoc- tion. Extent of its range. Blended with the chemistry of the day. CL. III.] H^MATICA. [ORD. Highly ingenious and partial- ly correct. How far carried by Frank. In what respect incorrect. a fermentation, concoction, or ebullition, by which the noxious matter was separated from the sound humours ; and the evacuation to a despumation or scum which such separation produces, or rather to the discharge of this morbid scum from the emunctories that open externally. Galen supported this view with all the medical learning of his day ; and it is the only explanation of fever to be met with in medical writings, through the long course ofthree thousand years; in fact, till the time of Sydenham, who still ad- hered to it., and whose pages are full of the language to which it naturally gave birth. It blended itself almost insensibly with the dialect of the chemists of the day, notwithstanding the professed hatred of Paracelsus and Van Helmot towards the whole range of Galenic doctrines, and the solemn pomp with which the former had condemned and burnt the entire works of Hippocrates and Galen. And hence, under the influence of chemistry, at this time assuming a soberer aspect, the supposed animal despumation was contemplated as possessed, ac- cording to different circumstances, of different chemical qualities and characters ; and particularly as being acid, alkaline, efferves- cent, or charged with some other acrimonious principle, too highly exalted, or in too great a proportion. This doctrine, considered merely hypothetically, is not only innocent, but highly ingenious and plausible. It is in unison with several of the phaenomena of pyrectic diseases ; and derives a strong collateral support from the general history of exanthems or erup- tive fevers, in which we actually see a peccant matter, producing general commotion, multiplying itself as a ferment, and at length separated and thrown off at the surface by a direct depuration of the system. There is no writer, perhaps, in our own day, who has carried this view of the subject farther, or even so far as Professor Frank, who regards typhus, plague, petecchial and all pestilential fevers, and indeed nervous fevers of every kind, whether continued or re- mittent, not only as proceeding from specific contagions in the same manner as exanthems, but from contagions producing a like leaven in the system, and matured and thrown off through the various outlets of the body, by the same process of depuration ; and hence, after describing all the varieties of malignant nervous fevers under the character of pestilential, he tells us, " non alitor haec methodus in ips t pestk turn in pestilentiali, sic. vocata, febre, profuisse visa est: ubi, maturo satis tempore, contagii per cutem expulsio solicite amedentibus absolvebatur."* So far however as relates to exanthems, the opinion is sufficiently correct. But the moment it is brought forward as the proximate cause of fever properly.so called, in which there is no specific eruption, it completely fails. For first, no explanation is here given as to the means by which any such concoction or fermentation, or multiplication of morbific matter m any way takes place. ^ Next, there are many fevers pro- ' Pe Cur. Horn. Morb. Epit. Tom. I. p. 130, compare with the § p. 127 ul. m.J SANGLTNEOL'sS FUNCTION. [ord. i. 33 duced evidently by cold, fear, and other excitements, as well mental Order I. as corporeal, in which most certainly there is no morbific matter FeverB.Ca introduced, and wherein we have no reason to conceive there is any fa"*,!"1310 generated internally ; while the disease, limited perhaps to a single l Doctrine paroxysm, closes nevertheless with an evacuation from the skin or "ion.0"000' the kidneys. And, thirdly, we sometimes behold fevers suddenly cured, as Dr. Cullen has observed, by a hemorrhage so moderate, as for example a few drops of blood from the nose, as to be inca- pable of carrying out any considerable portion of a matter diffused over the whole mass of the blood ; while we are equally incapable of conceiving how such diffused morbific matter could collect itself at a focal point, or pass off at a single outlet ; or of tracing in the discharge, after the minutest examination, any properties different* from those of blood in a state of full health. I have observed that this hypothesis is, however, harmless enough f (j|"el,meu when merely brought forward as a speculation. But it has not always an injurious been limited to this point; for it has occasionally been advanced as a i)raclice- practical and efficient principle ; and the febrile commotion, and par- - ticularly the hot fit, has, in treating the disease, been purposely in- creased, with a view of assisting nature in her curious but unknown process of expelling the peccant material; and the most dangerous consequences have followed. II. The acute and penetrating mind of Boerhaave, who was born "'the1110* in 1668, was sufficiently sensible of this danger ; and the discove- blood. ot ries which were now taking place in chemistry and physiology, led Boerhaave. him progressively to the construction of a new theory, which in a few years became so popular as to obtain a complete triumph over that of the Greek Schools. Leeuwenhoeck, by a delicate and indefatigable application of the j^"^6 microscope to animals of a transparent skin, had endeavoured to establish it as a fact that the constituent principles of the blood consist of globular corpuscles; but that these corpuscles differ in size in a regular descending 'series according to the constituent principles themselves ; and that each set of principles has its pecu- liar blood-vessels, possessing a diameter just large enough to admit the globules that belong to it, and consequently incapable, without force, of allowing an entrance of those of a larger magnitude ; and hence that the blood-vessels possess a descending series as well as the particles of the blood. It was upon this supposed fact that Boerhaave built his hy- How. pothesis. He conceived that almost all diseases may be resolved pp 'e' into an introduction of any given series of particles of blood into a series of vessels to which they do not properly belong; and he distinguished such an introduction by the name of error loci. He conceived still farther, that this heterogeneous admix- j^'00' ture is very frequently taking place; and that its chief cause consists in a disproportion of one or more sets of the sanguineous principles to the rest, by which their globular form is occasionally broken down or agglutinated ; and hence rendered either too thin and serous, or too gross and viscid. The viscidity of the blood he distinguished by thr namp of lector : and to a prevalence of this Vot,. IT.—ft U cl.UJ.1 ILlvYlATICA. L^-1- Order I. ientor, or viscidity, he ascribed the existence of fever ; maintaining Feve's011, that the general disturbance which constitutes fever proceeds from Proximate an ERROr loci of the viscid blood, whose grosser corpuscles, from nTentorin their undue momentum as well as superabundance, press forcibly the wood. into improper series 0f vessels, and stagnate in the extremities of the capillaries, whence the origin of the cold stage, and consequently of nomencia- the stages that succeed it, to which the cold stage gives rise ;* and turTheCnce hence those medicines which were supposed capable of dissolving influenced. that tenacityi or breaking down the coalescence of such a state of the blood, were denominated diluents, humectants, and attemj- ants, whilst those of an opposite character were called inspissants ; terms which have descended to our own day, and are still retained even by those who pay little attention to the hypothesis that gave them birth. An elective The system of Boerhaave, therefore, consisted of an elegant and comtuuing artful combination of both the earlier and later doctrines of corpus- parts of cular physiology. Without deserting the humoral temperaments of others. Galen, or the constituent elements and elective attractions of the alchemists, he availed himself of the favourite notions of the corpus- cular pathologists, their points or stimuli, their frictions, angles, and spherules, derived from the Cartesian philosophy, which was now exercising as triumphant a sway over the animal as over the mate- rial system ; and interwove the whole into an electic scheme, so plausible and conciliatory to all parties, that all parties insensibly felt themselves at home upon it, and adopted it with a ready assent. In the emphatic language of M. Quesney, it was " la medicine col- lective." Fact in fa- The most triumphant fact in favour of the Boerhaavian hypothesis hypothesis, is, that the crust on the blood in inflammations, and cauma or in- butunavaii- flammatory fever is often found peculiarly dense. But as fevers (and certainly the greater number) are found without any such crust; and as a simdar crust, though perhaps not quite so dense, exists under other and very different states of body, as in pregnancy and scurvy (porphyra), even this leading appeal has long lost its power of conviction : whilst the abruptness with which fevers make their assault, from sudden occasional causes and in constitutions of every diversity, forbid the supposition that in such cases a Ientor or sizy crasis of the blood, and especially a glutinosum spontaneum can have time to be produced, however it may exist occasionally, and be, perhaps, the source of other disorders. The subject, however has of late been again taken up by Dr. Stoker of Dublin, with the view of reviving the humoral pathology in its more important doc- trines, and of extending the arguments which have hitherto been urged in its favour, t inspasm III To the period of Boerhaave in the production of fever and Tsseis6 . ed ot a11 other dlseases, the human body was regarded as almost doclxine0' entirely passive, a mere organic machine, operated indeed upon by Hett S°me AUTOCRATEIA, aS NATURE, Or a VIS MEDICATRIX, but in the and Cullen. * t1^' ?56' Comment Van swiet. Tom. n. p. 528. Edit. Lugd. Bat. 40 174A. r Pathological Observations, &c. Dublin, 8vo. IS-J3. I,offman presented to the world a more correct system, in a more attractive style ; but apparently with a disingenuous concealment of the source from which he had borrowed his first hints. He omitted the meta- Hoffman^ physical part of the Stahlian hypothesis ; took from the mind the hJ^oiB-'* conservative and remedial power over the different organs with which linguished Stahl had so absurdly endowed it; seated this power as a law of stahi's. life in the general organization ; separated the nervous from the muscular fibres, the latter of which were regarded as only the ex- tremities of the former by Stahl; allowed a wider range and longer term to the constrictive spasm of fever ; and changed its name from spasmus tonicus to spasmus periphericus :* giving also to the moving power of the muscular or irritable fibres the name of vis insita, as that of the nervous fibre was called vis nervea. It is highly to the credit of Boerhaave that his mind, in the latter lngenuout,- part of his life, was so fully open to the merits of his hypothesis, that Boerhaave. he admitted the agency of the nervous power, though a doctrine that struck at the root of his own system, of which we have a clear proof in the change which occurs in the fourth edition of his Apho- risms, and particularly aphorism 755, where he lays down the prox- imate cause of intermitting fevers. Hitherto it had run thus " unde post accuratum examen totius historiae intermittentium causa proxi- ma constituitur viscositas liquidi arteriosi.*, But to this, in the edi- * Med. Nat. Systemat. Tom. m. § i. cap. 4. Bochmer, Diss, de Spatmi Periphe- ric! signo in febribrw cootinentibus. Hal. 17B£. 36 Order I. Pyrcctica. Fevers. Proximate cause III. Spasm of the extreme vessels. Ingenuous- ness of Gaubius. CL. III.J 1LUMATK A ORW. I. General inclination to the same views long in previous existence. Baglivi, Willis, Gilchrist, Cullen's modifica- tion in the formation of a new system. Its high merit. tion before us, is added the following: ~ forte et ncrvosi (liquuh) tarn cerebri, quam cerebelli cordi destinati, inertia."* It is also equally creditable to the learned Gaubius, that, though strongly attached to the Boerhaavian school in which he was educated, and a zealous contender for many of its doctrines, his understanding was alike open to the clearer and simpler views of the chemists of the day, upon various points not yet generally adopted, and allowed him to become a more thorough convert to their philosophy. The reader may judge of this change in his mind by the following pas- sage : " An et naturae humana) facultas inest, moleculas, acris de- tritas aut iiitropressas angulis, in sphaerulas tornando, blanditium cre- andi ? Non satis constat speciosam ideam aequaliter in fluidam solidamque acrimoniam quadrare.—Credibilius profecto mixtione chemica magis quam mechanica rotundatione, id opus perfici."t In effect, there not only was at this time, but had been for many years antecedently, a general feeling among the cultivators of medicine, that neither the laws of animal chemistry nor of the living fibre had been sufficiently studied for the purposes of a correct pathology : in proof of which it may be sufficient to refer to various articles on both subjects, inserted in the Ephemerides Natural Curiosorum, published at Frankfort, in 1684 ; and the writings of Baglivi,! and Dr. Willis;§ and still more particularly to Dr. Gilchrist's elaborate treatise on nervous fevers, inserted in the Edinburgh Medical Transactions ;|| in which last the author, following up the hint thrown out by Boer- haave in the aphorism just quoted,'endeavours to show how well the two ideas of Ientor and spasm are disposed to amalgamate in form- ing the proximate cause of fever ; the spasm consisting of an uni- versal muscular tension, and the Ientor being united according to the nature of the case with inflammation, acrimony, or both ; and hence often producing what he denominates an alternate nisus and re- xisus. The materials, however, were now becoming too unwieldy ; and the wheels of the machine were clogged by the very forces that were designed to increase its motion. Dr. Cullen was well aware of this, and boldly ventured upon a new attempt for the purpose of simplifying and facilitating its progress. As his basis he took the hypothesis of Stahl as modified and improved by Hoffman : and on this basis erected his stately and elaborate structure, so well known to the medical world, full of ingenuity and daring genius, and which if it be at this moment crumbling into decay, certainly is not falling prostrate before any fabric of more substantial materials or more elegant architecture. Dr. Cullen has been accused of the same want of ingenuousness towards Hoffman, as Hoffman is chargeable with towards Stahl; and of having introduced his system to the pub- he with little or no acknowledgment of the sources from which he has drawn. But surely no one can bring forward such an accusa- tion, who has read with any degree of attention the preface to his Practice of Physic, in which he gives a full account of Dr. Hoff- t £^0t" Ta0T1£?- Theoria Medica vera. Halle, 1734. t Pathol & 2Qft by its novelty, the indolent by its facility, and every one by the bold- ness of its speculations. It circulated widely, and soon acquired popularity abroad as well as at home. Man, according to Dr. Brown, is an organized machine, endowed Hypothesis with a principle of excitability, or predisposition to excitement, by exv ame' means of a great variety of stimuli both external and internal, some of which are perpetually acting upon the machine ; and hence the excitement which constitutes the life of the machine is maintained. Excitabihty, therefore, is the nervous energy of Dr. Cullen ; and, Excitability like that, is constantly varying in its accumulation and exhaustion : ac'cumuia- yet not, like the nervous energy of Dr. Cullen, under the direction ^^ and guidance of a vis conservatrix et medicatrix naturae distinct from the matter of the organization itself, but passively exposed to the effect of such stimuli as it may chance to meet with, and necessarily yielding to their influence. Upon this hypothesis excitement is the vital flame, excitability ^j*ratt1J|rti0D the portion o*f fuel allotted to every man at his birth, and which, varying in every individual, is to serve him without any addition for the whole of his existence : while the stimuli by which we are sur- rounded are the different kinds of blasts by which the flame is kept up. If the fuel or excitability be made the most of, by a due tem- perature or mean rate of blasts or stimuli, the flame or excitement may be maintained for sixty or seventy years. But its power of supporting a protracted flame may be weakened by having the blast either too high or too low. If too high, the fuel or excitability will, from the violence of the flame, be destroyed rapidly, and its power of prolonging the flame be weakened directly ; and to this state of the machine Dr. Brown gave the name indirect debility, or exhausted 40 »;l. m.J HiEMATlCA. [oKD. I. Order I. excitability. If the blasts or stimuli be below the mean rate, the FeZ's'"" fuel, indeed, will be but little expended, but it will become drier and Proximate more inflammable ; and its power of prolonging the flame will bo iv "ecu- still more curtailed than in the former case ; for hall the blast that «ha££dr would be required to excite rapid destruction antecedently, will be excitability, sufficient to excite the same effect now. This state of the machine. therefore, the author of the hypothesis contra-distinguished by the name of direct debihty, or accumulated excitability. Doctrine of Upon these principles he founded the character and mode of Sd^d treatment of all diseases. They consist but of two families, to which treated. he gave the name of sthenic and asthenic ; the former produced by accumulated excitability, and marked by direct debility ; the latter occasioned by exhausted excitability, and marked by indirect debility. The remedial plan is as simple as the arrangement. Bleeding, low diet, and purging, cure the sthenic diseases ; and stimulants of various kinds and degrees, the asthenic. Fevers, therefore, under this hypothesis, like other diseases, are either sthenic or asthenic : they result from accumulated or exhaust- ed excitability. Synocha, or inflammatory fever (cauma under the present arrangement,) belongs to the first division, and typhus to the second. Uet us try the system by these examples. We1'hrein "^he **rst symPtoms °f inflammatory fever, like those of all others, thesisyfa0iis. evince, as I have already observed, debility or languid action in every organ,—let the debility be distinguished by whatever epithet in respect it may. The vital flame is weak, and scarcely capable of being tory fever, supported ; and yet the fuel is more inflammable than in a state of health, the excitability is accumulated. This scheme, therefore, completely fails in accounting for the origin or first stage of inflam- matory, or, in Dr. Brown's own language, sthenic fever. in respect Typhus pestilens, or jail-fever, is arranged by Dr. Brown as an fotyp us. astjienjc disease ; and, as such, we have reason to expect debility as characteristic of its entire progress. Yet what is it that produces this debility ? The blast or stimulus is here contagion ; and the ex- citability is exhausted by the violence of this blast or stimulus ; but there is no means of its becoming exhausted without increasing the excitement: the fuel can only be lessened by augmenting the flame that consumes it. Yet in typhus, according to this hypothesis, the fuel is expended, not in proportion as the flame is active and violent, but in proportion as it is weak and inefficient. The excitability is exhausted, and the debility increases in proportion as the excitement forbears to draw upon it for a supply. The blast blows hard, but without raising the fire, and yet the fuel consumes rapidly. This scheme, therefore, completely fails, in accounting for any stage of low or asthenic fevers of every description. o7uroqwn'C9y Dr' Brown' hovvever, was not a man of much practice ; his writ- descripTions ings show that he was but little versed in the symptoms of diseases; ?anndgeament. his descriptions are meagre and confused : and hence, when he comes to assort diseases into the only two niches he allots for their dishes6 recePtion* he makes sad work ; and maladies of the most opposite united. characters, and demanding the most opposite mode of treatment, are huddled together to be treated in the same manner, in manv cl. m.j SANGUINEOUS FUNCTION. [oiin. r. 41 cases with no small risk to the patient. Thus, among the sthenic Order I. diseases are associated rheumatism, erysipelas, scarlet and inflamma- Feveie °a tory fever ; and, among the asthenic, gout, typhus, apoplexy, and 0>a°gemato dropsy. iv. Accu- The Brunonian hypothesis, nevertheless, offers one principle that Shougfed0' is unquestionably founded on fact, and is peculiarly worthy of atten- excitabiiitv. tion ; I mean that of accumulated excitability from an absence or piS* worthy defect of stimuli; in colloquial language, an increase of energy by ofnoUco' rest. And it is this principle which forms the hinge on which Hypothesis turns the more finished system of Dr. Darwin. Sensible of the objection that weighs equally against that part of Spirit of the system of Dr. Cullen and Dr. Brown which represents the energy modifiod," or excitabihty of the living frame as capable of recruiting itself after ^JjjJ™0 of collapse or exhaustion, without a recruiting material to feed on; he directly allotvs the existence of such a material; regards it as a pe- culiar secretion, and the brain as the organ that elaborates and pours it forth. The brain, therefore, in the system of Dr. Darwin, is the common fountain from which every other organ is supplied with sensorial fluid, and is itself supplied from the blood as the blood i= from the food of the stomach. All this is intelligible ; but when beyond this he endows his sen- sorial fluid with a mental as well as a corporeal faculty, makes it the vehicle of ideas as well as of sensation, and tells us that ideas are the actual " contractions, or motions, or configurations, of the fibres j^rt°„Pon which constitute the immediate organ of sense,"* he wanders very Brown: but unnecessarily from his subject, and clogs it with all the errors of wiX8 mate- materialism, lialism. He supposes the sensorial power, thus secreted, to be capable of exhaustion in four different ways, or througb four different faculties expi&uied. of which it is .possessed: the faculty of irritability, exhausted by external stimuli affecting simple irritable fibres : that of sensibility, exhausted by stimuli affecting the fibres of the organs of sense : that of voluntarity, exhausted by stimuli affecting the fibres of the voluntary organs acting in obedience to the command of the will ; and that of associability, exhausted by stimuli affecting organs as- sociated in their actions by sympathy or long habit. By all or any of these means, the sensorial power becomes evacuated, as by food and rest it becomes replenished, often, indeed, with an accumulation or surplus stock of power. In applying this doctrine to fever, he considers its occasional How ap- causes, whatever they may be, as inducing a quiescence or torpor of Fever. ° the extreme arteries, and the subsequent heat as an inordinate exer- tion of the sensorial power hereby accumulated to excess ; and, con- sequently, the fever of Dr. Darwin commences a stage lower than that of Dr. Cullen, or in the cold fit instead of in a collapse of the nervous energy lodged in the brain. Now, allowing this explanation to account for the cold and hot Fails in stages of a single paroxysm of fever, like the spasm of Dr. Cullen, it for the "e will apply no farther. For when the sensorium has exhausted itself p^L^, * Zoonoro, Vol. r. Sect. it. ii. t. Vol. II.—6 12 cx.iw.] 1UEMATICA. loR1K l' Order I. Qf its accumulated irritabilitv, the disease should cease. It may, Fevers^" perhaps, be said that a second torpor will be produced by this very Proximate exnaustion, and a second paroxysm must necessarily ensue. Ad- iv8eAccu- mitting this, however, for a moment, it must be obvious that the first exhausted" or torpid stage only can ensue ; for the system being now quite ex- excitabiiity. hausted, the quiescence that takes place during the torpor can only be supposed to recruit the common supply necessary for health ; we have no reason to conceive, nor is any held out to us, that this quan- Fads in tity can again rise to a surplus. Yet it must be farther remarked, foTcoT'"5 that in continued fevers we have often no return of torpor or quic- tinued tucie whatever, and, consequently, no means of re-accumulating irri- tability ; but one continued train of preternatural action and ex- haustion, till the system is completely worn out. And to this ob- jection the Darwinian hypothesis seems to be altogether without a reply. It is not necessary to pursue this subject further. Other conjec- tures more or less discrepant from those now examined have been offered, but they have not acquired sufficient notice or evinced sufficient ingenuity to be worthy of examination. v. Proxi- V. There are other pathologists who have referred the proximate placed in cause of fever to a morbid affection of some particular organ, or set dlseMe!0*1 °^ organs associated in a common function. Thus, Baron Haller alludes to several in his day, who ascribed it to a diseased state of Vena cava, the vena cava :* Bianchi pitched upon the liver,t Swalve on the Pancreas, pancreas,^ Rahn on the digestive organization generally.§ Pro- Frank1:9 °' fessor Frank has divided the different kinds of fever between the digestive organs, the arteries, and the nerves, each in a particular state of diseased action; so that with him all fevers are nervous, inflam- matory or gastric.H The Italian pathologists eagerly caught up this of Brous- view, and modified it in various ways ; and M. Broussais has of late given it another modification, by placing fever in the mucous mem- brane of any of the viscera, but chiefly in the mucous membrane of the digestive canal; and consequently gastric fever with M. Brous- sais, takes the lead of all the rest both in variety and vehemence of action: the particular character or intensity of the fever being resolvable into the temperament, idiosyncrasy, or other circumstances inflamed of the individual.1T Dr. Clutterbuck has still more lately in our own doctrine of country, and with far more reason and learning brought forward the buck?r" brain instead of the stomach ; to an inflammation of which organ he ascribes fevers of every kind, 'regarding them merely as so many varieties of one specific disease, originating from this one common hereby cause.** But this is to confound fever with local inflammation, the confounded idiopathic with the symptomatic affection. In treating of inflam- »miM. mation under the ensuing Order, we shall have sufficient opportu- *ion. mties of seeing that an inflamed state of almost any organ, and * Bibl. Med. Pr. i. p. 112. T Hist. Hepat. p. 112. I nT"\?C\.P'„M1, § Briefwechsel, Band. i. p. 150. II De Cur. Morb. Horn. Epitome, Tom. v. 8vo. Mannh 1792-4 J. VEB?oZsnai^^ ct des S-^mes de Nosoiogie, &c. Par F ** Treatise on Fever, 8vo. cl. in.J SANGUINEOUS FUNCTION. [onn. r. 4'J especially of membranous organs, or the membranous parts of organs, Order I. is sufficient to excite some degree of fever or other, and not unfre- Fevers! quently fever of the highest degree of danger from its duration or cause"1116 violence. And hence, the liver, the lungs, the stomach, the intes- y. Organic tines, the peritonasum, and the brain, have an equal claim to be I3case' regarded as furnishing a proximate cause of fever when in a state of inflammation. A very striking objection to Dr. Clutterbuck's hypothesis is his limiting himself to a single organ as the cause of an effect which is equally common to all of them. And on this ground it is that ^cver2 . Professor Marcus of Bavaria, who has contended with similar with' strenuousness for the identity of fever and inflammation, has regarded ,"0snUgnDya" all inflamed organs as equal causes; and is hereby enabled to Marcus account, which Dr. Clutterbuck's more restricted view does not so well allow of, for the different kinds of fever that are perpetually springing before us, one organ giving rise to one, and another to another. Thus, inflammation of the brain, according to Dr. Marcus, is the proximate cause of typhus; inflammation of the lungs, of hectic fever ; that of the peritonaeum, of puerperal fever ; and that of the mucous membrane of the trachea, of catarrhal fever : a view, which has lately been adopted by several French writers of consi- derable intelligence, as an«mprovement upon M. Broussais's hypo- thesis.* The general answer, however, to pathologists of every description Objections who thus confound or identify fever with inflammation, whether of tification'1 a single organ or of all organs equally, is, that though fever is ^tn*™'nd commonly a symptom or sequel of inflammation, inflammation is fever. not uncommonly a symptom or sequel of fevers. And hence, though post-obit examinations, in the case of those who have died of fever, should show inflammation in the brain, the liver, or any other organ, it is by no means a proof that the disease originated there, since the same appearance may take place equally as an effect, and as a cause. Whilst a single example of fever terminating fatally without a trace of inflammation in any organ whatever, and such examples are perpetually occurring, is sufficient to establish the existence of fever as an idiopathic malady, and to separate the febrile from the phlogotic divisions of diseases. " A fever, therefore," to adopt the language of Dr. Fordyce, " is Fever, as a disease that affects the whole system ; it affects the head, the Fordyce. y trunk of the body, and the extremities ; it affects the circulation, the absorption, and the nervous system ; it affects the skin, the muscular fibres, and the membranes; it affects the body, and affects likewise the mind. It is, therefore, a disease of the whole system in every kind of sense. It does not, however, affect the various parts of the system uniformly, and equally ; but, on the contrary % sometimes one part is much affected in proportion to the affection of another part, "t The result of the whole, as observed at the outset of this intro- General duction, is that we know little or nothing of the proximate cause of r^ximnre cause liti?" * M Gaultier de Clanbry, Vide Journ. Gen. de Medicine, Avr. 1823, and M. Ta- kno™. cheron, Recherches Anatomico-Pathologiques snr la Medicine Pratique, &c. 8vo. 3 Tomes, Paris, 1S». t On Fever, Dissert. !. p. 28. u Order I. Pyrectica. Fevers. Remote onuses of fever. Regarded by Cullen as sedative powers. CI. 111.J ILEMATICA. .[OKU. Marsh and human effluvia remote causes. Auxiliary remote causes of Cullen. Sufficient weight not allowed to them. Distinction between marsh and humnn effluvia of no great benefit. Miasm and contngion, what. fever or the means by which its phaenomena are immediately pro- duced. In the language of Lieutaud applied to the subject before us, they are too often atra caligine mersse; nor have any of the systems hitherto invented to explain this recondite inquiry, however ingenious or elaborate, answered the purpose for which they were contrived. c From the proximate cause of fever let us next proceed to a tew remarks upon its remote causes. Dr. Cullen, who has striven so strongly and so ingeniously to simplify the former, has made a similar attempt in respect to the latter. He first resolves all remote causes into debilitating or seda- tive powers, instead of being stimulant as they were formerly very generally considered, and as they are still regarded by many patho- logists, and especially by those who contemplate fever and inflam- mation as identic. Whether this position of Dr. Cullen be correct or not, it was necessary for him to lay it down and to maintain it, or he must have abandoned his system of fever altogether, which sup- poses it to commence in, and be primarily dependent upon debility. These sedative or debilitating causes he reduces to two : marsh and human effluvia. To the former of which he limits the term miasmata, and the power of producing intermittent fevers, which, with him, include remittent; while t5 the latter he confines the term contagions, and the power of producing continued fevers. It is true he has found himself compelled to take notice of a few other powers, as cold, fear, intemperance in venery or drinking: but these he is disposed to regard as little or nothing more than sub-agents, or co-agents, scarcely capable of producing fever by themselves. " Whether fear or excess be alone," says he, " the remote cause of fever, or if they only operate either as concurring with the opera- tion of marsh or human effluvia, or on giving an opportunity to the operation of cold, are questions not to be positively answered; they may possibly of themselves produce fever : but most frequently they operate as concurring in one or other of the ways above mentioned."* To cold, however, he attributes a power of engendering fever more freely than to the rest; " yet even this," says, he, " is commonly only an exciting cause concurring with the operation of human or marsh effluvia."! We shall find, as we proceed, that these complemental causes may admit of addition ; as we shall also that they more frequently exist as independent agents than Dr. Cullen is disposed to allow. Yet there can be little doubt that the chief and most extensive causes of fever are human and marsh effluvia. No great benefit, however, has resulted from endeavouring to draw a line of distinction between these two terms, and hence it is a distinction which has been very little attended to of late years Masm is a Greek word, importing pollution, corruption, or defile- ment generally ; and contagion a Uatin word, importing the appli- cation of such miasm or corruption to the body by the medium of touch. There is hence therefore, neither parallelism nor anta- * Pr«ct. of Phvs. Book i. Ch. 1 v. Sect, xrvir. + ibid. Sect i*. m.] SANGUINEOUS FUNCTION. [obd. i. 45 gonism, in their respective significations : there is nothing that Order i. necessarily connects them either disjunctively or conjunctively. fVvwS!?*" Both equally apply to the animal and the vegetable worlds-^—or R"mot« to any source whatever of defilement and touch ; and either may be predicated of the other; for we may speak correctly of the miasm of contagion, or of contagion produced by miasm. And hence it is that the latter term is equally applied by Sauvages Miasm, to both kinds of effluvia : " Miasmata, turn sponte in sanguine enata apjdied by turn extusex aere, in massam sanguineam delata."* Sauvages. In a work of practical information it is hardly worth while to The denial follow up the refinements of those writers who deny, and endeavour hardiytae,0B to disprove the existence of contagion under any form or mode of j^^,,- origin.! Such speculations may be ingenious and very learned and to. find amusement for a leisure hour in the closet, but they will rarely travel beyond its limits, and should they ever be acted upon would instantly destroy themselves. It is a question of more importance whether we have yet the means of realizing the distinction between human and marsh mias- mata,! which Dr. Cullen has here laid down, and which has been generally adopted from the weight of his authority. All specific ah misasmata may be regarded as morbid ferments, capable of sus- "S8"1 pension in the atmosphere, but varying very considerably in their ferments, degree of volatility, from that of the plague, which rarely quits the person except by immediate contact, to that of the spasmodic cho- lera of India, which, as observed when treating of it,§ works its way, if it be really from a specific poison, in the teeth of the most powerful monsoons, despising equally all temperatures of the atmos- phere and all salubrities of district, and travelling with the rapidity of the fleetest epidemy. They are of various kinds, and Jppear to of various issue from various sources, but we can only discriminate them by from3 *" their specific effects. These are most clearly exemplified in the v"'°us order of exanthems: in which for some thousands of years they have Those of proved themselves to be of a determined character in all parts of d"tinc?and the world where they have been the subject of observation, differing specific. only in circumstances that may be imputed to season, climate, and other external causes., or to the peculiar constitutions of the indi- viduals affected. Thus, the miasm of small pox has uniformly conti- nued true to small pox, and that of measles to measles ; and neither of them has in a single instance, run into the other disease, or pro- duced any other malady than its own. But can we say the same of the supposed two distinct miasms of Tho(:nsofd marsh and human effluvia ? Is it equally true that the former has never human produced any other than intermittent fever, or the latter any other than gffluuav,jy ™l continued ? And is it also equally true that each of these maladies adheres as strictly to its own character in every age, and every part * Nosol. Method. CI. h. Febr. Theor. Sect. 79. t Lassis Recherches sur les veritables Causes des Maladies Epidemiques appellees Typhus, on de la Non-contagion des Maladies Typhoides, &c. 8vo. Pans, 1813. Maclean's Results of an Investigation respecting Epidemic and Pestilential Dis- eases, &c. X Johnson, Influence of Tropical Climates, &c. pp. 20,21. Third edit. 1822. S Class i. Ord. i. Gen. nr. Spec. in. 46 CL. III.J HJSMATlCA. [OBD. I. Order I. Fyrectica Fevers. Itomote causes. but supposed so in Cullen's Bystem. The supposition contradict- ed by daily facts. Febrile miasm in intermit- tents; sometimes contagious. Febrile miasm probably the same produced from both effluvia. Proposed elucidation of the Eubject. Insalubrious effluvium from the decomposi- tion of all dead organized matter. of the world, as small pox and measles; and that theyjj£ve™ formly shown as strong an indisposition to run into eacn^ oiner . Dr Cullen's system is bum upon an affirmative to these questions. For it, in fact, allows but two kinds of fever, each as distinctly pro- ceeding from its own speciiie miasms as any of the exantliems. But this is to suppose what is contradicted by the occurrences ot every day : which compel us to confess that, while we cannot draw aline of distinction between marsh and human effluvia from tneir specific etiects, we have no other mode of distinguishing them. Some writers, indeed, have denied that intermittents, or rather the intermittents 01 marsh-lands, are produced by a miasm of any kind; for they deny that any kind ot miasm is generated there ; and contend that the only cause of intermittents, in such situations, is air vitiated by being deprived oi its proper proportion ot oxygene in consequence of vegetable and animal putrefaction, combined with the debilitating heat of the autumnal day, and the sedative cold and damp of the autumnal night.* but this opinion is too loosely supported to be worthy of much attention, it is sufficiently disproved by the intermittent described by feir George baker, as existing in the more elevated situations of Lincolnshire, while the adjoining fens were quite free from it.j And in like man- ner the severe and intractable intermittents of whatever form or modification, that exercise their fearful sway from Cape Comorinto the banks of the Cavery, from th& Ghauts to the coast of Coro- mandel, not unfrequeiitiy pass into a contagious type, and propagate themselves by contagion.J We have as much reason to suppose a febrile miasm in intermittents as in typhus; and in some instances they have been tound as decidedly contagious. " That intermittent fevers, says Dr. t ordyce, " produce this matter, or, in other words, are infectious, the author (meaning himself) knows from his own observation, as well as horn that of others."§ And notwithstanding that it becomes us to speak with diffidence upon a subject respecting which we are so much in want of informa- tion, 1 may venture to anticipate that the evidence to be advanced in the ensuing pages upon the general nature and diversities of fever, will show that there is more reason for believing that the febrile principle produced by marsh and human effluvia is a common miasm, only varying in its effects by accidental modifications, and equally productive of contagion, than that it consists of two distinct poisons, giving rise to two distinct fevers, the one essentially contagious, as contended for by Dr. Cullen. In effect, we shall, 1 think, perceive, that this mysterious subject is capable of being, in some degree, more clearly elucidated and still farther simplified than it has been by preceeding pathologists. In the decomposition of all organized matter, whether vegetable or animal, when suddenly effected by the aid of heat and moisture. an effluvium is thrown forth that is at all times highly injurious to the * Currie Trans. Amer. Phil. Soc. t Medic. Trans. Vol. hi. Art xiii cissron ,he Epidemic Feio°i&T™£\bi ?": Ains,*'smi;h' »« cl. in.] SANGUINEOUS FUNCTION. [ord. i. 47 health, and, in a closely concentrated state, fatal to life itself. Order i. Thus, we are told by Fourcroy, that in some of the burial grounds Fevers.08' in France, whose graves are dug up sooner than they ought to be, Remote the effluvium from an abdomen suddenly opened by a stroke of the Burial' mattock, strikes so forcibly upon the grave-digger as to throw him p'raoce!'" into a state of asphyxy, if close at hand ; and if at a little distance, to oppress him with vertigo, fainting nausea, loss of appetite, and tremors for many hours : whilst numbers of those who live in the neighbourhood of such cemeteries labour under dejected spirits, sallow countenances, and febrile emaciation.% This effluvium is from the decomposition of animal matter alone ; but the foul and noisome vapour that is perpetually blown off the coast of Bavaria, and the stinking malaria that rushes from the south-east upon the Malaria on Guinea coast, though loaded with vegetable exhalations alone, coast,01"6 triumph in a still more rapid and wasteful destruction. The last peculiarly so as being thoroughly impregnated with destructive miasm while sweeping over the immense uninhabitable swamps and oozy mangrove thickets of the sultry regions of Benin, insomuch that Dr. Lind informs us that the mortality produced by this pestilen- tial vapour in the year 1754 or 1755 was so general, that in several negro towns the living were not sufficient to bury the dead; and that the gates of Cape Coast Castle were shut up for want of sen- tinals to perform duty ; blacks and whites falling promiscuously before this fatal scourge. In this case, as in the preceding, the vapour is always accompanied la these with an intolerable stench from the play of affinities between the accompa- different gases that are let loose by the putrefactive decomposition ; a1gtn 1816, as fully and admirably described by Dr MuseraveC at Anjgua and to which we shall have occasion to refer still more particulariy in its proper place. r ' * See Sir Gilbert Blane's valuable article on Yellow Fever in l.i« . I. Order I. I have dwelt the longer upon this subject, because it is desirable Fevers?'1' to reconcile as much as possible the conflicting testimony of respec- Remote tabie writers, who, having adopted different theories, are insensibly causei' led to support them by inaccordant descriptions of the same disease. Counter In direct opposition to Dr. Musgrave, Dr. Jackson, Dr. Bancroft, of mheT19 and a host of distinguished writers who think with them, we are told writer*. by Dr. Pym, that the Bulain fever, admitted by Dr. M usgrave to be the same as the above, not only is contagious, but is never introduced into any fresh region but by contagion.t While Dr. Rush, speaking of the yellow fever of Philadelphia, of 1793, asserts that "there were for several weeks two sources of infection, viz. exhalation and contagion. The exhalation," says he, "infected at the distance of three and four hundred yards, while the contagion infected only across the streets. After the 12th of September, the atmosphere of every street in the city was loaded with contagion."' He adds, that a few caught the disease who had it before : thus taking a middle course between Dr. Musgrave, who tells us that recovery affords " no exemption from a second attack," and Dr. Pym, who affirms that the fever " attacks the human constitution but once." In the fever of Cadiz of the year 1800, Sir James Fellowes, who coincides in the view adopted by Dr. Pym, asserts not only that it was conta- gious and propagated only by contagion, but that the air " from its stagnant state became so vitiated, that its noxious qualities affected Atmosphere even animals : canary birds died with blood issuing from their bills, tam°inated and in all the neighbouring towns, which were afterwards infested, atCadir no sParrow ever appeared."| birds. I do not remember to have seen this last fact so directly affirmed by any modern writer ; but it is not contradicted in the course of the controversy, and is in perfect coincidence with the state of the air during the plague in most places,§ and particularly at Athens, as Similar fact described by Thucydides :|1 Tea/Mipiav & ruvfiev reiovrat opndm eiriXu-tyn .is stated by pa>vTo evn aAAw;, evre wept toiovto* ov&t. Ot Thucydi- ££ KVVe? /miX>i.ov ctB-fartv 7rxpei%ov rev ohtovccivovtos, hct Te ^whxiTocsHxu Whence Lucretius, who does but little more than translate Thucy- dides : Nee tamen omnino temere illis solibus ulla Coraparabat avis, nequc noxia sccla ferarum Exibant sylvis ; languebant pleraque morbo, Et moriebantur ; cum primis fid i canum vis Strata animarn ponebant in omnibus aegre : Extorquebant enim vitam vis morbida membris.H Nor longer birds at noon, nor beasts at night Their native woods deserted ; with the pest Remote they languish'd and full frequent died. But chief the dog his generous strength resign'd, Tainting the high-ways, while the ruthless bane Through every limb his sick'ning spirit drove. * Essay on the Disease called Yellow Fever, ut supra. t Observations upon the Bulam Fever, which has of late years prevailed in the West Indies, on the coast of America, at Gibraltar, Cadiz, and other parts of 6nain, &c. in 8vo. 1815. * * ' 1 Reports of the Pestilential Disorder of Andalusia, which appeared at Cadiz in theyears 1800, 1809,1810. and 1813, &c. 8vo. 1815. ** 5 Diemerbr. De Pcste, Cap. vi. Van Swieten, ex prof. Sorbait, in sect. 1407 (I Hwt. si. 52. «r De Rer. Nat. Lib. vi. II17. UL. III.] SANGUINEOUS FUNCTION. [OR». I. 61 There can be or rather there ought to be no question, therefore, Order i. that the fever before us was in some regions contagious, or produced Fevers!.0*' from human effluvium ; as in other regions, and under other circum- Remot0 n ~ causes. stances, it was produced from marsh effluvium. And though, from Hence the a prejudice of education that will presently be pointed out, the con- produced'6' trary is still contended for by names of considerable weight, they W a Uko seem to be overbalanced in number as well as in authority, by those usuh^g both who have enlisted themselves on the opposite side of the question ; ^'uman and of which last it may be sufficient to set down the names of Lind, mnrsh Clarke, Belfour, Chisholm, Blane, M'Grigor, and Johnson, from efflu.via' among our own countrymen ; and of Berthe, Bequine, Dalmas, Bally and Pugnet, among foreigners. The facts brought forward by Sir James M'Grigor upon this subject are decisive indeed of them- selves.* And those who are more voracious of proofs may satisfy the most exorbitant appetite by the numerous and conclusive narra- tives collected by Dr. Chisholm, and especially the fever described by Dr. M'Cabe,t as prevailing among the Royal York Rangers sta- tioned at Trinidad. " The causes of this fever in its origin were h'^Vated excessive heat, marsh effluvia from a marsh of immense extent in the immediate vicinity of part of Spain, considerable labour and fatigue. Its contagious character superadded to its marshy, was produced by an influx of Spaniards from the Spanish main, in a deplorable state of misery and wretchedness. It was among these unfortunate people that the contagious fever began. "J It is probable that Sir James Fellowes, and Dr. Pym might contend that in this quarter the fever was imported, and maintained by con- tagion alone, as they have contended was the case in the Yellow Fever of Cadiz in the year 1808 ; but even in this last case they And hence have completely failed in establishing the question of its supposed the MedI-° importation by a shjp's crew from Spanish America ; and as there „enjaonan is no doubt in the mind of those who have not buckled on the armour American of controversy, that this fever was the common fever of the Mediter- [he East" ranean coasts, so well described by Dr. Cleghorn, and which, under and West different names, and with different degrees of violence commits its and the ravages mostly about the autumnal equinox, from the swampy shores VaHed°oyy of the Nile to the oozy banks of the Tiber, and which is often found incidental as destructive in the Campania as in the East or West Indies, there stance!" should be no longer any doubt of the operation of one and the same miasm or febrile principle in all these cases; sometimes issuing from the effluvia of the living body, and sometimes from that of dead organized matter : generated, to adopt the language of Professor Frank, " Tam in aegrotantium variorum, corpore, quam in atmos- phaera, plurimorum exhalationibus inquinata, favente anni constitu- tione;"§ and consequently, that the whole of that part of Dr. Cullen's *fence, system is erroneous which supposes a different specific principle of doctrine on fever to be generated in each ; the one distinguished by being ^Jon8eu0bJgCt limited to the production of uncontagious intermittent fever, and the other to that of contagious continued fever. And it is of the more Ar0^epj * Medical Sketches, passim. t Edinb. Med. and Surg. Journ. Oct, 1819. \ Climate and Diseases of Tropical Countries, p. 42, 8vo. 1822. S De Cur. Horn. Morb. Epit. Tom. i. 8vo. March 1792, 52 cl. in.] HiEMATICA. [ord. 1. Order I. importance that the error of this doctrine should be pointed out, reve™ca since it has proved the very ground-work of that altercation which has cluTs6 prevailed upon the subject before us. For the writers on both sides theU3°s' having equally d u ik from the Cullenian fountain, and being equally thatTTaw™ impressed with the truth of this doctrine, have only warred with arisen. each other in support of Dr. Cullen's distinction ; and hence those who have so clearly witnessed the origin of the fever from marsh effluvium, that they have been compelled to acknowledge this as its source, have felt themselves compelled at the same time to deny that it is contagious ; while those who have as clearly witnessed its contagious power, have as forcibly felt themselves compelled to deny that it has sprung from marshy miasm. illustrated Dr. Jackson affords us one of the clearest proofs of the truth of Jackson. tnis remark in his late as well as in his earlier works. There is no writer who has more distinctly pointed out the close analogy between the symptoms of the marsh endemic of the West Indies, and conta- gious fever as they very frequently show themselves, than he has done; " th? derangements," says he " are exteriorly so much alike, that the discriminating characters cannot be delivered but with doubt and hesitation ; the result of the whole appearances will often deter- mine the judgment, but the symptoms separately considered lead to no certainty. The causes of endemic and of contagious fevers were equally connected under certain conditions, with eruptions on the skin, ulcers of the extremities, diarrhoea, purging, dysentery, or flux, fever of an intermitting or remitting form, of a form continued,— violent and rapid in course, moderate and of ordinary duration, or slow, lurking and irregular, ceasing and returning at intervals,— changing from general to local disease of various descriptions, and from local disease to general and formal fever.—The general man- ner of attack, the course, changes and duration of endemic and contagious fevers have great similarity.—Certain modes of action or combinations of action prevail n:ore frequently in the one disease than the other, but forms and modes do not constitute characteristic differences: thus affection of the stomach and biliary system,— vomiting and yellowness are less frequent in contagious than in endemic fever ; yet they do occur in the former, and sometimes to considerable extent : affection of the chest, alternating with deli- rium or affection of the head, appears to be more common in contagious than in endemic fever ; so likewise is a peculiar maniacal derangement or lively delirium, occurring in the progress to recovery: yet the frequency of these appearances does not furnish a charac- teristic mark."* That is to say, all the leading symptoms which make and determine the diseases are the same ; and yet thouffh practically and in fact they run into each other and are the same, ^nSPnm W 7 ^ the°ret,cally they are not the same, and never can run into each other in the opinion of this valuable writer muTproc^ifom "Z ft d°Wn *• d'Ctum «ta SSSS must proceed from paludal rmasm aod be uncontaoinm and con.ag.ous fevers from the morbid effluvium of alXofe al2 * History and Cause of Fever, pp. 213. 214. 216. cl. m.] SANGUINEOUS FUNCTION. [oed. r. 53 Yet, after all, the substantive part of the tenet seems to be relinquished Order I. by Dr. Jackson in the following passage, which occurs in his remarks FevMsf*' on the yellow fever that ravaged the Spanish coasts in 1800, not- Remote withstanding the firmness with which the Cullenian doctrine is osten- sibly maintained. " Tl e case may perhaps be thus explained. The yellow fever, during the reign of epidemic influence, often strikes like a pestilence by the mere concourse of people in a close place; and if a mass of sick persons be collected into a hospital during the epidemic season, the common emanations from the sick bodies, whether saturated with contagious particles or not, often act offensively on those who enter the circle, and often appear to be the cause of the explosion of a disease, which, without such accessory or changed condition of the medium in which man lives, would have probably remained dormant for a time and perhaps for ever."* Iu typhus, or the fever that originates in crowded jails, and other How far thronged and noisome abodes, there is no longer a question con- proxlmates cerning its human origin or emanation from sick bodies, and its con- |p yellow tagious property ; at least, among practical writers. But typhus does not differ more widely in its symptoms from some of the modi- fications of the fever we have just contemplated, than such modifi- cations do from others of the same fever, varied by the varying power of its co-operating agents, t And hence, we have reason to a modified conclude that typhus also is generated from the same common from tho febrile miasm, modified in its action by influential contingencies. common In effect the yellow fever itself, under peculiar circumstances, miasm. assumes something of a typhous character even in its first origin, and feveHteeif where the source has unquestionably been marsh miasm. The ?fto" tVDnOUS second form of the Andalusian fever as described by Dr. Jackson, from the and specially characterized by defective energy, peculiarly exem- firBt" plifies this remark ; and such was expressly the case with the asthenic remittent at Breslaw in 1757,| as well as in the island of Edam on the coast of Bavaria in 1800, and is still oftener found in the remit- tent that takes place along the Gambia, after rain in the spring or early part of the summer ; when there is less organized matter remaining on the surface of the earth to be decomposed, and what there is has been acted upon by a lower temperature and a shorter duration of heat than in the autumn. " In the month of June," says Dr. Lind, " almost two thirds of the white people were taken ill. Their sickness could not well be characterized by any deno- mination commonly applied to fevers: it however approached nearest to- what is called a nervous fever, as the pulse was always low, and the brain and nerves seemed principally affected. It had also a tendency to frequent remissions." The patients were often attacked with a delirium, and ran into the open air, where they received benefit from an affusion of heavy rains upon their naked bodies. The delirium, however, it seems, " soon returned; they afterwards became comatose, their pulse sunk, and a train of nervous symptoms followed; their skin often became yellow." And even But more J r J frequently * Remarks on the Epidemic Yellow Fever, &c. on the South Coasts of Spain, p. 44. Lond. 8vo. 1821. t Caizerques—Memoires surla Contagion de la Fievre Jaune, Paris. t Chisholm, Manual of the Climate and Diseases of Tropical Countries, fee p. 38. 1822. 54 cl. in.] HtEMATICA. [ORD. I. Order I Pyrectica. Fevers. Remote causes in its progress. Both originate in similar 'situations. Oause of their difference. Further illustrated from the late levers in Spain". where the disease has commenced with symptoms of great excitement, and an intermittent type, it is so much disposed, under peculiar incidents, as great fatigue, disappointment, and short provisions, re- run into a typhus fever, as at Walcheren* and during the retreat ol the British army from Corunna, that many nosologists have tnougm themselves called upon to make this form a distinct variety or even species of fever, which they have usually distinguished by the name of typhus icterodes, or yellow typhus. In like manner, » here the vellow fever has commenced originally from contagion, or, in other words, from a decomposition of human instead of marsh miasm, it has been under the very same auxiliaries of filth, poverty, crowded numbers, and a stagnant atmosphere, that give rise to typhus. Thus the fever of Malaga of 1803, uniformly admitted to be of the same kind as that of Cadiz in 1800, spread first, according to Professor Arejula's description, through the nar- row, crowded, and offensive lanes of the district de Perchel : and that of Cadiz itself, according to Sir James Fellowes, made its ear- liest appearance in the Barrio de Santa Maria, a part of the town in which the streets are narrower, less ventilated and cleanly than any other part, and where the poorer inhabitants, dirty in their persons and crowded in filthy rooms, generally live together. It is true that it was conjectured by many persons, and among others by both these writers themselves, that the contagion did not originate in either of these situations, but was introduced into them by foreign shipping ; but such a conjecture has, in the first place, no trust-worthy evidence for its support, and, in the second, the mere testimony of the captain of the ship referred to was directly contradicted by the chief physi- cian of the hospital at the Havannah, who was on board the whole time and was privy to the cases in question. In effect, a cause thus secondary seems to have been superfluous, for the local causes enu- merated by Sir James Fellowes and Professor Arejulat appear to have been perfectly adequate. They are, as near as may be, the same as those which operate so fatally in the miserable and crowded cabins of Ireland ; and if the fever had shown itself at a cooler season of the year, and the subjects of it had been still more broken down in constitution by mental dejection and low diet, it would pro- bably from the first have assumed a continued and typhous character, instead of a remittent and more energetic. The proofs offered upon this subject from personal and accurate observation by Dr. Jackson and Dr. O'Halloran are in full confirmation of this view : for there can be no doubt that the fever of 1820 and 1821, which they describe, was the same as that of 1800 and 1803. " From an impartial consideration," says Dr. O'Halloran, "of all the circumstances attending the epidemies of Spain in the year 1821, the conclusion is, I think, fairly deducible that the disease was not, and is not occasioned by imported contagion, and that its origin cannot be attributed to the germ of a former epidemic, resuming original activity from the operation of a peculiar state of atmosphere * ^kisholm, Manual of the Climate and Diseases of Tropical Countries. &c t Brieve Description de la Fiebre Amarilla, p. 229. Madrid, 1806. i;l. in.] SANGUINEOUS FUNCTION. [ord. i. 55 without which it would remain dormant, perhaps, for ever.—All the Order I. towns and cities which suffered from the yellow fever were, with the Fevera.ca exception of Cadiz, filthy in the extreme, disgustingly so, and very J^^f objectionable on the score of ventilation, situation, and form of con- struction : while the different towns of Arens, Matero, Badalona, Tarragona, Vinaros, Benicarla, Valencia, Aliama, Velez, Malaga, Marabella, Estepona, Vejer, Conil, Puerto Real, Rota, Chipiona, Orcos, and Medina Sidonia,—all of which are in the vicinity of the sea, and which, it may be presumed from their relative situations, communicate freely with the theatres of disease, were not affected by the malady. They seldom, indeed, suffered in any other years; because, independent of their localities, being better chosen for health, they are comparatively clean."* The febrile miasm then, generated by a decomposition of human Miasm from effluvium and of dead organized matter, appears to be essentially the effluvium same, modified alone in one or two of its qualities by the co-opera- "J"'^^ tion of the heat, moisture, stagnant atmosphere, and perhaps some matter de- other unknown agents, that are necessary to give it birth or activity, essentially The chief difference produced in this miasm under these distinct 'he samo> modes of origin is, that when generated by the decomposition of modified iu effluvium issuing from living human bodies, it is less volatile,! and properties.3 has at the same time a power more directly exhausting, or debilitating chief the sensorial energy, than when generated by the decomposition of between dead organized matter. Whence fevers originating in jails or other ^'nem]re air confined and crowded scenes contaminate the atmosphere to a less necessary distance than those from marshes or other swamps, but act with a extensive greater degree of depression on the nervous system when once re- spread. ceived into it. Yet even the latter have a definite atmosphere of action, beyond which they lose their power, and an atmosphere of a more limited diameter than we might at first be tempted to conceive: for we learn from Sir Gilbert Blane that in the unfortunate expedition to Walcheren, the crews of the ships in the road of Flushing were entirely free from the endemic of the country, as were also the guard- ships which were stationed in the narrow channel between Flushing and Beveland ;—the width of which channel is only about six thou- sand feet.| In whatever mode derived, the remark of my excellent and distin- guished friend Dr. Hosack will still hold, not indeed that it is alto- gether incapable of taking effect in a pure atmosphere, but that" an impure atmosphere is indispensably necessary to extend the specific poison."§ And I should also fully concur with himself and Professor Brera1! in censuring the application of the term epidemic to any of the febrile diseases hereby produced, provided this epithet were usu- * Remarks on the Yellow Fever of the South and East Coasts of Spain: compre- hending Observations made on the Spot, by actual Survey of Localities, &c. By Thomas O'Halloran, M.D., &c. p. 184. Lond. 8vo. 1823. f Hist, and Cure of Fever, by R. Jackson, M.D. Part. I. Ch. in. p. 102. t Select Dissertations, &c. p. 107. § Observations- on the Laws governing the Communication of contagious Diseases, 4to. New-York, 1815. || De' Contagi e della cura de' loro effetti, Lezioni Medico-pratiche del Cavaliere Brera, M.D. &c. 2 Vols. 8vo. Padua, 1819. 06 ci. m.] IliEMATICA. [oRD. I. Order I. ally confined, which I am not aware of, to disorders supposed to re- FCca* suit from some primary intemperament of the atmosphere itself: and Ee-noto provided also every attempt at distinction were not likely to perplex cau,es' rather than to simplify a subject sufficiently intricate ab ovo; of which M. Deveze has furnished us with an ample specimen in his late treatise.* why an Why a corrupt state of the atmosphere should be necessary to the Zosphere general action of the febrile miasm, is a question which still remains ExC7a9nay to be discussed. Dr. Hosack supposes that the latter "produces its tion'ofa" effects by some chemical combination with the peculiar virus se- Hosack. crete(j frorn the diseased body," and which is floating in the atmos- phere : of the nature of which virus, however, he has not given us Of ohis- any information ; while Dr. Chisholm conceives that it is the impu- holm' rity of the atmosphere itself which operates by " increasing the sus- ceptibility of the system to the action of the poison introduced."! But to this explanation Dr. Hosack successfully rejoins, " that the predisposition of those who are most exposed to such impure air is less, while those who reside in the pure air of the country are most liable to be infected when exposed to the contagion."* Exp'.ana- The true state of the case appears to me as follows. In a pure i)y"the ere atmosphere, the miasmic materials easily become dissolved or decom- author. posed ; but slowly and with great difficulty, perhaps not at all, in a corrupt atmosphere, already saturated with foreign corpuscles. In a state thus crowded, moreover, they less readily disperse or ascend beyond their proper periphery of action ; and perhaps by their tena- city adhere to bodies more ponderous than themselves, and thus loiter for a still longer period within the stratum of human intercourse. And is it is from the same tenacity they adhere to various kinds of clothes and filth, we may easily perceive why on the shaking or agi- tation of such substances, as in clearing a ship's hold or unpacking its cargo, a pestilence may be generated of which the crew have hitherto given no signs. J avoided118 Upon this explanation it is not necessary to suppose that febrile hy this miasm has a power either of concentrating its virulence,§ so as to explanation. ren(jer itself more active ; or of multiplying its own form, so as to increase its numerical strength; against both which views, there are weighty objections. Every distinct particle thus suspended, and withheld from dissolution, becomes an active individual in the field of battle, and is almost sure to grapple with its man. So that hereby alone we have a force equal to any degree of mortality that can be conceived. While, then, the remote causes of fever are of different kinds, its Origin and chief and most effective is febrile miasm ; the origin and laws of febrile0 which, so far as we are at present acquainted with it, may be ex- miasm. pressed in the following corollaries : 1. The decomposition of dead organized matter, under the influ- ence of certain agents, produces a miasm that proves a common cause of fever. * Traite de la Fievre Jaune. p. 354. 8vo. Paris, 1820. J Letter to Haycartb. I Blane, Select Dissertations, &c. p. 307, Lond. 1822. «»yg«n. § Jackson, ut supra, Part i. Ch. x. p. 246. .a,.jii.j SANGUINEOUS FUNCTION, [ditn. i. o) 2. The whole of these agents have not yet been explored ; but so Order I. far as we are acquainted with them, they seem to be the common Fevers.0"' auxiliaiies of putrefaction, as warmth, moisture, air, and rest, or Eemotc stagnation. 3. The nature of the fever depends, partly upon the state of the body at the time of attack ; but chiefly upon some modification in the powers or qualities of the febrile miasm, by the varying propor- tions of these agents in relation to each other, in different places and seasons. And hence, the diversities of quotidians^ tertians, and quartans; remittent and continued fevers, sometimes mild and some times malignant. 4. The decomposition of the effluvium transmitted from the living human body, produces a miasm similar to that generated by a decom- position of dead organized matter, and hence capable of becoming a cause of fever under the influence of like agents. 5. The fever thus excited is varied or modified by many of the same incidents that modify the miasmic principle when issuing from dead organized matter; and hence a like diversity of type and Vehemence. 6. During the action of the fever thus produced, the effluvium from the living body is loaded with miasm of the same kind, com- pletely elaborated as it passes off, and standing in no need of a de- composition of the effluvium for its formation. Under this form it is commonly known by the name of febrile contagion. In many eases, all the secretions are alike contaminated ; and hence febrile miasm of this kind seems sometimes to be absorbed, in dissection, by an accidental wound in the hand, and to excite its specific influ- ence on the body of tie anatomist. 7. The miasm of human effluvium is chiefly distinguishable from that of dead organized matter, by being less volatile, and having a power of more directly exhausting or debilitating the sensorial energy, when once received into the system. Whence the fevers generated in jails or other confined and crowded scenes, contaminate the atmosphere to a less distance than those from marshes and other swamps, but act with a greater degree of depression on the living fibre. 8. Tlie more stagnant the atmosphere, the more accumulated the miasmic corpuscles from whatever source derived ; and the more accumulated these corpuscles, the more general the disease. 9. The miasmic material becomes dissolved or decomposed in a free influx of atmospheric air; and the purer the air the more readily the dissolution takes place : whence, e contrario, the fouler as well as more stagnant the air, the more readily it spreads its infection. 10. Under particular circumstances, and where the atmosphere iss peculiarly loaded with contamination, the miasm that affects man, is- capable also of affecting other animals;. 11. By a long and gradual exposure to the influence of febrile miasm, however produced, the human frame becomes torpid to its action,* as it does to the action of other irritants; whence the natives id'swampy countries, and prisoners confined in jails with typhous * Brera, De' Contagi e della curade' loro eftetti, &c. ut supra, Padua, 1819 Vol. JT.—R oS ut.ui.5 xLfcMATlCA. l"*»-*- Order I. contamination around them, are affected far less readily than Feleecr3ica' strangers ; and, in numerous instances, are not affected at all. Remote 12. For the same reason, those who have once suffered from cauSM' fever of whatever kind hereby produced, are less liable to be influ- enced a second time; and, in some instances seem to obtain a com- plete emancipation. noctriim of It only remains to offer a few remarks upon the doctrine of 0ri5es- crises ; or that tendency which fevers are by many supposed to pos- sess, of undergoing a sudden change at particular periods ot their progress. Orii-is, what A sudden and considerable variation of any kind, whether favour- J»"esontday. able or unfavourable, occurring in the course of the general disease* and producing an influence on its character, is still loosely expressed Primary by the name of crisis. The term is Greek, and pathologically imports "lTuscor a separation, secretion, or excretion of something from tbe body; the term, which was in truth the meaning ascribed to it when first employed, agreeably to the hypothesis of concoction which we have just consi- dered. The original hypothesis is abandoned ; but the term is still Critical continued in the sense now offered. "If the matter of the disease," ofFrank?8 says Professor Frank, " be expelled by some one convenient outlet, in the skin, kidneys, bowels, or blood-vessels, the crisis is simple ; if by several of these at the same time, it is compound ; if the whole be carried off at once, it is perfect. If it be carried off at different times, it is a lysis,* or resolution." crisis often That changes of this kind are perpetually occurring in the progress M^modern of continued fevers, must, I think, be admitted by every considerate *°™e of the and experienced practitioner. Nothing is more common than to behold a patient suddenly and unexpectedly grow decidedly better or worse in the progress of a fever of almost any kind, and pass on rapidly towards a successful or an unsuccessful termination. Whether in But the important question is, whether there be any parti ular the ancient ... sense, or on critical expected ? Hippocrates conceived there were : he endeavou ' to periods in the progress of a fever in which such changes m y be point out and distinguish them by the name of critical days. As- clepiades and Celsus denied the existence of such periods ; and the same diversity of opinion has prevailed in modern times. nm easy to It is not very easy to determine upon the subject in the present ietcmane fay^ and especially in our own country. For, first, fever, like many ■limates. other complaints, may have undergone some change in its progress from a like change in the nature of its remote causes, or in the constitution of man. And, next, it seems to be generally allowed' that sudden transitions, whether regular or irregular, are more apt to take place in almost all diseases in warm than in cold climates On these grounds, it is probably a subject which will never become of great practical importance at home. Yet it is well worthy of attention as a question of history, and which may yet be of Pi-eat importance to many parts of the world. h -oSs "^ «™™ tho.ptenoinena of the animal economy, as they in „, 4, occui in a natural series, we shall find that they are in almost every * De 0.nri» Hominom Morbi. Epitome, &c. Tom. 1. De Febr.p, 26. cl. in.j SANGUINEOUS FUNCTION. [ord. t. $9 instance governed by a periodical revolution. A man, in a state of Order I. health and regular habits, generally becomes exhausted of sensorial Fevers.0*' power within a given period of time, and requires a periodical sue- Doctrine ci cession of rest: his appetite requires a periodical supply, and his phenomena intestines a periodical evacuation. This tendency equally accom- animal panies and even haunts him in disease ; he cannot disengage him- economy. self from it. Gout, rheumatism, mania, rapidly and pertinaciously Examples establish to themselves periods of return. The hemorrhoidal dis- "1^11, charge often does this ; and the catamenia constantly. The same occurs in fevers, but especially in intermittents ; for the quotidian, the tertian, the quartan, have, upon the whole, very exact revolu- tions. And, though accidental circumstances may occasionally produce a considerable influence on every one of these facts, whether morbid or natural, the tendency to a revolutionary course is clear and unquestionable. Now, although Hippocrates has not appealed to this reasoning, They it forms a foundation for his observations : and when, stript of the obscrva- " perplexities that encumber his writings upon this subject, partly H°pp00cfra,es produced by erroneous transcripts, and in a few instances perhaps upon by his own irresistible attachment to the Pythagorean hypothesis of day8c.a numbers, he may be regarded as laying down the following as the critical days of continued fever : the 3d, 5th, 7th, 9th, 11th, 14th, ^'ticft' 17th, 20th ; beyond which it is not worth while to follow the series, Hippo°cro for it is not often that they extend further. ,cs' In other parts of his works, he regards also the 4th and 6th, and even the 21st as critical days; so that in the first week, every day, after the disease has fully established itself, evinces a disposition to a serious change ; in the second week, every other day; and in the third week, every third day. It is not easy to determine why the 21st day should be a critical day as well as the 20th. Various conjectures have been offered upon the subject; by some, it has been regarded as a mistake in the Greek copy, and by others, as a piece of favouritism in Hippocrates for this number, in consequence of its being an imperfect one in the Pythagorean philosophy, as the commencement of a septenary. De Haen with rigid and patient assiduity has put Hippocrates to Hippocrates the test upon these data ; for he has accurately analyzed Hippo- &", b°y Do crates's own journal of the numerous cases of fever he has so Haen- industriously collected and recorded, and finds the positions, in most instances, to be strictly justified ; and that out of 168 terminations of fever, not less than 107, or more than two-thirds, happened on the days denominated critical, not reckoning the 4th, 6th, or 21st, and that the 4tb and 6th were very frequently critical. Tiee are a few anomalies; but it is not necessary to notice them, because they are easily referrible to accidental causes, similar to those that retard or accelerate the paroxysm of intermitting fevers. Now, admitting the Hippocratic table to be true, the continued ^'^ fever, in its progress, is measured by the various types exhibited by Hippo'cratee intermittent fevers. Thus, the quotidian prevails through the first frrc°upn0*ti seven days ; there is on each day a slight exacerbation, and no one the types of dav is more critical than any other. After this period the tertian dt£mil 6(1 ex. 1U.] ILEUVTICA. [ORD. Order I. I'yrecticn. levers. Tlie suhject confirmed by Cullen'd experience, runt lordyce's. Still lesa distinct in cold than in hot ellrrrafes- I»iflicullies attending tho subject. Cullen, who has examined this subject with great attention, and simplified it from many of its difficulties, directly asserts that Ins own experience coincides with the critical days of Hippocrates; Dr. Fordyce, who scarcely does justice to Cullen upon other points, unites with him upon the "present, and justly compliments him. upon his ingenious examination and explanation of the Greek distribu- tion of critical days : and Dr. Stoker of Dublin has arrived at a like conclusion after what appears to have been a very patient, discriminating, and extensive inquiry.* It is, nevertheless, ad- mitted on all hands, that the order of succession is far less distinct as well as less regular in cold than in- warm climates ; and that it requires a thoroughly attentive and practised eye to notice these changes in our own country, or indeed in any part of northern Europe. And hence, Craanen says, it is lost time to look for them ;t Stoll, that they are only to be found in inflammatory fevers ;| Le Roy, that the supposed critical days liave no influence and can lead to no prognosis or peculiarity of practice :§ and Frank that nature has fixed upon no one day rather than another, for a solution of fever, nor at any time forbids our attempt at executing a present indication.ll Dr. Jackson, partly from the strength of his attach- ment to the doctrines of Cullen, and partly from having principally practised in hot climates, is a great advocate for the existence of critical days, and beUeves them to take place in fevers from human as well as marsh miasm ; though less distinctly as also less fre- quently in the former than in the latter.H Why the first week of a fever should incline to a quotidian type rather than to a tertian, or the second to a tertian rather to a quartan, we know no more than we do why fevers should ever intermit, or at any time observe the distinctions of different types. We are in total ignorance upon all these subjects. We see, moreover, that intermitting fevers, whether quotidian, tertian, or quartan, have their paroxysms recur regularly in the day time ; the quotidian in the morning, the tertian at noon. and the quartan in the afternoon ; and that in no it.stance do the paroxysms take place at night: and we see also that in continued fevers, the exacerbations uniformly take place later in the day than the paroxysms of the latest intermittent; for these rarely recur earlier than between five and six o'clock in the evening, while the paroxysms of the quartan return commonly before five. Of these interesting and curious scenes we are spectators ; but we are nothing more; for we are not admitted to the machinery behind the curtains. * Medical Report of the Fever Hospital, &c. for 1816. Tran« of lhP K^o' Queen's Coll. Dnbl. Vol. 11. 434. 8vo. 18'J4. e Kw° t Pe Homine. I Rat. Med. Part IV. p. 283. rt "u *;pon0s. 83. ■-*. in.) SANGUINEOUS FUNCTION. [okd. i. <>3 In this simple shape of the disease, the pathognomic symptoms <»EN- J; are few and striking ; for, however violent, it is confined to a single DiarTfeveV. paroxysm of three distinct stages, shivering or languor, heat, and f.taseB°f • . ■ 1 . l 1 1 i i ^ i -i , diarv 'ever, perspiration ; each most probably dependent on the other, and three. ceasing, when true to itself, after having followed up the movements of the animal frame through a single diurnal revolution. The cold stage, however, is often scarcely perceptible, and sometimes altogether imperceptible, the general languor taking place with- out it. The genus exhibits two common and very distinct species ; and if the ephemera sudatoria of Sauvage , 'he sweating-sickness or English plague of other authors, be regarded as belonging to it, as unquestionably it ought, it will tben afford us another after the manner following : 1. EPHEMERA MITIS. MILD DIARY FEVER. 2.--------ACUTA. ACUTE DIARY FEVER, 3.--------SUDATORIA. SWEATING-FEVER, SPECIES I. EPHEMERA MITIS. MILD DIARY FEVER. WITHOUT PRECEDING RIGOR ; LASSITUDE AND DEBILITY INCONSIDER- ABLE ; PAINS OBTUSE, CHIEFLY ABOUT THE HEAD ; HEAT AND NUMBER OF THE PULSE INCREASED SLIGHTLY : PERSPIRATION BREATHING AND PLEASANT. The common exciting causes are excess of corporeal and espe- Gen. t. cially of muscular exertion ; long protracted study ; violent pas- Ca^* sion ; suppressed perspiration ; sudden heat or cold. There are few persons who have not felt this species of diary The fever fever at times, from one < r other of the causes just enumerated, rronaone When a man has worked himself up into a violent and long con- "^'^ei of linued fit of wrath, whether there have been reason or no reason, causes. and more especially in the latter case; when he has taken a long and fatiguing journey on foot, walking with great speed, and suf- fering beneath great heat and perspiration ; or when he has devoted the whole of the day to a particular study, so profound and abstract- ing as to exhaust almost the entire stock of sensorial power that can be drawn from other parts of the system, at the single outlet of the attention ;—and when, beyond this, he still urges his abstruse and protracted train of thought into a late hour of the night or the morning—there is a general irritation or undue excitement pro- duced, that simple rest cannot at once allay ; his sleep is short, roscripiicn. hurried, and interrupted if he sleep at all; he vawns. stretches his bi Gem. I. Spec. I. Ephemera inui.v Mild diary fever. CL. III. J HAEMATIC A. |_ORD. Medical treatment. tiamesters frequently suffer sovorely from this species. limbs, terns himself again and again in his bed for an easy, perhaps for a cool place, for his skin is hot and dry ; but for a long time he turns in vain. The morning strikes upon his eyes, but he has had little sleep and no refreshment : he is indisposed to leave his bed; and if he rise, he is still feverish, and unfit for business. He passes the day in disquiet, which perhaps increases towards evening; but at night he feels a moisture breaking forth over his ^kin, and com- fortably succeeding to the heat and dryness that have thus far dis- tressed him ; he recovers perhaps even while sitting up ; but it, as he ought to do, he goes to an early bed, a quiet and refreshing sleep supervenes, and he wakes to the health he before possessed. It is not easy to explain why the febrile paroxysm should be more disposed to close its career sometimes towards the evening, bui more generally later at night, except for the reason, whatever that reason may be, that all fevers are far more apt to commence their paroxysms in some part or other of the day-time, and especially in- termittents, and consequently to drop them as the day declines. Thus the quotidian makes its assault in the morning, the tertian at noon, and the quartan in the afternoon : as though the diurnal revolution were somewhat regularly divided between febrile attack and febrile cessation or truce. It is possible indeed, that a fever of any kind may open its onset at any hour, but this is so contrary to the ordinary rule, that Dr. Fordyce affirms from his own observation that ten fevers commence in the day to one at night. The species before us forms scarcely a case for medicine : since nature or that instinctive power which is ever operating to the general welfare of the animal frame, will be usually found compe- tent to its object. So that if any thing remedially is attempted, it should be confined perhaps to a slight increase of the peristaltic action of the intestines by a dose of neutral salts, and to a removal of the dry heat of the skin by diluents and small doses of ipeca- cuan, which combines admirably with most aperients, and increases their power, while its own diaphoretic quality continues at least undiminished and is often improved. This is now well known, though not a discovery of recent date ; for Gianella, Vater, and various writers of credit, strongly recommended the same from per- sonal experience nearly a century ago.* Gamesters, after sitting up all night, and being worked up to madness by the chances and reverses of their ruinous stakes, arc peculiarly subject to this species. A very cold and w< t towel tied round the temples, seems to give some check to the violent excite- ment of the brain, and diminishes the morbid excess of sensorial power it is in the act of secreting ; but, in the long run, I have generally found persons who have adopted this practice become debilitated and dropsical, and sink into an untimely grave, or creep on miserably through the fag end of a lingering life,that affords no retrospective comfort, with a hospital of diseases about them. But whether this proceed from the practice adverted to, or from the habitual exhaustion which necessarily accompanies a course of .«.Gi*nella> £e adp'.ra&Hi Ipeeacoanhse virtutc in curandis febribus. &c Pitar 175-1.—V,ter. Diss. d«; Ipecacoanhre virt'ite febriftnr», &c. Witeb. m<> oj,. sn.J SANGUINEOUS FUNCTION. |ord. i, b'5 gambling, may admit of a doubt. Yet, the habit itself appears Gen. I. mischievous, however pleasant at the time, as having a strong ten- Ephemera dency by frequent repetition to torpify the secretories of the brain jj$'d8'diarv by the rapid and violent change of action they are thus made to fever. undergo. SPECIES II. EPHEMERA ACUTA. ACUTE DIARY FEVER. SEVERE RIUOR ; GREAT HEAT ; PULSE AT FIRST SMALL AND CON- TRACTED, AFTERWARDS FULL AND STRONG ; PERSPIRATION C0- TIOUS ; GREAT LANGUOR. In a few instances the accession is slightly marked, and there is Gen. I. little chilliness or rigour. The heat that succeeds, however, is bVEC' always considerable; the face is red and bloated; and there are often pungent and throbbing pains in the head, corresponding with the pulsations of the arteries ; though at times the pain in the head is dull and heavy. The high-coloured urine deposites a sediment with a tinge of orange-peel. We cannot always trace the remote causes of this species; but Gro|eur^dy it is usually produced by some morbid affection of the stomach or by some /» .1 n .-. • affection of of the collatitious viscera. • the chyio- The most obvious and common cause is that of a surfeit, whether p?etic of eating or drinking. And there is no great difficulty in inter- stomach. preting the means by which this cause operates. The stomach, in the language of Mr. John Hunter, and it is [/^ *e language confirmed by the experience of every day, is the great ipecies is seat of general sympathy, and associates with almost every other cited"' organ in its action. The digestion of even an ordinary meal is a work of some labour to it, and especially in weakly constitutions: a greater degree of heat, as I took occasion to show, in the proem to our second class, is regularly expended upon it during this pro- cess, and unquestionably also a greater degree of sensorial power: both which, though taken directly from the brain, are taken indi- rectly from the system at large as from a common stock ; and the consequence is that, in infirm habits, a considerable degree of chill and debility are felt during this process, and other organs become torpid while the stomach is in a state of increased action. Hence infants and old persons sleep during digestion.; delicate females feel a coldness shooting over their extremities; and those of irri- table fibres become flushed in the face, and show other signs of irregular action. Now if this be the case in the digestion of ordi- nary meals, what disturbance may we not expect during the diges- tion of a meal that overloads the stomach, and with which tfrr Vol. TI— 9 66 cl. ui.j ILEA! A TIC A. [oki>. I- Gen. I. stomach is incapable of grappling ? what, more especially, when at Bphemer"' the same time, by an immoderate use of wine or spirits, the brain acuta. becomes exhausted of its energy by the excess of stimulus applied fev"' y to it I The general chill over the surface, which, in the digestion oi an ordinary meal, is only felt by the weak and delicate, is here often felt severely, and sometimes amounts to a horripilation. The first stage of fever is hence produced: and as the heat and perspiration are most probably a necessary result of the first stage, a foundation is hereby laid for the entire paroxysm. With the re-action that ensues a greater degree of sensorial power is again secreted; the general frame as well as the brain is roused to an increased energy ; the diaphragm and its associate muscles, instinctively or remedially, contract, and the stomach disgorges its contents, or thrusts them forward half-digested into the duodenum. The only and well known mode of cure consists, in the first place, in imitating this process; in unloading the stomach of its mischievous freight by a powerful emetic, and the alvine canal of whatever por- tion of the heating and crapulous mass has passed into it by a brisk cathartic. The fever hereby excited will often subside in a diurnal revolution; and no tendency to a return of the paroxysm be produced. If the species before us, however generated, do not subside within this period of time, or a few hours beyond it, the disease becomes a cauma, or inflammatory fever of the continued kind, and consequently belongs to the genus enecia. There are, however, a few exceptions to this rule: for Forestus gives a case in which the paroxysm led to a fatal hectic :* and Bo- relli gives another of equal singularity, in which it kept true to a tri- ennial revolution, returning punctually once every three years. + Treatment. Sometimes beronssa ?auma, or assumes noma other form. SPECIES III. EPHEMERA SUDATORIA. SWEATING FEVER. TENSE PAINS IN THE NECK AND EXTREMITIES ; PALPITATION : DYSPNOEA; PULSE RAPID AND IRREGULAR; HEAT INTENSE; IN- TOLERABLE THIRST ; DROWSINESS OR DELIRIUM ; EXCESSIVE SWEAT. Gen. I. I have followed M. de Sauvages in introducing sweating-fever, Deicnption.the ephemera maligna of Borsiera,J or Burserius, as he is more com- monly called, and the sudor Anglicus of most foreign writers into the present place. Dr. Caius, who practised at the time of its appearance at Shrews- bury, and has written one of the best accounts of it extant, calls it '■ Lib. i. Ob*. 7. [ Institnt. Med. Prp< I Cent. u. Obs. 100. Syo. 4 Tome*., Ven. 1782-5 . ... Ul.J SA.NGUINKOUS ll\OTI(>\. (.mid. i. 67 " a contagious pestilential fever of one day.'' " It prevailed," says J*T'*'Ji\ he, " with a mighty slaughter, and the description of it is as tre- Ephemera ' mendous as that of the plague of Athens." And we are told by sudatoria. Dr. Willis, " that its malignity was so extreme, that as soon as it en- fever. " tered a city it made a daily attack on five or six hundred persons, of whom scarcely one in a hundred recovered." It was certainly a malignant fever of a most debilitating character, but without an] tendency to buboes or carbuncles, as in the plague : though during some parts of its career as fatal. It ran its course in a single pa- roxysm ;* the cold fit and hot fit were equally fatal; but if the pa- tient reached the sweating fit, he commonly escaped. Hence the cure consisted in exciting the sweating stage as quickly Mode ot as possible, and in supporting the system with cordials throughouttiea,ma the whole of the short but vehement course of the fever. At Shrews- bury, it continued to rage for seven months, and during that period of time a thousand fell victims to its violence. But after the disco- very of the benefit of the sweating-plan, it was certainly far less fatal. It made its first appearance in London in 1480 or 1483: Caius General says in the latter year, first showing itself in the army of Henry VII. hl9torv on his landing at Milford Haven. In London, to which however it does not seem to have travelled till a year or two afterwards, it took up its abode with various intermissions of activity for nearly forty years. It then visited the continent, overran Holland, Germany, Belgium, Flanders, France, Denmark, and Norway; among which countries it continued its ravages from 1526 to 1530: it then re- turned to England, and was observed for the last time in 1551. It commenced its attack with a pain in the muscles of the neck, shoulders, legs, or arms, through which a warm aura seemed to creep in many instances ; and after these symptoms, broke forth a profuse sweat. The internal organs grew gradually hot, and at length burn- ing, the pungent heat extending to the extremities; an intolerable thirst, sickness and jactitation followed speedily, occasionally with diarrhoea, and always with extreme prostration of strength, head- ache, delirium, or coma, and a wonderful wasting of the whole body. The sweat was tenacious, saburral, and of an offensive smell: the urine thick and pale : the pulse quick, often irregular ; and the breath- ing laborious from the first. The modes of treatment were often puerile, and offer nothing instructive. A good constitution and ex- posure to free air seem to have been most successful in promoting a cure. Dr. Caius asserts, that a thick noisome fog preceded the distem- per, especially in Shropshire, and that a blaok cloud uniformly took the lead, and moved from place to place ; the pestilence in a regular march following its direction. There may be some fancy in this: but it is an unquestionable fact, that the most fatal pestilences of an- cient and modern times have been ushered in by stinking fogs or mists, or some other intemperament of the atmosphere, of which the reader will find various instances in the sequel of this work. The disease is generally, however, supposed to have been produced * Holinshed, Vol. vm. 4to. T.onii. 1808. 63 cl. in. | H.-MMATICA. [ORD. I Gen. I. by inclement harvests, and vitiated grain, particularly wheat, which Epbeme'ra1' is less hardy than other grains and sooner infested with albigo (mil- sudatoria dew), ustilago (smut), and clavus (ergot or spur). And in proof that fever"'"5 this last was the actual cause, it is observed by Dr. Willan, that the contemporary inhabitants of Scotland and Wales, who fed on oaten or barley, instead of on wheaten bread, were not affected. Never- theless whatever was the primary cause, a peculiar miasm or conta- gion seems to have been generated by the disease itself, which Englishmen chiefly contributed to its spread and continuance. For we are told nav. been concurrently by all the writers, that Englishmen who withdrew from subject to it. their own country into France and Flanders with the hope of escap- ing the attack of the disease, fared no better than their countrymen at home. To which Dr. Freind adds, that, while Englishmen abroad were thus subject to the contagion, foreigners and even the Scotch in England were rarely or never seized with it ;* a feature that has been copied by Dr. Armstrong in his very forcible description of the complaint, which is perhaps better adapted for poetry than for sober prose. Some, sad at home, and, in the desert, some Abjur'd the fatal commerce of mankind; In vain: where'er they fled, the fates pursued. Others, with hopes more specious, cross'd the main, To seek protection in far distant skies, But none they found. It seem'd the general air, From pole to pole, from Atlas to the East, Was then at enmity with English blood : For, but the race of England, all were safe In foreign climes ; nor did this fury taste The foreign blood which England then contained.! Something may, perhaps, be set down to the score of a national diathesis ; but without examining very closely into the accuracy of this wonderful part of its history, we may at least indulge a hope that this peculiar, most virulent and fatal contagion has long since worn itself out, and become decomposed; though it may be stdl only la- tent, and waiting for its proper auxiliaries once more to show itself in the field. J It is said, indeed, by Dr. Coste, the learned editor of Dr. Mead's works in French, that the disease continued to manifest itself occa- sionally as an epidemic in Picardy; but that, instead of terminating in a single day, it ran on to the third, fifth, and sometimes even to the seventh. It is hence sufficiently obvious that the two fevers, though possessing many points of resemblance, are not precisely the same Yet M. Bellot, in his thesis " An febri putrida? Picardii suete dicta?' sudorifera?" has maintained Dr. Coste's opinion. ?£&?(2?£sltlL%. tArt <>f *««*•« Health, B. ,„. •i. hi. , SANGUINEOUS I'l NCTIO.N. |ord. i. b*9 GENUS II. ANETUS. INTERMITTENT FEVER. AGUE. PAROXYSM INTERMITTING, AND RETURNING DURING THE COURSE OF THE DISEASE : THE INTERMISSIONS GENERALLY PERFECT AND REGULAR. Under the preceding genus, the remote cause, whatever it con- Gen. II. sists in, lays a foundation for not more than one paroxysm. In the genus before us, the cause introduces a tendency to a recurrence of the paroxysm from the first; and, in most cases, with an interval that continues true to itself as long as the disease lasts. I say in most cases, because we shall see presently, that, when intermittent fever has raged very extensively, it has not unfrequently established a type Type of one kind in one person, and of antoher kind in another ; whilst in *°™|£mea the same patient quotidians have changed to tertians, tertians to quartans, quartans to quotodians, and all of them in a few instances to continued fever, in the most capricious and anomalous manner. Dr. Cullen unites intermittents and remittents into one section of United witji fevers, merely distinguishing them as intermittents with an interposed byCuHerr! apyrexy, and intermittents with remission alone : and, as already ob- served, he makes it a part of the pathognomic character of both that they are derived from marsh-miasm—miasmate paludum ortce—as though there were no other cause of their production, whence Dr. Young gives to intermittents and remittents the common name of paludal fever. The only ground then assumed for this union of intermittents and JJ^n"",, remittents, is the supposition that the cause which generates them is is well single, common to the two, and never generates any other fever. Now, although the febrile miasm issuing from marsh-lands is by far the most common cause of intermittents, it is by no means the only cause; for we find intermittents, like all other species of fever, pro- duced from various sources; existing in hot countries as well as in cold, in high lands as well as in low lands, sporadically as well as epidemically ; sometimes excited by sympathy, sometimes by con- tagion. Even in tertians, Dr. Cullen is obliged to admit of instances in which other agents are necessary; but, then says he, they are only co-agents, and would not operate alone. " Has potestates excitantes pro parte principii hie admittimus, licet neutiquam excitassent, si miasma paludum non antea applicatum fuisset." But this is the intermit- very point of controversy; for in many instances they produce the 0et'ncrfrom disease where marsh-miasm cannot be suspected. I have seen an *£™cms . isolated case of a regular tertian on the highest part of Islington; mi*"™1"* 70 cl. hi.j ILlvMATKA |0R1>. ' Gen. II. Anetus. Intermittent fover. A "MO. Sometimes found in highlands, while lowlands escape. Illustrated in modern rireeci'. Xorthfleet and another on the dry and gravelly coast of Gosport, a situation so healthy that all the inhabitants escaped, when in the year 1765 a most fatal and epidemic fever, originating unquestionably from the miasm of swampy grounds, pervaded the whole island of Portsea, si- tuate at not more than a mile distant on the other side of the water, and exhibiting, in different individuals, and often in the same person, all the diversities of the intermittent, remittent, and continued type. Dr. Fordyce affirms, that he has seen an intermittent communicated by infection, meaning the miasm from human effluvium ; and where the yellow fever has long existed or become widely diffusive, this is common. Where it arises from sympathy or organic affection, the case is still clearer. " Two children," says Mr. J. Hunter, " had an ague from worms, which was not in the least relieved by the bark ; but by destroying the worms, they were cured. We have in like manner agues from many diseases of particular parts, more es- pecially of the liver and the spleen, and from an induration of the mesenteric glands."* De Meza gives a.i instance of an intermit- tent produced by a repelled herpes ;| and Baldertius, by suppressed lochia. J But one of the most singular and convincing proofs, that the de- composition of marsh-lands is not essential to the production of in- termittent fever, is to be found in the epidemic intermittent of 1780, as described by Sir George Baker, and which we shall have occasion to advert to more particularly hereafter ; for, during this, the inter- mittent harassed very extensively the elevated parts of I .incolnshire, while the inhabitants of the neighbouring fens were free from its ra- vages^ And in like manner, the dry and healthy climate of Minorca is sometimes attacked with remittent or intermittent fever, while Sar- dinia, proverbial for its insalubrity and febrile epidemics, escapes.il " In the year 1812," says Dr. Macmichael, " I was detained several months at Trichiri, a small sea-port in the mouth of the gulf of Volo in Thessaly. The town is built on a dry lime-stone rock, but it i? notorious for malaria. During my stay here, I made an excursion to visit the celebrated pass of Thermopylae, and slept one night near the marshy district in that neighbourhood. On my return, the friends whom I had been waiting for arrived from Athens, and we all em- barked on board a Greek vessel, to cruize in the Archipelago. On the following day I was seized with a most severe fit of the ague; and at the same time a servant belonging to the party suffered a similar attack. It might be said that I had caught my intermittent at Thermopylae, but the servant had not quitted the dry rock of Tri- chiri, upon which he had remained more than a week."1T In like manner Sir Gilbert Blane informs us that while the village of Green Hithe, nearly on a level with the marsh of Northfleet, is unaffected with intermittent fevers, the adjacent hills suffer considerably from them : and he refers to other anomalies of the same kind.** t Act. Soc. Med. Hafn. Tom. i. N. 10. § Med. Trans. Vol. in. Art. jriii. •On Blood, Part n. ch. iv. p. 411. t De Putridine, Urbin, 1608. || Clegborn, Diseases of Minorca. IT New View of the Inf.cion of Scarlet Fever. &c. 8vo. 1822 ** Select Dissertation"!. &r. p. 111. cl. in.J SANGUINEOUS FUNCTION.. [obd. i. 71 To unite remittents, therefore, with intermittents, from an idea of Gen. II. their having a single and common origin, is to depart from the clear b,ternu'ttent line of symptoms into a doubtful region of etiology. If intermittent £ver- ought to be separated (as unquestionably they ought) from con-Hence no tinued fevers, so ought remittent to be separated from intermittent. B^uTrot To say that intermittents often run into remittents, is to say nothing, cuiien s ar- for reinvents as ofteii run into continued fevers ; and it is now an ,angoraen established doctrine that there is no continued fever whatever without occasional remissions. In effect, all fevers have a tendency to run into each other, and many causes are perhaps common to the whole. The difficulty is in drawing the line : yet a like difficulty is perpetu- ally occurring to the physiologist in every part of nature; and equally calls for discrimination in zoology, botany, and mineralogy : and Dr. Parr has correctly observed, that " if a specific distinction can be established in any branch of natural history, it must be in the separa- tion of remittents from intermittents." Vogel unites remittent with continued fevers, to which Cullen, rightly enough, objects ; but the former has as much reason on his side, as the latter has for uniting them with intermittent. Sauvages, Linneus, Sagar, and most modern writers, correctly distinguish each from the other. It must never- theless be admitted that marsh-miasm is by far the most frequent cause of intermittents ; and hence the frequency and severity with which they visited our own country in the sixteenth and seventeenth centuries, before the lowlands were artificially drained of their moisture, and consequently the atmosphere of its taint: during the former part of which Dr. Caius tells us, that the mortality from agues in London was such that the living could hardly bury the dead ; and Bishop Burnet, that at one time, 1558, they raged like the plague. When an intermitting fever or ague is by the operation of marsh- intermit- rniasm, or any other cause, once introduced into the system, and r)u\yim«lo has once discovered its type, or given an interval of a particular [Ji*',^5o measure between the close of the fir^t and the commencement of person, the second paroxysm, it continues true, as a general rule, not merely to the same measure or extent of interval, but to the length and severity of paroxysm, through the whole course of the disease ; the character of the cold stage, determining that of the hot, and both together that of the sweating stage ; and the paroxysm ceasing because it has completed its career. But the first interval, like the but occa- first paroxysm, which regulates the rest, is of different duration in v'arTin different ^ases : of the reason of this difference we know nothing ; d,^?r?JDt, . , . . a individuals sometimes it seems to depend upon the season or the temperament of the atmosphere; operating upon the febrile miasm that is diffused through it, and all who have agues in the same place or at the same time, have them of the saiae kind. Sometimes, on the contrary, it seems chiefly to depend upon the time of fife, the idiosyncrasy, or the particular condition of the constitution, for, as already observed, different individuals even in the same piac.-• and under the same roof exhibit different types. But upon this subject we have no clear information. Nevertheless, whatever may be the cause of this difie, ence, it. i.iys a good foundation for dividing the intermittent genus into di«- 7*J cl. ni.j 11/EMAT1CA. [oKD. I. Gen. II. tinct species, and the five following are sufficient to comprise all it^ intermittent principal diversities :— fever. 1. ANETUS QTJOTIDIANUS. QUOTIDIAN AGUE. 2.-------TERTIANUS. TERTIAN AG IK. 3. ------- QUARTANUS. QUARTAN AGUE. 4. ------- ERRATICUS. IRREGULAR AGUE. 5. ------- C03IPLICATUS. COMPLICATED AC; IE. As the connexion between all these is peculiarly close, and they occasionally run into each other's province ; and more particularly as the same mode of treatment is common to the whole, it will be most convenient to defer the general history and praxis, till we have taken a survey of these species in their respective definitions and the varieties they often exhibit. It may, however, considerably assist the .student, and simplify his pursuit in acquiring a knowledge of their characters, to attend to the three following remarks :— Axioms in Firstly, the shorter the intermission, the longer the paroxysm. revere1.1 te" Secondly, the longer the paroxysm, the earlier it commences in the day. Thirdly, the more durable the cold fit, the less durable the other stages. illustrated. Thus, the quotidian has a longer paroxysm and a shorter interval than the tertian ; and the tertian a longer paroxysm and a shorter interval than the quartan. And thus again, while the quotidian has the longest duration, it has the slightest cold stage ; and while the quartan has the shortest duration, it has the longest cold stage. It is also the most obstinate to cure. ah the Each of these species, however, admits of considerable varia- sSbjecl to t'on^ : f°r sometimes we find the paroxysm protracted beyond its varieties: proper period ; sometimes anticipating, and sometimes delaying its proper period of return. In other cases, we find each of these spe- cies catenated with or giving rise to foreign symptoms or other dis- eases. And we also meet with a peculiar variety of the quotidian ague, in its being sometimes limited to a particular part or organ, in which case it is usually accompanied with very distressing pain. particularly The most irregular of all the species is the fourth, for this is the fourth. sometimeg found to deviate from all the three rules I have just laid down : but particularly in the greater length of its interval, which is sometimes double or even treble that of the quartan, whose inter- val of seventy-two hours is the longest of the three more disciplined species; it is henc*» found under the various forms of a five-day, a six-day, a seven, eight, nine, and even a ten-day ague ; and some- times is so extremely vague as to bear no proportion whatever between the violence of its paroxysm, the duration of its stages, and the period of its return. The fifth species is distinguished from the rest by its pecubar complexity, consisting of double tertians, triple tertians, unequal tertians, duplicate tertians, together with as many varieties of the quartan type; the nature and key of which will be more particu- larly noticed under the species itself cl. m.J SANGUINEOUS FUNCTION. [ord. i. 73 SPECIES I. ANETUS QUOTIDIANUS. QUOTIDIAN AGUE. I.\PERMISSION ABOUT EVERY TWENTY-FOUR HOURS : PAROXISM COM- MENCING IN THE MORNING ; USUAL DURATION UNDER EIGHTEEN HOURS. The genuine quotidian is of less frequent occurrence than the Gen. II. other species ; but it has a considerable resemblance to that variety RefembW of the complicated intermittent, which has generally been denomi- the double tertian" nated a double tertian, and with which it is often confounded. It How dis- is distinguishable, however, to an attentive eye by the regularity of f,^"^ its paroxysms, which are true to themselves on every return ; while in the double tertian the alternate paroxysms only are true to each other, as we shall have occasion to observe more particularly in the proper place. The quotidian, like the tertian and quartan, has sometimes been epidemic. The quotidian intermittent is occasionally limited in its attack to a particular part, and is occasionally connected with other affec- tions. It deviates also now and then from its common rule, in having an imperfect intermission, and in precipitating or procrasti- nating every subsequent paroxysm : and, hence, affords us the fol- lowing varieties : ot Partialis. Partial quotidian. & Comitatus. Catenating quotidian. y Protractus. Protracted quotidian. ^ Anticipans. Anticipating quotidian. e Cunctans. Retarding quotidian. In the partial quotidian, the febrile attack is confined to a par- « A.quo* ticular part or organ, and usually accompanied with distressing partialis. nain Partial Pdln* quotidian. Under this modification, sometimes one side of the body has suf- fered, whUe the other has escaped ; sometimes one or both eyes ; but more generally the whole or half the head, not unfrequently resembling cases of cephalaea, and particularly that species of it which is called hemicrania. In the catenating quotidian, the disease associates with or ((dAnquusu< gives rise to various foreign symptoms or other diseases. And comitatus. hence, is often found in union with rheumatic affections, particu- qu^JJiJ'ivf larly lumbago and sciatica. Sauvages quotes a case in which it associated with daily attacks of a frightful epilepsy.* And Dr. A. + Class n. Febr. Intermit. Quot. Spec, iv Vox, U.—10 74 ex. m.] 1LEMATICA. [okd. j. Gen. n. Spec. I. (3 A- quo- tidianua comitatus. Catenating quotidian y A. quo- tidian us protractus. Protracted quotidian. t A. quo- tidianus anticipans. Antici- pating quotidian. e A. quo- lidianus cunctans. Retarding quotidian^ Munro, in the Edinburgh Medical Essays, narrates a similar instance, though less severe, and alludes to several others that had occurred to him.* Torti has made a collection of numerous exam- ples of this variety, and has united them into one family, under the name of febres intermittentes comitatae. Galen has described one or two of them under the name of epiala. In the protracted quotidian, the intermission is inordinately short or imperfect. In the former case the paroxysm is lengthened beyond the usual period of eighteen hours; and in the latter case it does not so completely subside as to leave the intermission totally clear of febrile symptoms. On which last account the Latins described this variety under the name of quotidiana continua ; and the Greeks under that of amphemerina. In the anticipating quotidian, which is the name given to our fourth variety from Dr. Fordyce, the paroxysm precedes its antecedent period usually by about two hours, and continues the same fore-march at every recurrence; so that the accession may hereby be thrown into any hour of the day or night. This form is denominated a febris subintrans by Professor Frank and various other writers.! The retarding quotidian, which like the last, has been par- ticularly noticed and named by Dr. Fordyce, forms a direct counter- part to the anticipating ; the paroxysm delaying its antecedent period usually by about two hours, and continuing the same delay at every recurrence ; so that here also the accession may be thrown into any hour of the day or night. There are few diseases, moreover, in which the quotidian is not occasionally to be found as a symptom ; but it occurs especially in hysteria, catarrh, gout, peripneumony, ischury, quinsy, and several species of odontia. SPECIES II. ANETUS TERTIANUS TERTIAN AGUE. INTERMISSION ABOUT FORTY-EIGHT HOURS: PAROXYSM COMMENCING AT NOON: USUAL DURATION UNDER TWELVE HOURS. Gen. II. The tertian ague, the tritaeus of the Greeks, occurs most fre- D8Pscription: quent.ty "i the spring and summer months ; though there is a spuri- ous kind that shows itself in the autumn. The chill, during the cold fit, is intense, with convulsive shivering, rigidity, and gnashing of the teeth. It is, however, of shorter duration than that of the quar • * Vol. ii. Art. xlx. , t 3- f;«?raDk' De c"randis Hominum Morbis Epitome. Tom. i aemu. 1792, ' ' p- 41. Mann- •l. in. j SANGUINEOUS If: NOTION. [okd. 1. 7o tan, and sometimes passes off in less than half an hour ; and is sue- Gen. If. ceeded first by nausea or vomiting, and afterwards by a pungent Anetus penetrating heat, frequent respiration, urgent desire for cold drink, J^anus. wakefulness, and head-ache, sometimes delirium. At length a ague. moisture on the skin, gradually advancing to a copious sweat, breaks forth, the urine commonly deposites a lateritious sediment, and there is often some looseness of the bowels. The entire parox- ysm sometimes ceases in six hours, but more generally extends to eight or ten ; if it exceed twelve, as it does occasionally in the autumn, the disease forms the spurious tertian I have just alluded to. As the quotidian is mostly common to infants and persons of deli- ^m { cate habits, the tertian chiefly affects those of riper years or of thehaieand firmer fibres, and especially persons of a bilious temperament. It Duration, was the opinion of Hippocrates that the tertian ague, if left to "c^™- nature, would run itself out in seven paroxysms ; and Vogel adds, Hippocra- that, when this is the case, there is usually the qppearance of a dry ***• scabby eruption about the lips on the fourth or fifth paroxysm. But the period pointed out by the former does not hold in our own day ; and the disease has often continued obstinate in spite of cutaneous eruptions, not only about the lips but over the body. Sydenham asserts that in the autumn, in which, however, a genuine tertian is rarely to be met with, its ordinary natural course is double the term allotted by Hippocrates, or rather that the term of its paroxysms amounts to the space of fourteen days. The tertian exhibits occa- sionally the two following varieties : Comitatus. Catenating tertian. * Protractus. Protracted tertian. to both which the explanation already given under the same terms Jf*P„"jer in the preceding species will equally apply. As an associate dis- thepre- ease, it is chiefly to be found united with syncopal and soporose ^jf, affections, indicating some oppression of the brain; or with cholera, win apply or dysentery, mostly indicating irritation or congestion in the liver, varieties. It is also to be traced occasionally as a species in syphilis, sea- scurvy, worms, and scabid eruption?. 76 CL. HI/) HAEMATIC A. foRD. i. SPECIES 111. ANETUS QUARTANUS. QUARTAN AGUE. INTERMISSION ABOUT SEVENTY-TWO HOURS : PAROXYSM COMMENCING IN THE AFTERNOON : USUAL DURATION UNDER NINE HOURS. Spec III This, which is also the quartana of Celsus, is the tetartaeus of the General ' Greek writers. It is rarely found in the vernal season, but is com- eharacter, mon m tjje autumnai ; in which quarter, also, it is far the most obstinate of all the species, and especially if, as Celsus observes, it show itself only a short time before the commencement of winter. Its chief subjects and sufferers are those of advanced years, and of a melancholic habit; for children and young persons, who princi- pally feel the effects of the two former species, are but little obnox- ious" to it. It commences usually about or a little before "five o'clock in the afternoon. The cold fit is less vehement than in the tertian, but of longer duration, and will sometimes continue for two hours, but usually without sickness or diarrhoea. It yields to a heat that is rather troublesome from its dryness than from its inten- sity, and which is rarely succeeded by a sensible perspiration. and effects. There is a heaviness or dulness in the head rather than acute pain ; and often during the intermediate days, a sense of soreness over the body, as though it had been generally bruised, which strikes through to the bones. It is here also we principally meet with parabysmic tumours, and especially of the spleen and liver: in the former of which organs they are vulgarly called ague-cakes. The quartan offers the following varieties : A Comitatus. /3 Protractus. y Anticipans. ef Cunctans. Catenating quartan. Protracted quartan. Anticipating quartan. Retarding quartan. Often ao companies or alter- nates with other dieases. Of all which an explanation will be found by turning to the same varieties under the first species. From the tendency which this species has to affect the abdomi- nal viscera, it is often met with as a symptom in diseases of the spleen, liver, and various adjoining organs. And hence it occa- sionally interchanges with dysentery, and particularly when the latter is a prevailing or epidemic disease. This remark will also apply to the preceding species : and under the one or the other form was often found exemplified in the fatal dysentery that ravaged a larger ul. m.J SANGUINEOUS FUNCTION. [ord. i. Ifi part of Ireland in the year 1818 ;* and which still more frequently Gen. II. orcurs in tropical climates.! Anetu's quartanus. ^^^ Quartan ------■ izue. SPECIES IV. ANETUS ERRATICUS. IRREGULAR ague. INTERMISSION AND PAROXYSM POSSESSING LITTLE REGULARITY ; THE FORMER MORE THAN SEVENTY-TWO HOURS. We have already perceived that there is occasionally some Gen. II. degree of irregularity in all the preceding species, least of all, how- SpEC- ™- ever, in the quartan. And hence all the above might, in such instances, be named erratic. But the peculiar character of the Distinctive present species is, that the duration of the intermission exceeds that of all of them ; on which account it can never be confounded with any of the rests The chief varieties are the following ; which, however, might be considerably enlarged, but it is unnecessary. They are principally taken from Sauvages and Vogel: and for other authorities the reader may turn to the volume of Nosology. et Quintanus. Five-day ague. /3 Sextanus. Six-day ague. y Septanus. Seven-day ague. $* Octanus. Eight-day ague. e Nonanus. Nine-day ague. £ Decimanus. Ten-day ague. vi Vagus. Vague and irreducible Several of the above have occasionally persevered with great Sometimes . peculiarly obstinacy ; in some instances for upwards of two years without obstinate. ceasing. The last variety is equally irregular as to the violence of its paroxysm, the duration of its stages, and the period of its return. Several of Sauvages' species of hemicrania may be properly referred to this place, and especially those which, by some writers, have been denominated intermittentes larvat^e, or disguised intermittents. * Medical Report of the Whitworth Hospital, &c. By J. Cheyne, M.D. &c. Dublin Reports, Vol. in. t Climate and Diseases of Tropical Countries, &c. By C. Chisholm, M.D. p. 62. Lond. 1822. CL. III. ILEMATICA. oitn. i' SPECIES V. ANETUS COMPLICATUS. COMPLICATED AGUE. PAROXYSMS INTRICATE, MULTIPLICATE, OR BOTH. Gen. II. There are numerous examples of ague which, to an inattentive Spec. V. eye? are as irreducible to any regular order as those which belong its^n'rica" to the last variety of the preceding species ; but which, when mi- °r' nutely examined, are found, however intricate, to be composed of types, not that uniformly resemble each other, but that recur in alternate sets, every set being true to itself, while it differs from that with which it alternates in the duration of its intervals, or of its paroxysms, or of the time of its accession. And hence, although in some shape or other, most of them return perhaps every day, and are often mistaken for irregular quotidians, they are, in fact, double or triple tertians, or quartans, discovering their real nature by these alternating distinctions. The following are the chief varieties : * Tertianus duplex. Double tertian. Quartanus duplicatus. Consisting of a single quartan ; compii- Duplicate quartan. with two paroxysms on the re-cate" ague' gular day of attack: the inter- vals being of ordinary duration. .9- Quartanus triplicatus. Consisting of a single quartan with Triplicate quartan. three paroxysms on the regular day of attack : the intervals be- ing undisturbed and of ordinary duration. Having thus distinctly noticed the several species and chief varie- ties of intermittent fever, I shall proceed to offer a few remarks upon its general history, and medical treatment. Whenever the accession of an intermittent is violent, be its type cfencrai ,. .. . 11. i i ■ history of what it may, it is sometimes attended with very alarming symp- intermittent toms, as syncope, apoplexy, vehement spasms over the whole {"fo""^, system, or a coldness or torpor which threatens death. Yet, when dangerous. not violent, nor of very long duration, and especially when of the serviceable* tertian type, it is often serviceable to the general health, and carries off many chronic and lurking disorders of other kinds ; Dr. Fordyce affirms that he has seen it of considerable use in curing or alleviating chronic rheumatism, habitual indigestion, cutaneous eruptions, pro- tracted inflammations, epilepsies, and hysteria.* And his assertion is corroborated by other authorities.t It is to this kind of remedial ^P"r0aft0I? fever that Professor Frank gives the name of depuratory.\ Frank. The duration of intermittents is of great uncertainty. The ver- ""rarlj°£ nal agues generally disappear with the advance of summer: the autumnal are more obstinate, and especially the quartan.§ Where they have remained long, and have become habitual, even their removal must be attempted with" great caution ; for when abruptly suppressed, they have been known to lay a foundation for a host of other maladies, often of a more fatal description, as paralysis, various visceral affections, and even sphacelus. Ludolf gives an instance of an eight-day ague (anetus erraticus Has. octanus), continuing for eighteen years; yet this was probably a through a double quartan ; while we have abundant examples of a continuance ffea,feP:ar' of the regular quartan for nine,|| twelve tf eighteen** twenty,! \ twenty- four ,ff and thirty years,§§ and one instance of its lasting for not less than forty-eight years. |||| It is in this species, therefore, that we chiefly ^^Xt * On Fever, Diss. ii. p. 16. t Salmuth, Cent. n. Obs. 14.— Ephera. Nat. Cur. Dec. m. Ann. in. Obs. 30. X J. P. Frank, De Curandis Horn. Morb. Ep. Tom. I. p. 48. § lb. p. 44. || Eph. Nat. Cur. Dec. II. Ann. vm. Obs. 45. IT Avicenna, Fen. i. Lib. iv. Tr. n. Cap. ti. * * Madai, Von Weekselfiebern. Sect. 144. ft Eph. Nat. Cur. Dec. in. Ann. ix. and x. Obs. 51. JJ Marcellus Donatus, Lib. m. Cap. xiv. p. 291.—Pontanus, De Febr. Conel. 5§ Binninger, Obs. Cent. v. N. 64. Wierius, Obs. p. S7. (til GabelcWer, Cent. vi. Obs. 74. and other congestions. SO cl. m.] HiEMATICA. [okw. i. Gen: II. meet with those congestions in the spleen which are called ague- iotermhtent cakes, as also with scirrhosities in the liver, pancreas, and other fever> abdominal organs, which by Bonet, Swalwe, Senac, and other writers, have been regarded as causes of the disease, but by Van Hoven, and all the pathologists of the present day, are more correctly resolved into effects. Has been Schenck gives a case of congenital quartan, or in which it appeared congenital, in an infant immediately after birth ;* and PauUini another, in which, though not strictly congenital, it appeared in very early infancy.T Has But such examples are rare. Among other singularities, I may fnTsingU observe that the accession has sometimes been so violent as to paroxysm, destroy the patient in the course of the first paroxysm, of which an The instance will be found in Senac,J whde at other times it has been so EaS" sbght and rapid, that the entire paroxsym has run through its course completed in a minute.§ nnute.m" The character of the intermittent seems in a considerable degree to depend upon the age or idiosyncrasy of the individual and the auotidians temperament of the atmosphere. We find also that variations more variable usually take place in the quotidian than in any other type, which we than any should, perhaps, ascribe to its occurring more frequently in early life, "type' when the frame is more irritable ; and to the debility which the constitution suffers from this type above that of any other, in conse- quence of the greater length of its paroxysms, and the greater brevity of its intervals, by which means the prostrated strength of the system has no time to rally or recover itself. intermit- In this metropolis, from causes which have not been handed down 'ecuiiarW to us' ana* which, indeed, do not appear to have been traced at the frequent in time, intermittent fevers were more than ordinarily frequent from the ivomdi78i year 1781 to 1785 : and the remarks I have just made apply in an to 1785. especial manner to all these. As a single example, let us select those of 1782, as described by Sir George Baker and Dr. Reynolds, in an article drawn up by the former with an admirable combination of learning and liberality, sound critical judgment, and inquisitive research. Sir George "The type of the fever of 1781-2," says Sir George, " was account of either tertian or quotidian ; the former being more common in the 17&1-2, first part of the winter ; the latter, from the' middle of February to the end of June. With respect to the former nothing occuRKEn to my observation which is worthy of notice. On the latter, Dr. Reynolds has communicated to me the following remarks : and any addition would be unnecessary relative to a subject which he has so well exhausted."|| This communication is too long to be copied verbally, but it is fully entitled to the praise which the learned Baronet has bestowed upon it. It will be sufficient for our present purpose to transcribe its leading features. as oommu- Dr. Reynolds, in his communication to Sir George Baker, tells Reynolds? us that the quotidian fevers of the above year were irregular in their * Obs. Lib. vi. N. 36. t Cent. i. Obs. 94. r Von Weekselfiebern, B. n. Cap. vi. § Reil, Memorab. Clin. Vol. II. Fast Medical Transactions. Vol. m. Art. xin. 1 £ in.] SANGUINEOUS FUNCTION. [okd. i. 81. invasion, and uncommon in their appearance ; and that no cases Gen. h. resembled each other, except in very few circumstances. The first fnterrna- attack generally commenced with a horror; but the subsequent,cnt fever- paroxysms, though often beginning with a sense of cold, were chiefly without horror. The intermission was short and seldom perfect. The symptoms were very severe, and in many cases dangerous, and leaned strikingly to a typhous form. Great and sudden oppression of the head, anxiety, depression of spirits, a dry, parched tongue, yet less covered with hardened mucus than might be expected ; a pulse low, quick, and intermitting ; bowels variable ; urine dark-red and clear, without any sediment, constituted the ordinary signs. Many had a low muttering delirium; two or three, a laborious res- piration ; a few, spasms and twitchings of the tendons: aphthae appeared occasionally ; and one patient exhibited symptoms of violently acute rheumatism. The bark was universally successful; and, " I was as much pleased," says Dr. Reynolds, " with its present efficacy, as I was in the year 1781 mortified by its extraordinary want of power. Half the quantity of it which I used on that occasion was 'sufficient on this." In other words, idiosyncrasy and atmospheric temperament were General both peculiarly visible, and gave a peculiar character, in the one heTe"*? instance to particular cases, and in the other to the general disease. In plethoric habits the head was greatly oppressed, with a tendency to delirium. In those of a nervous or irritable disposition, the intermittent was connected with spasms and twitchings of the ten- dons. And those disposed to rheumatism had acute arthritic pains. The state of the atmosphere, and general character of the season Dr. Reynolds has forgotten to notice: but we see evidently, and indeed he himself allows, that they gave a typhous impression to the epidemic ; which, from the same, or from other causes, is also peculiarly distinguished by the easy victory it yielded to the use of the bark : as that of the preceding year was distinguished by its obstinate resistance to this medicine. If we ascend a year higher, or to 1780—1, we shall meet with Sir George an equal diversity of symptoms. " These fevers," (intermittents,) owrTac- says Sir George Baker, " were in general no other than the common ^SqIi* ague ; but in the more inland counties of England, they were often attended with peculiarities extraordinary and alarming. For the cold fit was accompanied by spasm and stiffness of the whole body; the jaws being fixed, the eyes staring, and the pulse very small and weak.—In many cases dehrium was added to spasm, under both Symptoms which symptoms the patient laboured quite to the end of the parox- severe" y ysm. And though the senses returned when the fever subsided, yet a convulsive twitching of the extremities continued even in the intermissions, to such a degree, that it was not possible to distinguish the motion of the artery at the wrist. " This fever had every kind of variety ; and, whether at its first Peculiarly accession it were a quotidian, a tertian, or a quartan, it was very apt vamb,e- to change from one type to another. Sometimes it returned two days successively, and missed the third, and sometimes it became continual. I am not informed that, anv died of this fever whilst, it Vol. IT.—11 rvJ <%. mi. j ILEMATICA. |0Ki>. J. Gen.H. Anetus. Intermit- tent fever. Often raged in high grounds and not in low grounds. Among females in the house rather than males abroad. Obstinate resistance to the bark. Medical treatment. General character of rcincdies for inter- mittents. Antispas- modics and tonics, with what views employed. Pungent antispas- modics of Bergius. Indian practition- ers: Chisholm ■ intermitted. It is, however, certain that many country people, whose illness had, at its beginning, put on the appearance of intermission, becoming delirious, sunk under it in four or five days. It is a remark- able fact, and very well attested, that in many places, whilst the INHABITANTS OF THE HIGH (JHOUKDS WERE HARASSED BY THIS FEVER, IN ITS WORST FORM, THOSE OF THE SUBJACENT VALLEYS WERE NOT affected by it. The people of Boston and of the neighbouring villages, in the midst of the Fens, were in general healthy, at a time when this fever was epidemic in the more elevated situations of Lincolnshire : and other examples of a like kind have already been noticed.* It is likewise singular, and worthy of notice, that in many families the female servants were nearly exempted from a disease which very few male servants, especially the labourers in the open air, escaped. But the distinguishing character of this fever was its obstinate resist- ance to the Peruvian bark ; nor, indeed, was the prevalence of the disease more observable than the inefficacy of the remedy. Though the quantities of the bark usually given were exceeded, the fit was apt to return, rarely altered, either with respect to the time of invasion, or the intenseness of the symptoms; and just as if no means had been used to prevent it. A drachm of the bark in powder was fre- quently administered every second hour without averting the fit."t In casting our eyes over the great diversity of medicines that have been employed for the cure of intermittents, we shall find that, innumerable as they are, they may be arranged under two general heads, tonics and antispasmodics ; as though, long before the time of Dr. Cullen, his two principles of the disease, debility and spasm, had been uniformly admitted and acted upon. The antispasmodics, consisting chiefly of stimulants, sedatives, and relaxants, have been confined to the term of the paroxysm, with a view to weaken and shorten it; and the tonics, consisting principally of bitters and astringents, have been employed throughout the intervals with a view of fortifying the system against a recurrence of the attack. In discussing the medical treatment of intermittent fevers, it will be sufficient to limit ourselves to these two indications. It was a favourite practice with Bergius to anticipate the cold fit, constituting the accession of the paroxysm, by pungent stimulants, in the hope that if he could successfully combat this first stage, he should gain a complete victory, not only over the individual paroxysm, but over all future incursions. His favourite medicines for this pur- pose Were garlic, mustard seeds, and capsicum, which in his day was described under the name of piper Indicum. And he boasts of having, in numerous instances, completely succeeded with each of these ; though he admits that the mustard-seeds answered best in vernal intermittents, but did not in general prove sufficient for the autumnal quartans. The Indian practitioners, I may here observe employ chakka or ginger, and sometimes the sison ammi for the same purpose, and Dr. Chisholm has occasionally succeeded with seal * Sir Gilbert Blane, Select Dissertations, p. 111. 8vo. Lond. 18™ t Med. Trans. Loc. citat. cjl. iu.j SANGUINEOUS FUNCTION. [om>. i. »8 lions.* Bergius, however, placed his chief reliance on the capsi- ,pEN-Ir- cum, six grains of which he was in the habit of giving, combined intermit- with two scruples of bay-berries in powder, " incipiente primo Meateai"' rigore ;" and of repeating it every day, at the same hour, for three treatment. or four times in succession. And he assures us that he has very fre- quently seen obstinate intermittents removed by this powder, and without any relapse. The practice, however, has not been equally successful in other inei&ciiv* hands ; not even when capsicum has been given in a much larger hand* quantity, or exchanged for ammonia, treacle-mustard (clypeola Jonthlaspi), or black or white-pepper, the latter of which is only the former denuded of its outward tunic, mixed up with brandy or Hol- lands. They have all, indeed, sometimes answered, but the result is uncertain ; and, as was long ago observed by the Baron Van Swieten, if the medicine do not succeed upon a full dose, and especially when combined with ardent spirit, it will often extend its influence to the hot fit, and greatly exacerbate it; and not unfrequently convert an intermittent into a continued fever. Upon the whole, therefore, this plan is not to be recommended, however varied. The least pernicious material is the ammonia, but then it is also the least effective. A large draught of cold water has been not unfrequently had re- GoM wat.« course to for the same purpose, and also, in a few instances, with epasmodfe. success. The object is, by taking it about half an hour before the cold fit is expected, to excite a strong re-action and powerful glow over the entire system against the time when the cold fit returns, and thus to pre-occupy the ground ; and, by disturbing the regularity of the type, to subdue the intermittent altogether. But this plan has, perhaps, more frequently failed than the preceding: and when the shivering or horripilation produced by the cold water has not been followed with a stimulant effect, as in delicate habits more especially. it has often continued so long as to run into the term of the febrile cold fit, and very considerably to increase its power. Ballonius relates a case in which it proved fatal.t <_ The next division of antispasmodics which have been directed Sed>tir«s against the paroxysm, and especially against the rigor with which it modfes* makes its onset, is sedatives : and of these the chief have been opi- omum!"* ates, which, when given in the form of laudanum in a dose of from thirty to forty drops at the commencement of the chill, has, in many cases of intermittents, been highly beneficial; diminishing the dura- tion of the stage, and moderating its symptoms. Dr. Trotter says Trotted that he practised this plan with general advantage in an epidemic in- opium- termittent that attacked the Vengeance, one of the channel fleet , under Lord Howe : and adds that, " if the first dose of opium did not produce a sensible relief and exhilaration of spirits in half an hour, he repeated it, and never found it necessary to go beyond a second dose." Sir Gilbert Blane adverts to the same plan as pur- * Climate and Diseases of Tropical Countries, &c. 1822, p. 53, * Opp. Tom. i. p. 193. 84 CL. HI.J ILEMAT1CA. [oRI>. Gen. II. Anetus. Intermit- tent ferer. Medical treatment. land's. Relaxants as antispas- modics. Antimoni- als. The same preparation often affects different individuals differently. Relaxants combined with opiates. Oase suc- cessfully treated by Fordyce. sued at Walcheren during the English expedition to that island, and with an equal success.* We have already seen, however, that there is some cause or other, probably the peculiar temperament of the atmosphere at the time, that baffles on one occasion the remedy that has best succeeded on another. And hence opium has often failed in other intermittents in every form, but especially when given in the cold fit. And owing to this diversity of effect Dr. Lind thought it most useful in the hot fit; and asserts that, if administered to the extent of twenty or five and twenty drops of laudanum half an hour after the beginning of the hot fit, it produced the advantage of shortening and moderating the heat, calmed the anxiety and head-ache which are usual conco- mitants, expedited the sweating stage, made the paroxysms more regular, and sometimes stopped the fever altogether. Other physicians have commenced with relaxants; and where these are selected, the antimonial preparations are to be preferred to ipecacuan. They tend more directly towards the surface, and, where it is useful to excite vomiting, which is often the case, they act sooner, and maintain the action longer, and hence make a double effort to accelerate the sweating stage. The antimonial preparations differ chiefly from each other by having the reguline part of the an- timony they contain in a more or less fusible state ; and their ope- ration will often vary according to the quantity or quality of the acid they meet with in the stomach; and hence the different effect of the same preparation in different persons, and even in the same per- son at different times. The rubinus antimonii, or antimonial febri- fuge of Craanen, was at one time regarded as a specific in intermit- tents on the continent, and was in particular favour with Stahl, Diete- rech, Vogel, and many other physicians of reputation ; but it does not appear to be of superior efficacy, in any respect,, to the antimo- nial powder of the London College. The most efficacious practice which I have witnessed, consists in uniting relaxants with opiates ; and, where this joint effort is pur- sued, ipecacuan may answer as well as any of the preparations of antimony. We cannot have, for this purpose, a more useful medi- cine than Dover's powder; and it should be commenced with much earlier than is consistent with the usual practice, so as not to regu- late the hot and sweating stages, but to anticipate the cold fit. And we may still farther add to the ingredients of the medicine a full dose of volatile alkali with great advantage ; for it is in this form, if in any, that we can employ stimulants with a certainty of doing little mischief, and very nearly a certainty of considerable benefit. In the case of a quartan in St. Thomas's Hospital which had lasted two years, Dr. Fordyce determined upon this plan; and prescribed a full dose of Dover's powder with a sweating draught of carbonate of ammonia two hours before the paroxysm was expected. It suc- ceeded perfectly. A profuse perspiration anticipated the period of the cold fit, and hereby entirely prevented it; bark was next given freely, and this obstinate ague was cured in a few days.f * Select Dissertations, &c. p. 105. Lond. 6to. 1822. t Ediub. Med. Comment. Vol. ti. p.S59. ' L. III. J SANGUINEOUS FUNCTION. [ORD. I. So means. How far the use of Dippell's or any other animal oil might be ser- Gen. II. viceable as an antispasmodic in intermittents, I cannot say. Dr. interrntt- Hoffman was highly impressed in their favour; and asserts that a j£"tdifc3g1cr' single dose of from twenty to thirty drops, given six hours before the treatment. accession of an intermitting fever, will frequently prove a complete o\"™al Cure to the complaint. They appear certainly to be sedative and diaphoretic, and it is said that the sweat they excite by a single dose may continue for twenty-four hours without languor or debility. As a medicine, these oils have perhaps been thrown aside too hastily. Whatever be the relaxant or sudorific employed, it should be as- Diluents sisted by plentiful potations of warm diluents and by placing the auxiliary patient between the blankets instead of in the sheets of his bed: for I have already had occasion to observe that upon these auxiliary means depend, in many instances, the accomplishment of the object we have in view, without which the most urgent diaphoretic exerts itself to no purpose. The most important season, nevertheless, for medical operation Period ot is in the intermission of the paroxysms : since, however successful 8i0n chiefly we may be in moderating the febrile attack, it is rarely that we can d°peended depend upon any plan which may then be adopted to prevent a re- upon. currence of the fit. The opinion of mankind seems to have concurred in most ages, Tonics; {.,,.,. - i i - ,• and their in regarding debihty as either the proximate or predisponent cause properties of intermittents, since almost the only medicines that have been and^suin- brought forward to guard against the recurrence of their periodic gents. attacks have been tonics, with the sensible qualities of bitterness or astringency, or of both. In what way these act upon the moving fibre at any time, and Tn wuat particularly in the disease before us, we cannot say with any degree Tctf of precision. The tone of the moving fibre depends unquestionably in some degree upon the state of the fibrous material itself, but per- haps in a much greater degree upon the quantity or quality of the nervous fluid that issues from the brain and is communicated to the fibrous structure, or as it is modified in any particular set of fibres. We have great reason for believing that astringents, in producing tone, act upon* the fibrous material itself, for we find them operating in a like manner upon animal fibres both in a living and a dead con- dition. But whether, as Dr. Cullen conjectures, it be the part of bitters alone to act upon the nervous power or living principle which adheres to them, and especially in the very singular manner in which he represents them as acting, is a different question; and the present is not the place for entering upon it. If we contemplate the nervous fluid as a peculiar secretion, and the brain as the secreting organ, we can readily conceive that the com- ponent parts of this organ as well as of any other may be invigorated by medicines that have a peculiar influence on its structure, and pro- bably concentrate and give tension to its fibres ; and that, in conse- quence hereof, it may be rendered capable of secreting its proper fluid in greater abundance, or a more elaborate perfection. And wn can also readily conceive that such effects may be produced l" 36 ul. nr.j HiEMATICA. [OKU. Gen. II. Anetus. Intermit- tent fever. Ague. Medical treatment. Cullen's hypothesis unsatisfac- tory. Cinchona. History of its introduc- >ion into Europe. When introduced into England. both bitters and astringents, as well as by medicines that possess some other sensible qualities, though these are the most obvious in their operation. But should we, with Dr. Cullen, affirm that the same bitter employed in the same proportion, produces both tone and atony, energy and debility; that it both cures the gout, and occasions it; that employed for a certain time it effects the former, and, after such time, the latter ; and should we beyond this affirm, with him also, that the nervous fluid is not a secretion, but an inherent power of the brain ; that it admits neither of increase nor diminution ; is changeable in its state, but unchangeable in its essence ; becomes excited and collapsed, or rises and falls in its energy, but experiences nothing of the decomposition, or recruit of every other part of the living frame around it; we should travel into a labyrinth of incon- gruities, and only enlighten ourselves with a will-o'the-wisp. Dr. Cullen's system, like himself, is a work of no ordinary stamp ; it is full of immortality, but mixed up with weak and perishable materialsf Of the remedies appertaining to the one or the other of the two divisions we are now considering, those of astringents and bitters, the cinchona or Peruvian bark, which unites both qualities in itself, is on every account entitled to our first attention. This valuable medicine, which some practitioners are apt to de- spise or think lightly of in the present day, has never been altogether without its opponents ; and there are many facts respecting its operation, which, if not altogether anomalous, are of very difficult solution. Peruvian bark, according to the authority of Don Joseph Ville- robel, a Spanish physician noticed-by Badus, was first brought to Spain in the year 1H32 ; but here, as in every other country, it had for a long series of years to encounter the prejudices of the medical profession ; and consequently was very rarely made use of, and un- questionably would have sunk into oblivion but for the activity of the Spanish Jesuits, who continued zealously to recommend it, and to import large quantities of it from their brethren in South America. Through these means it was at last recommended by Pope Innocent X. in 1661, as a medicine perfectly innocuous and salutary : and a Schedula Romana, drawn up under the sanction of the physician to his holiness, pointed out in express terms, the time and proportion in which the bark was to be taken. Unfortunately the time stated was frigore febrili incipiente, " at the commencement of the cold fit:'' and it being administered in this manner with only temporary benefit to the Archduke Leopold of Austria, a year or two afterwards, it immediately fell into great discredit with a very large and learned part of the medical community of Europe ; and a most acrimonious warfare was instantly waged in every quarter on the subject, in which the combatants on both sides seemed more desirous of victory than of truth. In our own country the bark began to become popular about 1655. In 1658, Mr. Underwood, an Alderman of the city of London, died while using it, and was instantly reported to have fallen a sacrifice to its power ; and so prejudicial was the effect of this rumour, that Cromwell, who was attacked with an ague in the ,«ame Year. \va« ul. in.] SANGUINEOUS FUNCTION. [ord. r. X7 suffered to languish and at length to die without an exhibition of the Gen. II. bark, his physicians being afraid to make a trial of it in consequence inteYmi't- of the fatal accidents that had so lately accompanied its use : in the -3"1 feve1, words of Morton, " nondum vires corticis in hoc veneno subigendo, Medical saltern hie loci, comprobatse erant."* treatment. In England, therefore, as well as on the continent, there was a Begins to great conflict of opinion. Dr. Prejean, who both preceded and sue- nanced"19 eeeded Dr. Harvey as president of the College of Physicians, ap- pears openly to have advocated its employment in 1658, according to facts adverted to by Sir George Baker in his admirable article on intermittent fevers,! from which these hints are chiefly drawn up. Dr. Brady, professor of physic at Cambridge, appears equally to have countenanced it; as does Dr. Willis according to his own statement: while Dr. Morton professed himself inexperienced upon its virtues, and Dr. Sydenham was decidedly averse to its use. Sydenham, however, was a man of reason and liberality. His Candour of prejudices, and especially those derived from the hypothesis that a y en am' fever is a fermentation in the blood raised by nature to throw off some peccant matter at the surface, and which ought not therefore to be checked in its course, however wise it may be to moderate it in its violence, were all at arms against the use of the bark under any cir- cumstances : and the mischievous effects to which he had been an eye-witness in some instances, and its total inertness in more, gave a sanction to suspicion, if it did not justify hostility. But he was de- termined to watch it for a still longer period through all its variable effects, and to abide by the result when fairly cast up. He soon be- came sensible that it was, in most cases, a powerful engine; that in many instances it was highly serviceable ; and that in those in which its progress it failed, the miscarriage was rather to be ascribed to some error in an improper handling it, than to a want of power in the drug itself. t\on-nistra Sydenham had sufficient ground for this last conclusion. The mode in which it was, at this time, usually administered, was in doses of two drachms given twice in the twenty-four hours; and, as already observed, the time selected for the purpose was during the existence of the paroxysm. It is moreover highly probable that it by being was sometimes considerably adulterated, from the difficulty of obtain- J"^^^"1' ing it in any considerable quantity. In 1658, we learn from Sturmius, who warmly patronized its use, its great that pure bark was so scarce on the continent, that twenty doses of fir"01" a the powder were sold at Brussels for sixty florins, for the purpose of being sent to Paris; and that this order so completely exhausted the apothecary's stock, that he himself was incapable of obtaining any even at that price. And hence for the use of one patient, who was attacked with an obstinate intermittent fever in the month of February of the same year, he was obliged to wait till the June fol- lowing before he could obtain a supply.J Nor was it less difficult to be procured at Brussels than in many other parts of Europe ; for Bartholine, then residing at Copenhagen, having received as a great * Pyretolog. p. 17. t Medical Transactions, Vol. m. Art. xm. T Febrifugi Peruviani Vindiciarnm Pars prior, p. 84. Antwerp, 165° 88 cl. m.j HiEMATICA. (oru. i. Gen. II. Anetus. Intermit- tent fever. Ague Medical treatment. Syden- ham's regulations. Adminis- tration in the for a long time had resisted the power of the bark, though taken in very large quantities. Iifiiintro- The rea"Dark was °ow also tried for the first time: it was proved but found t0 be °^ untmestionaDly superior virtue to that in common use; but rrp^PMive • even a moderate dose of it so often oppressed the stomach and ex- Med. Transact. Vol. hi. p. \$5, ul. m.j SANGUINEOUS FUNCTION. Iohd. i. 91 cited nausea and vomiting, probably produced by its containing a ^w. II. larger proportion of resin, that, writing at this very period, Sir intermit- George Baker tells, u I have for some time avoided the use of it." ^nl6*"' It contains, however, by far the largest proportion of quinine, and.Medical i, , . , Jc .. • o r r ~i i treatment is now usually selected for this purpose. but I may here observe that in the East a variety of other astringent coone,tains and bitter barks are also employed both by native and European quinine. practitioners, and apparently in those regions with considerable ad- folks' vantage ; as that called in honour of Van Swieten, Swietenia/efcn- ?rn[l2f®d fuga, so warmly recommended by Dr. Roxburgh : that of the bead- swietenia. tea (Melia Azedarach) and the Tellicherry bark. It does not ap- ^^'. pear that these were made trial of in the practice just adverted to, but they have been employed since, yet with a far less success in this part of the world than they seem to produce in India. Arsenic was also tried in combination with opium. It is admitted A™™* that it often effected a cure; but was frequently productive of vio- injurious lent vomitings, colic, and dysentery. It seems however to have JJ^'jgr. been given at this period in a somewhat rude and unscientific form. " Arsenic," says the distinguished writer whom I have just cited, " is mentioned in books as a febrifuge, but it is one of those substances of which we are not as yet so far masters, as to be able, by any art, to render it transferable from the list of poisons to our Materia Me- dica; and it cannot be deemed to be a proper remedy for an inter- mittent fever whilst an intermittent fever is less formidable than arsenic." But to this substance we shall have to return presently. If the praxis, therefore, frequently failed wbich was in use about ^^ half a century ago, it was by no means for want of distinguished in an abilities, great diversity of means, or an ample field for experiment. p^j0cdrnot And, although a few other medicines have since been submitted to f™.™antof trial, or some few of the same in improved forms, I am afraid we6'' have no great reason to boast of much clearer illumination or supe- rior success in our own day. We may not, indeed, be disposed to encourage the farther trial of such operose preparations as milk boiled just seventy-seven times over,* which was one of the most popular charms of the above pe- riod ; but I have heard of several remedies in high favour and in common use among ourselves, which have as little claim to distinc- tion. The chief bitters and astringents that have been called into J^JJJ^ requisition, independently of those already noticed, are, gentian, oas- since. carilla, willow-bark, nux vomica, and the leaves of the cherry bay, or prunus Lauro-cerasus; the chief astringents, tormentil, galls, and oak-bark; the bark of "both species of the swietenia or maho- gany tree ; avens or caryophyllata (the geum urbanum Linn.), the Lycopus Europeans of the same naturalist, called in Piedmont, where it is supposed to rival the bark, Herb China, alum, and several of the metallic oxydes. To all these a common remark may be applied, that, where they JjJJJ^ have been of real service, it has generally, though not in every in- astringent principle. And hence • Ephem. Nat. Car. Dec. hi. Ann. vii. ym. Obs. 48. !;'""$ 92 ex. in.] 1LEMATI0A. L*RD- l- Gen. II. stance, seemed to arise from their uniting the two qualities of a bit- bSt- ter and an astringent, and that they have rarely answered where tent fever. t^ere has been only one of these qualities to depend upon. Thus Medfcai tormentil, one of the most powerful vegetable astringents we pos- treatment. gesg^ and gentjan one 0f our most powerful vegetable bitters, suc- ceed so rarely alone, that no dependence is to be placed upon them ; but when given in combination, they almost rival the virtue of cinchona ; and have occasionally succeeded where the latter has failed. "Joined," says Dr. Cullen, " with galls or tormentil, in equal parts, and given in sufficient quantity, gentian has not failed in any intermittents of this country in which I have tried it."* But the There is, however, a principle, independently of bitterness and posaew e " astringency, that seems absolutely necessary to enter into conjunc- furTher ^on witb these, in order to give full efficacy to any medicine employ- unknown ed as a febrifuge in intermittents ; and a principle that has hitherto pnncipe. eiU(je(j an research. For if the cure depended upon the inten- sity of a bitter and an astringent quality alone, galls, oak-bark, and mahogany-bark ought to succeed better, not only that an union of tormentil and gentian, or chamomile and alum, which have also been found very serviceable, but than cinchona itself; which every one knows they do not. although, when Peruvian bark cannot be obtained, they become desirable substitutes. Nux The nux vomica and (gnatius's bean (strychnos Nux vomica, and ignatia amara, Linn.) combine, with an intense bitter, a most ac- tive narcotic virtue; and how far the last may be peculiarly opposed to a recurrence of that spasm on the extreme vessels which consti- tutes the cold fit, it is difficult to determine. M. BourieuT from his own practice strongly recommends the latter, and Paullini| and Aas- kow§ the former. If Dr. Fouquier's remark be well founded, which we shall have occasion to notice more at large when treating of paralysis, that these poisons have a power of augmenting energy in debilitated muscular fibres, while they leave those in health unaffect- ed, we can account for some part of the success which has been so vauntingly ascribed to them in the case of intermittents. But, not- withstanding that they have been for this purpose before the public for upwards of a century, the infrequency of their use is a strong argument that they are not much entitled to commendation. " In a very small dose," says Dr. Cullen, " the fabaSancti Ignatii has the effect of curing intermittent fevers."|| But whether he reports this from his own practice, or from that of others, we cannot exactly de- termine : nor does he tell us what is the small dose he refers to. I have tried the nux vomica to the extent of eight grains in powder every six hours for an adult under palsy, without any mischievous effects except a slight stupor in the head. And much beyond this Fatal case we cannot proceed with prudence. Hoffman gives the case of a ubT lU g|rl often years of age, who was killed by taking fifteen grains of it, divided into two doses, for an obstinate quartan. If rfnni. The laur°-cerasus was at one time, as we are told by Dr. Brown * Mat. Med. Part n. Ch. 11. p. 72. t Hist, de la Societe R. de Med. 1776. p. 340, * ™eiit™,1,,°> 45' * Act- Socict- Med. Hafn. Tom. ii? l . Mat, Med. Part u. Chap. n. p. 76. * Philos. Corp. Hum. Morb. P. u. Cap. vm ;l. m.J SANGUINEOUS FUNCTION. [ord. i. 93 Langrish, a common medicine in his neighbourhood for the cure of Gen. II. agues :* but he takes no notice of the dose or mode of administering intermit- it. Its properties are nearly the same as those of bitter almonds ; *n'uf*™' and Dr. Bergius informs us that he has frequently prescribed an Medical emulsion of bitter almonds with success in intermittents, in the quan- £?,*„ ent' tity of a pint or two daily during the intermission; and that it has almonds. sometimes cured where the bark had failed.t This is an authority worth attending to ; and as the same medicines are said to have a peculiar power of resolving visceral obstructions, they have an ad- ditional claim to a cautious series of experiments. It is generally Th«'r supposed, in the present day, that their poisonous property depends supp°o"ed to upon their containing a portion of native prussic acid : the taste of ^^ on prussic acid, however, is not bitter, but sweetish and acrid. Yet it prussic is chiefly the bitter we seem to want in the present instance ; and if Hence prussic acid really exist in other, and could be separated from the de8iraabt'ee t0 bitter principle from which it appears to be distinct, we might be put this from into possession of a medicine of considerable importance. p^in'cip'i"" The only metallic oxyde really worthy of notice is that of arsenic ; Metallic for although various oxydes of iron, mercury, zmc, and copper, °* have been tried, and occasionally extolled, none of them have proved so decidedly beneficial as to render it worth while to try them over again. Mercury, as we learn from Sir James Johnson, was tried exten- Me>:curJ'- sively some years ago at the Bocca Tigris in the East, on the crews of two ships of war, the Grampus and Caroline, in consequence of the stock of bark being exhausted. The paroxysms, he tells us, were invariably put a stop to as soon as the system was saturated ; but he adds that three fourths of the patients thus treated relapsed as soon as the effects of the mercury had worn off; and this after three, and, in a few instances, four successive administrations, so as to ex- cite ptyalism.J And hence mercury, even where it is successful, does not appear in this case to produce any permanent impression upon the system. Iron, though of little value in most of its forms, has been said ofIr01!' late to have succeeded completely in that of its prussiate. Dr. Zol- lickoffer has given various instances of this in a foreign journal, and places its powers above those of arsenic or bark. It must be tried however upon a much larger scale before it is entitled to an estab- lished reputation. The ordinary adult dose is about four grains two or three times a-day in a little sugar and water. Arsenic, under various forms, has also been employed from a Arsenic very early period.§ • It is, strictly speaking, an oriental medicine, ns use and has been in vogue immemorially in India, and indeed, all over ftonTindia. the East, but especially among the Tamul practitioners, as a most powerful alterant, as we shall have occasion to notice more at large when treating of syphilis and elephantiasis. It was probably intro- duced into European practice by the medical students under the brilliant caliphate of Bagdad: and seems to have been first appropri- * Experiments on Brutes. See also Phil. Trans. No. 418.420. t Mat. Med. p. 412. - American Med. Repository, July, 1822. § Act. Med. Berol. Dec. t. Torn, m' 94 cl. in.] ILEMATICA. [OKU. !■ Anetui. intermittent fever. Ague. Medical treatment. Liquor Gen. II. ated to the cure of intermittents by the Jewish physicians of Poland. In Sir George Baker's time, we have seen already that it was m extensive use, but productive of such very different results, that, how- ever successful it might prove occasionally, this distinguished pa- thologist thought it a worse evil than any ague whatever. At that period, however, it does not appear to have been tried in its most commodious forms, which are those of an arsenite or arseniate of potash. M. Macquer recommends the latter ; Dr. Fowler, many years ago introduced and gave abundant proof of the utility and general commodiousness of the former; and under this modifica- arsenicaiis. tion it hag at iengti, foun(i lts way into the Pharmacopoeia of the London College, under the name of liquor arsenicalis. Sir Gilbert Blane tells us that it was used with great success in our unfortunate expedition to Walcheren, where the stomach could not retain the bark: but was combined with opium, and in most cases with bitters and aromatics.t often The cases of success from the use of this medicine are so mime- usefufd'y rous> an^ its employment is now become so general, as to render it though not unnecessary to advert to particular authorities in proof of its febrifu- t0 a11' gal power. With many constitutions there can be no question that it disagrees very considerably; and there are numerous instances of its failure : but it is a medicine wf real and inappreciable value in many diseases, and in none more than in intermitting fevers. Dr. Fowler advises it to be taken in doses of from two to twelve drops, according to the age and strength of the patient, once, twice, or oftener, in the course of the day : and the directions are so broad, and at the same time so much within limit, that no actual harm can Advantage- occur from following them literally. It will, however, often be found united with advantageous to combine a few drops of tincture of opium with opium. each dose, to guard against the vomiting and griping which it is some- times apt to excite; and the bowels should be kept open by warm aperients during its use. Under the French Directory a similar pre- paration of arsenic formed a part of the political constitution of the day: for an edict was formally published, commanding that the sur- geons of the army of Italy should, within the course of two or three days, cure the vast number of soldiers suffering from agues caught in the marshes of Lombardy, by the use of this medicine, under pain of military punishment. It is a singular fact, and ought not to be passed by without notice, that since the establishment of the large copper-works which are now carrying on in Cornwall, the intermitting fevers which were almost constantly present in the neighbouring marshes, are now rarely Kipiained. to be met with in any shape It should hence seem that the atmos- phere is armed with a specific by becoming impregnated with metallic oxydes or carbonates : and that Cornwall should be the spot recommended for change of air in many cases of chronic or other obstinate intermittents. The result of this general survey is, that the cinchona offers by Remedial power of neighbour- ing copper works. Result of tde forego- e- minal tension, dyspepsy, or some other affection of the viscera of the lower belly ; and is hence called b> Professor Frank, as well in the Gastric ensuing as in the present species, gastric fever,* intermittent, remit- prank. tent or continued, according to the type it assumes. It occurs at all seasons of the year, but more frequently in the autumn ; the ordinary temperament of the season uniting with the patient's infirm state of health, and thus adding an exciting to a predisponent cause. Fatigue, cold, or long exposure to the rays of the sun, are also, at this time, powerful concomitants, and quicken the appearance of a disease, the seeds of which have for some time, perhaps, been lurk- ing in the system. The patient complains of drowsiness, and feels languid; is Diagnosis. occasionally chilly, and afterwards flushed, but without perspiration; for the skin is hot and dry, the thirst considerable, commonly with nausea and a total loss of appetite. In the course of the day, but usually towards the evening, the pulse quickens, the heat increases, and at length terminates in a sweat, which, however, is sometimes only partial, rarely free and copious, and never critical: for, on its ceasing, the skin is still dry and heated, and the pulse accelerated. Sometimes the exacerbation occurs about noon, and sometimes in the middle of the night. If the disease be left to itself, the symptoms augment in severity Prognosis. daily; the head occasionally, but more generally the liver, or some s other abdominal viscus, gives proof of being loaded and oppressed, and the restlessness is intolerable ; or a sudden cholera supervenes, and carries off the complaint by a salutary crisis. * De Cup. Moid. Horn. Epit. Tom. i. § 50. 99. 8ro. Mannh. 1792 Vol. II.—13 98 ex, in.] HtEMATICA. [oRD. 1. Gen. III. Spec. I. Epauetua mitis. Mild remittent- Medical treatment. Remittent fever of infancy. Ordinary cause. Symptoms, This species seems to be primarily dependent upon torpitude, or obstruction in some one or more of the chylopoetic organs, and generally yields to a course of active purgatives, among which calomel ought to take the lead. These should be repeated two or three times a-week, and the intervals be filled up with mild diapho- retics. The pulse wid generally be found from ninety to a hundred strokes in a minute ; but as soon as it sinks below this, and the heat and dryness of the skin have yielded to a general softness, columbo alone, or combined with sulphuric acid, will easily complete the cure ; though the disease not unfrequently runs on for ten days or a fortnight. The remittent fever of infancy, which is generally ascribed to worms, does not essentially differ from the present, regard being had to the greater irritability of the moving fibre in early life. Worms, there can be no doubt, are sometimes the cause of this infantile fever, but perhaps rarely ; and there is no instance on record of their having been traced in the bodies of those who have fallen victims to it. Dr. Hunter, indeed, expressly declares that he has often searched in vain. The ordinary cause is, crude accumulations in the first passages, whence the digestion proceeds imperfectly ; there is great general irritation, with considerable languor; the belly becomes tumid and often full of pain ; the food is nauseated ; the head is hot, heavy, and often comatose ; as though there were water in the ventricles, which is sometimes suspected, though without foundation ; the skin is pale or livid with occasional flushes in the cheeks. It is a singular fact, that if the exacerbation or increase of fever take place in the night, there is wakefulness and perpetual jacti- tation •, if in the day-time, drowsiness and stupor. Dr. Butter recommends, as an aperient, small doses of neutral salts, and, when the bowels have been opened, nitrate of potash ; or, if there be considerable irritation, the extract of hemlock. Generally speaking, however, there is such a sluggishness in the peristaltic action of the bowels, as well as in the intestinal secer- nents, that neutral salts will not answer the purpose ; and, in con- sequence, rather add to the irritation than carry it off. And hence, much stronger purgatives should be employed from the first; as calomel, resin of jalap, or gamboge dissolved in milk ; and it may safely be prognosticated, that, till this plan is had recourse to, the disease will in most instances maintain its ground if it do not make a fearful advance. But with a course of brisk cathartics, in con- junction with perfect quiet, good ventilation, and light nutritive food, it will usually give way in a week or fortnight. • ■!.. in.j SANGUINEOUS FUNCTION. [orp. t. 9H SPECIES II. EPANETUS MALIGNUS. MALIGNANT RE3IITTENT. PULSE SMALL, HURRIED, IRREGULAR ; DEBILITY EXTREME : OFTEN WITH SIGNS OF PUTRESCENCY. Extreme debility may be inferred from the symptoms of great Gen. m. weakness and irregularity of the voluntary motions ; weakness of |""meIL sensation ; weakness, and wandering of the mind ; weakness of debility the pulse and of respiration ; coldness and shrinking of the ex- denceT" tremities ; and a tendency to faint in an erect posture: nausea, vomiting, and a total disinclination to nourishment; difficult de- glutition, depending upon an atony of the muscles of the fauces; involuntary excretions, depending upon an atony or paresis of the sphincters. A putrescent state of the fluids may be determined from the Putre«cency following symptoms: pulse quick and tremulous; heat of the fluids6, how surface sharp and pungent, giving to the finger a peculiar tingling evidence*. for some minutes afterward ; the skin parched, or soaked with sordid, fetid sweat; the smell offensive to a considerable distance; the breath hot and fetid; the mouth aphthous ; the tongue clammy, fetid, livid, greenish-black ; the lips swollen, puckered, cracked and purple; the urine brown or blackish, and offensive; black discharge often in profuse quantity from the stomach ; the stools blackish, colliquative, very offensive, parted with profusely and insensibly; the mind wandering ; twitching of the tendons ; swelling and ten- sion of the belly : petecchial spots, vibices, and hemorrhages from different parts, without proofs of increased impetus. This species may be traced under four varieties, each sufficiently marked by its own symptoms : » Autumnalis. Autumnal Remittent. /3 Flavus. Yellow Fever. y Ardens. Burning Remittent. ^ Asthenicus. Asthenic Remittent. The autumnal remittent is that which so frequently shows «E- "■*• itself in our own country, in the season from which it derives its autumnairs. name, with a strong tendency to assume the tertian or double tertian ^m^™' type : or, in other words, with striking exacerbations every other day, or where the double tertian is imitated, every day, the exacer- bations commencing at noon, and the duration being usually under twelve hours ; the intervals consisting of remissions, which, how- ever, are not always very clearly determined. Where the double 100 CL. III.] HiEMATICA. [ori>. r. Gen. II. tertian type prevails, and the patient has to labour with two distinct ^Ema1-1' sets of tertian exacerbations, it is obvious that one of these must lignus take place every day, as it must occur in the remission of the AJiu'rn'r.Vr other. And this variety is, in consequence, often mistaken for a remittent quotidian remittent. But a little attention will point out the real (sometimes ^ ..J ., , n , mistaken nature of the disease. For while the one set will usually be lound Quotidian distinguished from the other by evincing some difference in its Ho"w dtatin duration or its violence, both will be distinguished from the quoti- s^shabie. dian by the time of their attack, which is at noon, while the quotidian attacks in the morning ; and by the comparative brevity of the paroxysm, which is always under twelve hours, while that of the' quotidian runs on towards eighteen. The perfect apyrexy which takes place in the interval of inter- mittent fevers gives the constitution a full power of recovering its Return of energy and recruiting its sensorial supply ; and we have hence ob- yamdiffieuit served that there is great difficulty in accounting for a return of the to be paroxysm : I mean in cases in which the patient is removed from for in inter the miasmic atmosphere ; for otherwise the cause that commenced mittents. tjje disease will be present to continue it. Habit may possibly effect this after a recurrence of several paroxysms ; but this will scarcely apply to the second, in which no habit can with great strictness of But less so language be said to have taken place. In remittent fevers, however, tenu""1" something of this difficulty is removed, for the constitution, even during the remissive interval, is still struggling with disease, and has not an opportunity of recovering its sensorial power. Fevers There is no perplexity in accounting for a greater tendency to freqnmu'tn febrile affections towards the autumn than in any other quarter of the autumn, the year : and this, whether we allow the operation of a specific febrile miasm from marshes or not. When the animal frame has for some months been exposed to the stimulus of a high atmospheric temperature, and not unfrequently, perhaps, to that of the direct rays of the sun, all its organs become relaxed and debilitated. The sensorial fluid is secreted less abundantly, perhaps less elaborately; or, in the language of Dr. Cullen, is in a state of collapse ; a general languor and inertness prevail over every part of the system, and most of the functions are performed feebly and laboriously. And hence if debility be the first stage of the proximate cause of fever, this part of the cause is continually present. But this is not The organs all; the calorific rays of the sun act more powerfully upon some weakened1*1 organs than upon others: and most of all upon the liver. The iyThe'heatliver is hence in. a state of PerPetual irritation : an unusual pro- of the portion of bile is secerned, a part of which is very generally re- se^onithe sorbed and carried into the circulation ; and, in tropical climates, pmicu- so large a part as to form one of the causes of that tawny hue by which the skin is there characterized. And as the greater propor- tion of the surplus often passes off by the bowels, we see an obvious foundation laid for that variety of diarrhoea which we have already described under the epithet of bilious. The liver, more- over, becomes weakened and torpid in proportion to its degree of wrTesuons ««teinent; and, hence, more disposed to congestion ; and where and a congestion or any other obstruction takes place in a large organ, • l. m.] SANGUINEOUS FUNCTION. [ord. i. 101 there is instantly a disturbance in the balance of the circulating Gen. III. fluid; and a disturbance which, in so irritable a state of the general a E M"a.' system as we are now contemplating, can rarely exist without fever ''snu3 or a tendency to fever. Autumnal There is no question that this general disturbance of the balance {Jf™"6"1, of the circulating fluid and increased excitement of the digestive circulating organs may terminate in actual inflammation in some part of these organs, and especially in their mucous membrane ; and hence, those an^^ca" pathologists who regard fevers of all kinds as consisting in inflam- gastric or mation, contemplate the remittent before us as an enteric, or gastric j£*™ Son. phlegmasia : but this, as we have already had occasion to observe, is rather to denominate it from its result than from its essential nature, and to make the cause and effect change' places : a remark which will apply to yellow fever as well as to the present variety. All this mischief is apt to occur in autumns of temperate cli- ^hekfr*mde mates, that are peculiarly dry and uniform in the range of the often by thermometer. But it often happens that even in the most temper- {J^^p1' ate and healthy climates, like our own, the autumnal months are the season. chequered with sudden vicissitudes of heat and cold: and the pools and rivers are suddenly inundated with equinoxial rains, overflow their banks, and cover a wide surface of land with stagnant water. And the animal frame has, hence, to contend against the dangers of invisible damps, and abrupt changes of temperature, as well as against solar excitement: all which become occasional causes of fever, operating upon a state of body already predisposed to its influence. And, hence, even without the existence of febrile marsh-miasm, Marsh- we see sufficient causes for a more frequent appearance of fever in often the the autumn than in any other season of the year : whence, indeed, »™£ one reason for its appearing in warm seasons in fleets that are cruising at a considerable distance from ports, as has been justly observed by Dr. Burnett.* But in many districts, perhaps even in some sporadic cases, we have reason to believe that marsh-miasm does co-operate, and itself form the remote cause ; and more espe- cially where such cases are frequent, the residence a low-land, and the season hot and rainy. Dr. James Johnson makes a like dis- J"^,^8*' tinction between the causes of the ordinary endemic fevers of the in Europe. East. " The fever in question," says he (bilious remittent), "fre- quently arises from atmospheric heat, or rather atmospheric vicissi- tudes, deranging the functions or even structure of important organs; and is, as Sir James M'Gregor supposes, sympathetic of local affection. Where marsh-miasm is added, which is generally the case, then we have the endemic of the place, modified by the peculiar nature of the effluvia, and from which we are not secured, but by local habituation to the cause, "t In consequence, the symptoms have often a close resemblance in both cases, so much so indeed, that when both diseases co-exist, it * On the Bilious Remittent of the Mediterranean. t Influence of Tropical Climates, &c. Sd Edit. p. 105 102 cl. m. j HiEMATICA. [okd. i Gen. III. Spec. II. a E ma- lignus aulomtisilis Autumnal remittent. Difficulties in explain- ing the nature of remittents, yet not greater than in other parts of physical study Remark of Sydenham. Diagnos- tics. Violence of incursion and duration of the fever not necessarily in propor- tion. is sometimes found difficult to distinguish them. " The occur- rences," says Dr. O'Halloran, " which preceded the appearance of the epidemic of Barcelona in 1821, corresponded with the old and recent observations on a similar subject in other countries: it almost invariably happening that the yellow fever of Spain is preceded by unusual diseases of various form and force ; more particularly by bilious remittents, which are not unfrequently so aggravated and malignant that physicians themselves do not ven- ture to define the lines of demarcation between them and the avowed epidemic."* There is still, however, a difficulty in determining why the type of any fever hereby produced should be remittent rather than inter- mittent or continued; and why its declinations should imitate one form of intermittents rather than another. Pathology has its mys- teries as well as every other branch of science ; and let the man who would accuse us of ignorance, because we are incapable of explain- ing these secrets of nature, first tell us, to adopt the language of Sydenham, " why a horse reaches his full growth at seven years old, and a man at twenty-one ? or, why some plants flower in May, and others in June? if," continues he, " the most learned men are not ashamed to make an open avowal of their ignorance upon these points, I cannot acknowledge myself blameable if I modestly forbear reasoning upon a subject quite as difficult and perhaps alto- gether inexplicable. At the same time I am persuaded that the progress of nature is as certain and regular in these cases as in any others, and that the quartan and tertian intermittents are as subject to the natural laws, and as much governed by them, as any other occurrences whatever." The autumnal remittent commences with lassitude, a general soreness over the body, yawning, inquietude, and most of the other concomitants of a febrile incursion. As some of the larger organs have been more affected by the influence of the season than the rest, we find them giving way in proportion. Hence, the head is sometimes severely tried with pain or heaviness ; the bowels are overloaded with bile, or the stomach is exquisitely irritable, and rejects whatever is introduced into it. Generally speaking, the stomach, from this symptom, suffers more than any other organ; and, along with the sickness, we have often a very troublesome and debilitating looseness which resists every attempt to check its course. Sometimes, however, the bowels are costive from torpor, and the stomach is but little affected. The violence of the symptoms are commonly in proportion to the violence of the incursion; but not the duration of the disease: for I have often seen a fever that commenced mildly and insidiously, hold on for upwards of three weeks ; whilst another, that com- menced with great severity and threatened the utmost danger, has softened its aspect in a week, and entirely quitted the patient in a fortnight. The exacerbation ordinarily takes place at noon, or early in the afternoon, and consists in an increase of heat and pul- * Remarks on the Yellow Fever of the South and East Coasts of Spain. &c. 8vo. 1828. ' ' ex. m.] SANGUINEOUS FUNCTION. [ord. i. 103 sation, for there is rarely any preceding chill, and as rarely any Gen. HI. salutary moisture when the heat diminishes. The early part of ^"'J1' .the night is hence peculiarly restless, and no part of it tranquil: y'g™» the patient dozes perhaps for a few minutes, but without being Au^umnu5' sensible of sleep, and talks incoherently while dozing ; the images' reraiwenU before him being partly furnished from dreaming and partly from delirium. And even during these snatches of unquiet slumber, he is perpetually turning from side to side in quest of ease, which no position affords him. Every symptom is obstinate ; laudanum rarely produces sleep, and no sudorific perspiration : the coolest and most refreshing drink is rejected from the stomach; and if loose- ness teaze the bowels, it is retained, as already observed, with great difficulty. It is hence of little importance what nourishment is offered, and every preparation seems almost equally to fail in sup- porting the strength of the system. In effect, the debility increases with every fresh exacerbation ; and if no favourable change take place before the fourteenth or fifteenth day, there will always be reason for alarm. The progress of this disease is admirably de- Continued scribed by Professor Frank, under the name of febris continua gas- o? i>ank!eT trica,* the remittent form being with him, as with Dr. Cullen, a section of the continued fever. In the case of a young lady in her seventeeth year, whom I lately illustrated attended, the attack was slight, and no serious evil was at first 0fgrecaatSe apprehended. The pulse was about ninety in a minute, and rather severity. small; the bowels were relaxed, the motions bilious, and the sto- mach suffered from nausea. A gentle emetic seemed to afford some relief to the stomach, and a dose of rhubarb and calomel to the bowels ; but the fever continued with a daily and increasing exacerbation, for the most part at mid-day or soon after. The stomach again became irritable and sick, and the sickness was again connected with a diarrhoea, but the stools were colourless and watery, and nothing was rejected from the stomach but the diluent food that was swallowed. The skin was now very hot and dry, the pulse from a hundred to a hundred and twenty strokes in a minute, the nights were passed in perpetual jactitation, or in short and talkative dozings. Opium, rhubarb, neutral salts, diaphoretics, and mild astringents, in almost every form and combination, were tried with very doubtful advantage, and the first with evident mis- chief. Anodyne injections were of as little avail ; but sponging the limbs with cold water, or brandy and water, which was em- ployed as well during the remissive as the aggravated symptoms. diminished the pungent heat, and for a time afforded some refresh- ment. Still the fever continued its career; the stomach retained nourishment with difficulty, the bowels were daily teazed with six or seven watery evacuations ; the pulse was quicker and weaker. and the nights without rest. The heart at length became oppressed with a sense of fulness rather than of throbbing ; the lips were considerably swollen, ragged and black : a hemorrhage occasionally issued from the nostrils and the fauces ; and the general debdity was + De Cur. Morb. Horn. Epitom. Tom. i. § 100. 8ro. Mannh. 1792. 104 cl. in.] HiEMATlCA. |okd. I. Gen. III. Spec. II. a E ma- lign us autumnalis Autumnal remittent. Ucneral treatment. Emetics, v/heu little or no sickness. Aperients, whether useful or not. Venesec- tion, when useful. greatly augmented. Such was the appearance towards the eleventh day. The tongue was not much furred, the pulse, though small, and rarely under a hundred and twelve, was steady : but the heat was intense, and the thirst unquenchable. The mineral acids in dilution, sometimes singly, and sometimes in the combined form of aqua regia, with acidulated beverages, were now chiefly trusted to, in connexion with farinaceous foods, jellies, and beef tea ; and cold water was permitted in any quantity. This plan was continued till about the eighteenth day ; when every thing allowed being re- jected, and every evacuation accompanied with faintness, it appeared to me that the plan should be changed; that the chief cause of irritation was at this time debility; and that a more stimulant treat- ment should immediately be commenced. My colleagues, for whom I have a high respect, acceded with reluctance, as conceiving that we should only exasperate the febrile symptoms; and that if the stomach could not retain tasteless things, it would instantly reject wine or convert it into an acid. The attempt, however, was made ; sound old Madeira was administered by tea-spoonfuls, and shortly afterwards a small portion of chicken-jelly. Both remained on the stomach ; but the diarrhoea continued; and for this, as modern preparations had proved of little use, I recommended a scruple of the confectio Damocratis in half an ounce of cinnamon water after every loose motion. The diarrhoea ceased as by a charm ; the ensuing exacerbation was less marked, the night was passed more tranquilly, and columbo, in small doses of the powder, was commenced the next morning, and persevered in. The change of treatment being thus found to succeed, was adhered to, and the patient slowly but effectually recovered. It is not often that the autumnal remittent is thus obstinate. But whether there be sickness or not, an emetic should be admi- nistered, as one of the best means of determining towards the skin. And singular as the advice may appear, it is rather to be recom- mended where there is little or no sickness than where the sickness is incessant; for in this last case the stomach is often so extremely irritable, that emetics only exasperate it and add to the distress. It will also be useful to evacuate the bowels on all occasions, though the emetic alone will frequently be sufficient for this purpose: and hence Stoll allows of nothing beyond: for purging, says he, aug- ments the fever, while an emetic strangles it as at a blow.* The use of the lancet must depend upon the circumstances of the particular case. Where the onset is violent, and particularly where the patient is plethoric or of a vigorous habit, it should be employed instantly and freely ; for, without it, from the urgency of the symptoms, there can be little doubt that some large organ or other will soon become locally affected with effusion or congestion, which is always to be avoided as one of the worst symptoms that can occur. And if we ha.e reason to believe that such local affection exists at the time of the attack, and more especially that it is the cause of it, copious depletion will be still more necessary: * Rat. Med. Part i. p. 227. ox,. ra.J SANGUINEOUS FUNCTION. {W i. 166 for in this case we have not only to contend with the fever, but to Gen« m- guard against phlogosis or inflammation in the infarcted organ. /"ma"' But except in such cases there is no call for the lancet, and we 'is1"*8 may concede to Stoll that its use is injurious. Copious diluents, Autumnal* and small doses of antimonial powder in effervescing neutral Treatment- draughts, will ordinarily take off the burning heat of the skin by When exciting a breathing moisture; and if this can be maintained through otter0*1*' the day, the ensuing exacerbation will probably be mitigated in its remedies- violence. If not, eight or ten drops of the tincture of digitalis should be added to the antimonial draught, and all tendency to sickness be restrained by a few drops of laudanum: keeping the bowels in the mean time open with some gentle laxative, as rhu- barb, and the sulphate or supersulphate of potash in combination. Blisters are never of service except when topically called for, or as Blisters stimulants in the last stage of debility. If the diaphoretic plan fail serviceable, of effect, and the heat be pungent and augmentive, acids, vegetable, Acids. mineral, or both, will ordinarily constitute the best sedatives and refrigerants : and where the debility is extreme, the stimulant plan should be had recourse to which is laid down in the preceding case. One of the severest and most fatal forms under which the malig- 0E. nm. nant remittent shows itself, is that of the yellow fever, constituting al"us. the second varikty of the present species ; so denominated from £*"°w the lemon or orange hue which is thrown over the entire surface of Distinctive the body, almost from the first attack of the disease, and which feaWre9, gives it a distinctive feature. The heat is here also intense, the thirst extreme, and the vomiting strikingly obstinate; but not, as in the preceding species, consisting of a colourless material, or the food that has been swallowed, but of a yellowish matter at the be- ginning and through the height of the fever, ^nd of a chocolate- coloured colluvies towards its close. The common remote cause of this fever is unquestionably Common marsh-miasm : and hence it holds a stationary abode in the swampy cause, soils and morasses of the intertropical regions, exposed to a high {J?^* solar heat, and perpetually exhaling a decomposition of animal and vegetable materials ; and is found occasionally in all climates that make an approach to the same character: where, in the correct picture of the poet, The rivers die into offensive pools, And, charged with putrid verdure, breathe a gross And mortal nuisance into all the air. It is nevertheless a striking fact that although such '• mortal YeUo* ^ nuisances" have been exhaled into the atmosphere in all ages malignant within the range of the tropics, the fever we are now entering upon [°™f is only of modern date in its malignant form. Whether this be origin-. owing to any degree of general change that has taken place in the human constitution, or to a~1arger accumulation of that mixed animal and vegetable compost which forms the hot-bed of the present destructive miasm, or to any other cause, it is difficult to determine. It certainly seems, as Sir Gilbert Blane has observed, VnL. IF—14 106 cl. in.] ha:matica. ipmi.i. Gen. III. to have some bearing upon the slave-trade, with which it is precisely fPE.ma"' coetaneous. Small-pox, syphilis, and rickets, were equally un- lignus known to the ancients, yet the causes of their origin, as indeed YeZw those of all other epidemic or constitutional diseases, are involved in inscrutable darkness ; and, in the language of the poet, fever. History of its rise and range; visits America; visits Europe; visits Europe afresh. Atmosphere of its miasm. Like the miasm of human effluvium, less volatile than the miasm of theordinary bilious remittent. Illustrated from Ferguson. —Noctescunt tenebris caliginis atree. The yellow fever first showed itself, so far as we have any record of its origin, at Barbadoes in 1647, whence it spread to various other West Indian Islands, and at length made its appearance at Boston, in North America, in 1693, to which place it was carried from Martinique by the fleet under Admiral Wheeler. In Europe its earliest footsteps were traced at Lisbon in 1723,* after this period it seems to have declined as well in its violence as in its visits to the same regions, particularly in respect to North America and Europe. But in 1793 anew era of its prevalence commenced; the disease showing itself then and down to the present day with a frequency and fatality it had never evinced before, especially in the West Indies and North America. This aggravated form, however, did not manifest itself in Europe till the year 1800, when, after an interval of six and thirty years, it appeared at Cadiz in all its hor- rors. Since this period it has visited Cadiz four times ; and has thence spread to neighbouring sea-port towns in the South of Spain at short intervals. Among other places in this line of coast it has several times visited Gibraltar; first in 1804, when more than one-third of the garrison and population were carried off; and occasionally since, but with little comparative loss on account of those precautionary means which had been entirely neglected on the first visitation. To what extent the miasm of yellow fever, as it arises from its swampy and putrescent base may s;.>reaJ before it becomes dis- solved or decomposed in the surrounding atmosphere, it is not easy to determine. " It is probable, however, that where a trade wind or monsoon sets over a large tract fraught with febrific miasmata,- these invisible agents may be carried to a much greater extent than where calms or gentle sea and land breezes prevail. This is exem- plified in the fever of Corimbatore, and ought ever to be borne in mind by navigators in anchoring ships in the vicinity of swamps, or generals in pitching tents or stationing troops." | It is also satisfactorily proved that the modification of miasm producing yellow fever, does not spread so far or rise so high, and, consequently, is not so volatile as that producing the ordinary bilious remittent of hot climates, a feature by which it makes a nearer approach to the miasm of human effluvium, and shows that affinity to it, even from the first, which we have endeavoured to establish in the introductory remarks to the present order- J Dr. Ferguson has given us a striking illustration of the truth of this + infl .Gilbertr^ane? S.e,ect Dissertations, &c. p. 284. Loud. 8vo. 1822. ! ss: s^sai:1^&c-by j- johns°n' w-d- sd ej- p-»*■ •^l. in.] SANGUINEOUS FUNCTION. [ord. r. .107 remark, as also of the relative barometrical elevations of the re- Gen: III. spective regions of yellow fever, ordinary bilious remittent, and a ^;"'. pure and healthy atmosphere, in the following passage, in which nus'flavus1! he is taking a medical periscope of the island of Antigua. " The feve°w autumn of 1816, became very sickly, and yellow fever broke out in all its low marshy quarters while the milder remittent per- vaded the island generally. It was the office of the white troops to take the guards and duties of the dock-yards among the marshes below; and so pestiferous was their atmosphere, that it often oc- curred to a well seasoned soldier mounting the night guard in per- fect health, to be seized with furious delirium while standing sentry, and when carried to his barracks on Monk's Hill, to expire in all the horrors of the black vomit, within less than thirty hours from the first attack ; but, during all this, not a single case of yellow fever, nor fever of any kind, occurred to the inhabitants of Monk's Hill (a rock rising perpendicularly above the marshes, to the height of six hundred feet.) The result on the Ridge, (a hill about a hundred feet lower) was not quite the same, but it was equally curious and instructive. The artillery soldiers, seventeen in number, never took any of the night guards, but they occupied a barrack about three hundred feet above the marshes, not perpendi- ' cularly above them, like Monk's Hill, but a little retired. Not a case of yellow fever or black vomit occurred among them ; but every man, without a single exception, suffered an attack of the ordinary remittent, of which one of them died: and at the barrack on the top of the Ridge, at the height of five hundred feet, and still further retired from the marshes, there scarcely occurred any fever worthy of notice."* There is another feature in which the miasm of the yellow fever kike the shows its affinity to the febrile contagion of the human frame.^ and equai'iy evinces its less diffusibility ; and that is in readily attaching itself ^fft" to whatever bodies it meets with, though to some more than others. neighbour- Even the leaves and branches of trees, form powerful points of giances." attraction, and, where they are in the immediate vicinity of a swamp, illustrated. retain the contagious matter that rests upon them so effectually, as, in many cases, to keep the surrounding atmosphere free from pollu- tion, and become a safe-guard against febrile attack. " The town of New Amsterdam, in Berbice," says the same writer, "is situated within a short musket-shot to leeward of a most offensive swamp, in the direct tract of a strong trade-wind that blovys night and day, and pollutes even the sleeping apartments of the inhabitants, with the stench of the marshes; yet it brings no fevers, though every one is well aware that it would be almost certain death for an Eu- ropean to sleep, or even to remain after night-fall, under the shade of the lofty trees that cover the marsh at. so short a distance. All, too, are equally aware that to cut down the trees, would be a most dangerous operation in itself, and would certainly be productive of pestilence to the town."* As almost every territory in which the fever hereby produced, Known * On the Nature and History of Marsh Poison, Medico-Chirurg. Rev, Pec. 1821; ™m°".8 and compare with Chisholm, on Tropical Climates, p. 34. i08. ex. hi.] HjEMATICA. [ORD. I, Gen. III. has committed its ravages has given it a new name, it is as gor- Spec.II. ffeousiy arrayed with titles as the mightiest monarch of the east. nutflTvuf From the depredations it has committed in the West Indies and ™'°w on the American coast, it has been called the St. Domingo, Barba- does, Jamaica, and American fever : and from its fatal visitations on the Guinea coast and its adjoining inlands, the Bulam fever. In British India it is distinguished by the name of the jungle-fever, the hoogly-fever, or endemic of Bengal; and still further to the east by that of mal de Siam. Nearer home, in the lowlands of Hungary, and along the South of Spain, it is called the Hungarian or the Andalusian pestilence. From its rapid attack on ships' crews that are fresh to its influence, the French denominate it fievre ma> tellotte, as the Spanish and Portuguese call it fiebre amarilla, and still more frequently vomito prieto, or black vomit, from the slaty or purplish and granular saburra thrown up from the stomach in the last stage of the disease ; while, as its ordinary source is marsh lands, it has frequently been named paludal fever. Its more com- mon name, however, in the present day, and for the reason already assigned, is yellow fever : and when the attack upon new-comers Febiis is slight, seasoning. It is the febris gastrico-nervosa of Professor n^vosaof Frank,* who justly regards it as an intense variety of the ordinary Frank. autumnal malignant of temperate climates, as already described under this name. Exhibits From its showing itself in so many parts of the world, and under divereityof circumstances so widely different, it is not to be wondered at that symptoms, it should often be accompanied with a considerable diversity of symptoms ; and consequently that the paludal fever of one quarter should be regarded by many writers of considerable authority as Accounted essentially different from that of another. But an attentive perusal of the origin and laws of febrile miasm, as I have endeavoured to explain them, when treating of the remote cause of fever,t will, I trust, be sufficient to account for all such local distinctions ; and, if not to prove, at least to render it highly probable that they depend "partly upon the state of the body at the time of attack, but chiefly upon some modification in the powers or qualities of the febrile miasm itself, by the varying proportions of the co-operative agents of moisture, heat, stagnant air, and other auxiliaries which have not yet been detected, in their relation to each other in different places and seasons." Whether How far the yellow fever is capable of origination from any other Sriginiting cause than febrile miasm from marshy lands, or places subject to wuTefthan Uke decomPosi.tions and plays of chemical affinity, we cannot at jnarsh- present determine. Such places, however, are numerous, as damp miasm. unVentilated stations, stagnant water, thick impervious jungles, and causes woods that arrest the miasm as it ascends; even high and arid hills epumaraa -&fter he&t &nd ^^ faut aboye ^ & ^ ^^ rf ^ ^ Qn ^^ ships, whatever be the cause of such impurity. " Ships," observes Dr. Chisholm, « containing wine in their holds in a state'of decom- position, are generally extremely sickly, and the character of the cl. Hi.] SANGUINEOUS FUNCTION. [ord. i. 109 prevalent disease is that of yellow remittent fever. Several G***. m. instances of this took place in Fort Royal Bay in the years 1797, ^ ^maiig* 1798 ; and the situation of the ships in the open bay, far from the »>»s flavus- influence of marsh effluvia, precluded a suspicion of the fever from feve°.w that cause.—The ship Nancy, Capt. Needs, from Fayal, with a cargo of wine for the army, arrived at Fort Royal, Martinico, in the month of October, 1798 : she met with a gale of wind at sea on the 17th September, and several of the casks, from the motion of the ship, became leaky. The captain was taken sick at sea, and died with every symptom of the highest grade of yellow remittent fever. The mate and several of the crew were attacked with the same complaint: they recovered : but a mate, shipped at Fort Royal, fell ill on board and died. The ship lay out in the open bay; no vessel near her was sickly ; and she herself became very healthy after the cargo was landed."* Heat alone, however high the temperature, is not a cause of the H«»t alone fever before us: there must be moisture ; and as the result of both cause. a rapid decomposition and exhalation of organic remains. Provided the air is dry, even tropical climates are often found salubrious. " The burning province of Cumana," observes M. Humboldt, •' the coast of Cora, and the plains of Caraccas, prove that excessive heat alone is not unfavourable to human life." It has just been observed, however, that even high and arid situa- ^vu,nhea1t' tions, after heat and rain, may also furnish, by the chemical decom- high position of their soil, the specific miasm of yellow fever : and it fnr°yDbdes.' may here be added, that if, by the violence and redundancy of the come a rain, the swampy low grounds be at the same time overflowed, the auxiliary, latter will become an arena of health, while the heights are the seat ^«s ^ of disease. Such the hilly ravines of Portugal were occasionally ing present. found by the British army, during its occupation of that country in the summer of 1809, when a most destructive remittent suddenly made its appearance, while the overflowed swamps at its feet, were more than usually free from disease : " and such is frequently the ease," as Mr. Irvine has justly observed, " on the lofty ridges of Sicily, when their fiumari or water-courses, which are ordinarily dry and used for roads in the summer months, are filled and inun- dated with sudden torrents of rain. For here the malaria changes its station, and quits the overflowed low-lands for the heights of the primitive hills." But whatever be the original source of the fever before us, when once it has established itself and rages with severity, it is now very generally admitted that the effluvium from the body of the affected " is loaded with miasm of the same kind, completely elaborated as it passes off,"—and that the disorder is from this time capable of Secondarily communicating itself by contagion. And, from the statement and com- already given,t it appears far more probable that the fever at Cadiz b"uc'ont^e in 1800, that at Malaga in 1803, and that at both in 1820, had their |ion origin in contagion, or, in other words, in febrile miasm produced perhaps"09 by a decomposition of the effluvium from the human body, than {£'"""* duced. + Essay on the Malignant Pestilential Fever, Vol. I. p. 279. See also Dr. Dick- son's Topographical Remarks, &c. Sect. in. + Vt supra, p. 80, 81 110 ex.. in., H/EMATICA. [oRi>. !■ Gen. m. from the same miasm issuing from a decomposition of marsh-lands. #EEma"g- And on this account I have rather preferred the trivial name of nus kavus. yellow to that of paludal fever, which is too limited to express its fey""* source in every instance. The yellow fever at Xeres is ascribed by Don J. A. Ferrari entirely to this cause, as produced by importa- tion ; but its primary source he attributes to the decomposition of swampy lands, or other sources of putrefaction, which he seems to suppose may exist even in some parts of Spain.* In all instances it has a near approach to the autumnal remittent we have just described; Dr. Rush contemplates them as merely different degrees of the same disorder ; but Dr. Bancroft is, as it appears to me, more correct in considering them, after Professor Frank, as " varieties of one disease,"! in unison with the present arrangement. a certain jt should be observed, however, that for the yellow fever to be- telrfpera- come contagious, it seems necessary that the thermometer should saryforCit" be above 80° of Fahrenheit: since, like the plague, it demands for to become the activity of its miasmic corpuscles a certain range of tempera- mtagious. ture^ Dejovv which it ceases to operate, and its specific particles perhaps gradually become decomposed. It has never been known in North America nor in the South of Europe but at the season of the year in which tropical heats, that is those of 80° or upwards, prevail; and it has never failed to disappear in winter, even in the mild winter of Spain ; though typhus may at the same time hold its full career of malignity.J Remittent From the different impressions produced on febrile miasm under fncfd'en'ts"11 tnese diversities of origin and adjuncts, we find independently of evinces other discrepancies, that the fever it excites sometimes assumes a fonriHent caumatic or inflammatory cast, sometimes a typhous, and sometimes Yellow a synochous, or, in other words, begins with the first and runs rally the rapidly into the second or third. And it is in effect into these three synochus. SUDsecti0ns, that the Andalusian yellow fever has been lately re- stored by Dr. Jackson in his excellent work on the subject. Gene- rally speaking, the variety before us evinces the last of these cha- racters, as does also the variety we have just treated of: the two varieties that yet remain will afford examples of a typhous and in- flammatory bearing. Ordinary Its ordinary progress among those who are fresh to the tainted progress, atmosphere is thus accurately described by Dr. Mosely, who, from its resemblance to the causus of Hippocrates, denominates it endemial causus: a term which has since been adopted by Dr. M'Arthur,§ and several others. " When a new-comer is-«eized with a sudden loss of strength, and a desire of changing, for rest, into every position without finding it in any, those symptoms which constitute the endemial causus may be expected. The following day, but sometimes within twelve hours from the first indisposition, Fir*t staee. the violence of the disease will commence thus : There will be a * Edin. Med. and Surg. Joum. July, 1823. p. 369. t Essay on the Disease called Yellow Fever, &c. 1811. t Blane, Select Dissertations, &c. p. 314. S Account of the Causus or Yellow Fever of the West Indies &r ol. m.J SANGUINEOUS FUNCTION. [ord. i. [[{ faintness and generally a giddiness of the head, with a small degree Gen. ill. of chilliness and horror, but never a rigor. Then immediately will P- 77: lit! Ges. IIL Spec. 11. j3 E. malig- nus flavus. Yellow fever. In the Minorca f-jvpr. t l. in. HiEMATlCA. [ORD. Report of Blane on the mor- tality in Ascension Island, 1823. gion. The exhalation infected at the distance of three and four hun- dred yards: while the contagion infected only across the streets. The more narrow the streets, the more certainly the contagion in- fected. Few escaped it in alleys. After the twelfth of September, the atmosphere of every street in the city was loaded with contagion; and there were few citizens in apparent good health, who did not exhibit some mark or other of it in their bodies, particularly a pre- ternatural quickness in the pulse, " which occurred in negroes as well as in whites; and in a few who had the disease before." In like manner the Minorca fever, uniformly originating, as Dr. Boyd observes, in marsh-miasm, frequently, as he has also ob- served, becomes contagious :* of which, indeed, he has furnished us with a striking example in his own person : for we are told by Dr. Denmark that he caught the fever from one of his patients, and nearly fell a victim to it.t But we have had occasion to examine this subject so much at length, in the introductory remarks to the present order, that it is unnecessary to pursue it further,^ except by introducing the following irresistible illustration. Sir Gilbert Blane, having been requested by the Board of Ad- miralty, to examine into the dreadful mortality that took place at the island of Ascension, in the summer of the present year, 1823, reported, and from the manuscript of this report I was permitted to copy, that the officers and privates of Ascension Island were first stationed there in September 1821, in number twenty-eight, and continued in such full health, as to be without the loss of a man, till the arrival of the Bann sloop of war, in May 1823, The Bann had left Sierra Leone towards the close of the preceding March, at which time the yellow fever was raging there with great mortality, and, at the time of sailing, had no sickness of any kind on board: but, within a few days after sailing, the yellow fever made its ap- pearance, and continued its ravages till the beginning of June; during which time, not less than ninety-nine men had been attacked by it, and thirty-three cut off, out of a crew of one hundred and seven Europeans and officers, independently of twenty-seven African su- perannuaries, none of whom suffered from the disease. Upon the arrival of the Bann at the Isle of Ascension, an unrestricted com- munication took place between the sick crew and the healthful gaiv rison, the medical officers of the station, having adopted the opinion that the yellow fever is uncontagious. For want of such restric- tions, within a few days after the arrival of the Bann, the garrison became affected, now reduced from twenty-eight to twenty-two, in consequence of six men having been ordered to a distant part. And such was the dreadful mortality with which the disease raged, that out of this garrison of twenty-two officers and soldiers, not less than sixteen died, being rather more than three fourths of the whole. The medical officers were soon, though too late, convinced of their delusion, and most unreservedly admitted the quality of contagion; and that the disease they were called to contemplate, was genuine yellow fever will be placed beyond a doubt by the two following * De Febre Minorca, &c, 1817. t Medico-Chir. Transact, vi. 301, I !Tt snprn, p. 67—71. ML. III.j SANGUINEOUS FUNCTION. [okd. i. 117 symptoms that the surgeon of the Bann particularly notices as among Gen. hi. its other characters : " the skin tinged with yellow, assuming a deep-® e®™"''. er and deeper hue;" and, " before death, the vomiting of a dark nus'flavu?. coloured fluid, like coffee-grounds ;" conjoint symptoms, which as fcver°.w Sir Gilbert Blane observes, will apply to no other epidemic whatever. How far the tanks or pools of water, within the range of the whether febrile miasm, from whichsoever of the two sources produced, may tanks'may become sufficiently impregnated to propagate the disease, has not n|tednatmi been sufficiently determined. The Tamul or native practitioners well as air. on the Coromandel Coast, ascribe the epidemic that so often ravages their country to contaminated water as well as to contaminated air, and the able authors of the report on the Coimbatore Fever, incline to adopt this opinion. In France where, consistently with the popular doctrine of M. Doctrine ot Broussais, the disease is supposed to be seated in the mucous texture of the stomach or intestines, and to be dependent on contagion alone, as its means of propagation, a considerable degree of fancy has of late been indulged in, respecting the origin of this contagion; and the fancy has been varied according to the bent of the individual. Thus M- Morreau de Jonn§s has endeavoured to show, in a work Morreau de of some learning, but more imagination,* that the yellow fever onnes; however at first produced, which has eluded his researches, has been perpetuated among Europeans, in the manner of plague, leprosy, and syphilis, by a specific poison that has existed immemorially among the Indians of St. Domingo, and was communicated by them to the Spanish fleet, under the command of Columbus, in December, 1493 ; and from this fleet to all the world in succession, in conse- quence of the close intercourse which took place between the indivi- duals of the new settlement of Isabella, which was colonized out of the fleet, and the adjoining natives. In answer to which, however, it is sufficient to observe, after Dr. Chisholm,! that the Spanish writers, Herrera and Oviedo, appealed to in proof of this fact, rather unite in showing that the Spanish settlers received the disease in the first instance from marsh-miasm, and then communicated it to the natives themselves. While M. Adouard traces the same contagious AdouarO, poison, to an effusion or exhalation from the mucous membrane of the stomach of the individual affected, produced by an engorged or congested state of its vessels; and which, in consequence of the gaseous elasticity of the material thus eliminated, escapes by eructa- tion, and propagates itself by being swallowed, and thus communi- cated to the stomachs of others ; on the mucous surface of which it commences a like action and fructifies a like harvest of contagious matter ; the black material, which remains behind, being in his opinion a mere caput mortuum, unendowed with any infectious or other mischievous property.^ There is much truth in this last position, whatever becomes of all the rest. Black vomit, has been by many physicians, and was at Nature of black c vomit. * Monographic Historiqne et Medicale de la Fievre Jaune des Antilles, etc. f Of the Climate and Diseases of Tropical Countries, &c. I Relation Historique et Medicale de la Fievre Jaune, qui a regnee en 1821. a Barcelona ; par M. F. M. Adouard, M.D. &c. 8vo. Paris 18M. 118 cl. m.] ILEMATICA. [orp. I. Gen. III. Spec. II. 0 E. imilig- nus flavus. Yellow fever. Innocuous- Singular example of insuscep- tion of contagious miasm. Other ex- emplifica- tions- Disease rarely oc- curs a second time, with- out absence from the same cli- mate, though sometimes; yet milder. Voyaging 'o a differ- one time supposed by Dr. Rush, to be vitiated and discoloured bile; but it is now more generally conceived to be, as already stated, grumous or granular blood, let loose from the liver, stomach, or some other digestive organ, from the violent commotion of the disease. Dr. Bancroft affirms " that it is always insipid;" and we have numerous instances of orderlies in sick rooms who have had their hands and faces covered with black vomit suddenly ejected from the stomach, which they have taken little pains to wash off, while others have slept in sheets or blankets, stained and inundated with its flow, and yet have escaped the complaint. It marks, indeed, the violence of the disease, and is hence, commonly, though not always, accompanied with the formation of contagious miasm, but in itself it is not a source of con- tagion. The following instance of disgusting hardihood, though it has been brought forward in proof, not only of the innocuousness of black vomit, but of the uncontagious nature of yellow fever from any source, falls rather within the limit of an exceptive idiosyncrasy, in the escape with which it was accompanied, than lays any foun- dation for a general rule. A. M. Guyon, of Fort Royal, Marti- nique, we are told in the Revue Medical, had the bravery to wear, for twenty-four hours, the suit drenched with sweat of a soldier who had been labouring under this disease in its worst state ; he suffered himself to be inoculated in both arms with the yellow matter issuing from suppurating blisters ; he went into the bed of another patient, who had just died of the disease, while it was soiled with excrement; wore, at the same time, his shirt soaked through with black sweat and still warm, and himself slept soundly, and sweated through a good part of six hours and a half, which he dedicated to this delec- table trial; he exhibited several other feats of the same kind, and crowned the whole by drinking about two ounces of the black vomit discharged from the dead man's stomach—and nevertheless entirely escaped the fever. Admitting the truth of this marvellous story, there is still no great difficulty in conceiving that a man, who was so totally torpid to all delicacy of mental feeling ; might at the same time labour under a like torpitude of corporeal feeling, and be insen- sible to various irritants that would be sure to affect others. It is probably owing to an idiosyncrasy producing something of the same kind of insusceptibility to the action of the contagion of yellow fever, that while the miasmatic poison for the most part takes place immediately, it sometimes continues dormant for an indeterminate period. Dr. Jackson has known it remain in this state for two months, and Dr. Bancroft for even nine or ten. The individual who has passed through the disease is rarely attacked a second time. In the opinion of some physicians he obtains hereby an immunity at least equal to that afforded by the small-pox.* The examples, however, of a recurrence are too numerous to justify such a comparison: though, in most instances, where the disease has returned it has evinced a milder character. But this influence on the system, whatever it may amount to, seems to be lost by a short absence from tropical climates ; so that those * Peport of the Army Medical Board on Dr. Pym's Obsieryation?, ox. hi.] SANGUINEOUS FUNCTION. [obd. i. 110 who return to Europe for a few months, are as open to all the effects <|en^ HI. of a febrile incursion as though they had never been within the tropics @ e. maiig- V.nA»„ nus flavus. bef°re- ~ * ,.«. , • , ■„. „ Yellow As the larger viscera suffer very differently m different cases ot fever. this malady, the appearances on dissection have generally kept pace ^"s'toreT the with the previous indications: for, in some, the integuments of the ^ePti_ brain, or even its vessels, its substance, and its cavities have shown va'rfabie marks of inflammatory action, which have not been traced else where ; $%£%£. while in others, whose brain has appeared sound throughout, the section. stomach and its collatitious organs have been found chiefly affected with congestion, rupture, or, still more frequently, an erythematous inflammation, which, in some instances, has spread from the pylorus through nearly the entire range of the intestinal canal. In various other examinations the chest has exhibited the chief seat of disor- ganization ; and in others again the urinary organs.* The mucous membrane of the intestinal canal is by far the most frequently injured organ ; and this has been laid hold of with no small degree of triumph by M. Broussais and his adherents as affording a manifest proof of the truth of their favourite doctrine : and that yellow fever can be no other than une gastrite, or, in still later language, une gastro-entekite. But it should not be forgotten that most of the gastric symptoms, and all the severest ones, only occur in the course of the disease, and rarely in a very early part of it; and that they are hence rather to be regarded as effects of overwhelming febrile action upon the delicate and irritable texture of the membrane so severely excited, than as a proximate cause of the fever itself: and the more so as sometimes the biliary system, the lungs or the brain are chiefly affected, and the intestinal canal exhibits fewer proofs of suffering than any of these. Unfortunately the practitioners in warm climates have differed as J™^. much in their therapia as in their etiology ; for the latter, as might fo^^y be expected, has greatly influenced the former. Dr. Lind, Dr. inlbd[fferennt Clark, and Dr. Balfour, whose authorities were implicitly allowed bwd.^ ^ and submitted to some fifteen or twenty years since, alarmed at the sustaining debility which the system will have to encounter in the second stage methods of the disease, or as soon as it has run through its inflammatory career, shuddered at the thought of the lancet, and generally com- menced with clearing the stomach and intestinal tube by gentle emetics or purgatives or both, and immediately had recourse to the bark in as large doses as the patient's stomach could bear, paying little or no regard to the remissions or exacerbations of the fever : though the last of these physicians chose calomel as his cathartic, and alternated its exhibition with the bark till the disease was subdued or had effected its own triumph : at the same time allowing a free use of opium to keep the bark on the stomach as well as to allay pain and secure rest: to which were occasionally added wine and brandy in considerable abundance, three bottles of the latter having sometimes been given to a patient in less than twenty-four hour?, * Bally, surlaType Amcrique on Fievre Janne, Paris, 8vo.-PalIoni, Observa- tions Medicates sur\a Fievre regnante a Livourne, &c.-SaTeresy, DelaF.<>,-r- Jaune en Generate, &c. 12U cl. m.j HiEMATlCA. [o»d. t. Gen. III. and the same proportion continued for several days :* \jdiile recourse jf *£, mah> was only hacl to tne lancet where there was obvious proof of very nua flavus. violent local affection. fevo?-W The times, however, have since changed, and by far the more a^ddentiet- P°Pluar P^an °f late years has consisted in active, profuse, and ing mo- repeated venesections, large and quickly renewed doses of calomel, cold affusion, gestation in pure air, and, as advised by some, the * bolder exercise and rapid motion of a cart, spring-wagon, or any other carriage.! It was in this manner that Dr. Rush, regarding the imflammatory impetus as the sole cause of danger, boldly resolved to lay prostrate if possible the morbid Hercules at its birth, by bleed- ing, according to the state of the pulse, two or three times a-day during the first two days, and by following up the same plan as long as a single germ of an inflammatory diathesis should continue Rush's manifest. "I paid no regard," says he, " to the dissolved state of to bleeding; the blood, when it appeared on the first or second day of the dis- order, but repeated the bleedings afterwards, in every case, when the pulse continued to indicate it. It was common to see sizy blood succeed that which was dissolved. The dissolved appearance of the blood I supposed to be the effect of a certain action of the blood-vessels upon it. The presence of petecchiae did not deter me from repeated blood-letting where the pulse retains its fulness or tension." And he affirms, that both petecchiae and vibices disap- peared in various cases after bleeding. This plan he often pursued through the fifth and even the seventh day, in the course of which period, from a hundred to a hundred and twenty ounces of blood were frequently taken away by six or eight applications of the lancet. ns to His purgative plan was not less alert. Ten grains of calomel purging; amj fifteen 0f jalap, was the force with which he opened his re- medial attack, and which he repeated every six hours, till the alvine canal was effectually evacuated. This mode of treatment, he tells h-giiiy sue- us, he was led to by accident; and with it he became as successful as he had been unsuccessful under the tamer and more established method. Employed Under this plan of treatment, the venesection and the calomel enthviews.r" were employed on a principle of depletion alone, and of diminish- de^tion. '"^ a r or suPPosed increased action; and the former on the prin- ciple of a gradual depletion, Dr. Rush rarely venturing to withdraw more than sixteen ounces of blood at a time, though the venesec- tion was as closely repeated as the patient's strength was conceived equal to. Both these remedies have, however, still more lately been sudden and employed on different grounds, and under a different mode of ma- depletion, nagement. Blood, instead of being taken away gradually and suc- cessively, has by many, and especially by Dr. Jackson, who seems to have introduced the practice, been drawn off, on the accession of the disease, to thirty or forty ounces at once, with a view of making a decisive impression upon the system ; the same bold use of the lancet being repeated within three hours, if such impression be not effected : after which " such powers are recommended as stimulate * M'Cabe in Edin. Med. and Sur. Jour. Oct. 1819. Hist, and Cure of Fe^-er. by R. Jackson, MP. Part I. Chan. xi. p. 267—5'*!?. t.L. in.J SANGUINEOUS FUNCTION. [orb. i. 121 to a train of action, congenial to the action of health :"* and calo- Gem- HI- mel, instead of being employed as a purgative, has been enlisted f ^m"-- as a powerful alterant and deobstruent, and persevered in to saliva- f"9 flavus" tion, by doses of from five to five and twenty or thirty grains every l>ve"w third or fourth hour, according to circumstances, till this point is c^Xii™ obtained ; which, however, is not regarded as important in itself, entTather but as showing that the system is sufficiently under its influence, ^"^ve. Dr. Chisholm seems fairly entitled to the honour of having first tried s«Pfc°n and recommended mercury with this intention.* " It ought, says siJnoPf0its he, ". to be a general rule of practice to consider all remv - P- 215. mischiev- § Influence of Tropical Climates, &c. p. 50, 61, et passim. ous. | On the Bilious Remittent Fever of the Mediterranean. *f De Febre Minorca. &c. 1817. ** Medico-Chir. Trans. Vol. vi. V0T,. it—in iU c*. m-J HiEMATICA. j/wa. * Gen. ni. viscera, where the remissions are regular, and the epidemy is pretty f"maSt uniform in its character, large and repeated bleedings, as a gene- nusflavusT rai ru]e, must prove mischievous. They will not shorten the fcve'r career of the disease, but they will convert the remittent into a con- tinued fever: and we shall in the latter stage of its course stand wofully in need of that strength which we shall have squandered away at first, if we have commenced with profuse venesection. Further This is more especially the case where the disease makes its illustrated-. attack slow,y and jnsidjougiy, assuming in some degree a typhous guise, as in the Guzzerat form described by Mr. Gibson of the Bombay Medical Department:* in which he tells us that the debility is so great and instantaneous, as well as the tendency to putridity, that bleeding is never to be hazarded, except occasionally, to the robust new-comer ; and in which, even spontaneous hemorrhages, « instead of proving critical, have always seemed to hasten death, and indeed, without a single exception, in his experience, to prove This view fatal. And it was probably from a survey composed largely of carried™8 cases of this kind, though in the West Indies, that Dr. Hunter, in an extreme. a tone still more generally proscriptive, and which will meet with few defenders at present, thought himself justified in affirming re- specting venesection that even " in such cases as seemed most to require it—for example, where the patient was young, strong, of a full habit, and lately arrived from Europe—when the pulse was quick and full, the face flushed, with great heat and head-ache— and all these at the beginning of the fever—bleeding did nogood."t Pinkard's Dr. Pinkard, in his " Notes on the West Indies," has given a of hisown very interesting description of his own sufferings under this disease, Rttacjc. and 0f the remedial process to which he had recourse. His attack commenced in the more common manner, slowly and insidiously, and demanded eight or nine days to reach its acme. His head, stomach, and at last his bowels, were severely affected, especially the first ; but his intellect continued sound ; and, though the symp- toms were vehement, there seems to have been little tendency to that violent visceral inflammation which in the stage of debility is so apt to produce gangrene ; and consequently he had no black vomit. He lost twelve or fourteen ounces of blood at the commencement of the disease, and took a strong dose of calomel, which considera- bly relieved the pain in his head and eyes, and diminished the restless- ness ; but the thirst, heat, and dryness of the skin were still intense ; and his weakness became extreme. Affusions of cold water, old hock, opium, and bark, were made use of in profusion, and each seemed to afford great relief. Yet on the subsidence of the fever, he represents his feebleness as most deplorable, and such as it ap- peared impossible to recover from. Here a freer use of the lancet could have been of no avail, and, had not the author most judiciously forbade its further employment, in all probability he would never have been the historian of his own case.J where both On the contrary, if the disease make its incursion with great im- tobeLT81 petuosity ; if the pulse be full and strong, or even if it be only hard. cial, and ^mnrnritH * Edinb. Med. and Surg. Jonrn. Vol. xi. T On the Diseases of Jamaica, p. 118, 3d Edit * Vol. m. letter xu. p. 134 <.l. in.] SANGUINEOUS FUNCTION. [ord. i. 123 and there be great tendency to inflammatory congestion in any of Gen. III. the larger organs, as the head, the chest, or, as is far more common, /f^f maiig- the stomach, the spleen, and the liver, we cannot well be too bold nus flavur. both in bleeding and purging; and the plan laid down by Dr. Rush fever™ is by no means an exaggeration of what ought to be pursued. It may be, that eight-and-forty, or even four-and-twenty hours are the whole we have to work in ; and unless we can, so to speak, stifle or lay prostrate the sensorial power, and thus completely break down the inflammatory diathesis by debilitating and relaxing the living fibre or solidum vivum, rather than by diminishing the moles mo- venda, the organs mostly affected will in all probability become gan- grenous in a day or two, the oppressed blood-vessels will give way, and we shall have a chlorotic or livid skin, cold extremities, black vomit, and all the other apparitors of death, before the tamer plan of aperients and diaphoretics could have time to produce the slight- est impression on the system. Generally speaking, it will be best to bleed in an erect position, for the sensorial excitement, which is what we are chiefly to aim at, is best cut down by syncope, which an erect position will soonest induce ; and we may, hence, save the expense of several subsequent bleedings. Dr. Pym speaks with a very just discrimination upon this subject, in observing that while the Buiam fever, or the disease in its most violent attack, is relieved by free venesection, the yellow fever, more properly so called from the brighter hue on the surface, or, in other words, that which is slighter in its incursion, will not often endure the lancet. Dr. Musgrave's statement seems to oppose this asser- tion, for he distinctly tells us that" blood-letting in both forms is our sheet-anchor; the only pillar on which we can securely rest any hope of extensive success." The Antigua fever seems to have ex- hibited great severity in most instances, and hence called for a coura- geouscourse of practice with perhaps few exceptions. Yet the fol- lowing paragraph proves that it did admit of exceptions, and softens down almost to unanimity a clash of opinion and practice which after all is more ostensible than real: " we have repeatedly," says he, " with success, taken upwards of forty ounces of blood at one bleeding. With equal success we have in several cases renewed the bleeding up to the third, and even the fourth time ; but, generally speaking, those which require such reiterated evacuation evince an obstinacy not likely to admit of a favourable result under ANY MODE OF TREATMENT. It MUST ALSO BE REMEMBERED, THAT EVERY ONE WHO APPLIES FOR ASSISTANCE IS NOT ALIKE ABLE TO bear this liberal depletion." It only needs to be observed fur- ther that the bowels were emptied, as they ought to be, by calomel or jalap, or some other active purgative ; the head was shaven, and eold ablution preferred ordinarily to cold affusion, because of the fatigue endured under the latter. Bark was then instantly given, and, where the stomach would bear it, in the powder. Mercury, with a view of exciting salivation, was seldom tried, and not relied upon. In effect, in the milder cases it was not wanted for this pur- nose and, in the more urgent, there was no time for its use. There can be no doubt, however, of its being highly advantageous, £«£&, IU CL.IH.J 1-LEMAT1CA. i"™-* Gen. III. in a great multitude of cases, and of general benefit in various forms Swell. f tJis destructive epidemy. For whether we contemplate the Sus Cut fever as local or unrestrained, as consisting in violent universal ex- £Hr0W citement, or according to M. Broussais,in an inflammation of the when dis- mucous membrane of the stomach or duodenum irritating the bile- ursedmate,V ducts, and the liver itself by sympathy ; whether as threatening con- gestion to any of the larger organs, or actually accompanying con- gestion ; there is no medicine which, prima facie, affords a better prospect of relief than mercury, from its general action on the ex- cernent system, as well as its specific action on the intestinal canal, and the salivary glands.. It must, however, be admitted that it is only under a particular condition and tone of the vascular frame, that it can at any time be employed with good effect; and hence not only is a sound judgment constantly demanded in its application, which indeed is a requisite that ought ever to be present, but much important time is often lost in preparing the system for its remedial other re- introduction. In the case of entonic or strong vascular action, it is usS necessary first of all to lower, and in the case of atonic or weak employed vascular action, to raise the living power to the proper standard be- Mnjunc°.r,n foreptyalism can be obtained, which is the grand test of its having Uon; taken effect: and hence, to accomplish the former, bleeding, purga- tives and cold affusion, must be first called upon to exercise their re- spective powers ; and in the latter case, tonics and cordials; upon which last ground, Swediaur tells us that the most efficacious plan of treatment consists in giving calomel and columba, in doses of thirty- five grains each, five or six times a day.* It is truly said, indeed, by the advocates for mercury, that such other remedies are all valuable to which adjuvants ; and this is so far from being denied by those who are ascribe the hostile to the use of mercury, that they affirm, on the contrary, that benefit tne- benefit ascribed to this medicine, when it has once obtained a sway over the system, ought rather to be attributed to these adju- vants themselves ; which would have proved still more beneficial, Estimate of had they been left to their own power and intention alone. Mr. and1njuary Gibson, who is a strenuous advocate for the use of mercury upon nous the principle now adverted to, very candidly admits both these Oibson. causes of impediment. " In hotter climates," says he, alluding to the debilitating province of Guzzaret, " the phlogistic state of the system is adverse to the introduction of mercury: but the prudent abstraction of blood happily reduces it to that standard, which is most favourable for its action. In India, however, in fever, the dis- ease in which this is most speedily to be desired, the same means would, but in very few cases, be admissible : for the debility is so great and instantaneous, as well as the tendency to putridity, that only in the robust new-comer is it, if ever, to be hazarded. It would seem that debility and the plethoric system, are equally ini- mical to the specific mercurial action. If the patient is fortu- nately invigorated sufficiently to give the mercury influence, and be- fore any organ essential to life is injured, bv the strictest * Not. Nosol. Meth.. Syst. i. 2a. CL. III.] SANGUINEOUS FUNCTION. [oRD. I. 125 nursing and attention afterwards the recovery is almost certain, all Gen. III. morbid action yiel .ing from the moment ptyalism is brought on."* ^moiig- Even in cases, however, in which the mercurial action is fortu- nusiiavu. nately excited, the same intelligent writer tells us that he has fre- fever?" quently met with a very serious evil resulting from the mercury it- self; for such, says he, is at times the profusion of the ptyalism when once induced, that the most disagreeable consequences succeed, and the convalescence is long and precarious ; on which account he laments that we have no criterion to determine how far we may pro- . ceed with the mercurial process, and when we ought to stop. Dr. Bancroft. Bancroft advances much farther than this, and asserts that not only has the salivation retarded the convalescence, and produced very troublesome affections of the tongue, mouth and throat, with other ill consequences, thus acknowledged by its advocates, but that the salivators, even when they have been free from these evils, have not been more successful than other practitioners ;• and he particularly alludes to the admission of Dr. Rush, who was not unfriendly to the mercurial mode of treatment, that "in the City Hospital (of Phila- delphia, ,i when bleeding was sparingly used, and the physicians de- pended chiefly upon salivation, more than one-half died of all the patients who were admitted."! For like reasons Dr. Jackson Jackson. speaks with as little satisfaction of the same practice, not only upon his own experience but even upon that of Dr. Chisholm himself. Alluding to the high recommendation of mercury by the latter, he observes, " the detail of his testimonies does not warrant a conclu- sion so favourable; for the proportion of mortality in the detach- ment of Royal Artillery upon whom this practice is supposed to have been first tried, has perhaps scarcely ever been exceeded in a tropical climate. Further, it is a common observation that, where salivation actually takes place in continued fevers, it seldom shows itself till the violence of the symptoms has evidently abated: hence a suggestion arises that the appearance of salivation is only an indi- cation of the departure of disease :—no proof exists that the opera- tion of the mercury is the cause of this departure. Such are the re- marks which occurred in reviewing different modes of treatment in the hospitals of St. Domingo; to which it will not be superfluous to add an experiment made at the Mole in August 1796 by Mr. Lind, Surgeon to Jamaica. Out of fifteen cases of fever put under the care of Mr. Lind, on the first day of the disease and treated with the utmost attention, five died ; in three of whom salivation actually took place; five recovered, in whom no salivation took place ; in the other five, who also recovered, salivation was evidently esta- blished ; but, as is usual, not till the violence of the symptoms had begun to abate. Out of four who were put under his care on the second day of the disease, no one died ; but one only was affected by the mercury; one brought to the hospital on the third day of the illness, died: mercury was employed, but no salivation took place : one, on the fourth, likewise died, without marks of salivation ; one, on the fifth—the salivation was established, but the disease proved * Edin. Med. and Surg. Joum. Vol. xi. t Essavon the Disease called Yellow Fever. &c 8vo. 1811. 126 cl. in.] ILKMAT1CA. [ORD. 1 Gen. Ill- Spec. II- fj E. in ilig- nus flavus. Yellow fever. Hence the question still doubt- ful. Emetics. Carriage exercise. Genera) summary. Pure air by ventilation the most important mean of cure. Establish- ment of en- campments for this purpose; and their great benefit. Adopted in Barbadoes, Tobago, and Antigua: and about to spread further. fatal. In none of the above cases were less than ten drachms, and in most not less than two ounces of strong mercurial ointment rub- bed into the legs and thighs, with the employment of all other means which seemed calculated to promote the expected effect."* The question, therefore, to say the least of it, is still open ; and, admitting all that can be said in favour of employing mercury as a sialogogue, the evils which flow from the uncertainty of its action, both in respect to time and degree, and its frequent inroads upon the constitution, even where it has been of use, are serious and important. On the employment of emetics, there is now no longer any ques- tion. It is admitted, on all hands that, in the irritability of the sto- mach and its collateral organs during this disease, they are generally improper, and almost always augment the morbid action; on which account, even the antimonial sudorifics are of very doubtful efficacy: and, whenever ventured upon, should be combined with opium. And for the same reason, the use of carriage exercise, so strongly recommended by Dr. Jackson, and some of the most distinguished American practitioners, even " under the inconveniences of a scorching sun, of clouds of dust, and of a jolting cart,"! has rarely been put to the test, except in the emergency of the sudden retreat of an army : and has hardly been allowed to enter into the catalogue of ordinary remedies. The general treatment, indeed, may be summed up in few words. Copious bleeding, a free repetition of active purgatives, combined with opium where the ventricular irritation is considerable, in the commencement of the fever ; frequent sponging, or affusion of cold water, with an interposition of the neutralized salts as diaphoretics, during its progress ; and bark and other tonics, as soon as the febrile commotion begins to subside. The more powerful and violent reme- dies of repeated bleedings to faintness, mercurial salivation, or the stimulants of spirits, ether and opium, being alone added to the list according to the circumstances of the individual case. Pure air by a ventilation of the atmosphere, is however a more powerful remedial agent than all the rest put together ; and to this position I apprehend every class of writers will accede, how much soever they may differ upon other points. The Army Medical Board is therefore peculiarly entitled to the gratitude of the country for the great pains it has taken to give improvement to this important ob- ject, by an establishment of open and wide-spreading encampments, instead of confined and unperflated barracks; and no man can hear of the desirable success with which this enlightened measure has been attended without exultation. The attempt, as I am per- mitted to state from the manuscript documents in the possession of the Board, has been made at Barbadoes, Tobago, and Antigua; not more than four individuals being allowed to occupy a single tent, instead of ten or twelve, which is the usual proportion at home : and the success developed in these islands, has already become so con- siderable and decisive, that government has consented that a like * History and Cure of Fever, Part I. Ch. xi. p. 293, 294. + Jackson, ut supra, p. 287. M.. in.] SANGUINEOUS FUNCTION. jord. i. 127 trial should be made in all the islands around them. In the affect- Gen. Ill, ed crew of the Pyramus, distributed by Dr. Hartley into an encamp- p E. m'aUg. ment at Antigua, in the year 1822, not a single case of fever was nusflnvus. found to travel from one individual to another. We cannot wonder fever. therefore at beholding this able officer, anxious, in his report for ^"strl'ted 18.J3, that the same plan should be extended to other places, and in the crew adopted in other diseases. " In cases of sickness," says he, " and pyramu3. especially in yellow fever, I feel convinced in my own mind, that Hartley's r J J ir.-1-ii- l /. , • encomium. nothing could prove so beneficial in checking the ravages of this disease as separating the troops ; and particularly by removing them to some distant dry field from the locality of the attack. Nothing could more immediately substantiate the advantages of removing and encamping a body of men, than the result in the Pyramus's crew." In Barbadoes, where, as I have just observed, the same improve- ^gjjjjea ment has obtained a footing, the mortality for the last two years is does. almost incredibly abated. I have examined the tables subjoined to the annual reports in the office of the Army Medical Board, and have found that, from having been upon an average of seven years, about one in twenty-one of the sick list, in 1822, the mortality was only one in twenty-four ; and in 1823, only one in thirty-five. In this last year, however, it should be observed that the hospital list was some- what enlarged by the occurrence of an influenza unaccompanied with much danger ; yet the aggregate of patients amounted to not more than about a hundred beyond those of the preceding year. I am Olljj* «£ ready to allow that several other important regulations, for which we ,nci ' are equally indebted to the vigilance and the judgment of the Army Medical Board, may have contributed to this salutary change, but the greater part of it is still, perhaps, to be ascribed to the new plan of encamping. I cannot give a better description of the adjuvant regulations I am now referring to, than by adopting the words of Mr. Tegart, an enlightened inspector of hospitals at Barbadoes, who, in his manuscript report for 1123, thus enumerates them, and at the same time confirms the ameliorated health of the soldiers quartered in that station, and to which I have just referred. " The loss in that Tegm'a year" alluding to 1822, or the preceding, " was so comparatively small with former ones, that I hardly hoped to send so favourable a one again. This return, however, exceeds greatly any hopes I could have anticipated; being not one half of the average amount of the preceding six years: and not a sixth part of the yearly loss sustained in the fourteen years antecedent to those. There are many reasons for this favourable change ; the men are better clothed, better fed, and better looked after by their officers ; there are many local im- provements in the vicinity of the barracks, which formerly were not much attended to: such as draining swampy and marsh ground; clearing away brush-wood and long grass, which harboured moisture, and emitted, at certain seasons, noxious exhalations, producing fever and other diseases, the treatment of which was very different from that of the present day. I believe most sincerely that we are also indebted for the favourable comparison in the scale of mortality to the improved education of medical men, to the discoveries in the v? 12b cl. in-J HEMATIC A. [ORD. I. Gen. Ill- rious branches of medical science, and to the rationale of medical /"ma"- practice." The writer of this work cannot avoid adding his con- nus'flavus" scientious asseht to the correctness of these views. Velio fever. """There is another variety of malignant remittent which has been y e. maiig- known to medical practitioners from the time of the Greeks, though Ardent"-"" less frequent than the yellow fever, and which, by Hippocrates, has Ho°w de"'' been denominated causus ; as it has by later writers, who have only scribed by translated the Greek term, been called febbis ardens, ardent or crates. bur.mng remittent. From its being usually accompanied with Wco-T,.?85" much disturbance of the stomach and intestines, it is called by Pro- flammatoria fessor Frank, febris gastrico-infiammatoria, as the last variety is of frank, j?ebris gastrlco-nervosa. In Hippocrates it is briefly described as a fever, characterized by extreme heat, violent thirst, a rough and black tongue, complexion inclined to yellowish, saliva bilious. There is commonly an acute aching in the head, nausea, great anxiety of the praecordia, with frequently a gnawing pain at the sto- mach. The bowels are unusually costive, particularly at the com- mencement of the disease. The tongue, mouth, nostrils, and, in- deed, the whole surface of the body are parched and fiery-hot, whence, indeed, the Greek name for the disease ; the pulse is full and strong ; the voice hoarse : the breathing short and quick, with sometimes a slight cough, and occasionally delirium. Causes It chiefly attacks the young and the vigorous, who bear the attack better than old persons. The causes to which it was formerly as- cribed, are long exposure to the heat of the sun, great fatigue from Probably undue exercise or labour, or too heating a diet. It has of late, how- mlasm. ever, been supposed, and with much plausibility, from its frequent occurrence towards the autumnal equinox, and especially from its resemblance to the yellow fever, that, like the latter, its ordinary re- mote cause is the miasm of swamps and marshes. And, if so, it affords us a proof that under certain modifications, febrile miasm issuing from this source may, as I have already suggested, produce a caumatic or inflammatory, as well as a synochous or typhous ten- dency, in constitutions predisposed to this character of fever,* for the causus is, in fact, whatever be its cause, a vehement inflamma- conjbunded tory remittent. It is on this account that Dr. Mosely conceived the feU/by °W causus of the ancients and the yellow fever of the present day, to be Mosely. one an(j tjje same disease; whence he applies to the latter, the Greek Distinctive name of causus. This, however, is not quite correct: for in the real causus, the burning heat is more intense, the thirst more into- lerable ; while the stomach is generally less irritable, and will bear vomiting with advantage : and, in the second stage, the chilliness which, in the yellow fever, is merely accompanied with horripilation, and is a mischievous symptom, in the causus, is accompanied with a smart rigor, which often terminates in a copious and salutary sweat. The process moreover, in the causus, generally lasts only four days, and is terminated, when left to itself, by a critical diaphoresis, vomit- * Deveze, Traite de la Fievre Jaune, 8vo. Paris, 1820. Saveresy de la Fievre 3803%en genera,e' et Particulierement de celle qui a repnee a la Martinique en I'an ex. nr.j SANGUINEOUS FUNCTION. [obd. i. 129 ing, diarrhoea, or nasal hemorrhage ; but if the fever be not carried Gen. III. off in this way, it commonly becomes fatal. Spec. II. We have nevertheless satisfactory proofs that though the causus nus causus. and yellow fever be not precisely the same disease, both often issue fluent. from the same febrile miasm, and sometimes run their race con- Yet neV\{ jointly; the difference depending chiefly upon the idiosyncrasy or C° the peculiar condition of the constitution at the time of attack. Thus in that most formidable assault of yellow fever which took Proofs place at the Mole in St. Domingo, in the autumn of 1796, Dr. Jackson tells us that "the symptoms of the disease among a set of f™ men vigorous by nature, and often transgressing the rules of tempe- rance, were ardent and violent, with much vascular excitement in the early periods, often subsiding on the third day, and terminating rapidly in black vomiting, and a formidable train of horrors."* And he has since met with the same form in Spain, which, in effect, con- stitutes his first division of the Andalusian fever.t And, hence, Dr. from Chisholm informs us that " the diseases which originally proceed from ' IB °'" marsh exhalations, may be so impressed with the action of irregular temperature, as to render them highly inflammatory, although the character and nature of the original are so manifest as to make a mode of treatment suitable to the two diatheses, or rather the mixt diathesis, prevailing in the system, necessary." J And in proof of Army his remark, he has quoted several instances from the reports of the Bo^rT1 Army Medical Board, of which, that which occurred in the year 1812, at Brimstone-Hill, St. Christopher's, is probably most worthy of notice, on account of the topography and general healthiness of the spot, which is described as follows : "Situation N. Lat. 17°—soil light and dry—composition rock stjObris. touhcr e and sand—elevation six hundred feet—distance from the sea a quarter of a mile. Barracks exposed to currents of air and strong winds, directed on them by ravines. No swamps in the neighbourhood. Change of temperature sudden, from 70° to 80° and 90° in the course of a few hours. Rain abundant. Probable cause, previous hot dry weather, ill ventilated and ill-constructed barracks, some of them bomb-proof. Epidemic cause unknown; and prevalence of the disease cannot be accounted for." The cause, however, is not difficult to assign; and, in truth, we Explained. have already adverted to it in describing the occasional origin of yel- low fever : for however dry and elevated the situation may be, yet on the descent of copious and continued rains, such as are here set down, a temporary swamp is very soon produced, and of sufficient power, in hot climates, to generate even " on a light and dry soil, and a sandy rock," febrile miasm enough for the severest epidemic ; and especially where such miasm receives the collateral aid of ill-* ventilated barracks, and currents of cold air blowing down long ravines directly upon the troops while in a state of perspiration ; and * History and Cure of Fever, &c. Parti. CU. u. p. C6. . t Remarks on the Epidemic Yellow Fever on the South Coast of Spam, Loud. | Manuel of the Climate and Diseases of Tropical Countries, &c, Part in. Ch. i 8vo. Lond. 1822. Vol.. II.—17 130 cl. in.'] ILEMATiCA. |0UD. I Gen. HI- nroducino- a . multitudes, and a stagnant atmosphere : for here we have almost all the auxiliaries of febrile miasm operating for its production. The Exemplified - - • /• i-^ t , £•• . .•• r. . . in the late remittent epidemics of Cadiz and Malaga seem chiefly to have been epidemics of this kind : and they are the common pestilences of dis-spirited a^Main- armies, maintaining their ground with difficulty in the midst of great g"i chiefly carnage, surrounded by the dead and the dying, reduced to short pro- variety. visions, and worn out by the fatigues of the campaign. The writings of Sir John Pringle are full of examples of this kind ; and Professor N?(ed . De Haen has given a striking description of the same in his account aProsia\v! ° of the contagious epidemy that committed such tremendous havoc throughout the Prussian army, at Breslaw and its vicinity in the middle of the last century, constituting the disease to which M. De Sauvages has given the name of tritaeophya Vratislaviensis. It was peculiarly distinguished by irregular, action, great debility, and over- whelming dejection of mind. The lipyria, or coldness of the surface, with which the disease opened, rarely yielded to any general re-ac- tion, for the extremities seldom became warm, and were often rigid and convulsive ; at the same time that the interior parts burned like a fire ; the head and stomach suffered with acute pain ; there was great anxiety about the praecordia; and so exquisite a soreness over the entire surface that the patient had the greatest dread of being exposed to the contact of the external air, a mere change of the tem- perature being intolerable. De Haen himself at length became a De Hsan's prey to the infection, and his attack commenced as thus far stated. 0f his own On the fourth day, he tells us, all his symptoms were worse, his feet ca8e- quite chilled, but his hands red, and agitated with convulsive motions; he had occasional vomitings, and was terrified with the image of impending death. -On the eighth day the pulse was convulsive, and# he was continually crying out from his pains. On the ninth, deli- rium, and a rejection of grumous blood from the stomach. On the eleventh, perspiration and a tranquil pulse, but the voice was broken, the speech was interrupted, and the teeth grated. On the twelfth, the jaw was convulsed, there was a sardonic laugh and deafness. On the fourteenth, an icy coldness covered the whole body, accompanied with a cold sweat, but a frequent use of ablutions afforded relief. On the eighteenth, he had a vivid delirium, but fainted on being taken t Sur Ie Typhus Amerique, on Fievre Jaune, &c. Paris, fta> 1S& ex. hi.] HiEMATlOA. (ori>. i. Gem. III. out of bed ; vviiich was succeeded by hunger, copious sweats, and oSBEma"" profound sleep, with an intolerance of noise. At this time, every nus asthe- thing appeared new and extraordinary ; a feeling described by many Seme sufferers as soon as the violence of the disease begins to abate, and remittent. which Dr. Pinckard has very strikingly noticed in his own case. The symptoms varied considerably from this period, and he had still many dangers to contend with. He recovered, however, though very slowly, and Avith numerous draw-backs ; for on the thirty-sixth day, he had a cholera, and on the forty-eight his skin scaled off, and he lost his nails. fhedfaeaac. Towards the close of the disease, the skin was covered with a scabid or ichorous eruption, rather than petecchiae ; evidently from debility of the capillaries : a fact that has often occurred even in the slighter attacks of this variety of remittent in our own country, when it has occasionally broken out, as in 1705, among the troops station- ed in the vicinity of Portsmouth, and is particularly noticed by Dr. Lind. In this last case it was often suspected to be the itch, to which it had a very near resemblance: and it is highly probable that in many instances it was so, and that the acarus scabici found, in the stores, a convenient nidus for the deposite of its eggs. Exemplified There are situations, however, in which the febrile miasm pro- iVom0. 1. Gen. III. SrEc. HI Epanetus Hectica. Hectic fever. More com- monly slowly and insidiously. Remedial Irritable diathesis to be combated. Acids as sedatives and tonics Occasional aperients. Myrrh the only stimu- lant to be ventured upon. The lighter bitters useful with acids. Carle harmless, but of no avail. Bath wa- ters where the cause is local. little time bring them into imminent danger of their lives ; after which it has abated, and afforded hopes of recovery. But the hopes have been deceitful, for the hectic has still been fed by some lurking mischief; and, resisting the power of medicine, has gradually un- dermined the patient's health and destroyed him. More commonly, however, hectic fever commences slowly and insidiously, and is not suspected for some months: and the only symptoms noticeable are, lassitude upon slight exercise, loss of ap- petite, and a wasting of the flesh. But if these symptoms be con- nected with a general increase of pulse, so that the artery beats from ninety to a hundred or a hundred and twenty strokes in a minute, there will be real ground for apprehension. This is one of many diseases in which the art of medicine has hitherto laboured in vain to strike into any direct track of cure. The real cause is commonly involved in great and impenetrable obscurity, and we can do little more than attack single symptoms as they make their appearance. Where the disease is evidently symptomatic, the case must depend upon curing, or, if incurable, upon removing, when this can be ac- complished, the part affected. Where idiopathic, we must combat, as far as we are able, the irritable diathesis ; and above all thing9 endeavour to strengthen, without increasing, the action of the ma- chine. The best sedatives as well as tonics are acids, and of these the vegetable will usually be found preferable to the mineral, since, on account of their corrosive property, the latter can only be taken in small quantities. They abate the febrile heat, diminish the rest- lessness, and frequently succeed in checking the night-sweats. And if, as is often the case, the patient be tormented with pains in the limbs or joints, resembling rheumatism, and preventing him from sleeping, we may combine the acids with opium. The bowels must be kept regular by gentle laxatives, and the neutral salts seem to answer this purpose better than most others. It will, however, be convenient to vary them occasionally, and sometimes to exchange them for the senna confection, or some other aperient. Stimulants rarely answer any good purpose; and in many in- stances evidently heighten and accelerate the exacerbation. The Peruvian balsam has been given advantageously with nitre ; but myrrh is a medicine of fairer promise ; and beyond these we can scarcely ever venture to proceed. The lighter bitters are certainly serviceable in many cases, and may conveniently be employed in combination with the acids ; but bark, though tried in numerous instances, and with great perse- verance, has not been found successful. Dr. Heberden, however, says that he never saw it do any harm in the hectic fever, and his opinion is confirmed by that of Sir Edward Hulse, after having prescribed it for forty years. Yet neither of them ever obtained proofs of any beneficial result. A light and regular diet, regular hours, and gentle exercise, are coadjutants of great importance. When the disease is dependent upon some local affection, the Bath waters have often afforded re- lief; but in idiopathic cases they usually augment the fever, aggra- vate the patient's sufferings, and hasten his death. :um.j SANGUINKOf S FUNCTION h>m>. k 139 GENUS IV. ENECIA. CONTINUED FEVER. ONE SERIES OF INCREASE AND DECREASE ; WITH A TENDENCY TO EXACERBATION AND REMISSION, FOR THE MOST PART APPEARING TWICE EVERY TWENTY-FOUR HOURS. We now enter upon the important genus of continued fevers, or Gen. IV. those which run their course, not indeed without any change or by'shght6'' relaxation whatever, as many of them were supposed to do for- flu*es ani merly, and were distinguished by the term continentes, but with symptoms. occasional and slight fluxes and refluxes, which bear the same pro- portions to the exacerbations and remissions of the epanetus as these do to the paroxysms and intervals of the anetus or intermit- tent. When there are two tides or fluxes within the twenty-four Morning hours, the one occurs in the morning, and the other in the evening, 0ften dis- The last is always the most distinct; and takes place usually be- Dy1f,,u^eB3d tween five and six o'clock, which is somewhat later than the latest especially of the paroxysms of genuine intermitting fevers ; that of the quar-thelatter' tan, which is the latest of the whole, usually occurring before five o'clock. It should also be farther observed that where continued fever discovers but one augmentation in the twenty-four hours, it is always that of the evening. Dr. Fordyce attempts to show that, Fordyce's even in a state of the firmest health, we constantly discover some "vening tendency to a little febrile affection every evening ; this he calls the paroxysm. natural evening paroxysm of fever; and to this habit he ascribes the existence of an evening increase of continued fever. The genus, thus defined and characterized, includes the three fol- lowing species:— 1. ENECIA CAUMA. INFLAMMATORY FEVER. 2. - ■ TYPHUS. TYPHOUS FEVER. 3. ------SYNOCHUS. SYNOCHAL FEVER. Sauvages draws a line of distinction between these three from {?a™ee»'_ their respective duration, as well as from their more essential symp- tinction toms, affirming that the cauma terminates in a week at the farthest; JESSES*" the typhus in two, though sometimes protracted to three weeks; specie of while the synochus reaches beyond the second, and often beyond f°vneJ. the third week. As a general rule, this remark is worth keeping Holds only in mind, but the deviations from it in all the species, are too fire- genera •"' quent to enable us to lay hold of it in assigning their specific character 140 ci, in.] ILF-MATIC.A. I'™'- *• SPECIES I. ENECIA CAUMA. INFLAMMATORY FEVER. HEAT GREATLY INCREASED ; PULSE QUICK, HARD, AND STRONG \ URINE RED ; DISTURBANCE OF THE MIND SLIGHT. Gen. IV. This species has been distinguished by a variety of names by Spec. I. different nosologists and other medical writers ; the chief of which guished by are, imputrid synochus, which is that of Galen; imputrid continued n?!^=s fever, which is that of Boerhaave ; imputrid continent, which is that names, «/ ' ' j /• . • , • , r it *r of Lommius ; sanguineous continued fever, which is that ol lion- man ; and synocha, which is that of Sauvages, Linneus, Cullen, of which and most writers of the present day. Of these, synocha, for syno'cha3.1" reasons stated in the comment, to the Nosological Synopsis, is the worst; it has no clear or correct etymological meaning ; it has been used in different senses by different writers, and approaches so nearly to synochus, used as extensively by most of the same writers, as to create a perpetual confusion in the minds of young students; and the more so, as the disease before us is expressly denominated synochus by Vogel, whilst most writers employ this And hence term to import a different species of fever. On all which accounts above'ior1 I have judged it right to exchange synocha for cauma, a term already cauma. employed for the same purpose by Dr. Young, and which, derived from x,uta, " uro," is etymologically significant of the character of the disease it designates. The common English term inflammatory fever is excellent; and is, in truth, a direct translation of the Greek importing term cauma. Dr. Fordyce denominates it general inflammation: fnflamma- by which he clearly intimates that this species of fever bears a near Ford ce's resemblance to the symptomatic fever produced by the local affec- name for it. tions called phlegmasia^, or phlogotica, which constitute the next order of the present class, to which the term inflammations is now commonly limited ; but which Dr. Fordyce would distinguish by the term " local inflammations." Difference In effect, inflammatory fever and the fever of inflammations bear inflainma- the same relations to each other as the idiopathic and symptomatic ano'fev.Tof hectic : .in both there may be a general °r a local remote cause, inflamma- but the influence upon the constitution will be the same, whatever whether it be the source of excitement. It has been doubted, however, •Ic'e'tfrom whether cauma or inflammatory fever ever exists without a local alocai r°m cause ; and Dr. Cullen, who does not allow that hectic fever is ever ESSai found without a local cause, distinctly affirms that he has never seen cause va- inflammatory fever existing under the same circumstances : whence seT a".' Dr. Clarke, of Newcastle-upon-Tyne, who has too much generalized oiTteTby the subJect' has struck inflammatory fever entirely out of the list of different diseases, contending that even the term inflammatory ought never •-l. in.] SANGUINEOl'S FUNCTION. [ord. i. 141 to be applied to fever, excepting when fever itself only exists as a Gen. IV. concomitant of some local affection :* while Dr. Clutterbuck, as we e™°' l' have already observed,! has contended that this local cause is at all c™'a. times, and under every variety of fever, an inflammation of the brain, {of/feve'rl If, however, a cause of this kind be ever fairly made out, a variety supporters of facts of late detection, will be far more likely to fix it in an doctrine. inflammation of the arteries, the arteritis of the French writers, what!'19' who have recently examined the subject at considerable length, es- pecially MM. Portal,! Dalbant, and Vaidy ;§ and to which Dr. Frank has, indeed, already ascribed inflammatory fever in one of its forms.;| But the subject is still involved in great obscurity, as it is doubtful whether the change of arterial structure which has been found after death in many cases of supposed arteritis, has been really an effect of inflammatory action. In acute rheumatism it is probably a frequent cause or concomitant; but this is a question we shall have occasion to return to under that disease. How far either hectic or inflammatory fever may, under particular circumstances of human or atmospherical constitutions, occasionally originate from marsh or contagious miasm, it is difficult to determine ; but as Dr. Cullen was peculiarly desirous of reducing all fevers to these two sources ; and as, to say the least, they are not obvious sources of either of the diseases in question, his mind appears to have re- ceived some bias from this fact in rejecting them from the list of idiopathic fevers. And as it has already been shown that this deci- sion has laid a foundation for much of that " tug of war" in which many distinguished members of the profession have of late years been engaged, respecting the nature and treatment of particular species of fever, it is highly probable, also, that several of the more recent hypotheses concerning its proximate cause have originated from the same spring. Inflammatory fever, as it has often occurred in the author's own History of practice, and in that of others who have described it, usually com- ^""P10"13, mences with the symptoms of an acute ephemera, and may in fact be contemplated as the same disease running on from four or five to about eleven days without intermission or a renewal of the cold fit. It commences with a sense of languor and inaptitude for exer- tion, with a disrelish for food, which continues for a day or perhaps two. There is then chilliness and soreness over the surface, with nausea and head-ache, succeeded in the evening by a great increase of heat, and at night by perspiration, with great thirst, restlessness, and sometimes delirium : sometimes in young persons, convulsions with a stupid drowsiness. The bowels are usually costive, the urine high coloured, and the pulse quick and hard. With Dr. Fordyce the grand pathognomic symptom of cauma is Pathogno- hardness of the pulse. This accompanies it from first to last in its lom'hard"- simplest and in its severest state. When the disease is mild, it is nu^eof the hard alone ; when more violent, it is at the same time full, strong, Hardness of the pulse described * Observations on Fevers, &c. 8vo. London, 1779. t Vol. n. p. 61. and ex- t Cours d'Anatomie Medic. Tom. in. p. 127. 1804. plained, 5 Diet, des Sciences Medicates:—Journ. Compliment, vi. Aoiit 1819. P De Curandis Hominum Morbis Epitome. Lib. i. § 118. 8vo. Mannhem, 1791. 142 cl. m. j HiEMATlCA. [ORD. 1. Gen. IV. Spec. I. Enecia Unuma. Inflamma- tory fever. How differ., from ob- structed pulse- Progress of cauma. Termina- tion. Different organs differently affected. May some- times, per haps, arise from febrile miasm ; but more frequently, from violent passion, exercise, or heating foods ; and frequent. The obstructed pulse is often confounded with the hard, and it is not easy to distinguish them without considerable practice. There is a rigidity of resistance to the finger in each, but of a different kind. In the hard pulse, it is much firmer and tenser ; and is supposed by Dr. Fordyce to result from such an increase of arterial contraction as to over-balance its correspond'^,', dilata- tion. It indicates, in his opinion, a very high degree of living power, and is peculiarly characterized by a tardy coagulation of the blood when drawn freely into an hemispheric basin, in conse- quence of which the red particles have time to subside, and leave the surface colourless or with a buffy appearance. In the obstructed pulse, on the contrary, the blood coagulates at once ; and, the red particles not having time to separate, the surface is of the same hue as the cake below. The disease sometimes terminates abruptly and with a critical sweat, or some other evacuation on the fourth or fifth day : but more usually increases in violence, though with occasional declinations, for a week longer ; during which time, the pulse rises to a hundred or a hundred and ten strokes in a minute, but continues regular ; the nausea subsides, and the patient will take and retain what- ever is offered to him of simple nutriment or medicine : the thirst is less violent, but the tongue is deeply furred, and the lips are parched. The disease is not often dangerous ; and about the eleventh day gradually subsides, or yields to some critical discharge, which is usually that of a free and alleviating perspiration. The pulse soon sinks to eighty, and the chief symptom is weakness. During the course of ihe fever, every organ suffers from its morbid and increasing impetus ; but they do not all suffer alike : for in some parts there is, occasionally, a greater spasticity or tetanic resistance in the blood-vessels to the flow of the circulating fluid than in others, whence that acute pain which is often com- plained of in the head or the side : in the latter case, sometimes amounting to pleuralgia. And, not unfrequently, the vessels of one part will give way more readily than those of another, and there will be a sense of heaviness and oppression in the head, the heart, or the lungs : as though some effusion had taken place, which is perhaps actually the case in some instances. If the head be much affected, delirium is a frequent result, with raving and violence, rather than the low muttering incoherence of asthenic fevers. From the history already given of the malignant Causus, or ardent malignant remittent, it appears probable that inflammatory fever may sometimes be produced from febrile miasm, though it is commonly derived from other sources. Of these the stimulus of violent passions is, perhaps, one of the most common ; and espe- cially upon a vigorous and plethoric habit, which is the usual tem- perament in which inflammatory fever makes its appearance. Undue muscular exercise, heating foods, or excesses of any kind in the same habit, are also frequent causes ; while another may be found in the suppression of any accustomed discharge, as that of men- bL. ni.] SANGUINEOUS FUNCTION. jonn. 1. 140 struation, epistaxis, or periodical blood-letting. Suddenly sup- Gen. IV. pressed perspiration is, in like manner, a frequent, perhaps the Enecia' most frequent cause of any ; especially when the body is very hot, £",""* a_ and the change is affected by exposure to a temperature of great tory fever. cold, applied externally or internally, as that of a current of cold o"^^'.0'1 air, a large draught of cold water, or plunging into a river. «omed d«- Some writers, as Sennert and Crichton, have supposed inflam- sJddlnper- matory fever to be occasionally produced by an absorption of bile $„"£",■ into the blood-vessels under the excitement of a tropical sun, or of by a resorp- a torrid summer in milder regions ; and they suppose that the bile tlon of bl is, in this case, possessed of a more than ordinary degree of acri- mony, and that the symptoms are varied by a more pungent heat and-more intolerable thirst, with a more scanty secretion of urine, preternaturally acrid and high-coloured. That bile of this description is often forced back into the system ™7emear under the circumstances herp supposed, is unquestionable ; as it is a frequent also that inflammatory fever is a frequent accompaniment of this J^"'""^- morbid change. But, notwithstanding the above authorities, such sorbed wie, fever seems less attributable to the reflux of bde into the blood, than to the insolation or solar excitement: which, by unduly stimulating the liver has been the cause of an overflow of the bilious secretion. How far a more irritant or exalted acrimony may be communicated to bile thus operated upon, or what may be its effect upon the system admitting it to take place, it is difficult to determine ; but but p^p* i . . ... 1 1 -i .1 • never pro- there is much reason to doubt whether genuine bile in the sangui- duced by it. ferous system is ever a cause of fever, or stimulates the heart or arteries to increased action. For if this were the case, jaundice would always be accompanied with inflammatory fever. Instead of which, however, we find it accompanied with atony instead of entony, or diminished instead of increased power. Sauvages gives a case in which inflammatory fever was produced ^J0^^ by a mechanical irritation of the meninges of the brain, by a lodg- cfes in the ment of vermicles in the frontal sinus, of which seventy-two were ror discharged during a fit of vomiting and sneezing, from which time the patient began to recover. These vermicles were most probably the larves of some species of the oestrus or gad-fly, which had crept up into the frontal sinus, after being hatched in the nostrils in which the parent insect had deposited her minute eggs. This is a very common affection in grazing quadrupeds, and especially in sheep, which are often pecu- liarly tormented, and sometimes driven almost mad by the violence of the irritation. Stoll gives a case in which the brain, on examination after death, was found deluged with serum—diluvium serosum.* But such an appearance is rather to be regarded as an effect than a cause of the disease ; as an instance of cephalitis profunda, in consequence of the brain having suffered more than any other organ from the in- flammatory impetus. Hence the following varieties are noticeable under the present species : * Mat. Med. m. p. 294. sinus. 144 Gem. IV. Spec. I. Enccia Cauma. Inflamma- tory fever. III.] HiEMATlCA. [oRD. I. Plethoricum. Plethoric inflammatory fever. (3 Biliosum. Bdious inflammatory fever. y Pleuriticum. Pleuritic inflammatory fever. ^ Cephalalgicum. Cephalalgic inflammatory fever. Produced in a plethoric habit by great mental or muscular ex- citement, or heating foods ; or by a sudden suppression of per- spiration, or of other accustomed discharges. Accompanied with an excessive secretion of bile absorbed into the sanguineous system. Accompanied with a violent stitch or pain in the side. Accompanied with acute pain in the head. Remedial process. Venesec- tion- Cathartics. Relaxants. Crystallized acetate of ammonia. Emetics how far useful. Other remedies. As an inflammatory diathesis constitutes the essence of this fever, the cure must depend altogether upon a reduction of the vas- cular, and especially of the arterial entony: always bearing in mind the possibility that the disease may suddenly lose its inflam- matory character, and rapidly pass into that of a typhus. Regu- lated by this view, we should generally commence with bleeding and cooling purgatives. There are a few cases, indeed, in which bleeding may be dispensed with, as when the habit is by no means plethoric, and the pulse is obstructed rather than hard; but these are cases that rarely occur. Diaphoretics, or relaxants as they are denominated by Dr. Fordyce, may then be employed with advan- tage. Of these the tartarized antimony, the antimonial powder, or James's powder, are chiefly to be relied upon ; and may be given alone, or, which is often better, in saline draughts ; and par- ticularly those formed of the acetate of ammonia. And it may not be amiss to observe here, that the acetate of ammonia is sometimes prepared in the form of crystals, and sits more easily on the sto- mach in this than in any other shape. When given as a liquid, it is of importance that the solution should retain the carbonic acid gas of ammonia as largely as possible ; and for this purpose the union should take place in a strong close vessel. According to Bergman, nearly half the weight of ammonia depends upon the quantity of this gas which it contains ; so that in a pint of the solution of the acetate of ammonia, comprising four drachms of the latter, there wdl be extricated, if made in the manner here recommended, little less than a hundred and sixty cubic inches of air. As the stomach is for the most part but little affected, emetics, if used at all, can only be employed for the purpose of determining to the surface ; but as we can do this by the antimonial and other diaphoretics just referred to, as also by diluent drinks, it is hardly worth while to irritate the stomach in order to accomplish the same purpose. Perfect rest of body and mind, a reclined position, and a light liquid diet, destitute of all stimulants, are also indispensable towards recovery. The air should by all means be kept pure, by being constantly renewed, though without a sensible current, the temperature cool, the clothing light and as often changed as may be f..m.J SA.N C UINEOIS F I NOTION. [JORD. I. I4d necessary to maintain cleanliness, and the beverage, toast-water, Gen- iv> lemonade, or cool tea; which last Professor Frank recommends Eneda" *' to be made with cold instead of with boiling water, " Infusum chinse Cauma. cum frigida paratum."* IZffigZ. After all, however, it is not often that examples of pure inflam- Tel'rSade" matory fever are to be met with in the present day ; and it is con- with cold tended by very high authorities, and seems to be established by the iXmina- medical records of earlier times compared with those of our own, }"'* fever that it is a disease far less common now than it was formerly ; and mon'haa that it is seldom, to adopt the words of Mr. J. Hunter, " that phy- jTSSfc sicians are obliged to have recourse to the lancet, at least to that tured by excess which is described by authors in former times. They are, r' now, more obliged," continues the same writer, " to have recourse to cordials than evacuations; and, indeed, the diseases called the putrid fever and putrid sore throat are but of late date. I remember when the last was called Fothergill's sore throat, because he first published upon it, and altered the mode of practice. I remember when practitioners uniformly bled in putrid fevers ; but signs of debility and want of success made them alter their practice. Whe- ther the same difference takes place in inflammation, I do not know, but I suspect that it does in some degree ; for I am inclined to be- lieve that fever and inflammation are very nearly allied, and that we have much less occasion for evacuations in inflammation than there were formerly ; the lancet, therefore, in inflammation, and also purgatives, are much more laid aside."! It is not easy to account for this change in the national tempera- Whether ment. It is common, indeed, to ascribe it to an alteration in our chaVfe In mode of life, which is asserted to be much fuller than that of our *!ie C0lu'. 7 Dion mode forefathers. " We may be said," says Mr. Hunter, " to live above of life. par. At the full stretch of living, therefore, when disease attacks us, our powers cannot be excited further, and we sink so as to require being supported and kept up to that mode of life to which we have been accustomed." If this be a correct view of the times in Mr. Hunter's day, they Theiha.Uls have greatly altered and improved within less than half a century : do no°t ay for there has never been a period, since wines and fermented liquors Jj* j^"-. • have been introduced among us, so temperate and sober as the pre- tion. sent. Drunkenness, which was formerly common in our streets, is now rarely met with ; suppers are almost entirely relinquished; and instead of its being disgraceful, as was the case in ' the olden time,' for the master of the house to let his guests leave him either sad or sober, nothing is now so disgraceful as intoxication. It is true, we are got back again to a very free use of the lancet in many instances ; which would seem to show that we had completed a revolution in our general temperament, as well as our general temperance ; but it is not a little singular, that while the lancet is still used with com- parative caution in inflammatory fever, it is chiefly employed and often unsparingly in typhus or putrid fever. And hence, there is more reason, I fear, for suspecting a revolution in the professional + Ut supra, Tom. i. p. 197. * On Blood, v^c. Part U. p. 227. Vol. II—19 146 c;l. 111.3 HEMATIC A. LoHV. f Gen. IV. fashion than in national temperament; and that the bold and the Spec-I- timid plans have been alternately introduced, and alternately drop- cTum*a ped, not so much from any radical change in the constitution, as toK™: from their being found to fail, because employed as popular means. Treatment. or un come dissolved or decomposed; but slowly and with great difficulty, not at ail in perhaps not at all, in a vitiated atmosphere already saturated with a T,t,ated- foreign corpuscles.* In a state thus crowded, moreover, they less readily disperse or ascend beyond their proper periphery of action ; and where they are less volatile, as when issuing from human efflu- vium, they perhaps adhere by a peculiar tenacity to bodies more . ponderous than themselves, and thus loiter for a still longer period ^ within the stratum of human intercourse. And hence the fouler as Why mpre well as the more stagnant the atmosphere, the more general, and, CVifuued " Supra. CI. I. Ord. T. J?pct. 9. r>. 85. 148 ci.nL] ILEMATICA ]™p. i. Gen-. IV. from the former cause, the more malignant the disease : for as no- Spec. II. thing is so contributory to the preservation of sound health as pure tSus' air, so nothing tends so much as foul air to prolong or aggravate dis- f6ver- eases of every kind. And hence, again, wc have an obvious and sufficient reason why typhus should become more severe in propor- tion as it spreads and impregnates a given space with its specific miasm and accompanying colluvies. its con- To what extent febrile miasm, issuing from the source before us, S"not m&y spread in a free influx of pure air without becoming dissolved, fully ascer- or, in other words, so as to retain its contagious power, has never t'ho'S been very accurately ascertained. We know, however, that its range knowntobe js verv cirCumscribed, and reaches to but a very small distance from cumBcribed. the patient, or the nidus of foul clothes or utensils in which it may be lodged; and never infects a person in an adjoining street, or house, or room in the same house; nor even, as Dr. Haygarth baa observed, in the patient's own chamber, if large, airy, and kept clean. Does not It is also of great importance to know that typhous miasm, like clean* the specific miasms of exanthems, does not render clean clothes of any clothes kind contagious; or, in other words, does not adhere to or harbour Wt nnqucs- in them. When, however, they are not clean, they may unquestion- «ne]ean. abty De rendered contagious; and, hence, it is probable that the animal filth with which they are impregnated, while it is a source of additional miasm, becomes afomes of that already formed, and sepa- rated from the patient's body. Aiiindi- A susceptibility, however, to diseases of every kind varies very notequaiiy considerably in different individuals ; and hence we find that many receive the persons upon an equal exposure to typhus contagion with others, re- a°'on" ceive it far less readily, and in some cases seem to be almost favour- ed with a natural immunity. As we have already remarked that a peculiar state of body gives a peculiar tendency both to generate and receive typhus, we can easily conceive that where the body is in an opposite state it must be much less susceptible of its influence; and wc are thus put in possession of a general cause of escape. But there seems to be something beyond this, dependent, indeed, not upon the incidents of more vigorous health or higher animal spirits, but upon the nature of the idiosyncrasy itself. What pro- Dr. Haygarth has endeavoured to determine, from very ingenious Individuals an(^ plausible data, the average proportion of those who in this man- are natural- ner remain exempt from contagion, while spreading on every side ftomeitsP around them. And he limits the immunity to one in twenty-three : iifflaenco. for jie tens us? that when one hundred and eighty-eight men, women and children, were exposed fully to the typhous contagion for days and nights together, in small, close, and dirty rooms, all of them, except Miasm eight, were infected with this fever.* And he has farther endeavour- fatent "n" ed to. show, that the miasmic poison, when received into the body, the body continues in a latent state for seven days, from the time of exposure nndesome-S' to the contagion, before the fever commences, and may continue in the timesmuch same state for seVenty-two days, beyond which we have no instance of its producing any effect. And this deduction is in pretty close J.etter to Pr. Percival, p. 31. ct- in.] SANGUINEOUS FUNCTION. [orj>. i. unison with the experience of Dr. Bancroft,* who in ninety-nine Gen. iv. cases of orderlies and nurses that attended the English army on its t^;11" arrival at Plymouth from Corunna in 1809, observed that they were Typhus' rarely attacked with fever earlier than the thirteenth and in no in- fever stance later than the sixty-eighth day. Man, however, is so much the creature of habit, that his constitu- Man may tion is in a thousand instances brought by degrees to endure poisons Dy habifto of the most fatal power. This we see daily in the use of opium and oear,e*p°- j --i 1 iii-i • i • .. „ sure harm- ardent spirits ; and we shall m due time have to notice something of lessiy. the same kind even in plague. This adaptation of the constitution, however, to the circumstances by which it is surrounded, is in nothing more conspicuous than in the fever before us. Not, indeed, in all But not an persons—for all do not possess the same pliability of constitution— Equally. but in those who are endowed with it. And, hence, one reason why nurses and perhaps hospital-surgeons escape so often without injury; and especially why prisoners brought into a court for trial remain themselves occasionally in perfect health, while their clothes are so impregnated with the contagious miasm as to infect, a whole court, and communicate the disease to the judge or others who are at the greatest distance from them : of which we are furnished with melan- Examples. choly examples in the Oxford assizes of 1577, those at Exeter and Taunton in 1586, those of the Old Bailey 1736 and 1750; besides similar instances in various hospitals and ships of war. There are other persons again, as Sir George Pringle has well ob- Some more served, whose constitutions forming a middle line between those who feft^han readily receive, and who powerfully resist the contagious aura, are others; affected only in a modified degree. They bend to the assault, but are not cut down by it. They become feeble and irritable ; the sleep is disturbed ; the tongue white in the morning ; the appetite impaired ; the smallest exertion fatigues them, and accelerates the pulse; and in this state they remain for weeks together, and at length • recover without any formal attack of fever. We have seen that the same influence of habit exists under yellow jp yellow fever ; during which the natives of those climates, where its remote we]7asain causes are in almost perpetual operation, suffer far less when it attacks tyi)hu,i' them, and are far less susceptible of its attack. But though febrile miasm issuing from a decomposition of human Typhus effluvium has a peculiar tendency to generate typhus, we have seen produced8 that the same miasm issuing from a marsh effluvium or adecomposi- from tion of dead organized matter, under a peculiar state of modification, has produced remittents with a typhous character, and sometimes specific typhus itself, t And as, in this case, the miasm is apt to and then spread more widely, typhus has by many writers been said to be oc- any^plde- casionally epidemic. When, however, the disease issues from this J"^- source, it is far more generally in temperatures too low than too chiefly in high and heated ; since, as already observed, cold, and especially 1ra{uresnpe" cold and moisture, have a peculiar tendency to depress the living power: and hence this disease is said to be almost stationary at * Essay on Yellow and Typhus Fevers, p. 515. + Kpanetns malisrntts asthenicus. SuprA. CI. in. Ord. i. Gen. in. Spec, u. /. 150 cl. in.] ILEMATICA. [°m>. i. Gkn. IV. Carlscrone, or at least to have lingered there for four or five years on -r/phus"' some occasions* Typhus Typhus, therefore, originating from different causes, and all these fever* causes modified in their action by collateral circumstances, may readily be supposed to be accompanied with very different symptoms, and to appear under very different degrees of severity. The chief varieties, however, are the two following:— a, Mitior. Nervous fever. & Gravior. • Putrid fever. a e. Ty- The first variety, or mild typhus, was called by Dr. Huxhani $e™owOI'febris to1**1 nervosa, and has hence been commonly distinguished by fover. the name of low or slow nervous fever, from the great languor and dejection of mental or sensorial power with which it is always accompanied, and on this account it has sometimes been denomi- character, nated the hysterical fever A It is particularly characterized by slight shiverings ; heavy vertiginous head-ache ; oppression at the prae- cordia ; nausea; sighing ; despondency ; coma, or quiet dehrium ; whey-like urine. Sporadic When the disease appears sporadically, it is usually under this generally form. There is nothing alarming to the patient's friends on its ac- underthis cession. The first symptoms are slight, the tongue exhibits little Progress of change, and the pulse is only a little quickened, and somewhat the disease. gmauer than usual: at the same time, however, there is great anxiety and depression of mind ; so that the symptoms do not much differ from a mild and comparatively insignificant fever of any kind operating upon a nervous temperament. But as the disease ad- vances, all the symptoms of sensorial debility become severer ; the skin, which has hitherto been mostly dry, will about the third day be covered with profuse, clammy, debilitating sweats, while the heat is still inconsiderable, and the countenance pale and sunk. The sweat is often offensive to the smell, frequently acid, and sometimes, ac- cording to Stoll, as sour as the sharpest vinegar.| About the tenth day the weakness greatly increases ; all the limbs tremble ; and the tremors soon become convulsive, with a despondency and alienation of mind, at first observable only in the night, but soon continuing with little intermission : the delirium is of the mild or quiet sort, and rarely amounts to phrensy. The disease often runs on to the twenty-first day, and occasionally Rarely to a much longer period. It is seldom marked by that sudden a crisis.1* cnan?e which can be called a crisis ; but gradually becomes more Termina- aggravated in its symptoms till it reaches a fatal termination ; or slowly advances to convalescence, by evincing a disposition to na- tural sleep; more steadiness and firmness of pulse ; a more favour- able countenance; a tongue more florid at the edges ; a firmer and * Foxe Neuen Schwed. Abhandl. Band. vm. t Manninghara: on "The Symptoms, Nature, and Cure of the Febricula, com- monly called the Nervous or Bvaterical Fever." Lond. 1776. * Rat. Med. m. p. 79. cL. m.j SANGUINEOUS FUNCTION. [ord. i. lol more collected mind ; and a returning desire for food, often indeed Gen- iv« capricious, but without nausea or sickness. SZ*£' J1' t i i-i . aE.Typhug In an anomalous and very singular case, related by Dr. Satterley,* miti»f- the desire for food, which at first was greatly loathed in whatever fever0"8 form offered, re-appeared about the fifth day with an enormous era- SiDsuIat ving which it was impossible to satisfy. Animal food was preferred, typhus. but food of any kind was swallowed voraciously; and when food was not allowed, various indigestible substances were devoured in its stead. This desire returned with every returning ingravescence of the fever, which adhered to no regular period ; and it continued as long as the ingravescence lasted, which was usually ten or twelve hours. The disease extended with numerous variations to upwards of thirty days, when the fever unequivocally subsided, and the patient gradually recovered. Of the treatment we shall speak, after considering it in its severer forms. The heavier, severer, or putrid typhus chiefly differs from the 0E.TypiiU2 mild in the violence and rapidity of its march, and the marked and ^im' undisguised character it assumes from the first. While the mild J|ver- ^ therefore commences insidiously with only slight shiverings, the heat from mild" scarcely above the natural temperature, and the pulse small, and only nye?voUgor a little quickened, the heavy typhus opens with sensible and alter- fever. nating rigor and heat, succeeded by little or no perspiration ; the pulse is tense and hard, usually quick but fluttering; pain over the forehead and crown ; urine alternating from limpid to turbid ; deli- rium succeeded by stupor, purple dots or patches, and other early signs of putrescency. From the last feature, the disease has derived its common name Called also of putrid fever ; as it possesses the additional names of jail, ind'hospita; camp, and hospital fever, from its appearing so frequently in these fever- situations : while from the purple or flea-bite spots, which last are Spotted often called petechias, or as it should rather be written petecchiae, ever' this variety has been very generally treated of at home, under the name of spotted fever, and on the continent under that of febris Petecchiai petechialis, or petechizans; sometimes, as by Follinij and Mata- j^em" rasius,} under that of febris peticularis; sometimes, as by Jacobi and Morelli,§ that of febris purpurata; while by a Castro it is termed febris punctularis;'| and by De Cermona, febris cum punctulis.fi By the Spaniards, it was hence vulgarly denominated tavardillo or tabardillo, from tavardo, a spotted cloak formerly in common use. It is a termination very common in various parts of America. These punctae or vibices, however, are nothing more than symptoms of putrescency; and are common to other fevers, and even to dis- eases without fever, as land or sea scurvy (porphyra haemorrhagica and p. nautica) as well; and hence have no ground whatever for establishing a distinct species, and still less a distinct genus, though ' Med. Trans. Vol. v. Art. xxn. f Orationes de Natura Febris Peticularis. Colon. 1722. 8vo. { De Febribns peticularibus malignis, contagiosis, &c. Mezarini, 1722. 8vo. 5 De Febra purpurata epidemica. Lion. 1641. 8vo. il Febris maligna punctularis aphorismis delineata. Tub. 1693. " Trac\ de Peste et Febribns cum punctnlis. SeTilh 1591. 6vo 152 .x. m.j ILEMAT1CA. icnxv. i. Gen. IV. they might perhaps form a variety. By most writers therefore of l&Typhu. eminence from Cullen to Swediaur, they are arranged, and treated «ravior. Gf as different forms of the same disease. feverd During the first twenty-four hours the alternate heat and cold are Diagnos- considerable ; the fever increases every evening, and in the second week the delirium usually commences; the stupor following five, six, or seven days afterwards. From the first there is a heavy and vertiginous head-ache and vomiting, the pain over the forehead shoots through the eyes to the bottom of the orbits ; the eyes them- selves are full, heavy, and slightly inflamed; the countenance is bloated; the tongue white rather than furred ; the temporal arteries throb, while the pulse at the wrist is small and oppressed ; the ears tingle ; and the mind, antecedently to the delirium, is fearfully de- jected. There is also occasionally from the weak degree of action on the surface, livid but interrupted turgescence over the whole of the body as well as the face, not unlike the mottled appearance on the skin of a healthy person when exposed to a slight degree of cold. Why re- Dr. Hildenbrand has regarded this symptom as constant and pathog- !Tiiden-by noiRic; and has hence introduced contagious typhus into the list of brand as an exanthems specifically distinguished by this spotted efflorescence,* cxunt em. wfach jje seems further to believe is loaded with its peculiar miasm. So far, however, as the present author has seen, it is an occasional rather than a necessary accompaniment, and appears to be a natural result of the cause just stated. It subsides in a few days. Balance of The balance of the sanguiferous system is generally much disturbed, fcrous"sul n'om a greater degree of sensorial debility in some organs than in system dis- others; and hence, the blood is determined irregularly, and accu- tur e * mulation, effusion, and inflammation are frequent effects. These show themselves chiefly in the head, the lungs, and the liver; but there is no organ in which they may not occur ; and they never can External occur without danger. All the external senses evince great hebe- torpid. tude, and especially the hearing, so as often to amount to absolute deafness ; the stupor is increased, and the speech muddled ; while the patient appears to dream without being asleep, and talks deli- Typhoma- riously ; thus evincing the typhomania of the ancients ; being often aucientshe unconquerably riveted to a single idea or train of ideas. And as the nervous exhaustion increases he is indifferent to every thing, feels little or nothing, and if he answer at all to an inquiry how he is, says he is very well. Acme about About the thirteenth or fourteenth day, sometimes preceded by tccnthday. an augmented exacerbation, and sometimes without any, the fever suddenly abates, a relieving dew appears on the parched skin, and all the excretories evince the same freedom from spasmodic constric- tion : the tongue loses its dryness ; the nostrils are moistened with mucus, and occasionally discharge blood ; the lungs pour forth a free expuition which softens the harsh glottis and the fauces ; the bowels if not loose, feel more refreshed after evacuations ; and the urine is more copious with an abundant deposite : and to close the whole, in the elegant language of Professor Frank," increscunt pul- * Ueber der austechenden Typhus, von J. V. Edler von Hildenbrand, &c. Wiec cl. in.] SANGUINEOUS FUNCTION. [ord. i. 15'Ii sus, mollisque unda arterium ncquali rhythmo attollit: sequuntur Gen. IV. somni placidiores, reficientes, et oblatum regrotus cibum minus /ettoSi'. abhorret."* eravior. If however no critical change take place about the fourteenth day, fe* leading distinctly to an amended state, the symptoms of putridity increase both in number and degree. There is great faintness; dif- Symptom* ficulty of respiration, intermixed with deep sobs ; the breath is hot of danger' and offensive ; acute pains in the loins and limbs; a heat upon the skin biting and pungent, rather than burning; leaving a smarting sen- caior mot- sation on the fingers for several minutes after touching it, and which dica"8, from this very peculiar effect has been called color mordicans. The tongue, whitish at first, is now dry, dark, livid, black, or of a pome- granate colour. The lips are furred with a black tenacious sordes ; the urine becomes brown or blackish with a most offensive smell; a blackish or bilious matter is occasionally thrown up from the sto- mach ; the skin is more or less discoloured, as just observed, with flea-bite shaped or broad purple spots; the stools are blackish and highly fetid. Cold, clammy, colliquative sweats and convulsions, sometimes accompanied with haemorrhage from one or more organs, soon afterwards usher in death; the period of which is extremely uncertain, and ranges from the fifth to the eighteenth day, according to the malignity of the attack, the strength of the patient, or other contingent circumstances. I have said, that the milder variety or nervous fever usually shows Thisvariety itself sporadically, originating from some other cause tban febrile j"^ J££ miasm in an-irritable and atonic habit. Malignant typhus sometimes radically. commences in the same way, but usually by a decomposition of human effluvium accumulated in a camp, a ship, or even a large single family, where the space is too small for the number, the habits uncleanly, and the atmosphere stagnant and unventilated. The cause is one, and the fever the same, varied alone by accidental cir- cumstances, or symptoms, that depend altogether upon its less or greater degree of violence. In this metropolis, therefore, malignant typhus is almost exclu- Found sively to be met with among the poor ; and the more wretched and among the destitute they are, the more readily they become its prey. I cannot Poor.and better illustrate its rise and progress, than by the following simple and why! picture as furnished by Dr. J. Hunter : it is drawn from life, and will be easily recognised by every practitioner. " A poor family, consisting of the husband, the wife, and one or Picture of more children, were lodged in a small apartment, not exceeding {J^*^ twelve or fourteen feet in length, and as much in breadth. The family. support of them depended on the industry and daily labour of the husband, who with difficulty could earn enough to purchase food necessary for their existence ; without being able to provide suffi- cient clothing or fuel against the inclemencies of the season. In order, therefore, to defend themselves against the cold of the winter, their small apartment was closely shut up, and the air excluded by every possible means. They did not remain long in this situation * De Cur. Morb. Horn. F-pit. Tow, i. p. 107. 8vo. Mannh. 1792. Vot„ JI.—?n 154 <*• m.j 1LKMATICA. l_ORi*. i Gen. IV. before the air became so vitiated as to affect their health and pro- ofs Tii ducc a fever in some one of the miserable family. The fever was eravior. not violent at first, but generally crept on gradually ; and the sick- fcverd ness of one of the family became an additional reason for still more effectually excluding the fresh air ; and was also a means of keeping a greater proportion of the family in the apartment, during the day-time ; for the sick person was necessarily confined, and another as a nurse. Soon after the first, a second was seized with the fever ; and in a few days more the whole family perhaps were at- tacked, one after another, with tbe same distemper. I have oftener than once seen four of a family ill at one time, and sometimes all lying on the same bed. The fever appeared sooner or later as the winter was more or less inclement; as the family was greater or smaller ; as they were worse or better provided with clothes for their persons and beds, and with fuel; and as their apartment was more or less confined."* Causes There are a few auxiliary causes not noticed in the above faithful ?oUhumayn delineation, which seldom fail of being present, and have always a effluvium, very considerable degree of influence ; these are, the anxiety and dejection of mind so sure to accompany such a scene of misery, and the increasing carelessness and consequently uncleanliness of person, which are equally sure to follow. And we may hence see why typhus should so frequently make its appearance in the poorest and most miserable streets of a metropolis, and be generally confined to such streets ; why it should rage most extensively and most vio- lently in times of the severest public pressure and distress ; and hence again why it should be more common in Ireland than in Eng- Advantages land, in Dublin than in London. We also see the inestimable ad- esftahiish- vantage of such establishments as Fever Houses or Infirmaries in all mems. populous towns, when built upon the sound principles, and governed by the judicious regulations, and, I may add, superintended by the active humanity and established talents which are so conspicuous in the Fever Hospital of this metropolis. j ail typhus, To describe the typhus of jails, ships, camps, and other large co°mpiex a bodies of men, we have only to multiply the single family we have enlarge- just beheld into fifties or hundreds; ever remembering, that the mentoftheJ. . . fa1 above pic- virulence of the febrile poison increases in power, not in a numen- turo" cal, but in a sort of geometrical proportion to the numbers by which it is fed. So that if five patients produce a given ratio of pestilence, ten will produce, not as much again, but nearly a hun- dred times as much. And hence we may readily account for the fearful and deadly ravage which this cruel scourge is well known to inflict upon a people when closely pressed together, and incapable of flying from its pestilential aura, a3 in crowded encampments, or a besieged and pent-up town : and especially where, as is often the case, there is considerable carnage from the casualties of war, and a deadly calm prevails for weeks together in the atmosphere. This last concomitant, indeed, gives completion to the whole ; and is a heavier calamity than it is generally conceived to be : for the most * Observations on the Disease commonly called the Jail or IJospital Fever Bv Jobn Hunter. M.D. Physician to the Army. Sec Med. Trans. Vol. in. Art. kxii. cr. to.] SANGUINEOUS FUNCTION. [ord. r. 156 fatal pestilences of which we have any account seem to have been g*n. IV. preceded by a stagnant atmosphere. Thus Maitland, in his His- /b ??»£■ tory of London, observes, " that for several weeks before the plague savior. broke out in this metropolis in 1665, there was an uninterrupted fever.d calm, without sufficient motion in the air to turn a vane." The assertion is confirmed by Baynard, a contemporary physician ; and a like harbinger, as is observed by Diemerbroeck, preceded the plague at Nimeguen. In both varieties, the prognosis must be collected from the vehe- Prognosis mence of the symptoms, and the character of the idiosyncrasy; ortSe?"" and the cure must depend upon the means we may possess of sup- porting the vital power, and restoring its lost energy. The peculiar properties by which typhous miasm is distinguished Specific from miasms of every other kind, are the rapid and direct debility ofTy^hous with which it affects the nervous system, and seems to prevent a due miasm secretion of nervous fluid, or its secretion in a state of healthful elaboration ; the activity of its leaven, by which it assimilates all the fluids of the body to its own nature, and the urgent putrefactive ten- dency it gives to every part. The last of these properties may in some degree be dependent Septic upon the first; but it does not appear to be entirely so ; since we SSS often find the sensorial power reduced to a much lower ebb, as in dependent asphyxy from hanging or drowning, suffocating exhalations or debilitating lightning, catalepsy, and deliquium from loss of blood while there is power# an almost infinitely less degree of tendency to putrefaction. And, Proofs that in like manner, although the miasms of many of the exanthems, as secretions rosalia or scarlet-fever, small-pox, and plague, are also capable of ^enb.ody tainting the secretions of the body, none of them appear to do it so taminated- completely and universally as that of typhus when in its most malig- nant state ; in which the breath, all the egesta, and all the fluids are loaded with contagion. It has been propagated by the excre- ment,* by the odour of flowers employed to decorate the dead body ;f by washing the bandages employed in typhous gangrene,^: and, in innumerable instances, by the communication of a minute drop of any of the fluids of the dead body to a punctured finger during dissection. In forming- our prognosis, and attempting a cure, these properties Ti,e«e should always be prominent in the mind ; for they Will best enable properties us to calculate the nature and result of symptoms that are present,shouia be and will guide us to the most rational and satisfactory mode of the mil!" practice. «?$£ From the debility that prevails throughout the living fibre, even tice. from the first, the pulse is feeble and tremulous, the extreme vessels andnfffusion torpid or nearly so, and the circulatory balance greatly disturbed. {-^J1"* k. Hence, we have reason to expect that effusion and congestion, or ness and an irregular determination of the blood, will in many cases be an '" early attendant: and, if there be energy enough remaining in the organs thus affected to produce any degree of re-action, that local re-action will follow, and perhaps lead on to inflammation termina- * Riedlin, Lin. Med. 1695. p. 402. t Eph. Nat. Car. Dec. Ana. yji. Till, Obs. 19? t Hennen's Principles of Military Surgery, p. 218. irregular action. 156 ex. III."j H/EMATICA. [oKD. 1- Gen. IV. Spec. II. fl'E.Typhus gravior. Putrid fever. Sometimes inflamma- tion. In what consists the best hope of cure. As a com- mon rule severe bleeding and purging to be ab- stained from. Gentle aperients; bat not emetics, unless nausea be present. Marks of congestion or oppres- sion. Is the gene- ral rule here to be departed froift' ting in suppuration or gangrene ; of which Sir John Pringle has given numerous examples. And hence there is some ground for contemplating typhus, as Dr. Armstrong has done, under the three varieties of a simple, congestive, and inflammatory affection ; this last being sometimes seated in one organ, and sometimes in ano- ther : most frequently perhaps in the brain, where Marcus supposes it to exist in every case whatever; and occasionally perhaps in some of the secreting membranes, through all of which it is con- ceived, in every instance, to extend by Hildenbrand, the rete Mal- pighi, the membrane that lines the cavity of the nose, of the mouth and throat, the tunica arachnoidea, and the mucous membranes of the stomach, intestines, and organs of urine and generation * But it should never be forgotten that the disease in every stage and variety is one and the same ; a disease of sensorial debility leading on to putrescency ; and that our only hope of cure depends on economizing the nervous power that remains, supporting it as far as we are able without farther loss, and opposing the natural tendency of the disease by such tonics as the system will best bear. On this account whatever tends to weaken the animal frame generally, or any one of its functions particularly, must, as a common rule, be carefully abstained from : and hence severe evacuations. by bleeding or purging, are among the foremost objects of pro- hibition. The bowels, indeed, ought by all means to be moved by a gentle aperient, in order that no acrimonious material may be lodged there ; but beyond this we ought not to proceed, as we shall add to the debdity without obtaining any correspondent advantage. The grateful acids of tamarinds, cream of tartar, or prunes, are preferable, if found sufficiently powerfid ; but, if not, they should be combined with rhubarb and senna. And, as the stomach is less irritable than in yellow fever, an emetic may be given whenever indicated; but unless there be a troublesome nausea, even this had better be avoided. Ipecacuan will answer better than antimonial preparations, and the evacuation should be followed with a cordial draught. But congestion, as already observed, may take place, and this too in the larger and more important organs of the animal frame, as the head, the lungs, or the liver. If in the first, there will be a sense of oppression in the brain, most commonly combined with stupor, or low muttering delirium ; if in the second, a laborious weight on the chest and a difficulty of respiration ; if in the third, the bowels will usually be found costive, the motions pale and argil- laceous, and sometimes the skin and the urine chlorotic, or of a greenish-sallow from a regurgitation of bile, morbidly secreted, into the sanguineous system. Hence the fever will be aggravated from local irritation, and the affected organ will be in danger of inflammation if not of gangrene. Is the general rule in this case to be departed from ? is blood to be taken from the system ? and, if so, is it to be drawn locally or generally ? and to what amount 1 " Ueber der austechenden Typhus. «cc. Wien, 1816. ex. in.] SANGUINEOUS FUNCTION. [ord. i. 157 We have here only left to us a choice of difficulties. Nothing, Gen. IV, as Dr. Fordyco has justly observed, is more dangerous in any fever /fl^i than its affecting one part more than another ; but in typhus the g;avior. danger is extreme; and it must be combated boldly and rapidly fever.d by whatever plan has a chance of taking it off, and however onfa"6"1' hazardous in itself, provided the hazard be less than that of the choice of disease. And hence, in this case, bleeding must be had recourse to, {"Jf ?nX*°* for there is nothing we can so well depend upon. If we have but the reason to believe that the overloaded organ is without inflammation, musfbo the blood should be drawn locally and till relief is afforded; if^^a there be good ground for suspecting that inflammation has com- rapidly, menced, and especially if the organ affected be large and important, weeding!*6 it will be better to employ the lancet; and it cannot be employed too soon, nor ought it to be relinquished till it has attained its object.* There is a risk in the practice, but there is death without Risk in the it. Fainting may perhaps take place in the midst of the operation ; breath but this is rather to be wished for than guarded against; for the without "• exhaustion of sensorial power produced by deliquium bears no com- parison to that produced by the influence of the typhous miasm, acting as a leaven throughout the system. In this state of the disease, also, instead of merely keeping the stimulant bowels open, we should employ purgatives that may stimulate and pursa ives maintain a stimulating effect upon the whole of the intestinal canal, so far as that three or even four evacuations may be obtained daily ; and calomel will be commonly the best medicine for this purpose. For such an irritation will frequently prove revellent; and the drain of sensorial power hereby produced will be trifling in comparison to that occasioned by a continuance of the local excitement it is intended to remove. Such are the exceptions, and the only ones, we should allow to Examina- the general rule of opposing the disease, by economizing, support- practice of ing, and restoring the depressed tone of the nervous system. But aBBegenerai there are pathologists, and of considerable authority, who recom- instead of a mend bleeding, and even full bleeding, in almost every instance specta ru e" of the disease, as the first step to be pursued : thus inverting the mode of practice here laid down, and taking the exceptions for the rule, and the rule for the exceptions. The theory of this recommendation is but of little importance provided it be justified by its result. At the same time I cannot The advo- avoid observing, that its chief advocates have not been able to bring suchVac- themselves to any thing like a common theory, or to support their tice not ,. ... , i-i i • agreed upon recommendation upon common principles : than which nothing common can be more unfavourable to the reception of a doctrine, or more i,rmcii>,e8' hostile to its scientific pretensions. Typhus is, by Dr. Clutterbuck, regarded, like every other kind of fever, as the result of an inflam- mation of the brain ; and blood-letting is here grounded upon the Employed principle of attacking the cerebral inflammation, and debilitating the Uv'ii'g'c the action of the living fibre. The visceral and other local con- nbre- gestions and inflammations that so often occur, arc, by Dr. Arm- * i. P. Frank, De Cur. How. Morb. Epit. Tom. I. p. 136, 8ro. Mannb. 1792. Us CL. III. J H.EMAT1CA. [0K». I. Gen. IV. Spec. II. 0E. Typhus gravior. Putrid fever. Treatment. Employed to prevent debility in the living fibre. Employed directly to invigorate the living fibre. In what manner severe bleeding is sometimes serviceable in other cases than inflamma- tion. Singular case from Van Swie- fen. Exemplified in diabetes and lyssu. strong,* regarded as precursive and generative of the sensorial debility, while the disease itself is no more derived from the brain than from any other organ. And blood-letting, under this view of the subject, is recommended as the means of preventing debility in the living fibre, instead of adding to it. " We may perhaps find," says he, " sufficient data for concluding that the nervous appear- ances, even from the very first attack, are only secondary of vascular disorder." Now, these hypotheses, discrepant as they are from each other, may be both founded upon a mistake of the effect for the cause.t And such, indeed, seems to be the general opinion of pathologists upon the subject; and hence even admitting the benefit of blood-letting as an invariable or common rule, we have yet to search for some other reason by which such benefit is to be ex- plained. Dr. Jackson thought he had found this reason in the stimulant effect of venesection upon the system at large, which, by exciting new motions, suspends or changes morbid motions, and affords room from the vires medicatrices naturae to act with a more salutary power : while, by its mechanical effect in diminishing the circulating fluid, it adapts the moles movenda to the vis movens. Venesection, therefore, upon Dr. Jackson's hypothesis, acts not by debilitating, or even preventing debility, but directly by invigorating the living fibre : and in this view he employed it in fevers of every kind, entonic and atonic; inflammatory and putrid ; and, in his own belief, with nearly equal success. But this is to regard the blood as an incumbrance, a dead and foreign body in its own vessels, instead of as a living and nutrient principle ; the removal of which affords ease and freedom to every part of the animal frame, and clears it for the contest in which it is about to engage. A violent and general commotion produced in the system from severe bleeding, or any other cause, cannot fail of exciting a very deep impression upon every part; and has often suspended or changed the actual train of motions, and introduced a new train in its stead; and, in various instances, the change has unquestionably been beneficial and even salutary. This is particu- larly the case in sudden and overwhelming excitements of mental emotion, which have, sometimes, abruptly cut short the career of fevers as well as of various other complaints ; of which the Baron Van Swieten gives a striking instance in a man, who, while labour- ing under a continued fever, with delirium, was so alarmed at the terrific aspect of a person that burst suddenly into the sick room, vociferating that the house was on fire, which in this case was the fact, that he rose without help from his bed, ran out of the house with all speed, and was well from that moment. To this principle of salutary change of action excited by a violent and general com- motion throughout the system, it is probable that we are to ascribe the occasional benefit that has followed upon draining the vessels of blood in diabetes and even in lyssa or canine madness. And it is possible, therefore, that copious venesection may, also, in many instances, have cut short the attack of typhus, and thus proved a * Practical Illustrations of Typhus, &c. 8to. L Appendix to his Remarks on the Constitution of the Medical Department. &c, ll. ni.] SANGUINEOUS FUNCTION [ord. i. 159 rapid and effectual remedy. But if this be the ground upon which Gen« IV. it acts, few practitioners would be disposed to recommend it; while, ^Typhus if it be not, we have no other ground that will furnish us with a gravior. satisfactory explanation. f^f In the commotion which takes place from copious venesection, otoer™viii it should moreover be observed that there are often local determina- resulting tions of other kinds or to other organs, for the more we lessen the $££*. general strength, the more we make an inroad upon the instinctive power of preserving a balance in the circulating system: and as these new determinations are almost uniformly accompanied with an apparent though a deceptive increase of force as well as of ful- ness in the pulse, and other symptoms of great violence of action, the friend to phlebotomy is too often stimulated to an exercise of his lancet through several times in succession, still wondering at the perversity of an action whose mischievous and, it may be, fatal perseverance is only maintained by his own exertions. The follow- Pring. ing remark of Dr. Pring is, upon this subject, of great value, as well as perfectly correct. " It is commonly, and in my own experience it has been invariably, the case that those who have sustained great losses of blood, suffer more or less from what is called determina- tion to the head. The symptoms most commonly are intense pain and throbbing in the forehead or back part of the head, with a pulse seldom under 90. I have known these symptoms to proceed on with a pulse from 120 to 140 to delirium, apoplexy, and death."* But the author has observed that the theory is of little importance Theory of provided the practice has justified itself by the event. How then pSrtance if stands the sum of general opinion upon this subject, even apart from the practice such occasional fatalities ? The practice is, by no means, new, ficiai. though ordinarily supposed to be of recent origin : for it has alter- of^oftlce nately lived and died away, been revived and again sunk into dis- examined. repute, for considerably upwards of three centuries ; and its advo- many1"' cates have, in various times, been as numerous and as confident, ""^-j68' and have maintained as warm a contest, as we are called upon to alternately witness at present: of which any one may convince himself who abandoned? will turn to the books referred to in proof of this assertion at the foot of the page ;| of which the first three were published in the sixteenth century, the ensuing two in the seventeenth, and the last two in the middle of the eighteenth. The work of Professor De Biichner, of Halle, was strenuously opposed in his recommendation of venesection, at Paris by Chambon de Montaux, and at Rome by Sinibaldi. Yet, as in the present day, the supporters of the de- Former pleting system had also not a few controversies among themselves, sies be- r though they were not precisely of the same description as those in ady0"altp3e our own time ; the chief point of dispute being the part of the for the * Principles of Pathology, &c. by Daniel Pring, M.D. 8vo. 1823. t Bernardi Caxanes, De Katione mittendi sanguinem in Febribus putridisffeBarce- lon. 1592.—Sylvaticus, De secanda in putridis Febribus vena quam Salvatellam dicunt, 1583.—Thurini, An in orani FeUre putrida competat phlebotomia? Rem. 1545.— Nigrisoli, Progymnasma de vena in Febre maligna secanda'! an superiori an infe- riori? Guastalla, 1665.—Suavalla, Ergo maligna; febri venesectio? Paris, 1694.— De Biichner, Diss, de Venesectione in febris acutia-inalienis. Halle, 1757.—Gilchrist. Edin. Med. Essava, Vol. iv. Art. sxui. 160 cl. ni.J ILEMATICA. [ORD. 1. Gek. rv. Spec. II. P E-Typhus eravior. Putrid fever. Treatment. Inconsist- ency of practice in Marcus. The Bum of medical opinion against it as a gene- ral tule; though highly needful in particular cases. Its expedi- ency often dependent on the state of the at- mosphere. body from which blood could be drawn with most advantage ; some practitioners performing on the arm, and others on the leg or foot; a point, however, that gradually lost its importance, as the doctrine of the circulation of the blood became more generally adopted and understood. It is not a little singular nevertheless that Dr. Marcus, who is entitled to the distinction, if not of reviving the plan of sanguineous evacuation in the present day, at least of car- rying it to a more daring extreme than any other practitioner, and of stamping its general use with all the weight of his authority, was, only a few years before the publication of his " Special Therapeutics," in which the advantages of bold depletion were first triumphantly promulgated, one of the most ardent disciples of Dr. Brown of Edinburgh, and consequently one of the warmest advocates for the opposite system of cordials and stimulation. Judging, therefore, of the expediency of blood-letting from the history of the practice before us, when enforced as a general rule in typhus, the sum of medical opinion upon a trial of three cen- turies is against it. The practice has occasionally started into popularity, but it has never been able to establish itself. In the peculiar states of the disease I have already adverted to, it may be useful, and ought not indeed to be neglected : but every case must speak for itself, and the rule must not be confounded with the ex- ceptions. And such, in effect, was the opinion of Dr. Gilchrist, as expressed in his treatise on Nervous Fevers, published seventy- years ago, in which he tells us, that at that period, " the ordinary evacuations in the beginning were bleeding and vomiting," and that it was sometimes " necessary to bleed once, and again, by which the symptoms were considerably lessened."* But he had too much good sense to enforce this practice indiscriminately, and felt the necessity of yielding to contingencies : for in many instances, he adds, " though we bleed, the symptoms are not always much abated by it; and if we bleed freely, being deceived by an appear- ance of plethora, we do harm: indeed, in general," continues he, " I imagine bleeding seldom did much good ; and if great caution were not used, I suspect it was hurtful: but as I was not often called in the beginning, I am unwilling to pronounce positively about it." The passage is well worthy of attention, as containing the free opinion of an able, candid, and distinguished writer upon an extensive examination of the subject in his own day: and an opinion, too, which is very considerably in accordance with the opinion and practice of Sir John Pringle and Dr. Huxham, and still more lately of Professor Hildenbrand, who is well known to be one of the most extensive practitioners in the disease before us, as well as one of the most able writers upon it in the present day. It should never be forgotten, however, that the expediency of bleeding must depend, not only on the diathesis of the individual, but very considerably on the state of the atmosphere. This remark I wish to enforce very strongly on the attention of practitioners, as it is derived from experience, and is of more importance than it * Edin. MkI. Essays, Vol iy. p, 281. OL. III.] SANGUINEOUS FUNCTION. |okj>. 1. 161 may at first perhaps appear to be. As inflammatory fever has, Gen. IV. sometimes, a tendency from peculiarity of constitution or accidental f j^ypjJJs circumstances to run rapidly into typhus : typhus, in like manner, gravjor. occasionally meets with incidents that suddenly reverse its character fever? and incline it to an inflammatory type. A very stimulant plan of Treatment: treatment has sometimes done this ; but far more frequently a sudden change in the- atmosphere, from hot, hazy, and relaxing weather, with scarcely a breath of air stirring abroad, to a dry, cool, and refreshing east or north-east breeze: and I have often found a like tonic effect produced upon a patient labouring under typhus in a low, damp, filthy, and suffocating lodging, upon his being removed into a large, cool, pure, and well-ventilated chamber, such as is now generally found in our fever institutions. In this case, bleeding, which I had not dared to risk, notwithstanding some symptoms of oppression, before the removal, has been practicable without any risk afterwards, and has laid the foundation of a speedy and effectual cure ; and I am inclined to think that some part of the clash of clash of opinion, which prevails upon this subject in the present capable of day, proceeds from a want of due -attention to the different states Jjjj^y n" in which different or even the same patients are placed by this dif- reconciled. ference in the purity and temperature of the surrounding atmos- phere ; and that many hospital-physicians, who are the warmest advocates for sanguineous depletion in their own fresh, cool, airy wards, would hesitate upon its expediency if they were to attend their patients throughout in their own close, heated, and miserable habitations. It is not long since that I was consulted by a very respectable *jarther. practitioner in Hertfordshire, upon a plan of treating typhus, which was then raging with great violence among the poor of the town in which he resided. He had been a surgeon in the naval service of the East India Company : and having witnessed the benefit of early and copious bleeding in the yellow fever, had very generally fol- lowed it up in the contagion before him, and, as he frankly con- fessed to me, with a decidedly unfortunate result. My advice was, before he thought of the lancet to take care of the ventilation; and then to subject it to the restrictions here laid down, and to let every case be its own interpreter. And a letter received from him a few weeks afterwards expresses his obligations for the advice, and the success that had resulted from it. Upon this subject there is a passage in Dr. Hennen's Military Surgery so strikingly in point that I cannot avoid quoting it. After j*°5"'*l »* the famous battle of Vittoria, in July 1813, the sick and wounded m$T'm of the British and Portuguese army were chiefly removed to a tem- porary hospital established at Bilboa; where typhous miasm having soon been produced by its ordinary causes, of a foul and stagnant atmosphere, crowded wards, and depressed spirits, the sick were soon affected, and, whatever was the nature of the individual con- stitution, the wounds of all of them ran rapidly into a typhous gan- grene ; " exhibiting," says Dr. Hennen, " one of the most subtile and destructive poisons that ever infested an hospital, attacking equally the most robust and the most debilitated, and. if unchecked by Vol. II.—21 162 cl. m.j ILEMATiUA. [«hi>-/■ Gen. rv. medical aid, proceeding invariably to a fatal termination."* The lib Typhus atmosphere was, at this time, sultry and relaxing ; and greatly con- gra'vior. tributed to the general debility. " I need scarcely say," continues feuv". Dr. Hennen,t "that a remedy so strongly recommended as vene- Treatment. sectjon had early occupied our attention: but previous to the month of October the "obviously typhoid type of th« disease made us ex- tremely averse from employing it. At that period, however, a ehange in the weather from sultry to cold, and even frost (at night) took place, marked by a corresponding change in the thermometer, ivhich, at its medium range, was 20° lower than in the preceding month.—But what more than all convinced us of the change of type, and pressed on our consideration the propriety of blood-let- ting, was, that the spontaneous hemorrhages which formerly sunk the patient's strength were now accompanied with obvious relief." And he proceeds to state that from this time the practice of vene- section, on the appearance of inflammatory symptoms in a wound or newly-healed stump, became general, and was the only remedy had recourse to whether as a cure or a preventive. importance Of such importance is it for us to be guided by particular and ffuidedYioth general circumstances in the treatment, not merely of typhus, but iayrPandCU' °^ a^ diseases whatever : to let the rule have its exceptions, but not general to mistake the exceptions for the rule. " The art of physic," says Btances" Sir George Baker, " rarely admits of any perpetual precepts; and the best medicine-may do harm if not adapted to the patient as well as to the disease.";); Cold water There is another remedy of very extensive use in the cure of as a reme- tVpjluSi far iesg disputable, and which is founded altogether upon the indication of equalizing, supporting, and restoring the sensorial power: and that is, the free application of cold water, and espe- cially externally. employed This valuable medicament has been employed in some form or memoriaiiy; other almost immemorially. Hippocrates recommends it in malig- nant fevers generally in the form of epithems, or napkins wetted with cold water and applied repeatedly to the head or any other though not viscus as the cloths become warm.§ Among the later Greeks, very gem- jlowever^ jt joes not appear to have been in very general use ; and Greece" though ll is highly prized by Celsus, in various debilities, and espe- Rome. cially sensorial debility affecting the head, and combined with fever, in which, says he, " existat validissime repente aqua frigida infusa,"|| yet it does not seem to have constituted a fixed, or even a frequent Mtemafa" Practice in ms dav- In our own country it was successfully em- apphcation ployed by Dr. WUlis, in various fevers, and especially those accora- in England. panied with delirium ; and was hence strongly recommended by Sir J. Floyer and Dr. Baynard : and was used on the continent, not merely in the form of epithems,H and affusions, but occasionally in that of immersion, or cold bathing in a river adjoining the patient ** stiiieariier On the continent, indeed, it seems to have been employed at a continent. * Principles of Military Surgery, p. 19. t lb p 223 f, ffiicLrLib/'nIl'sect. „. * ^ "N— »■ P- «■ » T Mursinna uber Ruhr und Faulfieber. Loeffler, Beytrage, &c. ** Eph. Nat. Cur. Dec. m. Ann. m. Obs. 48. and Ann? v. vi. App. p. 128 ^l. m.j 8ANGI l.NEOt S Fl VTlON'. jotto. r. lu"3 much earlier period than in our own country, as we learn from Milot's Gen. IV. Dissertation, " Ergo febris frigidis et humidis expugnenda ?" printed /f|.Typhus at Paris in 1594; and Hernault's, on the same subject, " Ergo g;avior. propria febrium medela refrigeratio ?" printed in the same place in reUve"d 1630. It was also used internally as well as externally, both in our Treatment. own country as well as on the continent, especially in Spain and temaiiyas Naples, as is obvious from Dr. Hancock's Febrifugum magnum,* ^"maiiy. and Dr. Cyrillo's paper on the subject in the Philosophical Trans- actions. Even snow, or snow-water, under the name of aqua snow- nivata, or aqua nive refrigerata,-was also* occasionally employed;! wa,er' and, in the ardent fever, recommended by Paullini both externally and internally.t. Professor Hildenbrand of Vienna, during the ex- tensive range of practice which the Austrian Army afforded him in the late war, employed sometimes the cold-bath, sometimes affu- sion of cold water, and sometimes a general friction of the surface Snow with snow itself in the commencement of the fever.§ And to singular prove how torpid to common impressions the body is under nervous h0S|?h^i H° medicament! adsumpti virtus rnedica. Witteb. 1761. — I nomas, Diss, de usu Phosphor! Regiom. 1762. cl. in.J SANGUINEOUS EUNCTION. [or«. i. 167 typhus it was the most useful medicine we can have recourse to ; that Gen. IV. it procures rest without any inconvenience ; and that it is more to be ^ ^Typhus depended upon than camphor, castor, the sedative salt of Homberg, |«vior. or any other medicine of the same class.* It is best given in com- fever. bination with camphor; and there is ground for the assertion Bcs?jment' of-Lasonne and Halle, that, thus united, it produces less confusion of union with the head and disturbance in the dreams : and, so far as I have seen,campiffr' it agrees better with the young than with those of middle life. Hil- denbrand reserves it in every instance against distress from dysentery or diarrhoea. Antimonials are a doubtful remedy; they tend to throw the action Antimoni- ,i f i i 111 x-l als not often towards the surface ; but, as relaxants, they tend at the same time to useful. diminish the tone of the muscular fibre. It is not often that they can be employed with advantage. Blisters, judiciously interposed, Blisters. will be found, in many instances, a useful auxiliary, and especially where the head is much affected ; but the body should not be covered over with them, as is often the case from head to foot, so as to be highly distressing to the patient, and to exhaust the little irritability he has left. Cataplasms or bottles of hot water applied to the feet, when the circulation is unequal, will often be a better practice. Yeast, as an antiseptic, was strongly recommended to be taken Yeast. into the stomach by many practitioners about twenty or thirty years ago, and numerous cases were published of the wonderful cures which it performed. Of late it seems to have fallen into an un- merited neglect: it is a simple remedy, easily procured, and worth a more general trial. During the entire course of the fever, from the time the bowels Diet ami have been sufficiently evacuated, the patient may be allowed animalregHn( broths and jellies in alternation with the farinacea : he should be lightly covered with bed-clothes ; his chamber should be freed from all unnecessary furniture; his sheets and body-linen be frequently changed, and be instantly taken out of the room ; as should also the egestions of every kind. Above all things, the chamber should be freely ventilated, which Free venu- is infinitely the best way of purifying the air, and dissolving the fe- Ulwn' brile miasm as it issues from the body : upon which subject we have already touched. Where the ward or chamber is large, or the sick are remote from each other, simple ventilation by opening the opposite win- dows, or the windows and door, will be sufficient. But where the wards {^™«£ are small, or may not admit of sufficient ventilation, or the patients necessary. are numerous, fumigation with nitric or muriatic acid should not be neglected. At present we have no reason for a preference, except that the vapour of the former appears to be rather more volatile and penetrating. Of late years there have been attempts to decry J^'y,. the use of fumigations, and especially by M. Von Mons and Dr. Trotter, who conceive that they rather add to than diminish the sep- tic matter of the atmosphere. On which account they rather advise to sprinkle the room frequently with water, and maintain a good Clinical Experiments, Histories and Dissections. 8vo. Edinb. 1780. 16b on. m.j HiEMATICA. [OBD. I. Gen. iv. firei believing that febrile contagion is much better destroyed by /fE^'phus Pure aqueous vapour than by any other means. gravior. But this conception is founded upon a double hypothesis, and an fcJer? hypothesis apparently mistaken upon both points : first, that febrile bu't o^ftis'e miasm, and septon, or the elementary matter of putrescency, are principles, the same thing: and, next, that this common principle is nitrous oxyde, or oxyde of azote, agreeably to the conjecture of Dr. Mit- chell. Of septon, however, we know but little ; yet from the estab- lished power of hydrogene in exhausting or destroying animal irri- tability, it is more probable that M. Morveau's conjecture of its being a combination of hydrogene with azote rather than of oxygene with the same, is the real fact. But be this as it may, we have no more reason for believing that febrile miasm consists of either of these, than that it consists of animalcules of a peculiar kind, as was once contended for by Dr. Chandler. How acid Febrile miasm we have reason to believe is a peculiar and specific probably0"8 production ; the chief properties of which I have already endea- act* voured to point out. Pure air unquestionably dissolves it; and hence there may be other gases capable of dissolving it also, and even more readily ; or which, combined with pure air, may render the latter a speedier and more powerful solvent. And it is probable that the vapours of the mineral acids act in this manner. In this respect they may be useful; but if ever employed to supersede ven- tilation, the opinion of Dr. Trotter, that they do more mischief Aroma of than good, will be completely established. The aromas of volatile Tobacco, plants are of no benefit whatever ; and if the fumes of tobacco were ever serviceable in the plague, it was most probably, as Dr. Cullen conjectures, from their exhilarating the spirits like wine or opium, and diminishing the irritability. SPECIES HI. ENECIA SYNOCHUS. SYNOCHAL FEVER. COMPOUNDED OF CAUMA AND TYPHUS : IN ITS COMMENCEMENT RE- SEMBLING THE FORMER ; IN ITS PROGRESS, THE LATTER. Spec III' •*T *S n0t necessary' after our copious histories of the two prece- The most ' ding species, to follow up the present, which is a mixture of both, for'nToT throu?h a detailed description of its course. It is certainly the continued most common form under which continued fever makes its appear- ?resentndtahye. amre in our own country; for it is but rarely that cases of fever occur which preserve a strictly inflammatory character from the beginning drTacter l°the end* lt is in fact an inflammatory fever bent out of its proper career, often, perhaps, by the temperament upon which it has to act; but still more frequently, as Dr. Brocklesby has well observed. <;l. in. | SANGUINEOUS FUNCTION. [ord. i. 169 by confined and vitiated air, and hence dropping its inflammatory Gen. IV. pretensions in the middle of its course. Its causes are therefore the fn*^111" same as those that produce inflammatory fever. Dr. Cullen has synochus. entered it into his catalogue of genera after Sauvages and Linneus; feve°chal but with a doubt whether he is correct in so doing. u Since many fevers," says he, " are neither altogether inflammatory, nor alto- gether nervous, they cannot be referred either to the synocha (cauma) or the typhus: and I have hence inserted the genus synochus, whose type is frequently seen in this country. Yet between the typhus and synocha I cannot place any accurate limits ; and I doubt whether they should in fact be deemed genera, or have a different place allotted them." And in his First Lines he observes, "lam Supposed disposed to believe that the synochus arises from the same causes tobe"!6™ as the typhus, and is therefore only a variety of it." To me it ap- variety of pears rather to arise from the same causes as the cauma, for it com- but is rather mences with the cauma-type. The proper rank for all of them ap- |Xtee3"riy pears to be that of species ; and the present system in the text- cauma; book, in allotting them this character, steers just a middle course between Dr. Cullen's actual arrangement and his real opinion. And in this view it is distinctly regarded by Dr. Stoll, who sometimes describes it as an inflammatory fever assuming a putrid guise ; some- times as equally inflammatory and putrid ; and sometimes as an in- flammatory fever passing into a suburral fever.* By Kausch, and whence de- other German pathologists, it is hence denominated febris inflamma- febri^ln- torio-putrida.t It is, in many instances, the inflammatory typhus {^mmtarjj"a of Dr. Armstrong. Occasionally it shows a considerable tendency to terminate its Varies in course abruptly by a critical sweat; it is sometimes peculiarly symptoms1 marked with yellowness of the skin ; sometimes with great stupor of the head ; and sometimes with inflammatory tension of the perito- naeum. And it hence furnishes us with four varieties : a Sudatorius. Carried off by a critical sweat in an Sweating synochus. early stage of its progress. & Flavus. With yellowness of the skin, at- Yellow synochus. tended with a sense of burning heat. y Soporosus. Accompanied with stupor from the Comatose synochus. beginr \g. ^ Puerperarum. Accompanied with an inflammatory Puerperal fever. tenderness of the belly : mostly Child-bed fever. occurring on the third day after child-birth, p The symptoms of the first variety open with great violence. General There is usually an intense pain in the head with a vehement vomit- „ E8Sy- ing and purging, which is rarely removed, and sometimes aug- ^J"^ mented, by an emetic: the skin is peculiarly dry and hot. The Sweating balance of the circulating system is here greatly disturbed, and J^och lover. * Rat. Med. in. p. 97.106. 113, iv. 61. t Groner Alraanach, 1788 p. 37. Vor. II.—?2 ffO CX. XH-j HiEMATIOA. [onn, i. CrEN. IV. Spec. III. a E. Sy- nochus cudatorius. Sweating synocha! fever. Treatment P E. Syno- chus flavus. Vellow Bynochai fever. Geoerai Character. y E. Sy- nochus Boporosus. Comatose Bynochai ferer. Sydenham's Ascription. 'Treatment. o E Syno- chus puer- perarum. Puerperal fever. Child-bed fever. there is an evident determination of blood to the head, and proba- bly to the liver. Like the yellow fever, it rushes forward rapidly to a state of great sensorial debility ; and is best checked in its pro- gress by a free use of the lancet, which more than any thing else takes off the tendency to congestion, and the hardness from the pulse. A diaphoresis commonly breaks out soon afterwards, which proves critical, and should be maintained by diluent drinks, and small doses of antimonials and other relaxants. In the yellow-tinged synochus there is a high degree of he- patic irritation, and consequently an excessive secretion of bile, part of which is resorbed and carried into the system : whence Galea denominates it synochus biliosus.* It is found chiefly in the sum- mer season among young persons of a bilious habit, and is gene- rally produced, like the genuine cauma, by too violent exertion under a sultry sky. It is accompanied with intolerable thirst and sleeplessness. In few words, it is a causus or ardent fever without any apparent remission ; its symptoms, with this exception, are the same, and the same mode of treatment is demanded : for which the reader may turn to the second species of the preceding genus. While the symptoms rage violently, there is sometimes a great determination to the head, with a sudden exhaustion of sensorial power ; and hence, notwithstanding that this local affection is more severe and confirmed than in the first variety, there is a dull and ob» tuse, rather than an intense and pungent pain. It is the synochus soporosus of Guarinon and Sauvages, as well as of the present system ; and the continual fever of Sydenham for the year 1763. Among the chief symptoms, says he, was a coma, for the patient soon became drowsy and obscurely delirous. Occasionally, how- ever, it was a direct lethargy, which continued for two or three weeks, during which nothing but a violent noise would rouse the patient; when after opening his eyes, and being persuaded, perhaps, to take a little food or some medicine, he again fell into a sleep so profound, that Sauvages calls it a febrile cataphora. In some cases, however, instead of a lethargy, there was a low muttering delirium, in which the patient spoke incongruously and with fretfulness, with short snatchingsof stertorous sleep interposed. The fever rarely termina- ted in less than fourteen days ; and, when the lethargy prevailed, gene- rally ran on to twenty-one or even thirty days. The first symptom of recovery was usually a capricious longing for some absurd kind of meat or drink. The head for manv days still discovered great weakness, and even the muscles were incapable of supporting it in an erect position. Warm cordials were always mischievous : a free and repeated use of the lancet with brisk purgatives formed the best plan of cure, with diluting diaphoretics afterwards. Sauvages asserts that blistering the head was serviceable. Epithems of ice- water over the whole head, repeated as soon as they became warm, would probably have proved far more beneficial, as soon as the vessels of the head had been sufficiently emptied. We find the same fever still more frequently commencing with a like tendency to the peritonaeum instead of to the head, which runs * De Differ. Febr. cap. ir. De Criaibiw, cap. it. cl. in.] SANGUINEOUS FUNCTION. [ow>. i. 171 rapidly into a state of inflammation, with an imperfect attempt at Gen. IV. suppuration ; and especially where this membrane has been excited f"tj? by a sympathetic action with the uterus or anv other adjacent organ, <*»» i»»«- or by exposure to the atmosphere in consequence of a wound ptreT^TaV through the abdominal integuments. And hence this disea se occurs child bed occasionally in cases of tapping for a dropsy of the abdomen, and fever.' still more frequently after labour ; on which account it is commonly ffom^*5 known by the name of peritoneal, puerperal, or child-bed com»"»ed fever. From the days of Hippocrates to those of Boerhaave and tonea/in-*". Van Swieten, the uterus was supposed to be the chief seat of in- flammatiot- fiammation when the disease arises from this cause. But there is uterus now no question that it originates in the peritonaeum itself, and that £/££}*,„ the uterus is often very little affected ; and this too, though the be the chief inflammation should spread, as it often does, to other organs in the SH^i**" vicinity. The disease usually commences about the third day after deb- Descrip- very, or a wound made through the abdominal integuments by ac- ,,on" cident, or in tapping for a dropsy of the abdomen ; though some- times it occurs rather later, and, according to Professor Frank, sometimes a little before delivery.* It is marked by all the com- mon symptoms of a severe febrile incursion, in combination with the tenseness and tenderness of the belly. The muscles of the back and hips are in great pain ; the abdomen is tender, often acutely painful, and the pain is greatly increased by pressure, which peculiarly distinguishes this disease from enteritis; and as the dia- phragm is affected by contiguous sympathy, the breathing is also short and laborious, accompanied with most distressing anxiety. The head rarely suffers much at first, but in the progress of the disease is apt to become stupid and comatose. The flow of the milk and of the lochia are usually suspended, though the latter is not always so; but in this last case the discharge is thinner and more acrid. The stomach is sometimes, but not generally, troubled with sickness, and frequently discharges an offensive porra- ceous saburra ; and a troublesome diarrhoea attacks the bowels. The disease appears also at times, and by practitioners of deserved Sometimes credit, to have been confounded not only with enteritis but with ed^rth"111" simple irritation of the bowels produced by a retention of scybala, *imP,e '"'" indurated feces, or some other cause. In this last case, however, bowels. the abdominal tendeiness is usually less diffuse, and, in the com- mencement of the disease, the pulse less disturbed and the head more disposed to be affected. There is also a pretty full proof exhibited by the immediate and very sensible relief afforded by purgatives, and the very small benefit obtained by bleeding. Though there can be no question that if such intestinal irritation be suffered to continue, it may in the end prove as perilous as peritonitis itself, and even excite inflammation of the peritonaeum, or intestines, or both. To account for the inflammation of the peritonaeum, it is only J"^."'8' necessary to recall to mind the readiness with which, in particular peritoneum accoutred for. * De Cur. Horn. Morb. Too. 11. p. 189. 8to. Maaah, 1792. 172 cl. m.] HEMATIC A. [ord. ? Gen. IV. constitutions, or states of excitement from various internal or ex- f EEsyni-4 ternal causes, inflammation often takes place in interior cavities, chuspuer- anfj the rapidity with which it spreads over every part of them. Puearpue7a'i It is to this principle alone we trust in effecting a radical cure for a chSd-bed dropsy of the tunica vaginalis of the scrotum. The cavity here is fever. small, and we are not afraid of serious mischief; but were it as b^attinde'd large as that of the peritonaeum, he would be a bold operator who to in effect- should venture upon a like mode of cure, notwithstanding that the mg a cure- process 0f adhesion, so much more easily effected in the scrotum than in the abdomen, might diminish the chance of danger. Explanation In the opinion of Mr. John Hunter, the disease takes place in §!Ti!unter. consequence of an injury done to the peritonaeum, as forming a cavity, by which its present state is either suddenly changed or ren- dered imperfect. The injury done to the peritonaeum in the case of women after delivery, he ascribes, as his sentiments are delivered by Mr. Cruikshank, to two causes. Sometimes it proceeds from a want of disposition in the womb to recover itself after labour ; by which the peritonaeum, as a cavity must necessarily be affected. At other times from a too sudden emptying of the abdomen ; whence the peritonaeum cannot always recover itself so as to be properly adapted to its new condition. This last cause, he ob- serves, may also hold with men after the operation of the paracen- tesis. But, in them, besides the sudden emptying of the abdomen, there is the additional circumstance of a wound, which renders the peritonaeum, as a cavity, imperfect. When an inflammation of the peritonaeum occurs, it most frequently happens, as he still farther remarks, that it spreads over all the cavity of the abdomen. An extravasation of fluids takes place into that cavity mixed with pus. The different viscera adhere by their peritonasal coats. The intes- tines are distended with air. And the irritation, thus induced, kills the patient long before granulations or an obliteration of the cavity in the second method can occur.* These Neither of these two causes, however, by themselves will often, if we'iy'arie- ever, produce the fever before us, or even peritonaeal inflammation tCselves. alone' .For the uterus is Perpetually exhibiting a morbid enlarge- ment, without a disposition to recover itself; and the abdomen, sud- a peculiar den evacuation, while no such fever ensues. There must co-ope- mem of "bo- rate a peculiar temperament, or a peculiar condition of body at the Barman time ' -anc1, m PuerPeral patients, there is especially the general acces'sory3.: pyrectic excitement which necessarily follows, upon the very oreat change in various organs which takes place upon delivery, and the i^mleTa-" transfer of accumulated action from one organ to another. Another meToVthe accessory is also frequently found in the constitution in the atmos- atmosphere. phere ; for whatever change is most calculated to produce fever from a morbid excitement of the abdominal viscera, cannot fail to co-ope- rate in the production of this disease from a local cause. I have already observed that such a change most usually occurs in autumn and have stated the grounds on which it depends, under the history "1 epanetus autumnalis, to which the reader may turn at his leisure, t * Edin. Med. Comment. Vol. m. 322. *• See Vol. h. CI. m. Ord. i. Gen. m. Spec, n ex. m.J hANGLINEOUS FUNCTION. [ord. i. 17J And hence, so far as I have observed, a tendency to peritonaeal or Gen. IV. puerperal fever occurs more frequently at this season than at any s EEs'yno-' other ; and on this account it is said by Dr. Douglas, of Dublin,* chus Puer* M. Vondenzande and some other writers,! to occur occasionally Puerperal as an epidemy. J There is much reason, indeed, for regarding it in cwS-bed this last view ; for as most of the auxiliaries that unite in the produc- fever- tion of contagious miasm are present in a lying-in chamber, such miasm casionaHy is frequently the result; often indeed, as we have reason to believe J?"0™68 *" generated, after the manner of typhous miasm, and completely elabo- Contagious rated in the circulating and secreted fluids of the patient herself. Of g°n™rJ|£adsm this fact, indeed, we seem to have a striking illustration in the official y* in typhus. report of the malignant puerperal fever that raged so fatally in the lying- infection. in department of the General Hospital at Vienna in 1819,§ circulated under the authority of the Baron Von Mastoschek ; but there can be no longer any question, after the accounts of the disease published by Dr. Gordon of Aberdeen, and Dr. Young of Edinburgh, as it appear- ed in the lying-in infirmaries of these cities ; in which woman after woman continued to be infected to a very great extent, and especially where they had had close communication with puerperal patients, or had even been attended by nurses or midwives who had previously attended the latter without sufficiently changing their malignant dress. This disease was only subdued by the ordinary means em- ployed to exterminate contagious miasm, such as great cleanliness, repeated change of sheets and body linen, free ventilation, and a total separation of those who were labouring under the disease from those who were about to be confined.|| In all kinds of contagious fevers we find that some persons are Contagious more liable to be infected than others from incidental circumstances; finS Jo y and, as I have already had occasion to observe in laying down the puerperal laws of febrile miasm so far as we are at present acquainted with them, the miasmic corpuscles are modified in a few of their pro- perties by the accessories to which they are exposed, or by which they are produced. And by bearing these facts in mind, we shall have no difficulty in accounting for the limitation of this contagious fever to puerperal women, and the exemption possessed by persons who are not under the same circumstances. For, operative as the miasm unquestionably is where the predisposition exists and the ab- dominal organs are thrown out of the balance of healthy action, it is inert where no such predisposition is to be found, and these organs are in elastic vigour. Dr. Douglas extends this view of the case Facility of farther than many pathologists; for he conceives that women whe- the disease ther presmant or nursing, or for several months after confinement, nsyjpposed < . • -i i /. i ,- .1 i- by Douglas. though not nursing, are susceptible of the disease upon the applica- tion of contagion. H * Observations pratiques sur la Maladie connue sur le nom de Peritonite et de Fievre puerperale. Anvers, 8vo. 1821.—J. P. Frank, De Cnr. Horn. Morb. Tom. n. p. 197. f Treatise on the Puerperal Fever, illustrated by cases which occurred in Leeds and its vicinity in the years 1809—1812. By William Hey, Jun. &c, t Clark, Edin. Med. Comment. Vol. in. § Edin. Med. and Surg. Journ. No. lxxx. p. 83. || Compare Dr. Campbell's Treatise on the Epidemic Puerperal Fever, as it Die- vailed at Edinburgh in 1821-2. Edin. 8vo. 1822. «r Report on Puerperal Fever. Dublin Reports, Vol. in. p. 145 174 ex. in.J ILEMATIOA. [OBD. I. Gen. IV. Spec. Ill, S E. Syno- chus puer- pernrum. Puerperal fever. Child-bed fover. Whether febrile miasm mo- dified or a specific contagion Imperfect attempt at suppura- tion. Inflamma- tory range often very extensive. Frank. General treatment. Venesec- tion. Cathartics. But whether the miasm thus generated be the common febrile miasm we have contemplated in several of the preceding species, merely modified in its powers by accidental circumstances, or a contagion specific and peculiar to itself, is a question which, at pre- sent, we have not the means of determining. I have said that in the inflammation which takes place, there is an imperfect attempt at suppuration. The fluid secreted or effused is usually a whey-like material, or milky ichor, or, as Mr. Cruikshank has described it, an extravasated matter mixed with pus. But Dr. Hulme* asserts that he has sometimes found genuine pus apparently secreted without ulceration ; and Dr. Meckel informs Baron Haller that he has witnessed the same very extensively.! The nature of the fluid will, indeed, entirely depend upon the vehemence and rapidity of the inflammatory process. Where this is less violent, the secre- tion, as from the surface of other mucous membranes, may be pu- rulent or even genuine pus, and has sometimes amounted to several pints; but, where more violent, it will be a milky, caseous, or whey- like serum. It is rarely however so mild and temperate in its march as to produce pus; often running on, as Dr. Hulme has observed, to a state of gangrene at once : and in some instances has been found to involve the intestines, omentum, and all the neighbouring viscera, in the common mischief, as has been abundantly established by post-obituary examinations.J And hence, the uterus itself has sometimes participated in the inflammation, and has shown pus or gangrene according to the vehemence and rapidity of the morbid influence.§ The secreted fluid, from its abundance is called by Professor Frank " acutus purulentusque hydrops," who further tells us that he has sometimes traced it in the lungs, pleura, cavity of the chest, and even in the pericardium, where these organs have associated in the iuflammation.il The general treatment of this disease should closely resemble that already laid down for the severer varieties of the malignant remittent, which it very much resembles, with the exception that the fever is continued instead of being remissive : and that the local irritation is seated in the peritonaeum instead of in the liver or any other organ. This inflammation must be subdued, and that speedily, or the patient will perish ; and hence, abstraction of blood and calomel purgatives are the arms on which we have chiefly, if not solely, to depend ; and both should be employed decidedly and to as great an extent as we dare. Eighteen or twenty ounces of blood should be drawn from the arm, as soon as possible after the commencement of the disease, and repeated within twelve hours if necessary and the strength will allow : but if venesection have not taken place before the third day, the debility will have gained so high an ascendancy, and the general symptoms put on so putrescent a complexion, that little benefit is to be gained from it. The bowels should at the same time be moved by six or eight grains of calomel given in the form ♦Treatise on the Puerperal Fever. t Epist ad Haller. Script. VoL hi. i Hulme, ubi supra. De la Roche, Reeherches, &c. 5 Bane. Act. Soc Haffn r De Car. Horn. Morb. Epit. Tom. u. p. 1%. 8yo. Mannb; 179* vl. in.j vSANGUINEOUS FUNCTION. [okd. i. lid of a pill; and the same preparation, to the amount of three or four Gen« iv- grains—Dr. Douglas advances the dose to not less than ten grains f e"',"?' —should be continued every six hours till the tension and soreness chus P"ei- of the abdomen have abated. And it will often be useful to accom- Puerperal pany the calomel with one or more doses of castor oil, or the essen- cbfid-bed tial oil of turpentine, or both combined. fever. Dr. Vanderzande depends upon a free exhibition of calomel with- calomel"*" out venesection, which, after the manner of Or. Hamilton of Ips- wich, he unites witli opium ; and he boasts of the certainty of suc- cess which this treatment has developed ; though in conjunction with opium and calomel he sometimes employs mercurial friction.* There can be no question of the benefit of a liberal use of calomel in an early stage of the disease : but to let it supersede the use of the lancet, is to abandon our first chance of success, and to en- counter an unnecessary peril. It happens not unfrequently, however, that the patient's frame ^evilhebri ; is so weak and delicate that we should risk more by drawing blood some cases! generally than even by leaving the case to nature ; as it does also that the stomach and bowels are from the first in a very high degree of irritation, with violent purging and vomiting, and will not bear any additional Stimulant. Our wisdom is here to yield to circum- stances, and let the general rule admit of particular exceptions. Instead of the lancet, we should have recourse to leeches, and in ^"^ion. this manner remove twelve ounces of blood at the least; and unite Opium. opium with smaller doses of calomel. It does not follow that calomel in such a combination will increase the irritation of the stomach or bowels ; I have often seen the contrary ; and that by the exhibition of two or three grains with one grain of opium, repeated every five or six hours, the irritation has yielded to the commencement of a new action. It is also in such cases of extreme debility that the essential oil ^f^ur- of turpentine has often been found highly beneficial when em- pentine. ployed internally by itself; for while it operates as a mild aperient, it acts as a counter-irritant, and hence directly influences the morbid state of the peritonaeum, while the pulse is supported by its stimu- lant power, and a pleasant moisture is sometimes diffused over the surface. It is in truth, with the exception of camphor, the only cordial we can safely venture to employ. For the purpose before us the dose should be about two drachms ; which may be repeated every two or three hours.j Warm and anodyne fomentations to the abdomen are usually Jj'0,m®n,'v prescribed at the same time, and are often found palliative, particu- larly the essential oil of turpentine, which may be used externally as well as internally; but the common mode of applying them makes the bed wet and gives great fatigue to the patient. And f^luZt hence, I have ordinarily prescribed a large piece of folded flannel mode of wrung out forcibly in as hot water as can be borne, to be applied app lcatlon * Observations pratiques sur la Maladie connue sur le nom de Peritonite, ou de Fievre puerperale, &c. 8vo. 1821. t See Edinb. Med. and Surg. Journ. 1822. p. 53P. Communication from Dr. Hv Paine. 176 ct. in.J ILEMATICA. [oKD. I. Gen. IV. Spec. III. & E Syno- chus puer- perarum. Puerperal fever. Child-bed fever. Diapho- retics. Camphor. Cold epi- thems to the abdo- men instead of warm. over the whole of the pubes and abdomen, and covered by a broad flannel or linen swathe passed under the loins and folded over the epithem of reeking flannel, which is to remain for many hours, or till it becomes dry, as all that is wanted in this application, as in a common bread-and-water poultice, is warmth and moisture ; the flannel answers the purpose as well as the bread ; and whilst I do not recollect a single instance in which this application has not been soothing and serviceable, I have never met with a case in which a chill has been complained of. In the mean time, a diapnce or breathing perspiration on the sur- face should be attempted by small doses of ipecacuan, or Dover's powder, and with the addition of a solution of acetate of ammonia ;* and if the debility be very considerable, we may employ free doses of camphor, beginning with half a scruple, and proceeding to half a drachm at a time, every four or five hours, with great advantage. If this plan should not answer, and the skin be still hotter, drier, and more pungent to the touch, the pulse quicker and more wiry, and the tongue deeper furred, it may be adviseable to exchange epithems of hot for those of cold or even ice-water, as already re- commended in cases where the head is chiefly affected instead of the peritonaeum. I freely confess that I have not tried this plan myself hitherto, but it is strongly recommended by Loeffler and other physicians of great repute ; and as it is a practice in common use in our own country in the case of flooding, without any evil resulting from it, we have no reason to expect any evil in the case before us ; for the sensibility is here still more obtunded than in flooding, and nearly as much as in deliquium. * Beytragc sur Wondarzneykunst. Band. I. CLASS III. HJEMATICA ORDER II. PHLOGOTICA. INFLAMMATIONS. FIXED HEAT AND PAIN OR SORENESS; INCREASED SECRETION; LKSIOA OF A PARTICULAR PART OR ORGAN ; MOSTLY ACCOMPANIED "WITH FEVER. The diseases comprised under this order are sometimes called ClassIH. Local Inflammations; as the term General Inflammation is, by a •phe'spe- ' few writers, and particularly by Dr. Fordyce, applied to Cauma or c.ieB some- Inflammatory Fever. In the present text the ordinal name made local in- choice of is phlogotica, from Qxeya, "incendo," " ango." Lin- fj*™™11* neus employs phlogistica from the same root; but as the chemists Phlogotica have long since laid hold of phlogiston, and the term, though lately tTeyordfnai" disused, has a chance of being restored, the derivative phlogotica term- seems preferable. Dr. Cullen has phlegmasle, after Galen and Sauvages; but as phlegmasia, and phlegmatic, from the same source, import, in common medical language, a very different and almost an opposite idea, the author has also purposely passed by this term in order to prevent confusion. The nature of the fever Nature ot accompanying the inflammation cannot enter into the definition ; depends1 for this wUI vary with the nature of the inflammation itself, and ",pe°"nflaara?f not unfrequently with the structure of the organ. But we may mation. make this observation, that the symptomatic cauma, or symptomatic inflammatory fever, seems to have followed the fortune of this fever in its idiopathic state ; and to be as much less common in the pre- inflamma. sent day, compared with what it was formerly, as we had occasion a°iessefr" to observe the simple cauma is when treating of that disease. Such ^m"ttacn0tn'' is also the remark of Mr. Hunter. "I believe," says he, "wethanfc*- have much less occasion for evacuations in inflammation than there merly; were formerly ; the lancet, therefore, in inflammation, and also purgatives, are much more laid aside."* When an inflammation takes place near the surface of the body, j£lnamm^" there is not only heat and pain, or soreness, but more or less ascertained swelling, hardness, and redness, and we hence infer the existence Zrt.ed.e*v' * On Blood and Inflammation, p. 227 Vol. II.—23 178 cL.m.j HEMATIC A. L*»">-"• ClassHI. of these last symptoms in inflamed parts which he beyond the reach Order II. Qf vjsion. laalmml-' Inflammation in most cases appears to begin at a point; for, at ortfn and the commencement, all the local symptoms lie within a very small progress of compass. The spreading of the inflammation is owing to continued ■nflamma- thv^ the surrounfjing parts participating with the point of irri- tation ; and in proportion to the health of the surrounding parts and constitution, this sympathy is less. The act of inflammation seems to consist in an increased action of the vessels ; mostly, if not altogether, of the extreme vessels; for wherever inflammation appears, it may be confined to a point Mostly be- in which none but the smallest vessels can exist. Independently lan9iHar^s of which, we have already had occasion to observe that the capil- SdVhy!'' laries are endowed with the property of contractility, and conse- quently are more capable of sustaining the phaenomena of inflam- mation than the arterial trunks. Commences The first act of the vessels when the stimulus which excites in- Md..'ac-: flammation is applied, Mr. Hunter supposes to be precisely similar SlthTen-t0 a °lush ; and t0 consist m a simple distention or increased dia- Oe glow.0"" meter beyond their natural size ; such as we see takes place on the application of a gentle friction, or of gently stimulating medicinesr to the skin ; and the consequence of which is a warm glow, when limited to the degree we are now supposing; but which, if carried farther, would be followed with excoriation, suppuration, and ul- ceration. Coaguia- The inflamed vessels, being thus enlarged and irritated, begin to jinnwtnph separate, from the blood they contain, some portion of its coagulating separated: lymph, together with some serum, red globules, or whatever other fluid the vessels may be loaded with; and to throw these materials out on the internal surface of the part inflamed; probably through the exhalants, or, perhaps, through new vessels which may be now ami pro- forming around them ; whence the sides of the cellular membrane, hesions," which receive the effusion, become covered with it, unite with the opposite sides with which they are in contact, and thus form the first foundation of adhesions. " It appears," says Dr. Lucas, " that whenever the vessels act with unusual force, there is a ten- dency in the coagulating lymph to separate from the other consti- tuent principles of the blood—by the effusion of which, as the most sanguineous part of the blood, it is probable that the circulation of the remaining part is facilitated, independent of the relief obtained by the diminution of volume."* We may at least hereby readily account for much of that diminution of pain which often takes place together while the swelling still continues, or is even augmented. The in- creased creased bulk of an inflamed part is produced chiefly by this effusion ; andkrie anc* *^e increased redness, partly by the larger quantity of blood vessels. continued in the distended old vessels, and partly by the production of new vessels formed out of the coagulable lymph thus extrava- aated ; and which, by innumerable inosculations and adhesions, interpose a check to suppuration, which would otherwise most pro- bably take place. * On the Principles of Inthmmation and Ferer, «<-,>. I»2? -'».. m.J SANGUINEOUS MiNOTION. {ord. ir. 17y Inflammation, therefore, consists in an increased impetus and Class III. accumulation of blood in the vessels affected, accompanied with a Phwotic".' proportionate swelling and sense of heat. The pathologists have ipflamma-' pretty generally concurred in ascribing this accumulation of blood Hence to an obstruction of some kind or other; but they have differed inflamma- upon its nature and origin; and have not been able to determine ceased" whether it be dependent upon the crasis of the blood itself, or the L'ndaccu- resistance of the vessels that contain it. muiation of Generally speaking, however, it has, by all the schools of medi- Accounted cine, been ascribed to whatever has been supposed to be the proxi- ob'struction. mate cause of fever : and hence the humoral pathologists attributed Proximate it to a Ientor or viscidity of the circulating fluid; and the corpus- obstruction cular, to an error loci, concerning both of which we have already ^'"'"f1 treated; the cause of obstruction, in the view of either hypothesis, Doctrine of being seated in the nature or misdirection of the constituent parts rafiJt":mo" of the blood itself: while Dr. Cullen refers it to the same kind ofof »hecor- spasm which he regards as the proximate cause of fever ; and hence Hans" a derives the obstruction from a constrictive resistance in the vessels of CuUen' of the part affected : which, he farther supposes, forms but a mere link in the tensive chain of a phlogistic diathesis, which more or less runs through the entire habit at the time of inflammation, and con- stitutes the predisposition to its rise and progress. " That a spasm," says he, " of the extreme vessels takes place in inflammation, is presumed from what is at the same time the state of the whole arterial system. In all considerable inflamma- tions, though arising in one part only, an affection is communicated to the whole system ; in consequence of which an inflammation is readily produced in other parts besides that first affected. This general affection is well known to physicians under the name of diathesis phlogistica. It most commonly appears in persons of the most rigid fibres; is often manifestly induced by the tonic or astringent power of cold ; increased by all tonic and stimulant powers applied to the body ; always attended by hardness of the pulse; and most effectually taken off by the relaxing power of blood-letting. From these circumstances it is probable that the diathesis phlogistica consists in an increased tone or contractibility, and, perhaps, contraction of the muscular fibres of the whole arterial system."* To the first two of these hypotheses the same objections apply objections that we have already seen apply to them as causes of fever. That ^hypo- an error loci occasionally takes place, or, in other words, an entrance those*. of red or otlier particles of blood into minute vessels to which they do not naturally belong, is unquestionable ; but then this is rather a secondary than a primary link in the chain of inflammation, and consequently an effect rather than a cause, as we shall presently have to notice more at large. Yet the hypothesis of Dr. Cullen does not seem to be more satisfactory, and is especially open to the two following objections, to sav nothing of various minor difficulties with which it is attended. * Pracf. of Phy*. Vol. iv. Sect, ccxi.vu. 130 CL. III.J IL-EMAT1CA. [ord. ir. Class III. Order II. Phlogotica. Inflamma- tions. Objections lo Cullen's hypothesis. Its incon- gruity. Difficulty in his own ex- planation. admitted by Cullen. At variance with the common phenomena of inflam- mation ; which oc- cur more frequently in atonic than ento- nic habits. It supposes, in the first place, as a general rule, that inflammations of every kind, however minute and circumscribed, are dependent upon a particular habit of body at the time, distinguished by the name of a phlogistic diathesis. But we see inflammations occurring in habits of every kind, and varying in many of their features ac- cording to the variety of the habit; and we see them also arise in individuals who have no such phlogistic habit or diathesis as is here referred to. And we often, moreover, see examples of this very diathesis operating upon individuals for years, without producing any such effect as inflammation in particular parts. And we can- not, therefore, regard such a diathesis as a proximate cause of in- flammation in general, though it may often be so of a particular kind of inflammation. Dr. Cullen, indeed, was aware of this difficulty, and even admits it. " Such a state of the system," says he, " seems often to arise and subsist for some time without the appa- rent inflammation of any particular part; but such a state of the system renders it likely that a spasm may, at the same time, readily arise in any of the extreme vessels, and a particular inflammation be there produced. It does, however, appear, also, that the general diathesis frequently arises from inflammation begun in a particular part."* Now this is not only to admit the difficulty but to fall prostrate before it. It is to admit what at once settles the entire question. The cause and the effect are made to change places: and the phlo- gistic diathesis is as broadly stated to originate from inflammation in a particular part, as inflammation in a particular part is stated to originate in the phlogistic diathesis. But, secondly, this hypothesis seems not only to be chargeable with incongruity, but to be directly at variance with the ordinary train of phaenomena by which inflammation is accompanied. That the habit here alluded to under the name of diathesis phlogistica exists, and that very frequently, is not to be questioned; and Dr. Cullen has very lucidly described what is ordinarily meant by it. " It seems probable," says he, " that the diathesis phlogistica con- sists in an increased tone or contractility, and perhaps in an in- creased contraction of the muscular fibres of the whole arterial system ;"—" it appears most commonly in persons of the most rigid fibres." But I believe it will be found by every one who investigates the subject, that so far from this being the habit of body in which inflammation is most frequently to be met with, it is that in which it occurs more rarely than in many others. That it occurs in it at times is unquestionable, for inflammation under some form or other occurs in habits of every kind . but if we look for specimens of larger or smaller inflammation, of deep-seated or superficial nay even of suppurative or ulcerative, we shall meet with them if I mistake not, far more generally in constitutions marked by mobile and irritable than by firm and rigid fibres ; in habits characterized by atonic rather than by entonic action. It is not till the constitu- tion has been broken down, and the liver rendered feeble and torpid Loc. citat. vl. m.J SANGUINEOUS FUNCTION. [ord. u. 181 by the influence of a tropical sun, that hepatitis makes its appear- Class III. ance in its ordinary course of attack; phthisis occurs in relaxed S™*"'. and delicate, and not in hardy and robust frames: psoas abscess, inflamma-' peritonaeal inflammation, struma, and those vast formations of pus lI°"5 which are sometimes found in parabysmic tumours or physconies, for the most part follow the same track ; while the best, if not the only remedy for the innumerable host of erythematic inflammations, whether erysipelatous, gangrenous, or vesicular, pernio or inter- trigo, is to raise the part or the constitution to that scale of vigour the reduction of which is well known to form a common predisposi- tion to all of them. That there may exist such a condition of body as an inflammatory diathesis, or a predisposition to inflammatory action of some kind or other, according to the idiosyncrasy or esta- blished habit, or some controlling accident, is unquestionable ; but such a diathesis cannot be made synonymous with the phlogistic diathesis as described by Dr. Cullen, unless there be but one kind of inflammation, and that such an inflammation as has a natural and necessary relation to the entony and rigidity of fibre which is here presupposed. The little that we know upon the subject may, perhaps, be com- Summary prised in a few words : the standard of firm health is the best tmwn'w guard against inflammations of every kind, or the state in which up°;>tne a man is least susceptive of them ; and a deviation in either direc-B tion, whether towards a habit of entony or of atony, capacities him for breeding them. But it does not capacify him equally : for in the latter case they are produced far more easily and generally than in the former. In fibrous entony, obstruction appears to take in a.n en- place, and inflammation to follow, from an increased tendency to of^brcf? contraction and rigidity in the muscular tunic of the arteries gene- rally, and an actual contraction in those of the part affected ; in consequence of which the diameter of the tube is diminished, and the blood, though urged by a stronger impetus from behind, works onward with less freedom than usual. In fibrous atony, obstruction in an atonic takes place from the relaxed and yielding state of the vessels which slate" admit grosser corpuscles of the blood than what naturally belong to them, and thus become accessory to the error loci of the Boer- haavian school. But a mere error loci is not sufficient for inflam- mation ; since the erratic corpuscles are readily forced back, or pass diagonally into larger vessels from the numerous anastomoses that prevail in the arterial system. Of this we have a pertinent illustrated. example in the red suffusion which frequently takes place in the tunica albuginea of the eye ; which is often an effect of weakness alone, is unaccompanied with heat or pain, and consequently with inflammation, and perhaps passes off by the next day. In addition, therefore, to the relaxed state of fibres and the error loci before us, there must be something of that irritability which is so frequently an attendant upon relaxed and mobile organs, and which produces spasmodic and contractile action in a far higher degree, though, perhaps, in irregular fluxes and refluxes, than any habitual firmness or rigidity of fibre does at any time. And as in weak parts or habits a peculiar susceptibilitv of irri-In b°th R 1 l ' peculiar 1S2 CL. III.) ILEMA'flCA. [OUD. 11. ClassIII. tation seems to be a necessary adjunct in the production of inflam- pwo^otic"' mali°n->it; is possible that it may be equally necessary in the opposite inflamma-' state of excessive firmness and rigidity of fibre ; since this also, as susccptibiii just observed, will, at times, continue for years without giving rise to ty of irrita. any inflammation whatever, and seems equally to demand an ex- citing accessary. And hence the real inflammatory or phlogistic diathesis, constituting however a remote, more properly than a proximate cause, is perhaps to be found in increased irritability of the living fibre rather than in an increased rigidity and vigour. Chief dim- The great difficulty in the subject is that of reconciling the in- rec'Snciiing creased action which seems to take place in the vessels of an in- an increased flamed part, with the general intumescence of such part, and, as is vessels with commonly conceived, the augmented diameter of the inflamed ves- acrionTd se's themselves ; since the ordinary effect of increased arterial action seems to be that of an increased contraction, and conse- quently a diminished diameter of the affected vessels which would lead to an extenuation, rather than an enlargement of the inflamed Hence an part. And hence a directly opposite view of the subject has been hypothesis taken by many pathologists of deserved authority in our own day, which who have regarded the proximate cause of inflammation, as con- decfeaTo sisting in a decreased instead of an increased arterial action, and action*"1' consequently as evincing a lower instead of a higher degree of con- tractility. Upon this hypothesis the inflamed arteries give way too readily to the impetus of the blood from the heart, and the part affected becomes swollen from the excess of blood that flows into it, and acquires additional heat and redness from the same cause. This hy- There is something highly plausible in this explanation ; and plausible at those who wish to trace it farther may find a very neat and interest- first sight; mg statement of it in Dr. Bostock's valuable Elementary System of Physiology.* It was first advanced by Vacca, an Italian physio- and ably logist, about the middle of the last century, and has since been sup- =upp°"c p0rte{j by Mr. Allen in his lectures at Edinburgh, by Dr. Parr, Dr. Wilson Philip, Dr. Thomson, and Dr. Hastings. I have said that there is something highly plausible in this hypo- But only thesis at first sight. Beyond this however its plausibility does not first'sight.01 proceed ; and hence these respectable authorities, while they agree insur- in the main principle of diminished action of the capillary arteries. objections differ widely concerning the actual state of the vessels, and parti- t0 il- cularly upon the question whether the velocity of the fluids they Does not contain is diminished or accelerated. Let these effects however the chief °r be as they may, the hypothesis, as it appears to me, equally fails in symptoms, accounting for the heat and the soreness or pain which are essential characters of inflammation, and which accompany it from its com- mencement. As those of The augmented heat is accounted for from the accumulation of heat6*8"*1 a larger proportion of blood. But a mere accumulation of blood can produce no such effect. Its natural temperature is 98° of Fahrenheit, and, however it may be congested, it cannot without wine other change, give forth a heat of 99° or 100°. In the exer« * Vol. i. p. 420. 8to. 1P24. cl. iii.J SANGUINEOUS FUNCTION. (okd. u. Ibii cise of walking or running the increased heat produced is the result Class III. of increased action ; and so far from being that of increased accu- JiSjJfiii' mulation of blood, the heat continues to augment as the blood, in inflamma-' conjunction with the other fluids of the body, continues to diminish.t,ons' The soreness or pain is ascribed to the distention. But distention and p*'" or in vessels or organs of any kind that are in a state of relaxation, 'iO^ern08S• and possess little contractility, produces no pain or soreness even when carried to an extreme : while in the case before us these symptoms, as just observed, show themselves from the first, and are even most severe when the distention is least of all. But independently of these objections, both the existing causes and the treatment of inflammation seem far better to coincide with the idea of redundant than of defective action ; and the case upon this point is put so candidly by Dr. Bostock that the reader will thank me for substituting his words for my own. " All those cir- other ob- cumstances," says he, " which we are usually in the habit of consi- JBostock.b7 dering as stimulants excite inflammations ; and where the same effect is brought about by sedatives or by agents of a more powerful operation, still we can generally perceive the existence of what has been termed re-action, which is the immediate precursor of the change in the state of the circulation. In the same way the reme- dies for inflammation appear to me to be more adapted to remove or relieve an excess than a defect of vital energy, as for this purpose, except under peculiar circumstances, we always apply either direct or indirect sedatives, and find stimulants to be as injurious as the others are beneficial. For these considerations I am induced to recur to the former idea of increased action being the proximate cause of inflammation, or at least as being essential to it, and to inquire whether there be no correct method of combining a state of increased action with distention of the vessels."* In the prosecution of this inquiry Dr. Bostock observes that the Suggestions distention must be produced by an obstruction of some kind or fng axway,n" other, and he suggests that the cause of such obstruction may be **"> «i'ffie«'- derived either from the contained fluid, or the containing vessels, am on The first he seems to think may be produced by an actual increase 'ancct;0"ed of fibrin or a greater tendency in its usual proportion to coagulate, occasioned by the inflammatory action itself; or by some new ar- rangement in respect of the sanguineous globules so that they may coalesce or be more strongly contracted together. And the second may spring from a relaxation in the minute arteries augmented in proportion to the vigour of their contraction so as to admit the fibrin and the globules of the blood into vessels which have hitherto been impervious to them, where they must necessarily become im- pacted from the vis a tergo on the one hand, and the decreasing diameter of the minuter vessels opened into on the other. Future experiments and inquiries may find no small degree of ^j^"^1 truth in the one or the other of these suggestions. But it should in proof not be forgotten that increase of action by no means necessarily {{j,*1 dnlutg*n" imports increase of strengtli, and that the motific or contractile follow upon * the com- mon hy- * Elementary System of Physiology, p- 426. fn^JfT 184 ClassIII. Order II. Phlogotica. Inflamma- The con- traction of muscular fibres not continuous but with alternate pauses. Such pauses or relaxa- tions more prolonged and obvious in debilita- ted organs; the more common condition of inflamed parts. Capillary vessels peculiarly subject to such in- creased al- ternations, und why. CL. III.J HAEMATIC A. [ord. ii, Hence the difficulty solved. Remote causes. Accidental violence. Local irritation. power communicated to the muscular fibres never flows, even in o state of health, in a continuous or interrupted tenour, but with an alternation of jets and pauses. Upon this subject we shall treat at some length when examining the morbid actions of the nervous system, as well in the Proem to that class as under several ot its subdivisions, particularly the genus clonus or clonic spasm;* where we shall show that in weakly habits, in which a morbid increase of nervous action must frequently take place, the more violent the jet and consequently the contractile effect that ensues, the more pro- longed and complete the alternating pause, and consequently the relaxation in the same fibre ; excepting in cases of rigid or entastic spasm, which will be explained in its proper place. And hence the very fact of increased contraction paves the way for a subsequent and alternating dilatation, and this too in proportion to the violence that the contraction exhibits ; since the stream of nervous power, thus communicated by jets from the sensorial fountain, is expended instantaneously and before the next supply arrives. This must be the result in all cases of inflammation, whether the part affected, or the whole constitution, be in a state of atony or of entony. But as we have already shown that inflammation far more generally takes place in the former than in the latter ; and, as we have shown also, that the capillary vessels in which inflammation seems to com- mence, are endowed with a far higher proportion of contractile power than the larger arteries, it must follow that the morbid irre- gularity of action which exists of necessity in the vessels of an inflamed part, by such sudden and alternate exhaustions of con- tractile power, and consequently such intervening periods of rest and relaxation, must lay a foundation for distention ; the posterior current of blood now rushing forwards almost without resistance into the inflamed part; where, also, it must accumulate, as, in the same vessels, beyond the inflamed limit, there is no such morbid rest and relaxation, and consequently a continuance of the uniform re- sistance of a healthy state. And when to these facts we add also the necessary intermission of the globular and larger corpuscles of blood into vessels whose ordinary diameter is too small to receive them, we can be no longer at a moment's loss to account for the phaeno- mena of an enlargement of the inflamed vessels and a distention of the inflamed part. Concerning the proximate cause of inflammation, however, there is yet much to be unravelled. Of its remote causes and a few of its laws, we are in some degree better informed. The remote causes may be contemplated under the three following divisions : First, some accidental violence applied to a part, so as to make a wound or bruise from which it cannot recover except by the pro- cess of inflammation, or which at least, has a natural tendency to excite such a process. Secondly, some irritation which does not destroy the texture of the part, but merely its natural action ; as pressure, heat, cold, blisters. pungent applications, and often fevers of every kind. * CI. Iv. Ord. in. Gen. n vl. m.j SANGUINEOUS FUNCTION. [ord. ii. 186 Thirdly, a particular disposition to inflammation, founded, per- ClassIII. haps as we have just observed, in an irritability in the morbid part g^JJ- itself, and which we often behold in constitutions of the best state of inflamma-' health ; affording proof that the general habit is not, in such cases, Particular concerned in the morbid change. Inflammations from any of these disposition causes, will, however, partake of the character of the constitution; matioT' and hence proceed kindly or unkindly, according as the constitution is in a diseased or a healthy condition. Yet the general principle inflamma- of inflammation is the same in all; for we can only contemplate it |f™ tl£ as a remedial process, an instinctive effort, or exertion of the vis principle; medicatrix naturae, to bring about a reinstatement of the parts nearly to their natural functions. Yet, though inflammation is uniformly the same in its principle, it yet differs often differs widely in its mode of action, and consequently in its ,onf,£™00nd.e result; for as .it has a tendency to partake of the character of the constitution, and especially where it is extensive, according as the constitution is healthy or unhealthy, so will be the nature of the in- flammation and the diversity of its progress. Healthy inflammation consists probably of one kind alone, and is Healthy no farther divisible than into different stages of a restorative action, «0flna.mma" the effect of an instinctive stimulus rather than of morbid irritation. Unhealthy inflammations consist of many species, for numberless are Unhealthy the diseases that affect the health of the constitution ; and conse- t?0flnamma' quently that may influence the character of the inflammation, by su- peradding peculiarities or specific actions of its own : though it is often affected also by the particular condition of the part in which the inflammation takes place. And hence it is no uncommon thing for illustrated. particular parts to run into particular inflammations with the cha- racter of which the constitution has little concern ; such as those that are occasionally found on the skin, particularly the erysipelatous, as they are commonly but not quite correctly denominated, and .which we shall presently have to describe under the name of erysipelatous erythema. Simple or healthy inflammation is capable of producing three dif- Three ferent effects, which, where the whole take place healthily, follow in enfcts'of regular order, and constitute so many stages. These are adhesion healthy jn- of the parts inflamed, suppuration, and ulceration ; to which three adhesive1!"1.' different effects Mr. Hunter has given the names of the adhesive, the J"1epuarnld" suppurative, and the ulcerative inflammation. ulcerative. There is good reason for this division into different heads; for Good although, where the whole take place healthily, they follow in the ce0n8tem-fo1 order now enumerated, yet the whole do not always take place U^"5," either healthily or unhealthily ; nor is the order thus enumerated in three effects every instance attended to. For pus, as we shall have occasion to ^es'oT3' observe more largely hereafter, is often produced where there is no stages. adhesive inflammation; and ulceration, where there is neither adhe- sion nor suppuration : while occasionally the suppurative and adhe- sive inflammations take place simultaneously; the former being hur- ried on before the other has completed its own bounds, as is often the case in peritoneal inflammation after child-birth. The degree of violence also with which the inflammation commences, produces VoT. TT — S-i. 186 ci. m.] ILEMATICA. 1™D- TI ClassIII. a considerable influence upon these points ; and the nature of the pKoSc"' parts themselves still more. ..... fin inflamma- With the nature of the parts that constitute the chief held.-, oi in- ,10"s' flammation, it is of high importance that we should make ourselves deeply acquainted from the first, that we may be able to determine concerning the particular course the inflammation is likely to run, and regulate our treatment accordingly. And it is of still farther importance that this subject should be attended to on the present occasion, because it is on this distinction of parts, producing a natu- ral tendency to distinct inflammations, that the genera of the order before us are principally constructed. nmtei'a The whole of the observations of Mr. Hunter upon this interesting uons'on'the point are entitled to the most patient study, and cannot be too closely S?brl"vaiue committed to memory. In the present place I can only remark, that, 6' in treating of inflammation, he divides the body into two parts : firstly, the circumscribed cavities, organs, and cellular membrane which connects them ; and, secondly, the outlets of the body, commonly called mucous membranes, as the ducts of the glands, alimentary canal, and similar organs. He distributes inflammatory affections, as I have just observed, into three sorts, adhesive, suppurative, and Adhesive ulcerative. Adhesive inflammation belongs chiefly to the former of iion,^bere the above two parts of the body, wliere they are deeply seated; and seated appears intended to take place for the purpose of preventing suppu- ration. It applies, therefore, peculiarly to that genus of the present order which we shall denominate empresma, and which will embrace the visceral organs, allowing for one or two exceptions that are oc- Suppura- casionally interposed. Suppurative inflammation belongs chiefly to chiefly "'" tne same division of parts placed near the surface; and consequently seated. applies to the two genera here denominated phlegmone and phy- uicerative, ma, embracing small cutaneous abscesses of various kinds. The ebiefly ulcerative inflammation belongs chiefly to the second order of parts, seated. as the mucous and serous membranes and outlets ; and hence applies principally to the genus erythema, or inflammatory blush ; often, but improperly, called erysipelas, which is an exanthem or eruptive fever, accompanied with erythema. It also applies to that peculiar inflammation which characterizes the whitloe, and will be found in the present derangement under the genus phlysis. Deep-seated suppurative inflammations and abscesses cannot well be placed in either of the genera we have thus far noticed ; and have a claim to be considered by themselves. They are hence included in the genus apostema, with which the order will be found to open. often In circumscribed cavities, where from a peculiarity of constitution, BrKy' or the peculiar nature or degree of excitement, an inflammation is deflected from its common tendency to produce adhesion ; we often find it run on with great rapidity from one part of the cavity to another, till the whole becomes affected. We have already had oc- casion to notice this in inflammation of the peritonaeum ;* and we shall have further occasion to notice it in psoas abscess! and acute rheumatism. And we may hence account for the alarming progress f Cl. in. Ord. i. Gen. iv. Spec. m. t CI. m. Ord. n. Gen. i. Spec, it cl. m.J SANGUINEOUS FUNCTION. [ord. u. 18? of the same morbid action when it attacks the surface of arteries or Class 1H. veins, from an accidental wound, as in venesection, from true aneu- 85JJ52: rism, or from any other cause ; of which acute rheumatism seems, ipflamma- at least, occasionally to be one. The French writers, who have t,onB' studied the subject with considerable attention, are disposed to regard these inflammations as in many instances idiopathic, and have dis- tinguished the former by the name of arteritis.* But I am not Arteritis, aware of their having hitherto been found to occur otherwise than as concomitants or sequences of other affections. The inflammation of veins, by some writers called phlebitis, has Phlebitis; of late occupied more attention than that of arteries. It is occasion- mation'of ally a result of an irritated varix, and especially where such varix has »ein.9: . , 1 , • /• i i ,i /> i . Accidental undergone the operation of removal, as we shall further observe causes. when treating of this complaint:] it has also occasionally followed on venesection where the lancet has been affected with rust or some other irritant; and especially where the constitution, or perhaps the vein alone, has been in a state of morbid irritability. And it has sometimes occurred where no distinct cause could be assigned either during life or on dissection afterwards. It is by no means easy, and Difficulty of for the most part altogether impossible, to trace an inflammation of fhese'by'"8 a vein or artery by external signs ; for although, in the former, there external is sometimes a red streak or two accompanying the general pain s'sns' and swelling of the limb, and in the latter a more rapid pulsation or throbbing, and in both a line of hardness like that of A chord ; yet. in various cases nothing of the sort is to be found, and consequently they cannot be regarded as pathognomic criteria. And on this account the author has allotted no distinctive place or name to these affections in the course of his classification ; as feeling that to do so would be to make an empty display, and a verbal subdivision unat- tended with any real use. In a striking case which proved fatal, de- Exempli- scribed by Dr. Duncan, the disease was so little indicated by either e ' the general or local symptoms that it does not seem to have been suspected, and was only accidentally discovered on a post-obit ex- amination. At the time when the symptoms were most aggravated and less than twenty-four hours before death, when the swelling had extended up the arm, and the pulse was at 120, the limb had an uni- form appearance, the intumescence a defined margin, " but still without much redness, heat, or pain, unless in a point at the bend of the arm on considerable pressure, and on the outside of the elbow."J A knowledge, however, of the precise fact could have made little or no difference, nor ever can do so, in the mode of treatment; which must uniformly be founded upon the general process for diffuse in- flammation, whether more or less complicated in its range. It is on this account that Dr. Duncan has rather chosen to regard [P^™1^ such wide spreading phlogoses, whether of veins, fasciae, tendons or tendous, lymphatics, as mere modifications of what he has specifically called &$*"*"■ * See Enecia Cauma, CI. m. Ord. i. Gen. iv. Spec, i.—as also Arthrosia \cuta. CI. hi. Ord. n. Gen. xn. Spec, i.—and CI. in. Ord. iv. Gen. s. Spec. u. Exaifgia Varix. t Ct m. Ord. .r.Genx.. Spec. „ t Case of an Inflamed Vein, Trans. Medico-Chir. Soc. Edin, Vol. I. p. 443- Sro. 1824. 188 ClassIII. Order II. Phlogotica. Inflamma- tions. Duncan's diffuse in- flammation of cellular texture. Perhaps too much general- ized: particularly as including erythema anatomi- cum. Inflamma- tion, how far affected in its cha- racter by incidents. Not chang- ed by speci- fic irritants in sound habits; but greatly changed in unhealthy as are the specific irritants themselves. CL. III.J HiEMATICA. [OUD. U- Illustrated. Tanner explained from vac- cination. " Diffuse Inflammation of the Cellular Texture,"* which, in truth, is in almost every instance, more or less affected, and in many in- stances, with an ulceration that knows no bounds. Perhaps this may be to generalize rather too much, and especially in the case of that very singular and more definite description of inflammation which takes place from contagion absorbed by a sore or wounded part in dissecting, and which the present author will be found there- fore to have separated for a particular investigation under the name of erythema anatomicum ;t but he is well aware of the difficulty of making even this distinction ; and of the tendency there is for the diffuse kind of inflammation we arc now considering to run into every form, exhibit every variety of combination, be conjoined with every type of fever, and productive of every diversity of danger, from the peculiarity of the general or the local constitution, the influence of the patient's habit of life, or some other incidental predisponent or concomitant. Inflammation, therefore, is influenced by the nature of the part in which it takes place. It is also, as we have already observed, equally influenced by the nature of the constitution itself; and, thirdly, it is influenced by the nature of the remote cause. And we may add, that, where the inflammation is regulated by the constitu- tion, and the constitution itself is healthy, specific irritants will not change the nature of the inflammation, but only determine its situa- tion, extent, duration, or some other peculiar property. But where the constitution is unhealthy, or predisposed to any particular morbid action, as that of erysipelas, putrid fever, or plague, (for some indi- viduals recieve even the plague much more readily than others) as soon as the specific virus is communicated, the disease will degene- rate into a mixture of both, and discover its double source ; it will give proof that a specific inflammation has been set down upon a constitution of a peculiar kind, and will partake of the nature of both. In consequence of which, the specific properties will by no means be so distinct or well formed as if they were to appear in a sound and untainted constitution. Thus, if the constitution have a susceptibility to become putrid, and the small-pox attack it, the inflammation will be that of the small-pox combined with the constitutional tendency to putrescency: which will so far affect the action of the small-pox as to interfere with the specific difference of its inflammation. In consequence of which, the pustules will spread, but not suppurate, and assume a livid hue, and perhaps prove fatal; while if another person possess- ing an uncorrupt, and, so to speak, unbiassed constitution, be inocu- lated even with this mixed virus, the variolous principle will separate itself from the principle with which it is combined, improve with the improvement of the new soil, and yield a crop of genuine and una- dulterated pustules. In like manner, vaccination is, generally speaking, a specific pre servative against the small-pox. But it sometimes happens, that it is not so ; and that the small-pox is caught and makes its appear- * Case of an Inflamed Vein, Trans. Medico-Chir. Soc. Edin. Vol. I. p. 455. Bro. 1324 T Cl. in. Ord. u. Gen. vi. Spec. t. «-*-. in.J SANGUINEOUS FUNCTION. [ord. n. 189 ance many years after vaccination has been resorted to, and per- ClabsIII. formed with all possible circumspection. And it generally happens p^og'ofi".' in such cases, though not always, that a mixed or hybrid disease, a infiamma- sort of degenerate small-pox of a milder character than the true, is tlons" hereby produced. The remarks just laid down will furnish us with a clear and suf- Application ficient clue to these singular and interesting facts.' Some persons remarks to have a peculiar predisposition to small-pox, which is by no means various easdy eradicated, and far less so than in others. Vaccination, which ties and' permanently counteracts the predisposition among mankind in ge- anomalies. neral, does not permanently counteract it here. It introduces a new but less rooted diathesis, and the former is rather suppressed than extirpated. In process of time the predisposition revives, re-acquires its anterior influence, and the moment it comes in contact with vari- olous contagion, subjects the system to small-pox. But while the variolous diathesis is thus again become predominant, the vaccine diathesis has not altogether lost its hold ; and the disease, as in the preceding cases, is a mixed product of both causes in co-opera- tion, or rather in antagonism. It is small-pox raised upon a consti- tution not yet totally liberated from the influence of vaccination ; I say, " not yet totally liberated," because we occasionally meet with instances in which the constitution, little open to the impression of the vaccine disease, even when first communicated, becomes in time liberated from its influence altogether, and receives the small-pox, after vaccination, as freely as if it had never been vaccinated, and with a violence that proves fatal in a few days. It is a wise and beneficent law of providence, and affords an in- inflamma- controvertible proof of the existence of an instinctive remedial 'b0nwasaays power, that inflammation, wherever seated, is always more violent |*mleuneyt0 on the side of the inflamed point nearest the surface, and shows a constant tendency to work its way externally rather than internally. This law applies equally to the thorax, to the abdomen, and to parts even in which lie close to the different outlets of the body. Thus, if an in-^fs".seateu flammation attack the peritonaeum covering an intestine, and adhe- sions are hereby produced between the two, the inflammatory action works upwards through the thick walls of the abdominal muscles, while the proper coats of the intestines in most instances remain sound. This, indeed, is not always the case ; for the inflammation may be so violent as to pass in both directions with great rapidity. or some accidental circumstance may force it inwardly ; but it is so common as to form a general rule. We see the same thing in the obstruction of the natural passage of the tears producing a fistula lachrymalis ; for here the ulceration points externally to the inner angle of the eye, while the inside of the nose defends itself by be- coming thicker ; so much so, in many cases, as to block up the ca- vity of the nostril, and produce inosculations with the septum ; which has been an occasional cause of failure in the usual operations for this disease.* We even find that if an abscess form in a frontal -inus from an obstruction in its duct, the matter will rather work its * See Hunter on Blood, Inflammation, &c. Part. u. Chap, it 190 ClassIII. Order 11. Phlogotica Inflamma- tions. Farther illustrated by eruptive fevers. Whether cancer forms an exception; whether syphilis. Hence healthy in- flammation a remedial process; illustrated by a brief review of its march. CX. III.J HiEMATIOA. [OKD. II. Remedial treatment. Resolution; its import. When to be attempted. way externally through the frontal bone than descend into the nose. In like manner, if an inflammation attack the cellular membrane on the outside of the rectum near the anus, although the latter be in contact with the inflamed part, the inflammation will extend to the skin of the buttock, while the gut itself is often but little affected. For the same reason we behold eruptive fevers conducting the specific poisons which excite them, as small-pox, measles, rosalia, or scarlet fever, and even the plague itself, to the surface of the body, rather than throwing them on parts that are deep-seated and vital. The cancer is said to form an exception ; but even here the progress of the disease towards the surface is quicker than its pro- gress towards the centre : while syphilis exhibits something of a si- milar disposition, though not in an equal degree. It appears, then, that simple or healthy inflammation is a remedial process for restoring a part to soundness when affected by a morbid impression that has a tendency to injure or destroy it: and that the first stage of this process consists in the effusion of a coagulable lymph, which binds the weakened organization into a closer bond of union, creates new vessels, and consequently introduces new life. If this effort do not succeed, and the morbid action still continues its progress, the affected part dies to a certain extent; but the co- agulable lymph which has been thrown out, and introduced new vas- cularity around it, still sets a boundary to the destructive career, and prevents it from spreading into the neighbourhood, or at least from spreading as far as it otherwise would do. When, however, a part is thus killed or destroyed, it becomes a substance foreign to the body, and must be removed, and have its place supplied by a forma- tion of new living matter. The process of suppuration, which we shall explain under the genus apostema, prepares equally for the re- moval of the dead matter and the formation of that which is. to fill up its post. This, however, is the progress of healthy inflammation alone ; for, as already observed, in unhealthy inflammation the mor- bid action will often run on to the ulcerative process or last stage at once ; or the adhesive or the suppurative may intermix with it; or all may imperfectly take place together. In attempting the cure of inflammation, our first endeavour should be to obtain what has been called a resolution of the general enlarge- ment ; or, in other words, a restoration of the part to its state of former health, without the necessity of its going through the entire range of the inflammatory process. And in doing this we are to be guided by the principle of being able to make a new impression upon the part, and to oppose a healthy or remedial to an unhealthy and mis- chievous action. The nature of the cause must hence be sedulously inquired into, for till this is ascertained and removed, it will be in vain to expect that resolution can take place, and where we can speedily accomplish such removal, resolution will often follow spon- taneously ; for the animal economy having a disposition in itself to discontinue diseased action, such action will readily subside upon a disappearance of the cause that maintains it. And hence by taking off the venereal action by the use of mercury, in the case of a bubo, cl. in.] SANGUINEOUS FUNCTION. [ord. n. 191 the inflammation will gradually cease, provided no other morbid Class ill. action has already arisen and united itself with the syphilitic. ?h*°goti".' Resolution, however, is not always to be attempted ; for there are I.nfl«nim»" many cases in which the attempt would be in vain, and possibly a when to bo few in which it would be improper. It is not to be attempted in ^&l accidents where there is a considerable exposure of the injured part; and still less in accidents where the part has been killed by their violence : for in these, suppuration is the first natural step to a cure, and we cannot prevent it if we would. Where inflammation arises from a morbid predisposition in the How dis- constitution, and belongs to the description which has been called irom'repui- critical, there is some doubt and much demand for circumspection : siom and in this case resolution is called repulsion. If the inflammation be really a concentration of the constitutional complaint, which, by bcw,g diiven from the part fixed upon, may be again diffused over the entire frame, and in waiting to fasten on some other part, it will often be better to encourage its stay. But the determination, even in this case, must be subject to the two following conditions : first, that the inflammation so concentrated will readily admit of a cure ; and, next, that the part on which it fixes is not of vital importance ; for otherwise the remedy may prove worse than the disease. When resolution is determined upon, independently of removing the cause of the inflammation, we may advantageously follow up its effects by all the common modes employed for this purpose, accord- ing to the nature of the particular case. The undue degree of action may be diminished by bleeding and purging; the distention by local applications that tend to contract the diameter of the vessels, as cold, and metallic or other astringents ; and if along with the distention there should be great pain, narcotics and relaxants will generally be found useful auxiliaries. To these in the present day are often added nausea and vomiting, the former of which operates by lowering the action of the vessels ; the latter by giving a tendency to a new action. The nature of the case must determine our choice. 192 ox. m.J ILEMATIGA Iorp. it. GENUS I APOSTEMA. APOSTEME. LARGE, SUPPURATIVE INFLAMMATION IN A DEEP-SEATED ORGAS ;. PUS COPIOUS AND CONFINED. Gen. i. The term apostema is Greek, from «^«tt^«, "discedo," "ab- tAePgeneric scedo,"—whence the Latins employed abscessus, to express the terrnamong same general idea. Yet they did not, strictly speaking, apply either and Latin abscessus or apostema to every suppurative inflammation, but only writers. to those that were deep-seated, and of considerable extent; chiefly indeed to collections of pus consequent upon fevers, or some pre- vious disorder of particular parts, especially abdominal diseases. This limitation is accurately drawn by Celsus immediately after his description of struma, furunculus, and phyma. " Sed cum omnes hi nihil nisi minuti abscessus sint, generate nomen trahit latius vitium ad suppurationem spectans. Idque fere fit aut post febres, aut post dolores partis alicujus, maximeque eos qui ventrem infestarunt."* How differs The term abscess, however, which was colloquially used in a loose scess.ab" sense in the time of Celsus, is used so much more loosely in our own day, that it is impossible to recall it to its precise and original mean- Apostema ing. Yet apostema has not been thus generalized ; and it is here, edtoUs"11" therefore, laid hold of and restrained to the signification expressed earlier ^ in the generic definition ; after the authority, indeed, of Sauvages, 1 a' who has employed it with the same limitation. The genus apostema in the arrangement before us will be found to include five species : the first of which is common to most fleshy parts, and possesses a common character ; while the remaining four are distinguished by some peculiarity of character, produced by a peculiarity of situation: 1. APOSTEMA COMMUNE. COMMON APOSTEME. 2.--------PSOATICUM. PSOAS ABSCESS. 3.--------HAPATIS. ABSCESS OF THE LIVER. 4. -------- EMPYEMA. LOBGMENT OF MATTER TN THB CHEST. 5. ———-- VOMICA. VOMICA. * Lib. v. cap. xxviii. § 11. ■ ..n >^\GT "FNKOUS FI'NCTION ,o»n. n. W SPECIKS 1 APOSTEMA COMMUNE.. COMMON APOSTEME. INFLAMMATION COMMON TO THE FLESHY PARTS : PAIN OBTUSE : TU- MOUR SPREADING EXTERNALLY : TENDER TO THE TOUCH : PUS LAUD.ABLC : RCAMT.Y INCARNING WHEN OPENF.D. In whatever part an apostcme is seated, it will sometimes spread Gen. I. to a wonderful extent, and be loaded with a prodigious weight of s„rag£me" pus. M. Balme gives us an account of an abscess that extended takes a through the whole parietes of the chest and abdomen on one side, Wl e rangc' and reached from the scapula to the thigh ;* and Hildanus was pre- sent, when, upon opening a patient after death, twelve pints of pus were found effused from a visceral apostcme into the cavity of the abdomen.t In all such cases the first stage of inflammation, that of adhesion, Whence must have been overshot in the violence of the action, or from some th'8 effe<:t' other cause, and the suppurative and ulcerative have commenced simultaneously from the first. For otherwise the coagulable,or, as Mr. Hunter prefers to call it, the coagulatmg lymph thrown forth, as has been already explained, into the crllular membrane in the earliest stage of the inflammation, would have formed a boundary wall by the production of new vessels and reticulations, much nearer . 4S3. 19S ex. m.J IIJ3MATICA. [OllD. II. Gen. I. Spec. I. Apostema commune. Common aposteme und what the pollula- tions con- sist of, according 'o J.Hunier. Two parts of the re- storative require ex- planation. The use of the pus: and how the dead matter becomes fitted for ibaorption. towards the skin ; and hence exactly contrary to the course of ulce- ration, which always begins in the superior part of an abscess. The process commonly succeeds best upon exposure to the air, or at least after an opening externally ; though there are instances of its having occurred where there has been no exposure whatever. The granulating pullulations, according to Mr. Hunter's explanation, consist of exudations of coagulating lymph from the vessels. He conceives it probable not only that the old vessels extend into these pullulations and become elongated, but that new vessels also form in them, and, like the old, still continue to secrete pus. The granu- lations, as they become formed, mutually and readily unite ; inoscu- lation or the attraction of cohesion is established between them ; and their vessels thus joined are transformed from secreting into circu- lating tubes. Immediately upon their formation, cicatrization seems to be in view. The parts which had receded, in consequence of a breach being made into them, begin now from their natural elasti- city, and probably from muscular contraction, to be brought nearer together by the new-created substance ; and the contraction of the sore proves a sign that cicatrization is speedily about to follow. This contraction takes place in every point, but principally from edge to edge, which brings the circumference of the sore towards the centre: so that the exposed surface becomes smaller and smaller, even be- fore there is any formation of a new skin. There are two parts, at least, of this wonderful economy that still demand explanation. The first is the real use of the pus after it is secreted: and the second, the means by which the absorbents carry off the dead matter. The same explanation may perhaps apply to both. That pus is a peculiar secretion distinguished by peculiar proper- ties, and not a solution of the dead animal matter which it is the design of nature to remove, has already been sufficiently shown. " But I am apt to believe," says Mr. Hunter, " that we are not yet well, or perhaps not at all, acquainted with its use, for it is common to all sores; takes place in the most perfect degree in those sores which may be said to be the most healthy, and especially in those where the constitution is most healthy."* It forms indeed, an exit to foreign bodies : is supposed by many to carry off humours from the constitution, or convert general into local complaints ; and by others to act as a preventive of numerous diseases. Yet all these services, even admitting them to exist, are but secondary, and the final intention still remains to be accounted for. In like manner, since the dead matter of an aposteme does not constitute the pus that is found in it, and hence can only be carried off by absorption, we have yet also to learn by what means it becomes prepared for an entrance into the delicate mouths of the absorbent vessels. There is no small difficulty in conceiving how these very minute mouths can apply themselves with sufficient activity to the various tough and hard substances they have to remove, as tendon and bone, when in close contact with them; but, as soon as the dead * On Blood, &c. Part n. Ch. v. p. 436 <-t-ni.| SANGUINEOUS FUNCTION. [obd.ii. 199 part becomes separated from the living, they are often no longer in Gen. I. close contact with them, except at the base, where there is little or Apostema no absorption at all; and in many cases, as in boils, carbuncles, and commune. other imperfectly suppurating tumours, possessing cores or tenacious aP°oTeme. sloughs, are at a considerable distance from them, with the entire ™fi?e di®' body of the contained pus placed intermediately in the hollow. explained. In the last case it seems impossible for them to act except through the medium of the pus ; in reality except through a solvent power 1>us p««- possessed by the pus and exercised upon the matter to be removed, solvent1 And if such be the nature of the action in this case, it is doubtless {J™^ j^61 the nature of the action in all other cases ; and hence we arrive at kind sup- one immediate and direct use of pus, which is, that of becoming a me^y/"01" solvent of the dead animal matter that requires to be carried off: and hence, not, indeed, by converting the whole substance at once into a solid antusePof" mass, and still less into a fluid mass of its own nature, as supposed thisflui(1- by Sir John Pringle, but only the surface of the substance to which it is applied : and which hereby is rendered fit for absorption, carried forward to the mouths of the imbibing vessels, and absorbed accord- ingly. And as the same power is exerted in succession upon every fresh surface of the dead matter that becomes exposed to its action, the whole is at length carried away, and a cavity produced where before was solid substance. That pus first kills and then dissolves the organized matter of an How far abscess was, as we have already seen, the opinion of Mr. Hewson. viewS°n s In the first part of this opinion he was completely mistaken ; for, as co"cct- we have already observed, the organized matter is dead before the process of suppuration even commences ; in the second, he seems to a certain extent to have been correct, though he still erred in sup- posing the dead substance to be melted down into its own nature, and was unacquainted with the important process of its absorption. But in advancing his own full and more elaborate hypothesis against How far the mistake of Mr. Hewson, Mr. Hunter ran into the opposite ex- ^"wtcr'B treme ; and contended that pus is not designed to be a solvent at all, erroneous-. and that animal substances are decomposed in it with very great dif- ficulty : thus leaving us totally at a loss to account for its use ; and equally so to explain the manner in which the mouths of the ab- sorbents of an abscess can operate upon or even, in many instances, get at the material they are to remove. Mr. Hunter, however, with the candour that so peculiarly belonged Hunter's to him, made this question a subject of experiment, and the experi- expert-t0 ment, as he conceived, fully established his pre-conceived opinion : ments- and gave proof that the pus of an abscess does not act as a solvent. This conclusion of his only shows how difficult it is for the most honourable mind, when biassed by a favourite hypothesis, to weigh with an even hand the evidence that lies before it. " To see," says he, "how far the idea was just, that dead animal matter was dissolved by pus, I put it to the trial of experiment, because I could put a piece of dead animal matter of a given weight into an abscess, and which could at stated times be weighed. To make it still more sa- tisfactory, a similar piece was put into water, kept to nearly the same heat. Thev both lost in weight; but that in the abscess most JOO cl. in.j ILEMAT1CA. (ord. n. Gen: I. And there was also a dhfercnce in the manner, for that in the water Apostoma1' became soonest putrid."* There is nothing in animal chemistry, commune, strictly so called, that decomposes animal substances so rapidly as ap'ostem". putrefaction. And yet in the present instance the pus of an abscess Wmenfap- evinced a more active decomposing power than the fluid of water. parentiy at though aided by the accessories of putrefaction. It is not very won- wltiThis6 derful that Mr. Hunter, though regarding this result as in his favour, conclusion, should not be disposed to "rely on its accuracy," and he refers us, Experiment therefore, for a further proof to a more competent experiment of nf Home. jyjr £nQW gir Everard) Home, which consisted in immersing a por- tion of muscle weighing exactly one drachm, u in the matter of a compound fracture in the arm of a living man, and a similar portion into some of the same matter out of the body; also a third portion into fluid calf's-foot jelly, in which the animal substance was pure, having neither wine nor vegetables mixed with it. These portions of muscle were taken out every twenty-four hours, washed in water, weighed, and returned again." ^rfmetit ^ne resu^ °f tnis experiment is still more in favour of the solvent alike at ya- power of pus than the preceding. At the end of forty-eight hours HanCter'9lth there was indeed no great difference, as the muscle in the abscess conclusion. was reduced to thirty-eight grains, and that in the other two fluids to thirty-six. But from this period to ninety-six hours the muscle in the jelly continued the same, while that in the abscess was reduced to twenty-five grains ; and that in the exposed pus dissolved :| the power of putrefaction, as Mr. Hunter observes, being in this last '•ase superadded to that of the pus itself. We hardly stand in need of other experiments. The solvent power of pus above that of water, of animal jelly, and hence we may conclude of animal fluids in general, is sufficiently established by the very evidence that is advanced in opposition to this power. And it should hence seem that one at least of the direct uses of pus is to reduce surface after surface, the dead animal matter which is exposed to its action to that state in which it may be rendered fit for absorp- tion, and at the same time conveyed to the mouths of the absorbent vessels. second use But I have for many years thought that it has also another equally asBiPstSin°the important use ; that, I mean, of assisting in the process of granula- processof tion ; and a late article of Sir Everard Home in the Philosophical Uon. Transactions, containing the observations of Mr. Bauer upon the ger- mination of plants, and his application of those observations to the growth of the new vessels in animals, J seems, if not to have settled the question, at least to have very considerably favoured this view of it. Oonfirmrd Having sown a quantity of wheat for the purpose of noticing the menu'of changes which occurred from the first, Mr. Bauer took up every Bauer; jay several grains or plants for examination till they were ripe ; and in the course of his attention, was much struck with the rapid increase of the tubular hair of the root of a young plant of wheat in its earliest stage of vegetation; and, fixing his view entirely to that * On Blood, &c. Part n. Ch. v. p. 419. J Phil. Trans. 181«. p. 160—194. t Dissertation on the Properties of Pus, p. 32. CL. III.J SAi\ G U1NE0US F b N (JTION, [ord. u. 201 part of the plant, he observed small pustules of a slimy substance Gen. I. arising under the epidermis in the surface of the young root • and *Spec' L in a few seconds a small bubble of gas bursting from the root into ttS the slimy matter which it extended in a moment to the length the aP~ hair was to acquire ; when the slimy matter surrounding the gas immediately coagulated and formed a canal. He repeated his observations on another plant, whose pubescence consisted of a jomted hair, and observed the same effect; a bubble issued from the young stalk, and extended the slimy mucus to a short distance, form- ing the first joint, which immediately coagulated and became trans- parent ; and at its extremity a new pustule of the same slimy matter accumulated, into which, in a short time, the gas from the first joint rushed : and thus, in a moment, a second joint was formed. In the same manner, he observed, the formation of the hairs often or twelve joints take place. Impressed with the importance of these facts, Sir Everard Home and Home immediately began to inquire how far the same course is pursued in the production of new animal matter. He first ascertained by experiments of Mr. Brande, already noticed in the Proem to the second class of this work,* that blood in a state of circulation con- tains a considerable proportion of air, which, in the process of its coagulating, escapes in the form of carbonic acid gas, and in its escape produces bubbles as in the slime of plants; and that it escapes equally from the coagulating blood of veins and arteries, from effused serum, and from pus. And in pursuing the subject he found that, on the coagulation of a drop of blood placed in the field of a microscope, an intestine motion occurred, and a disengage- ment of a something took place in different parts of the coagulum ; beginning to show itself where the greatest number of globules were collected, and from thence passing in every direction with considerable rapidity through the serum, but not at all interfering with the globules themselves, which had all discharged their colour^ ing matter. Wherever this extricated colouring matter was carried, a net-work immediately formed, anastomosing with itself on every side through every part of the coagulum. When the parts became dry, the appearance of a net-work remained unaltered. In some instances bubbles were seen to burst through the upper surface of the coagu- lum ; this however did not prevent the ramifications that have been described from taking place. " When this happens," continues Sir Everard, " in living animal bodies, from whatever cause, and in whatever circumstances it takes place, no difficulty remains in accounting for its afterwards becoming vascular, since all that is necessary for this purpose is the red-blood being received into the channels of which this net-work is formed. He next proceeded to the subject immediately before us. " As the globules of pus," says he, " are similar to those of blood, I made experiments upon the fluid in which they are suspended, and found inspissation produce the same effect on it as coagulation does on the other; that a similar net-work is formed and apparently by the same means, since if pus * Vol. i. p. 341 V0L. II.— .?6 202 tx. m.] ILEMATioA. [ord. ji. Gen. I. be deprived of its carbonic acid gas (of which it contains a large Apostema quantity) by exhaustion in the air pump, no such net-work takes commune, place." apMteme. Additional experiments are still necessary upon this interesting other ex- subject; but so far as they go, they seem very clearly to indicate necessary; the important and double use to which pus is subservient: that it present acts as a solvent upon the dead matter, preparing it for absorption, "ea.r,y and as a fomes for granulation and the production of new vessels. No incon- Nor let it be observed in opposition to this conclusion that we are fheseVwo tnus endowing it with incongruous and contrary qualities ; and that qualities if it be erosive in the one instance it cannot be nutrient in the other ; tne^ame"1 for the animal economy presents us with various examples of like substance, effects, contrary indeed but not contradictory, produced by one and the same secretion on dead and on living matter, for which we need illustrated go no further than to the very common operation of the gastric juice ; qualities of which, while the most powerful solvent of dead animal matter in &i«ic tne wno^e range of animal chemistry, is a healthy stimulant to the living stomach, and even to other living organs : and has successfully been applied externally for this purpose by surgeons to weak and ill- conditioned ulcers, and employed by physicians as an internal tonic in cases of dyspepsy and cardialgia. juice SPECIES II. APOSTEMA PSOATICUiU PSOAS ABSCESS. PAIN AND TENSION ABOUT THE LOINS, SHOOTING DOWN THE SPINt AND THIGHS ; DIFFICULTY OF STANDING ERECT ; FLUCTUATING ENLARGEMENT ALONG THE PSOAS MUSCLE ; APEX OF THE TUMOUR IMMEDIATELY BELOW THE GROIN. Gen. I. This is one of the most lamentable diseases we can ever be called rrhnar H° uPon to attend- It commences insidiously, and at the same time seat of the in parts so deeply seated as to render it very difficult to determine difficult to the Place of its origin ; and hence the psoas muscle itself, the eel- be deter- lular substance interposed between the peritonaeum and the loins, the lymphatic glands near the receptaculum chyli, and the lumbar vertebrae have been pitched upon by different writers. It is probable that most of these have formed the primary seat of affection in different cases, and that the inflammation has subsequently spread cTane"of t0 °"° 0r more °f the other Parts: and hence, assuming no incon- chalfsfe" siderable degree of latitude, M. Chaussier denominates the disease Progress of Femoro-Coxalgie. The pain at first is by no means violent and thediaease. the patient thinks lightly of it; it is sometimes felt in the'back rather lower than the region of the kidneys ; and sometimes as low ■ow as the thlSh- Fror» ^e deceptive manner of it* attack, medical <:l. hi.] SANGUINEOUS FUNCTION. [ord. u. 203 advice, and particularly a free use of purgatives and the lancet, sGeNi '• which might have been of essential service at first, is fatally post- Apostema. poned; and the symptoms are regarded as those of an accidental p*"atsicum" strain. After the abscess is formed, however, the pain in most cases, abscess. increases considerably ; and the matter may be discharged into the ,nayCdi's- cavity of the abdomen, where it woul. I soon be fatal. On this account ?baJ?? it obeys the law of instinct we had lately occasion to notice ; follows, different in most instances, the course of the psoas muscle, and points exter- oullets'- nally a little lower than the inguinal glands ; or it passes down the thigh, where, however, it is apt to dissever the muscles and form sinous abscesses. Sometimes, though rarely, the matter passes through the muscles of the back, and is discharged in the loins ; and in a few instances it .has been known to fall into the cavity of the back part of the pelvis. The abscess, therefore, is highly dangerous ; J1*]^,. since under the most fortunate circumstances it is so long in pointing and often externally, even if it should make any visible pointing at all, that offataY™ the patient usually sinks under a hectic fever, produced by the local n«ctic. irritation. While in most cases, in which it has made a natural opening for itself, it has been found connected with so many deep sinuses, which cannot be followed up, that the same effect ensues. No mode of medical treatment has been found productive of any j^k"1 good purpose ; and the cause has been, in a very early stage of the rarely of suppuration, given over to the surgical practitioner. Yet even here avaif" different individuals have pursued different lines of conduct. Mr. Bell advises an early evacuation of the matter, lest the bones should become injured ; while Mr. Abernethy apprehends less danger from Surgical its being suffered to remain, and at last evacuates it at different inter- d^erepTnt. vals, and by successive operations : by which means the cyst, in which the pus is principally lodged, may have an opportunity of contracting ; and this, he thinks, it has a greater tendency to do than in abscesses where the inflammation is more violent. He is also attentive to close the opening the instant the matter is discharged, so as to prevent any increase of the inflammation by an access of air. The real cause of danger does not seem to have been hitherto hit JrajHJ00 upon ; but it may probably be referred to that tendency to a rapid reui cause spread of inflammation over their entire surface, which Mr. Hunter ° anger' has shown to exist in all internal cavities, and the hazard of which is in proportion to the extent of the cavity ; a subject already touched upon in the discussion of puerperal fever, and which we shall have other opportunities of illustrating as we proceed, particularly in some cases of varicose enlargement of the veins. Now in the disease before us we have not, it is true, any natural cavity, but we have an artificial cavity of long standing, and large extent, in a highly irri- table state, and which is therefore peculiarly predisposed to run into all the fatal effects of large natural cavities, when injured or other- wise rendered imperfect. The author throws out this hint, how- ^or. for future and general consideration 1 as sufficient indications. In a case of this kind that occurred to Gen. I. me in a young gentleman of about thirteen years of age, the shiver- Ap^;i|[IaI" ing was so considerable as to make the teeth chatter ; and within hepatis. a eight and forty hours the pulse sunk from a hundred and forty to a ^!iiwr.of hundred and twenty ; and the abdominal tension and tenderness jec"^° were considerably abated; as was also the distressing cough with which he had almost perpetually been harassed for some weeks. He was put upon a tonic plan of columbo and sulphuric acid imme diately after this change, and recovered gradually. SPECIES IV. APOSTEMA EMPYEMA. LODGMENT OF MATTER IN THE CHEST. FIXT PAIN IN THE CHEST : BREATHING LABORIOUS, BUT EASIEST IN AN ERECT POSITION ; DIFFICULT DECUMBITURE ON THE SOUND SIDE; FLUCTUATING ENLARGEMENT ON THE SIDE AFFECTED: DRY, TICKLING COUGH. To the symptoms enumerated in the above definition Hippocrates _Gen-*i adds,* edema of the feet, hollowness of the eyes, and a gurgling symptoms' sound on shaking the shoulder. Of these additional signs, the first "."''^ by two belong rather to the hectic fever that generally accompanies crates. empyema, than to the disease itself. The last has sometimes been met with in modern times.! Dr. Cullen regards empyema as a mere Not always sequel of pneumonia, which, with him includes inflammation of the pneumonia pleura, as well as of the lungs, but as it may take place from in- ?9pccT"cd flammation of the mediastinum, pericardium, or diaphragm, to say nothing of that from external injuries, and as it is often doubtful what particular organ is directly injured, a separate species seems decidedly called for. Goekel, indeed, describes a case in which the pericardium was affected in connexion with the right lung, and to such an extent that both were totally consumed. Most frequently, however, an empyema is produced by the burst- Most jve- ing of a large vomica of one of the lungs into the cavity of the produced pleura. In which case the cough becomes more frequent than be- bSrstinff of fore this result, and is either dry, or accompanied with a scanty, a vomica. frothy, and noisy expectoration. The breathing becomes extremely difficult, with repeated fainting fits, and the dew of a cold sweat hanging over the throat and forehead : the cheeks and lips are of an ominous red, while the nails are livid, the pupils dilated, and the sight dim. Death usually succeeds to the rupture of the apos- teme in a few hours. If percussion or the stethoscope be employed, before the vomica Diagnostics r of percus- sion and the * TT'oi TlaOi-'v, p. 476. 496. + Trecrmrt, Memoires de (Hiirnrgie. &<: stethoscope. •206 cl. in.] H.F.MATICA. [OKD. Gen. I. Spec. IV. Apostema Empyema. Lodgment of matter in the chest. Pus not always to be referred to any particular organ. lingular case related by Darwin. Hence internal medicines may at times be useful. OLher in- stances of metastasis. Double empyema. has broken, to the part in which the matter is seated, little or no sound will be returned in consequence of the pressing fulness which exists there ; but if these methods be resorted to afterwards, it will be found restored in a considerable degree to the part affected from the hollowness which now exists there, while it will be compara- tively found diminished in the posterior and inferior parts of the chest to which the discharged load is transferred. For the history and relative value of these diagnostics the reader must turn to the treatment of phthisis in the ensuing volume.* In some instances, however, there is no organ to which the pus can be referred as a process of ulceration ; and to such an affection Mr. Hewson has several references. " The cavities of the pleura. pericardium," &c. says he, " are sometimes observed to contain considerable quantities of pus without the least marks of ulceration. In one patient I found three pints of pure pus in the pericardium with- out any ulcer either on that membrane or on the heart. In another the cavity of the pleura of the right side was distended with a pus that smelt more like whey than a putrid fluid, and the lungs were compressed into a very small compass: but there was no appear- ance of ulcer or erosion either on these organs or on the pleura ; but only under the pus was a thin crust of coagulable lymph." We have already observed upon this secretion of imperfect pus, and it is not necessary to explain it any farther. Dr. Darwin relates a singular case of empyema, in which the pus seems in like manner to have been produced without ulceration, though he ascribes it indirectly to an abscess in the lungs. " A ser- vant man, after a violent peripneumony, was seized with symptoms of empyema, and it was determined, after some time, to perform the operation ; this was explained to him ; and the usual means were employed by his friends to encourage him, by advising him 'not to be afraid.' By which good advice he conceived so much fear that he ran away early next morning, and returned in about a week quite well." This should indicate that something may at times be accomplished by internal medicines, though no plan has hitherto succeeded that has been devised by professional skill. Nor is the present the only case on record in which the contained fluid has disappeared by metastasis. It has passed off by the in- testinal canal,t by the bladder,J and by the vagina,§ in the form of pus ; and is said in one instance to have vanished on the eruption of a scabies.|| It has also been frequently carried off by an open- ing formed by nature, and the patient has recovered his usual health. This opening has commonly been between the ribs, and most usu- ally between the third and fourth, but in one instance we find the abscess pointing and bursting under the scapula. *I Morgagni ha? * Vol. in. Cl. in. Ord. iv. Gen. in. Spec. v. t Kelner, Diss, de Empyeruate. Helm. 1670. Marchetti, Obfl. 82. 89. X Buchner, Diss, sistens solutionem Empyematis per mictionem purulentam. Hal. 1762. N. Act. Nat. Cur. Vol. i. Obs. 5. § Schlichtingj, Phil. Trans. Vol. xlii. p. 70. || Hantesierk, Recueil. n. p. 239. * Hnrten, Diss, de Ernpyematr. Aret-nt. 1679, •v,l. ui.j SANGUINEOUS FUNCTION. [ord. ii. 2>j7 recorded a singular case of a double empyema, a lodgment of pus Gen« '• being formed on both sides.* And Balme a still more extraordinary ij"^' case, in which the pus entered the cellular membrane and spread Empyema. over almost the whole trunk.t o/matter'in When the fluid is discha. ged by paracentesis, Hippocrates urges R^j^g repeatedly upon the surgeon to evacuate it only by degrees ;| and over the Borelli gives a case in which the patient seems to have sunk and AdviUTf* been lost under a sudden evacuation alone.§ There has also been Hippocrates no small discussion concerning the part of the thorax to which the tmg^hcre scalpel may be most advantageously applied. David, in his prize ghouTtakl dissertation, advises near the sternum ;.,' Mr. Sharp between the place. sixth and seventh rib ;H Mr. Bell wherever the pain or fluctuation may direct.** Mr. Warner, whose success made it many years ago a favourite Warner's operation in our own country, seems to have been of Mr. Bell's mode of opinion, and varied the point of opening according to the nature Practice- of the case. And so little danger did he apprehend from the use Evacuated of the scalpel on any occasion, that he not only evacuated in all of the con- instances the whole of the matter at once, but in one or two instances at'oncJ"15 operated, where there was neither a polarized pain, nor fluctua- tion, nor visible discoloration, nor any external sign whatever, to direct him to one part rather than to another, or even to determine the real nature of the disease ; otherwise than from the specific symptoms laid down in the preceding definition.tt In Mr. Warner's cases about twenty ounces of pus formed the Usu.aJ r /» i- i i /. i i« • jfl , mode of average ot discharge at the time of the perforation :|| the patients treatment, usually found instant relief; the pain, cough, and quickness of pulse diminishing, and the breathing becoming easier. He dressed the wound with a sponge-tent till there was no longer any discharge, and afterwards superficially ; and in about six weeks the patients were discharged cured. In this case it is perhaps more necessary to keep the wound open than in any other operation, since, till the ulcerated surface of the interior is completely healed, the secreted pus is apt to accumulate, and the operation must be renewed. Tents of all kinds are very properly exploded in most cases in the present day; but Mr. Bell has judiciously observed that in the paracentesis the old fashioned practice ought still to prevail §§ In some instances Cure by the operation might perhaps best be performed by a seton. DesaultROton' on one occasion passed a seton completely through the chest; and M. Founder tells us that, upon the strength of his authority, he pursued the same plan upon a soldier who had received a shot from a musket fired close against his breast, which passed directly through both lobes of the lungs from the left to the right side, and carried * De Sed. et Caus. Morb. Ep. xxn. Art. 13. t Journ. de Medicine, Tom. lxvi. p. 244. j Ylepi Nouawv, II. p. 476. I. 42. Iltpt twv sOvas Tladuv, p. 536. I. 15. § Cent. I. Obs. 72. || Mem. pour le Prix de l'Academic, x. IT Critical Inquiry, &c. Chap. vi. ** Surgery, Vol. n. 390. ft See Original Cases and Dissections, &c. by John Forbes, M.D. p. 257. 8vc, Lond. 1824. XX See Phil. Trans. Vol. xlvii. xlviii. li. as also his works in their collected form. !^ Surgery, Yol. II. Ch. xxn. Sec. iv H)H cl. m.} H/EMAT1CA. 1.okd. ii. Gen. I. with it pieces of the wadding as well as of his own clothes. These ApostonuT' were all discharged by the seton, and in twenty-seven days the wounds Empyema, were cicatrized.* of'matter1 Dr. G. Hawthorn has given an instance of this disease that for its Singula^6"'' severity and danger, and particularly for its successful issue, is well case by worth recording, t The patient was thirty years of age, and the dis- awt om. eage na(j ^een bought on jjy exposure to damp night-air in a state of intoxication. He suffered greatly from quickness of pulse, in- cessant cough, oppression, and dread of suffocation. A distinct fluctuation was perceived in about three weeks from the attack ; shortly after which he was a little relieved by a discharge of purulent matter effused into the bronchial cells, and expectorated to the ex- traordinary amount of five or six pounds daily, for many days in suc- cession, a fluid of an intolerably offensive smell, and putrid appear- ance. He continued, however, to grow worse and weaker ; his feet and legs swelled ; his countenance was ghastly, and he had colliqua- tive sweats. About twelve weeks from the attack the operation was performed, nearly twenty pounds of pus were discharged on the first day and night; and he gradually recovered. Riedlin operated with success twice on the same person. J The matter when discharged or examined on dissection has been found, as may be easily supposed, of very different consistences : sometimes pure pus, sometimes cheesy, and sometimes gelatinous. And the mischief to the interior of the chest has in some cases been very great. Several of the ribs have been found carious ;§ the lung on the affected side totally eroded ;|| and in one case the pericardium destroyed as well as the lung.T Matter discharged of various appearan- ces and qualities. SPECIES V APOSTEMA VOMICA. VOMICA* ijEKA.NtvED FUNCTION OF A THORACIC OR ABDOMINAL ORGAN' ; SUC- CEEDED BY A COPIOUS DISCHARGE OF PUS INTO SOME PART OF TnE ALIMENTARY CHANNEL ; AND ITS EVACUATION BY THE MOUTH OR ANUS. Gen. I. The specific term is a derivative from the Latin vomo, " to eject," Spec.V. especially from the stomach, but not exclusively so ; and hence, on henXTuse the present occasion, it is used in the comprehensive sense in which bf Delstis™ lt 1S emPl°yed °y Celsus, who applies it to a bursting of pus from hire copied, the liver, or any otlier large internal organ, as well as the lungs.** * Diet, de Sciences Medicales, Art. Cas. Rares. t Edin. Med. and Surg. Journ. No. lxi. p. 513. X Lin. Med. Ann. v. Obs. 30. § Henermann, Vermichta Bemenkungen, n. p. 217. ]| Kelner, Diss, de Empycmate. Helmst. 1670. T Goeke), Gallicinium Medico-pract. ** De Medicin. Lib. iv. Cap. Tin cl. ui.j cJANGUINliOUS FUACTiO.N. (okd. n. 209 Sauvages follows Celsus in this interpretation, but distinguishes the Gen. I. vomica from the aposteme by making the discharge from the latter H££^' consist of pure pus, and that from the former of a mixt matter, being vomica. at first a sort of adipose mucus (mucus quidam adiposus) which at Vo,mca' length becomes purulent. Avenbrugger, to whom we are indebted n°\v evT for the Inventum novum, or method of ascertaining diseases of the Avenbrug- chest by percussion, takes nearly the same range, or rather carries ger it to a still wider extent, so as to include other depositions than that of genuine pus, and hence divides vomicae into purulent and ichor- ous, meaning by the latter term the reddish yellow fluid occasionally found in a sac from the destruction of a hepatized or scirrhous lung or other organ.* Boerhaave and Cullen confine vomica to the lungs, Employed and this in a more restrained sense than most writers ; for they limit restrained it to what has been called, though with no great accuracy, occult B,1S0hbyva vomica, "vomicae clausae." Linneus and Vogel on the contrary, and cullen. while they confine the term to the lungs, explain it by open vomica, a^'niiy " vomicae apertae,'' in which the pus is thrown forth profusely and by Linneus suddenly. One termination of the hepatic aposteme may be regard- May beSe' ed as a variety of this species, for, as we have observed, it sometimes [^hepa'tic issues in a discharge of pus by the mouth or rectum. Wherever it aposteme. occurs, it appears to consist in a conglobate gland, first enlarged by a Originates strumous congestion, and afterwards slowly and often imperfectly j" acongio- suppurating. Vomicae vary in size, from the diameter of a millet VarifsTn' seed to that of an orange. The smallest rarely contain any fluid,81Z0, and sometimes not even a cavity ; but they are often highly irritable, and maintain a very considerable degree of hectic fever. When Patient ulceration has taken place, and pus is secreted, the irritability fre- flattered"3 quently subsides ; the pulse improves, the febrile exacerbations are j"10 a f*lse less frequent and violent, and the patient flatters himself he is recover- recovory. ing. The vomica at length bursts and disabuses him ; he sinks gradually from the quantity of the daily discharge, and the confirmed hectic; or, if the disease be seated in the lungs, and the cavity ex- Sometimes tensive, he may be suffocated by the volume of pus that overwhelms suffocated. the trachea. Bartholine gives a singular case of an occult vomica of the lungs, Singular that, accompanied with an asthma, produced great emaciation ; but cure. was fortunately cured by the wound of a sword, the point of which passed between the ribs^lnd opened the sac. A considerable flow of pus followed, and the patient recovered gradually from the time of the accident.! The methods of percussion and mediate auscultation are now very Application generally resorted to»on the continent and occasionally in our own raethods of country to ascertain the existence and extent of this affection when ^"^""j. seated in the chest; the theory aryl employment of which the reader ration. will find explained at some length, under the treatment of phthisis in the ensuing volume.^ * Inventum Novum ex percussione thoracis humani, ut figno, abstrusos interni pec- toris morbos detegendi. Vten. 8vo. 1761. t Hist. Anat. xiv. Cent. 6. - Vol. in. Cl. in. Ord. iv. Gen. in. Spec. r. Vol. TT.—57 310 cl. ui.j IiEMVlTCA. [ORD. II- GENUS II PHLEGMONE. PHLEGMON. SUPPURATIVE, CUTANEOUS TUMOUR ; TENSIVE ; GLABROUS ; PAINFUL , AT LENGTH FLUCTUATING, AND BURSTING SPONTANEOUSLY ; THE PUS UNIFORM AND GENUINE. Gen. II. General character of phlegmon. In what sense used by the Greeks; loosely em- ployed in modern by Cullen; by Sau- vages ; oy Vogel: by Turton. More cor- rect mean- ing. Under the last genus we took a general survey of the process and economy of suppuration, and noticed many of the most extensive and dangerous forms in which suppuration ever presents itself. We are now advancing to inflammatory affections, consisting of tumours of small extent, and either entirety confined to the integuments, or dipping but a little way below them. The term phlegmon, from QXtya, inflammo," was used among the Greeks for inflammation generally. It has long since, however, been employed in a far more limited sense by medical writers of perhaps every school, though few of them have given a very clear definition of the exact sense in which they have intended to use it; or perhaps have formed such a sense in their own minds. Thus Dr. Cullen makes it comprise a multitude of tumours or tu- bercles of different degrees of inflammation, some suppurative, some unsuppurative, some serous, some callous, some fleshy, some bony; as boil, minute pimple, stye, stone-pock, abscess of the breast, and spina ventosa, or carious bone; with many others altogether as dis- crepant ; while by Sauvages it is limited, and far more correctly, to spheroidal tumours, possessing redness, heat, tension, violent throb- bing pain, spontaneously suppurating. Not indeed, essentially dif- ferent from the character now offered, and involving most of its species. Vogel, however, makes it a parr of its generic character that the inflammatory tumour, in order to be a phlegmon, must be at least as large as a hen's egg ; while Dr. Turton, in his useful glossa- ry, not knowing how to reconcile the clashing descriptions which are thus given of it, merely explains it after the Gfeek manner " an in- flammation," leaving the reader to determine the nature of the in- flammation according to his own taste. It is necessary, therefore, to come to something more definite; and I believe that the character now offered embraces the common idea of phlegmon ; or, if not, will propose what should seem to form a boundary for it. And thus explained, it. will comprise the following species :— ♦ a. in.] SANGUINEOUS FUNCTION [ord. ii. 211 1 • phlegmon*: communis. push. Gen. n. 2---------PARULIS. GUM-BOIL. IKgEiT 3.-----------AURIS. IMPOSTHUME in the head. 4------------PAROTIDEA. PAROTin PHLEGMON •5. ■-----------MAMMAE. 6.-----------BUBO. 7------------PHIMOTICA. PHIMOTIC PHLEGMON. ABSCESS OF THE BREAST. BUBO. SPECIES I. PHLEGMONE COMMUNIS. PUSH. COMMON PHLfiMON. rUMOUR COMMON TO THE SURFACE ; BRIGHT-RED; HARD; DEFINED; HEMISPHERICAL ; POLARIZED ; GRADUALLY SOFTENING AND BURST- ING AT THE POLE. In vernacular language this species is denominated a push; and in Gen. II. size has a near approach to a boil, or furuncle ; but essentially differs H^difflr's from it in having its pus uniform and mature, while that of the boil from a boi'- is always intermixed with a core. It is commonly a mark of high General entonic health, or a phlogotic diathesis ; and rarely requires any cha,acter- other medical treatment than bleeding, or a few cooling purgatives. Where, however, pushes appear in crops, and especially in succes- Habit in sive crops, they support a remark we had occasion to make in ^h il. opening the present order; that in conjunction with the phlogotic ^re- diathesis there is probably a peculiar susceptibility of irritation ; since we frequently find persons in the highest health, with firm and rigid fibres, pass great part, or even the whole of their lives, without any such affection as the present. Such susceptibility is far more common, indeed, to a habit of an opposite character, but it seems from this as well as from other circumstances, not unfrequentlv to inhere in the temperament we are now contemplating. 212 cl. hi.] HiEMATlCA. . I ord. u SPECIES 11. PHLEGMONE PARULIs GU3I-BOIL. TCMOUR SEATED ON THE GUMS ; DEEP-RED ; HARDISH : UNDEFINED : PAIN OBTUSE. Gen. II. This is sometimes limited to the substance of the gums ; and Spec. II. sometimes connected with a caries of a tooth or socket. In the first character, variety it is a disease of only a few days' duration, and ceases almost as soon as it has burst or is opened; in the second, it will often continue troublesome till the carious tooth is extracted, or the carious socket has exfoliated ; or the whole of its texture is absorbed ; in which case the tooth will become loose, and may at length drop out spontaneously. Swediaur tells us that he once saw this disease produced in a man, otherwise sound, in consequence of a suppression of an habitual hemorrhoidal flux, accompanied with a loosening of the wise and incisor teeth. In women he had frequently met with the same from * obstructed menstruation.* Suppura- Gum-boils, and especially where connected with a morbid condi- 9n0couraged, tion of the subjacent teeth, or their alveoli, rarely disperse without passing into the suppurative stage : and hence the means of prohi- biting this termination are usually tried in vain, much time is lost, and protracted pain encountered. For these reasons it is better to encourage than to repel the suppurative process by warm cataplasms and the tu- or fomentations ; and to open the tumour as soon as it begins to opened?0" Pomt- An early opening is of importance ; for, from the toughness and thickness of the walls of the abscess, it is seldom that the confined pus obtains a natural exit with sufficient freedom: while in some instances the ulceration assumes a sinuous character, or works into the substance of the cheeks, and at length opens on Gum-boil, their external surface. The worst and most painful gum-boils are wl!ereBt those which form on the dentes sapientiae; the swelling, from the violence of the irritation, spreads rapidly and widely; so that the entire cheek is sometimes involved in it, the neck indurated, and the eye closed. * Not. Nosol. Meth. Syst. II. 437 '■•in.j SANGUINEOUS FUNCTION. |obh. u. 213 SPECIES III. PHLEGMONE PAROTIDEA. PAROTID PHLEGMON. TUMOUR SEATED UNDER THE EAR ; REDDISH ; HARD ; PAIN OBTUSE : SUPPURATION SLOW AND DIFFICULT. It is not a little singular that Dr. Cullen, who extends the genus Gen. II. of phlegmone wide enough to embrace, not only inflammation of ^hen m the ear, and of the breast, gum-boil, and phimosis, but also, furun- arranged by cuius, varus, gutta rosea, stye, and, as already observed, several i00seiyand affections of the bones, should have banished suppurative inflamma- incorrectly. tion of the parotid and inguinary glands, not only to another genus, but to a very remote part of his system ; where they occur, in the class and order of local tumours, in company with worts, corns, and sarcomata, which have naturally no inflammatory character. Here, too, they are conjointly described under the generic name of bubo, with the generic character of " glandulae conglobatse tumor sup- purans ;" a definition which does not apply to the parotid gland, whose structure is not conglobate but conglomerate. The present, therefore, is the proper genus for including suppurative inflammation of the parotid and inguinal, as well as of the mammary glands. Phlegmonous inflammation of the parotid gland offers us the two following varieties :— «i Simplex. Incarning and cicatrizing easily. Simple parotid phlegmon. /5 Maligna. Accompanied with a foul slough, Malignant parotid phlegmon. and incarning with difficulty. In the simple or benign variety, though the suppurative pro- * p Par°- cess is slow and inactive, the incarnation subsequent upon the p'iex. breaking of the abscess is regular and unobstructed. I was requested f™$A not long ago, in consultation, to see a young lady of fifteen years of phlegmon. age, who had been troubled with this species of phlegmonYor more though8' * than three months ; there had been, for about a fortnight, an evident fa™ndesu_ pointing towards the surface, and a feel of irregular fluctuation ; it healthy. afterwards broke, a large quantity of good pus drained away daily,IIIu9tra,ed and the tumour, which at first was extensive and hard, by degrees very considerably diminished, and clustered or divided into lobes, and at length disappeared altogether. Her general habit was relaxed, but did not seem to be strumous. She had menstruated earlier than usual, and was of a disposition peculiarly sprightly and cheerful. The local treatment at the commencement was leeches, frequently Treatment. applied, and alternated with mercurial plaster. But no benefit pro- 214 cl. in.J ILEMAT1CA. [ord. n. Gen. II. Spec III. a P. paro- ;idea sim- plex. Simple parotid phlegmon. Treatment. Abscess sometimes very large. Pus some- times re- moved by metastasis. Examples. Has been confounded with mumps. P P- paro- tid ea ma- ligna. Malignant parotid phlegmon. Termina- tion. Treatment. Has been extirpated in a scir- rhous stare when of great weight. ceeding from the discutient plan, lotions of half water and half liquor ammoniae acetatis were afterwards employed to aid the suppurative process. The abscess in some cases of this variety is of considerable mag- nitude, and consequently the discharge of pus very large. And we have some instances on record in which the pus has been absorbed and carried off by metastasis to some remote organ. Dr. Saunders gives a case in which it passed away by the rectum ;* Alix, by a fontinel at the navel ;f and the Transactions of Natural Curiosities, by the Bladder.J It has sometimes been confounded with parotitis or mumps ; and has hence been said to sympathize with one or both testicles in males, and to be contagious. Cavallini has made this mistake in his collection of surgical cases ;§ and we find a like error in the Memoirs of Toulouse.II The second variety of parotid phlegmon is of a malignant character. It seldom appears in early life, and in females seems sometimes to follow upon the cessation of the catamenia. It is still slower in its progress than the preceding ; and when at length it breaks, the pus is imperfect and cheesy, or serous. It is also pro- fuse and protracted to a long period and accompanied with foul sloughs. The patient is debilitated by the discharge, the irritation excites hectic fever, and the case frequently terminates fatally. Bark, hyoscyamus, conium, and similar tonics and narcotics have been tried ; but for the most part with little success. It assumes, occasionally, a scirrhous hardness, and grows to a considerable extent. It has been extirpated, but with variable suc- cess, when upwards of three pounds in weight ;^ sometimes with a cure ;** but at other times it has degenerated into a foul, bleeding. extensive, and fatal ulcer.tt SPECIES IV. PHLEGMONE MAMMAE. ABSCESS OF THE BREAST. TUMOUR SEATED IN THE BREAST ; PALE-RED ; HARDISH ; Itf IRRE- GULAR CLUSTERS ; WITH A PRICKING AND ACUTE PAIN ; SUPPURA- TION QUICK AND COPIOUS. Gen. II. This is sometimes produced by some accident, as that of a blow Howfornf' or severe pressure ; but more generally proceeds from a redundancy od. and consequently undue stimulus of milk, when first secreted after * Observations on the Red Peruvian Bark. t Obs. Chirurs. Fascic. i. t Vol. i. Obs. 39. § Collezione di Casi Chirurgici, i. 447. || Histoire et Memoires de rAcadcmie de Tonlonse, Tom. i. 1782. 1\ Kalthchmied, Fr. de Tumore scirrhoso trium cum quadrante librarian glandul* Parotidis extirpato. Jen. 1752. ** Siebold, Parotidis scirrhosae feliciter extirpate Historia, Erf. 1791. tt Commcrc. Lit. Nor. 17S3—8. ol. iu.j SANGUINEOUS FUNCTION, [ord. n. 216 child-birth, so that the lacteal tubes have not time to enlarge suffi- GEN« J{; ciently for its reception : in which last instance it is usually called Phiegmonc milk-abscess.—" In either case the suppuralion commonly begins mamma;. in many distinct portions of the inflamed part; so that it is not one Uie^reast. large circumscribed abscess, but many separate sinuses, all of which generally communicate. Now it usually happens that only one of y^j'yj these points externally, which being either opened, or allowed to ii™of break, the whole of the matter is to be discharged this way. But '^seT. we sometimes find that the matter does not obtain a ready outlet by andhcuco this opening, and then one or more of these different sinuses make "„ separate distinct openings for themselves.* outlets. In this case the complaint is usually protracted and tedious, though, Whence where the constitution is good, and there is no lurking taint to tedious" intermix itself with the inflammation, the issue is always favourable. This sort of phlegmon was called by Dioscorides sparganosis By Dioseo- from the Greek term a-iraey**/, " tumeo, distendo ;" and after him it spargano- has still been so denominated by various modern writers. Spar- ^* h also ganosis, however, was employed by Dioscorides in a collective sense, imported to signify not only milk abscess, but a variety of tumours, and other H^ lb" diseases supposed to depend upon an overflow, suppression, misdi- rection, or depraved secretion of milk ; and especially those which have since been described under the general term galactirrhcea. Many of these have little or no connexion with each other ; and IhV h . . little c* particularly abscess of the breast, and that peculiar swelling of the nexi'oc lower limb which occasionally takes place soon after child-birth, to which the term is etymologically best applied, and to which there- fore it is restrained in the present system. iave SPECIES V. PHLEGMONE BUBO. BUBO. TUMOUR SEATED IN A CONGLOBATE GLAND ; REDDISH ; HARD ; OIF- FUSE ; NOT EASILY SUPPURATING ; OPENING WITH A CALLOUS EDCfE. > Bubo is a Greek term borrowed from the Hebrew verb yi or nj>3 Gen. II. (bo or boa.) importing " to swell," and merely doubled according Te"c* " to the analogy of the language, to give it an intense or superlative whence power, whence bobo, or bubo. Buboes are chiefly found in the inguinal and axillary glands. They Ordinary are sometimes simple glandular inflammations, unconnected with causes. any constitutional or foreign evil, and require nothing more than the Treatment. common treatment; but they are often a result of constitutional af- fection, and very frequently a symptom of lues and pestis, in which cases they can only be cured by curing the specific taint. Mr. Hun- Cured b«- v Hunter on Blood, p 469 2[b a. m.J HiEMATlCA. [ord. n. Gen. II. Spec. V. Phlegmone bubo- Bubo. Has been confounded with a scrofulous tumour. ter asserts that he has seen buboes cured by vomits after suppuration has advanced. In an early stage the inguinal buboe has been confounded with a scrofulous tumour. A nice finger will generally discriminate them with ease. The bubonous tumour, is smooth, uniform, and obtusely painful: the scrofulous is, to the touch, and sometimes to the eye, a cluster of small tubercles without pain. SPECIES VI. PHLEGMONE PHIMOTICA. PHIMOTIC PHLEGMON. Gen. II. Spec. VI, Produced under two states of the glans. TUMOUR SEATED IN THE PREPUCE ; DIFFUSE ; OBTUSELY PAIM'UL ; IMPRISONING THE GLANS, OR STRANGLING IT BY RETRACTION. If, at the attack of inflammation, the prepuce be in its natural state and cover the glans, it cannot be drawn back, and the glans is imprisoned. If it should accidently have been retracted, or be naturally short and truncated, it cannot, after the inflammation has firmly fixed itself, be drawn forwards, and the glans it strangled. And hence the species offers us two varieties: « Incarcerans. Incarcerating phimosis. fi Strangulans. Strangulating phimosis. The prepuce protracted and im- prisoning the glans. The prepuce retracted and strang- ling the glans. Paraphi- mosis, what. Often ad vances rapidly. The first variety alone is denominated phimosis by some wri- ters, the second being distinguished by the term paraphimosis, or circumligatura. But the inflammation is one and the same, and the sanie specific name should express it; for the difference is a mere accident. This inflammation, like the last, though often produced by com- mon causes, and hence perfectly simple, is often, also, the result of a specific virus, as in lues and blenorrlioea. It arises frequently with great rapidity ; the prepuce is prodigiously distended with effused serum, and the mucous glands of the internal surface secrete an enormous quantity of pus before there is any ulceration or breach Treatment, of surface. If the prepuce be* retracted violently, and the glans strangulated, and cold applications, and topical bleedings prove in- effectual, it is often necessary to divide the prepuce to set the glans at liberty. And occasionally it is also necessary to perform the same operation when the glans is imprisoned by a protraction of the pre- puce : for ulceration is apt to take place under these circumstances in either case, and the matter soon becomes erosive from communicating with the air: as much of it as possible, however, should be washed out by a syringe used several times a-dav. and an astringent solution be ••i.. ni.J SANGUINEOUS FUNCTION. [ord. ii. 21'J afterwards injected, consisting of alum dissolved in water in the pro- Gen. II. portion of about a scruple to a quarter of a pint. fuP,EC* Vr m, •__ ■ ,. . . ^ ., t Phlegmono 1 De unpnsonmg phimosis is said to occur not unfrequently from phimotica. laborious exertion in a very narrow vagina.* I have not met with Smon. this result, but often with a lacerated prepuce. In many instances Treatmcnt- of both kinds relief has been easily obtained by grasping the penis with a very cold hand, and dextrously urging the prepuce forward or drawing it backward according to the nature of the case.j When the inflammation is very violent, whether in the strangulated f0°™tim|s or retracted variety, and surgical attention has been neglected, gan- gangrene.y grene will readily ensue, and an amputation of a smaller or larger portion of the penis may be absolutely necessary. In an instance Mortified of an amputation of this kind, recorded by Mr. Jamieson of Kelso, «^?m" in the Edinburgh Medical Essays, the whole of the glans penis was tt*te,]- restored by a process of pullulation: the new shoots having at first been mistaken for fungus, and attempted to be destroyed by esraro- tics. The fresh glans was well shaped and proportioned.! ' GENUS III. PHYMA. TUBER. IMPERFECTLY SUPPURATIVE, CUTANEOUS, OR SUECUTANEOUS TUMOR , THE ABSCESS THICJCENED, AND INDURATED AT THE EDGE ; OFTEN WITH A CORE IN THE MIDDLE. Pyhbia, a Greek term importing a tuber, tubercle or small swel- Gen. III. ling, from q>vu, "produco, erumpo," was used among the Greek and tKrm°f Roman physicians with great latitude and no small want of preci- form«rl.v • i ?,. , t, , -, . \ very loose sion : sometimes, as by Hippocrates and ramus of ASgina, being and con- applied to scrofulous and other imperfectly suppurative tumours ;fusc'' sometimes, as by Celsus and Galen, to tumours perfectly and rapidly suppurative, larger than a boil, but less painful and inflammatory, and without a core or ventricle : and sometimes by other writers, as Celsus also informs us, to fleshy excrescences or warts on the glans penis, which it was then the custom to destroy by caustics. And in consequence of this vague sense of the term, and the latitude of its original meaning, the great body of the Galenists, as Sauvages ob- serves, applied it to protuberances of every kind. Modern writers have, hence, been at a loss in what exact signifi- J^**" cation phyma should be employed. Linneus and Cullen have reject- has hence 1 ' * excited dis * Essich, in Ziegenhagen Anweisung alle venerische Krankheiten—zu behandeln. A. D. B. xcv. 421. t Andree, on the Gonorrhoea—Heckeer, Von Venerischen KrankheiteD, &c-. X Vol. v. Art. xxxvi. Vol. If—58 21S (L. ni.] H.EMAT1CA. [ord. h. Gen. ni. ea it. Sauvages and Sagar have used it as the name of a distinct SuC and separate order. Vogel following the example of Hippocrates Most accu- and pauius, has reduced it to a genus of imperfectly suppurative and rate import. glandular tumourg. andi as a genus, it thus occurs in Dr. Wdlan's table of arrangement, including boils, carbuncles, and similar inflam- mations as its species. This seems to be the most accurate sense ; and as such it is adopted in the present system, and made to include stye, boil, sycosis, and carbuncle; in all which we find some degree of imperfection in the suppurative or the ulcerative process of these small abscesses, or in both conjointly ; and hence the pus is foul and sanious, or the walls or edges of the abscess are thick and indurated, or the dead matter is not completely carried off, and remains behind in the shape of a core or a fungus, sometimes black and spongy, and sometimes excrescent and granulating. The following, therefore, are the species included under it:— Common character. 1. PHYMA HORDEOLUM. 2. -----— FURUNCULUS. J. ------- SYCOSIS. 4.------- ANTHRAX. STY, BOIL. FICOUS PHYMA. CARBUNCI.r SPECIES I. PHYMA HORDEOLUM. STY. TUMOUR SEATED ON TnE VERGE OF THE EYE-LID ; GRANULAR : HARD ; REDOISII ; SORE TO THE TOUCH ; SUPPURATION CONFINED TO THL POINT. Gen. Ill, Spec. I. Origin of the verna- cular name. The vernacular term sty, or as it is sometimes written stian, is to be met with in the earlier writers, who obtained it from the Saxon, in which stihan signifies " a rising, springing up, or ascent;" and hence in Bedc's Bible, Mar. iv. 7. (stihon tha thornhas,) "upspring the thorns." Wickliffe spells the old English derivation stigh, but Spenser, who uses the word frequently, drops both the ln?t, lettrrs of Wickliffe, as in the following couplet: To climb aloft and others to excel, That was ambition, and desire to sty. From the hardness of the margin of the tumour, and the imper- fection of the suppurative process, Sauvages compares it to a small boil : and asserts that it is often the result of a morbid state of the Sometimes stomach; adding that he knew a man who uniformly had a sty after produced drinking ardent spirits. The inflammation, though often very trouble- drinking, some while it lasts, for the most part readily subsides upon the break- ing of the minute nrtpcrss. or puncturing it at its apex when mature. ■ x. tn.J SA.NGL1NEOVS FUNCTION. [ord. u. 219 SPECIES II. PHYMA FURUNCULUS. BOIL. TUMOUR COMMON TO THE SURFACE ; DEEP-RED ; HARD ; fclRcCM- SCRIBED ; ACUTELY TENDER TO THE TOUCH ; SUPPURATING WITH A CENTRAL CORE. The boil is a push with a central core : and like the push is found Gen. hi. in persons of an entonic or phlogotic habit, with a peculiar suscep- (fhafactw" tibility of irritation : on which account it often makes its appearance successively in different parts of the body, and sometimes synchro- nously, so that we meet with a crop at a time. This tumour is there- fore chiefly found in persons of high health and in the vigour of youth. The existence of a core offers a singularity in this affection that is Core. well worth attending to, and shows that from some cause or other the ulcerative part of the process is imperfect. Upon Mr. Hunter's How hypothesis, this must depend upon a weak action of the absorbents ; for on Hun- but as we have already endeavoured to show that the material to be |ne's8i&ypo" removed must be prepared for absorption, and conveyed to the mouths of the absorbent vessels before absorption can take place, and have suggested that it seems to be the office of the secreted pus to accomplish this purpose, it is probable that in the furunculus the Pus p>°ba- pus, from some cause or other, is not quite genuine, and is possessed so^venVthan of a less solvent power than in common abscesses : whence a part ordinaii'y- of the dead matter remains attached to the living after the hollow has burst, and is thrown oft' from the base by sloughing. The mode of treatment is simple, and rarely requires medical or surgical assistance: though the diathesis should be lowered by bleeding or purging, or both. SPECIES III. PHYMA SYCOSIS. FICOUS TUBER. TUMOUR EXCRESCENT, FLESHY ; FIG-SHAPED ; SPROUTING FROM THE HAIRY PARTS OF THE HEAD OR FACE ; GREGARIOUS ; OFTEN COALESCING ; DISCHARGE PARTIAL AND SANIOUS. The Greeks gave the name of sycosis from wkov " a fig," to G^c# **£ various tubers and excrescences, the shape of which was conceived specific to resemble that of a fig. By Celsus, however, it is limited to a °ahm^e particular kind of inflammatory and imperfectly suppurative tuber g™"*^, by Celsns; 220 CL. iil.j UiEMATICA. [ORD. 11. Gek. III. Spec. HI. Pliyma Sycosis. Ficous Tubor. by Vogel : by Bato- man. Where seated. General character when on the beard. General character when on the head. Resembles porrigo. of the head and face. Vogel has understood the term nearly in the same sense ; and Dr. Bateman has, hence, correctly described it as such in his list of cutaneous diseases. It is seated sometimes on the beard, and sometimes in the hair of the head. In the former case it consists of small tumours, hard, roundish, pea-sized ; commonly in clusters ; occasionally confluent or running into one another; and spreading from ear to ear ; the discharge is small in quantity and of a glutinous texture, whence the beard becomes filthily matted. The variety that appears on the head consists of softer tumours, of different sizes, and in clusters ; they are seated among the hair ; and throw forth from a fungous surface, an ichorous, copious, and fetid discharge. It is not often that this complaint is connected with any constitutional affection : and offensive as it is, it will generally be found to yield to cleanliness, and mild astringents ; of which one of the best is starch-powder alone, or combined with an equal pro- portion of calamine. It makes an approach to one or two of the species of porrigo, but has characters sufficiently marked to keep it distinct, and to determine the present to be its proper station. SPECIES IV. PHYMA ANTHRAX. CARBUNCLE. IUMOUR COMMON TO THE SURFACE ; FLAT ; FIRM ; BURNING ; PENE .TRANT ; LIVID AND VESICULAR ; OR CRUSTY ABOVE, WITH A SORDID GANGRENOUS CORE BELOW ; IMPERFECTLY SUPPURATIVE. Gen. III. Spec.IV. Specific term, whence do- rived. " Relation to the furun- cle. In what it differs. General character. Anthrax is a Greek term correspondent to the Latin carbunculus or carbuncle; literally a small live-coal, so denominated from the redness and fiery heat of the inflammation. The specific definition sufficiently points out its relation to the furuncle or boil, especially when the latter assumes an unkindly or malignant character from something peculiar in the part or in the constitution. " The inflammation that produces the carbuncle is, however, of a different nature from any of the former : it is station- ary," observes Mr. Hunter, " with respect to place, and is pretty much circumscribed, forming a broad, flat, firm tumour. It begins in the skin, almost like a pimple, and goes deeper and deeper, spreading with a broad base under the skin in the cellular mem- brane. It produces a suppuration, but not an abscess ; somewhat similar to the erysipelatous, when the inflammation passes into the cellular membrane ; for, as there are no adhesions, the matter lies in the cells where it was formed, almost like water in an anasarca. This inflammation attacks more beyond the middle age than in it, and very few under it. It is most common in those that have lived cl. nt] SANGUINEOUS FUNCTION. [ord. 11. %U well. I never saw but one patient of this kind in an hospital. It Gen. III. appears to have some affinity to the boil; but the boil differs in this j?*™;Vi' respect, that it has more of the true inflammation, therefore spreads Anthrax. less, and is more peculiar to the young than the old, which may be Carbunelei the reason why it partakes more of the true inflammation."* The carbuncle occurs chiefly, perhaps uniformly, in weakly habits, °h°°"r8. and hence, often in advanced life. But it is not all debiluated per- weakfy"1 sons who have inflammations, that exhibit this disease: and we have Jj'a**co- here, therefore, another striking proof of the influence of idiosyn- «ar kind." crasy, or a peculiarity of constitution upon the general laws and progress of inflammation ; or of a peculiarity of that part of the constitution in which the inflammation shows itself: and but for which, the inflammatory stages of the present disease would in all probability succeed each other in regular order, and the anthrax be reduced to the character of a common and benign abscess. Of the The Pecu- nature of this peculiarity we aro too often able to trace out little or known!111 nothing; but so long as it continues, we have only a small chance of bringing the inflammation to a successful issue. The carbuncle shows itself under the two following varieties : et, Pruna. With a black crust; and oozing an erosive Escar-carbuncle. ichor, or sanies. f3 Terminthus. Core or fungus spreading in the shape and Berry-carbuncle. colour of the pine-tree berry. The first of these varieties was called pruna by Avicenna, from a p- An- its assuming the colour, and often the oval figure of the sloe, or fruit na™* of the prunus spinosa, Linn. The second derives its name from its Esorts. cuticle with difficulty from their thickness ; and hence become dif- fused, and, in the latter case, separate the cuticle from the skin beneath. Aoc(utePain» In tne whitlow, the acute and lancinating pain complained of duced. arises partly from the thickness and inelasticity of the skin about the finger-nail, but more from the hardness of the finger-nail itself; both which act like a tight bandage upon the inflamed part, and do not Cecuiiarims a^ow lt to swe^l or glve way to the extravasation. In these cases, usefui.ar y therefore, we can easily see why the application of poultices should be of more service than in any other ; for they can here act mecha- nically ; or, in other words, their moisture becomes imbibed by the cuticle, as by a sponge, so that it softens, grows larger in its dimen- sions, and less rigid in its texture: while the nail itself loses a part be1ow,awny of its hardness, and becomes suppler. It is in consequence of the Sirou'h the Peculiar firmness of the skin around the nail that the soft parts below opening. ° are so often seen pushing out through a very small opening in the skin as soon as this has been effected, and appearing like a fungus; but so exquisitely irritable as to give a more impressive idea of sore- ness, than, perhaps, any other kind of ulceration whatever. All this proceeds from the surrounding belts of the cuticle not giving way to Ptoirudca U'e .lncrease of the parts underneath ; whence they are squeezed out part not to ol Wia3 small opening like paint out of a bladder. It is a common ^l. in.J SANGUINEOUS FUNCTION. practice to eat away this protruded part by escharotics, as if it were Gem. V. a diseased fungus; but this is to give additional pain without any 3fi*?'Jm benefit, for the pressure from below will not be hereby diminished ronychia?' By continuing the poultice, the tumefaction will subside, and conse- bTremo'ed quently the pressure cease. byescharo- In the first stage of the complaint leeches should be applied, and Tmtmsnf. if the inflammation be hereby diminished, it may sometimes be carried off by astringent lotions, or ardent spirits, which excite the sur- rounding absorbents to additional action. Most of the causes of Produced inflammation operate in the production of this peculiar affection. It cauTeTot is also occasioned by an incurvation of the nail ;* possibly sometimes iDflamma- by a caries or morbid state of the subjacent bone in the tendinous BynPecniim and periosteous variety, as asserted by Siebold ;t and Mr. John c:iuse°' Pierson has shown that it may occasionally result from a syphilitic diathesis, or any other depraved habit.} It seems, moreover, in some cases, to be produced by the bite or burrowing of the larves of one or more minute, and, to the naked eye, invisible insects, hatched on the leaves of various field plants, and especially fescue-grass : and is said to be also occasioned by the bite of the gordius aquaticns, or hair-worm. GENUS VI. ERYTHEMA. INFLAMMATORY BLUSH. HED, GLABROUS, TUMID FULNESS OF THE INTEGUMENTS ; DISAPPEAR. ING ON PRESSURE : PAIN BURNING ; INFLAMMATION ULCERATIVE : TERMINATING IN CUTICULAR SCALES, OR VESICLES ; OCCASIONALLY IN GANGRENE-. This genus of inflammation is entitled to a minute and discrimi- Gek. Vi. native attention, not only on account of its violence and tendency gervHi»dof to an almost unlimited spread, but from its having been very gene- c.lose atte"' rally confounded with an exanthem or eruptive fever which, in one or two of its species, it frequently accompanies, but of which it is then a mere symptom. Erythema, from tpev6os, " rubor" is a term of Hippocrates, who Generic uses it as nearly as may be in the sense now offered ; and for which pioyed by many modern writers of our own country have not unaptly employed "^T the vernacular term inflammatory blush ; since the redness has often very much the appearance of a blush, or glowing suffusion of the cutaneous capillaries. For erythema Celsus and Galen have for which * Vicnt. Delect. Obscrv. Pract. t Chirtirsriscbes. Taohebueh. *?. ! Principles of Surgery, P. r. erysirn has •"■on 228 cl. in.] HiEMATICA. [ord. 11. Gek. VI. Erythema. Inflamma- tory blush. used by Celsus and Galen; though since ap- plied to an eruptive fever by many noso- logists : who have r cstorcd erythema to its original import: whence the two disorders have been confounded. Distinctive characters. Erythema sometimes used in a second sense. equally loose and indeter- minable. unfortunately adopted the term erysipelas, whence Duretus, in his Latin version of Hippocrates, has used suffusio crysipelatosa. And hence erysipelas has been made a very common synonym of ery- thema by general writers, while the nosologists, with a few excep- tions, have limited erysipelas to that species of exanthem or eruptive fever which is vernacularly known by the name of ^t. Anthony s Fire ; and have revived erythema to express the local affection, or peculiar inflammation before us, in which the pyrexy is mostly symptomatic. Frequently, however, as these two disorders have been con- founded, from an indiscriminate application of the same name to both, it will not be difficult to draw a distinctive line between them. Erythema bears the same analogy to phlegmon, as erysipelas does to small-pox. Phlegmon is local inflammation tending to suppura- . tion ; erythema, local inflammation tending to vesication : small- pox is an idiopathic fever producing a phlegmonous efflorescence ; erysipelas, an idiopathic fever producing erythematic efflorescence. Small-pox is always contagious ; erysipelas occasionally so ; phleg- mon and erythema have no such tendency. The distinction then between erysipelas and erythema is clear ; yet the confusion, just noticed, has been increased by some writers who have not only used erysipelas in its popular yet erroneous signi- fication of erythema, but have also employed erythema in a new and unjustifiable sense ; as occurs particularly in Dr. Willan's classifi- cation of Cutaneous Diseases : where, while erysipelas is made to embrace both erysipelas and erythema, as these terms have hitherto been commonly used, erythema is arbitrarily appropriated as the name of another collection of cutaneous erubescences of very dif- ferent characters, and produced by very different causes; some of them primary, others symptomatic affections ; some constitutional, and others local; occasionally smooth, papulous, tubercular, or nodose; most of which should be distributed under different di- visions. Thus introduced and explained, erythema, as a genus, will be found to comprise the seven following species, the first three of which are taken with little alteration from Mr. Hunter. erysipelatosum. gangrenosum. 1. ERYTHEMA CEDEMATOSUM. 2. 3. 4. 5. 6. 7. ----VESICULARUM. ANATOMICUM. PERNIO. INTERTRIGO. EDEMATOUS ERYTHEMA. ERYSIPELATOUS ERYTHEMA. GANGRENOUS ERYTHEMA. VESICULAR ERYTHEMA. ERYTHEMA FROM DISSECTION". CHILBLAIN. FRET. Most of these depend upon a peculiar irritability of the constitu- tion, or of the part in which the inflammation or erythema appears ; and the common, though, perhaps, not the sole cause of such irrita- bility is debility or relaxation. Galen, who justly distinguishes between suppurative, or, as he of Galea, calls it, phlegmonous inflammation, erythematic (with him erysipe- Proxiinate caueo mostly a peculiar irritability general or local. Distinctions l. in.] SANGUINEOUS FUNCTION. [ord. ii. 229 latous,) and edematous, ascribes the first, according to the old G™* VI. doctrine of temperaments, to a prevalence of the sanguineous dia- infiamma- thesis ; the second to that of the bilious ; and the third to that oft0,y blush' the phlegmatic or pituitous.* That there is generally a peculiar h°w f« habit in the last two, and often, as we have already observed, in the toUie pre- first, is so clear as to be indisputable : but it is by no means equally N^e61"13, clear that such peculiarity of habit is dependent upon the immediate cause Galen has adverted to. The temperaments of the Creek physicians, excepting when in excess, are not inconsistent with the condition of health ; and hence, therefore, in connexion with the temperament there is usually, in the last two inflammations, a habit of debility or relaxation. And where this exists, the very same ^y1|m?Jm^' stimulus that in a perfectly healthy frame would produce a common mation why adhesive or suppurative inflammation, under this state of the system "ather'tnan changes the character of the inflammatory action, and urges on the phiegmo- ulcerative process from the first. It usually commences with pecu- liar violence, and is peculiarly apt to spread ; the surrounding parts being easily excited to act or sympathize in an action to which they are prone. Hence, continued sympathy is a common though not f^11^!^ an universal effect; for we sometimes meet with very considerable common inflammations confined to the part irritated, notwithstanding that the ^jf®_'' and irritated part evinces great violence of action. Mr. Hunter has illustrated. illustrated this difference of effect by referring to a piece of paper under two different states, dry and damp. In dry paper a blot of ink applied to it will not spread, and remains confined to the point of incidence ; in wet paper it spreads easily, being attracted by the surrounding moisture to which it has an affinity. SPECIES I. ERYTHEMA (EDEMATOSUM. EDEMATOUS ERYTHEMA. (,OLOUR SCARLET ; SPREADING WIDELY AND DEEPLY THROUGH THE CELLULAR MEMBRANE, WHICH OFTEN IMPERFECTLY SUPPURATES, SLOUGHS, AND BECOMES GANGRENOUS. This is the " edematous inflammation" of Mr. Hunter, who Gek. vi. observes that, when the extravasated fluid is water, it has very much q**?^ ' the appearance of the adhesive inflammation, and probably resem- character. bles it more nearly than any other erythema, being of a scarlet colour, but much more diffused. The skin, through the whole range of the intumescence, appears glabrous, and the redness vanishes upon a pressure of the finger, but returns as soon as the pressure is removed. The extravasated fluid ■* De Tamoribus, Pneternat. Tom. in. xx, 230 cl. in.j HiEMATICA. [ord. ii. Gek. vi. is principally serum, and hence the swelling spreads wider than the Erythema' inflammation itself. It is very painful, or., rather, very sore, but has cedemato- |ess 0f fae sensation of throbbing than the adhesive inflammation. Edematous It is apparently limited to the surface, yet it probably goes much Pro'babiy deeper : for the extravasated fluid is in too large a quantity to be goes deeper furnished by the cells of the cutis alone : but as the swelling and the surface. inflammation do not here keep pace with each other as in the adhe- sive description, we have not the same guide to direct our judgment. "ropsica?6" C°mcidently with the remarks already offered, Mr. Hunter observes that " the difference between this and the adhesive inflammation arises, I conceive, from the principle of inflammation acting upon a dropsical disposition, which is always attended with weakness ; whereas a greater degree of strength would have produced the adhe- sive inflammation under the same cause or irritation. And what makes me conceive this, is, that in many cases of anasarcous legs we have exactly this inflammation come on from distention, which adds to the extravasation of the serum, as well as in most cases of tiw'more" scarifications of edematous parts to evacuate the water. When this lasting than inflammation takes place it is much more lasting than the adhesive; the^adhe- an(i | believe, seldom or never produces suppuration : but if it should Sometimes run into this stage, it is more general, and the whole cellular mem- suppuiates, , ., . ° . /,°.7 .„ ,,, spreads brane in the interstices ol parts is apt to mortify and slough, pro- andbe- ducing very extensive abscesses, which are not circumscribed."* comes There is no difficulty in determining why edematous inflammation fvn|r'ede-9 should rarely, if ever, produce suppuration, and why it should be of Agnation ^onSer continuance. Suppurative inflammation is, generally speak- rareiy ing, the process of a healthy part or habit taking place instinctively suppurates. for t^e pUrp0se of removing something that is dead, irritating, or otherwise mischievous, and of filling up the space hereby produced with sound living matter. In edematous inflammation the part or habit is unhealthy, and debilitated ; and hence, while there is neces- sarily less tendency to suppuration, there is less power of recovery. mWatoT8 'n some instances intumescence is migratory, of which Dr. Swe- diaur gives a singular case that had just occurred in his practice. The patient was a robust, sanguineous man of fifty-five years of age, who had for many years laboured under paroxysms of gout which had returned after certain intervals, but who, at the time, had been free from attack for a longer term than usual. The edema first suddenly showed itself in the eye-lids, and disappeared on the second day, when he complained of pain and swelling in the fauces with difficult deglutition. This was removed by astringent gargles, when the eye-lids became again edematous ; then the neck, and in a few days, in succession, the fingers of the right hand ; the fingers itched, became exulcerated, discharged an acrid humour, and the patient felt well. Some months afterwards the same erythema returned, travelled in the same direction, and it last fixed on the feet, which in like manner inflamed, ulcerated, and healed with a speedy return of general salubrity.! fn"Intion. ^he general curative intention therefore may be expressed in a * On Blood, Part. n. Ch. n. Sect. vii. p. 269. f Nov. Nosal. Meth. Svst. Vol. 11. 142. cl. in.] SANGUINEOUS FUNCTION. [ord. h. 231 few words. It should consist in whatever has a fair promise of giving Gem- VI. local or constitutional tone, or both. Hence the benefit of astrin- E^thema' gent epithems and lotions whether formed of earths, acids, or metallic oedemato- oxydes, applied to the part affected ; and of stimulants where the Edematous action is peculiarly weak, as camphor-water, or a solution of the erythema- acetate of ammonia, with proof spirit proportioned to the degree of torpor. And hence, as internal medicines, bark, columbo, myrrh, iron, will often be found highly serviceable, in conjunction with a generous diet, pure air, and such exercise as may be taken without fatigue. SPECIES II, ERYTHEMA ERYSIPELATOSUM. ERYSIPELATOUS erythema. colour deepish-red ; superficial ; with a determined edge in a serpentine direction ; the part which has passed through the action healing as the part next attacked becomes AFFECTED. This is the " erysipelatous inflammation" of Mr. Hunter; and is Gen. vi. evidently that which symptomatically accompanies the erysipelas as PEC" an exanthem, or eruptive fever. It is more commonlv cutaneous commonly ... I-.. < iii-" cutaneous; tnan situated in the deeper-seated parts ; although in some constitu- tions almost every inflammation, wherever it takes place, will run deep as well as wide. The skin, however, appears to be most sus- ceptible of its action ; for it will spread over a prodigious surface of skin, while it rarely affects even the cellular membrane under- a"d rare'y neath ; and in this respect, especially, it differs from the preceding cellular species. The extravasation moreover is less than either in the me",brane" edematous or even the adhesive inflammation. It appears to sup- Supports port itself by continued sympathy ; for it commonly begins at a point, continued and spreads in a migratory direction, as the part first attacked ^"part/' recovers. This cannot, therefore, be merely constitutional; for, if first at- it were, the parts already inflamed could not recover, while the mor- recovering" bid condition of the constitution disposes the surrounding parts to f"'1,08i".s . • f i 1 1 rr j thp m°rbid the same action ; but it affords an idea that, when the parts anected predisposi. have once gone through the action, they lose the morbid disposition acUonof8 and become healthy. This property is not peculiar to the inflam- *ne disease. mation before us; the ring-worm and many other cutaneous affec- °th°r ex; ° » amplesof tions have the same tendency. the same. Mr. Hunter observes that this inflammation is more common in M°re . the summer than in the winter, especially in hospitals ; and believes summer that it takes place more frequently after wounds on the head than any w,m"e1r" where else. " I have often," says he, " seen it begin round a wound more com- on the scalp, and extend over the whole head and face : the eye-lids woundl'on being very much swelled and the ears thickened; it has then advanced ||£ h^gd 232 cl. in.] HjEMATICA. [ord. n. Gen. VI. Spec. II. Erythema erysipelato- sum. Erysipela- tous ery- thema. where; migrates over the whole body, Sometimes stops ab- ruptly. If it reach the cellular membrane it suppu- rates ; forminjj the erysipelas phlegmo- nodes of Galen. Gives a peculiar sensation to the touch. Effusion should be soon evacuated. Some degree of fover at first: which soon subsides, while the inflamma- tion conti- nues. Treatment. Tonics. Absorbent earths applied locally. Starch. Calamine. Rhubarb. Sometimes attacks infants; to the neck, shoulders, and body, creeping along both arms and terminating at the fingers' ends; the part which attacks the body often descends to both thighs, passes down the legs, and terminates at the end of the toes. And while this is going on, it is as expedi- tiously cured behind, and ihe skin peels off from the cured parts." Sometimes, however, it stops suddenly in its course, and assumes a milder character. If it proceed deeper than the skin into the cellular membrane, it often suppurates, and at times occasions mortification in the cells by which air is let loose ; and it is this state of the disease that forms the erysipelas phlegmonodes of Galen,* Van Swieten,t and many later writers, who have used erysipelas in the loose manner I have already pointed out, as synonymous with erythema. The effect of this mixture of inflammations produces a strange feel, for it is neither^ that of fluctuation nor of crepitation : and as there are no adhesions, the matter finds an easy passage into the common cellular membrane, increasing the same kind of suppuration wherever it goes; and as mor- tification, and consequently putrefaction, follow speedily, the discharge becomes very offensive. As the parts loaded with effusion seldom ulcerate, they should be opened early ; for the fluid either gets into the cellular membrane from the want of adhesions, or separates parts that are only attached, as the periosteum from the bone, or muscles from muscles ; while the true suppurative inflammation, on the contrary, ulcerates briskly, and hence should be allowed to burst or at least should not be opened early. At the commencement of this inflammation there is commonly some degree of fever, accompanied with prostration of strength and dejection of spirits, and especially with loss of appetite. But the fever soon subsides, while the inflammation pursues its course ; yet since one source of irritation has thus departed, it is less violent, and sometimes assumes a chronic character. As this, like the last, is a disease of weakness, the same general tonic plan will be calculated to oppose it; and where there is a ten- dency in the separated skin to crack, absorbent earths or powders should be scattered freely over the ulcerative or oozing parts, to imbibe the acrid fluid as it escapes, or the ulceration will soon become extensive ; and the feeble and inflamed subjacent skin, hereby exposed to the stimulus of external agency, will grow gan- grenous with great speed. Finely pounded starch is a useful pow- der for this purpose ; as it combines a tonic and an astringent with an absorbent power ; so, likewise, is a mixture of equal parts of starch and finely levigated calamine or rhubarb. The last I have some- times thought peculiarly effectual in checking the irritation ; as the second appears to be in preventing the further spread of the inflamed outline that surrounds the separated cuticle. This species of inflammation sometimes attacks infants from a very early period after birth ; and, what is more singular, they have in a few instances been born with it. In such cases it appears to be produced by some occasional cause, co-operating with an erythe- * Mat. Med. Lib. xiv. cap. it. t Comment. Tom. n. § 72S. • l. in.] SANGUINEOUS FUNCTION. Luud. n. 233 matic diathesis derived hereditardy. It generally assumes the mixt Gen. VI, form of phlegmonous erythema ; suppurates imperfectly as it takes l^hen,"' its course through the cellular membrane, and is often succeeded by erysipeiato- gangrene. Its progress is very rapid from the relaxed state of the Erysipeia- infantile fibre : and from the extrication of air, as soon as gangrene S"roa7" is produced, the tumefied surface has the mixt feel already noticed chieaj in a of fluctuation and crepitation. It commences usually about the fZ^eZ'g genitals, works its way below towards the thighs and legs, and above whh sreat" towards the abdomen, and often excites on the peritonaeum the same and'spread- caseous or purulent secretion which is so apt to form on this mem- Nominal brane in puerperal fever. As there is no disposition to adhesion, viscera. the fluid spreads in every direction, wherever the ulceration makes lecrS a way for it; and hence it has often descended in great abundance ™* c°v*' into the tunica vaginalis and labia pudendi. Stimulant epithems of ether, alcohol, and camphorated spirits, Treatment. applied in the first stage of the disease to the parts affected, have been found the most beneficial practice: they act as counter-irritants, and takeoff the morbid excitement by the production of an artificial and more manageable inflammation. To these ought by all means to be added the use of the bark in any way in which it can be intro- duced, especially in that of injections repeated several times a day. SPECIES III. ERYTHEMA GANGRENOSUM. GANGRENOUS ERYTHEMA. THE COLOUR DUSKY-RED ; SUPERFICIAL ; CUTICLE SEPARATED FROM THE CUTIS BY A BLOODY SERUM ; THE CUTIS, WHEN DENUDED. EXHIBITING DARK BROWN SPOTS, DEPOSED TO BLISTER, AND SLOUGH : OCCURRING CHIEFLY IN THE EXTREMITIES. The gangrenous erythema, like the two preceding species, is a Gen. vi. frequent companion of debilitated or relaxed constitutions, but is wrfere mostly to be met with in advanced age, or weakly adolescence, or chiefly to infancy ; and particularly where, in old age, the constitution has been broken down by habits of intemperance and excess ; the circulation is languid, and the blood even in the arteries assumes a venous appearance. The inflammatory stages is in these cases sometimes Anteceded very slight, and the gangrene is ushered in with very little previous previous in- affection. flammatior.. Either of the preceding species will pass readily into the present, a result of in a warm, stagnant, and corrupt air ; for the same reason that all ding'specfes hospital wounds run rapidly into the same state under the same cir- ^ryiUated cumstances, as we shall have to notice hereafter. Local applications are here of far less importance than an atten- Curative tion to the general condition of the constitution. Stimulants and perfect cleanliness are perhaps all that are demanded under the first Vol. TI.—?0 134 cl. m.j TLEMATTCA. [ord. Gen. vi. head ; while, under the second, pure air, and a steady course of tonic Er^homa1' medicines and diet, adapted to the age and habits of the patient, are gangrreno- absolutely indispensable; andean alone furnish any hope of recovery. Ga^gre- How far this disease appertains to the ignis sacer of the Roman nousB in- wrjters, will be seen under the ensuing species, which forms another flammation. .'. , & l subdivision of the same affection. SPECIES IV. ERYTHEMA VES1CULARE. VESICULAR ERYTHEMA. COLOUR PALE-RED ; SURFACE ROUGHISH, AND COVERED WITH CROWD- ING MINUTE VESICLES, FILLED WITH AN ACRID, OFTEN A REDDISH FLUID ; PROGRESSIVELY TRAILING INTO THE NEIGHBOURING SOUND PARTS. Gen. vi. This species admits of two varieties, which have been pointed ' PEC' * out from the age of Celsus : » Benignum. Benign vesicular Erythema. /S Corrosivum. Erosive vesicular Erythema, a e. vesi- In the first, the redness and vesicles advance without a breach benignum. of the cuticle, as the part that has passed through the action is SSiSL he*linf• ..... erythema. In the second, the vesicles break in the part first affected ; and cuia'reecor- the erosive fluid produces tracks of sanious ulceration as the redness ErosWe' advances. vesicular Under the present and the preceding species is included the ignis General*' sacer of the ancients; about which much has been written, but remarks, which has been seldom understood, and never hitherto allotted a clear synony- methodic position. The author has taken some pains upon the Su^nd* subject, and trusts he will be able to establish the true boundary and the preccd- character of a disease, not more frequently described by the physi- mg species. Cl&n3^ tjian celebrated by the poets of antiquity. Common The common error has consisted in making the ignis sacer, or viewo?" holy fire, an exanthem or eruptive fever ; an erysipelas or a pestis ; ignis sacer; or some other idiopathic fever of the same order. There is no doubt, indeed, that, like the erysipelatous erythema, it has at times been met with as an accompanying symptom in pestis ; and when we shall come to treat of this disease, a distinct notice will be taken of the variety which such an accompaniment produces, and of which the plague of Athens seems to furnish us with a tolerable example ; compared but the ignis sacer>in its genuine and simple state, instead of being with but marked with a low eruptive fever, has often.very little fever of any wrexy. kind; certainly nothing more than symptomatic fever ; and by Celsus is described as beinir best cured by an ephemeral or anv cl. m.j SANGUINEOUS FUNCTION, [ord. 11. 23d other fever which may give increased action to the system ; hereby Gen. VI. proving that this, like the entire group of erythemas, is a result of SemT*' debdity. vesiculate. In ancient times some diseases were supposed to be inflicted on c^ylhem" mankind by the special interposition of the Divinity, or of his minis- £eb7,?tultof ters : and to these was assigned the name of sacer, or holy ; though impo'nof the peculiar crimes for which they were inflicted, or the names of Sine. the particular persons who in this manner first drew down the special vengeance of Heaven upon their atrocities, have not been communi- cated to us. The later term of Saint or Sanctus, as in St. Anthony's sanctus or fire or St. Vitus's dance, are of parallel origin, and express corporeal Sa,m" punishments first inflicted by the agents or supposed agents of the deity whose names they respectively bear. Ignis is a term expressive of the heat, redness, acrimony, and erosive power of a disease ; and is hence applied to the present in common with many other affections. The best description of the ignis sacer that has descended to us Description from the Roman writers, is that of Celsus. He represents it as a cXus. genus comprising two species, the first of which is precisely parallel "^fe^sy- with the species before us, and the second with the erythema gan- nonymou* gramosum, or the preceding ; and, in order to prevent any doubt eVythema upon this subject, the definitions of both species are here given, as vesicuiare. nearly as may be, in the words of Celsus himself. " It has," says he, " two species ; one (the vesicular erythema of the present sys- tem) is reddish, or a mixture of redness and paleness, rough with approximating vesicles (pustulee,) none of which are larger than the rest, and which for the most part are very small. In these are almost always found a fluid (pus), and often a red colour with heat."* Then follows his description of the two varieties just given, His two the benign and erosive, in the following words : " sometimes it trails ttaspccie"! along, the part healing that was first diseased ;" corresponding with the variety * of the present system. And " sometimes the part ulce- rating ; in consequence of which the vesicles (pustulae) break, the ulceration keeps spreading, and the fluid esca'pes;" alike correspond- ing with the variety /3. Celsus then passes on to describe his second His seconc species, which answers to the character and almost to the words of nonymo8us" erythema gangrenosum, or that we have just considered. " The j£e'm"r other species," says he, " consists in an ulceration of the cuticle, gramosum. without depth, broad, sublivid, but unequally so; and the middle heals, while the boundary lines advance ; yet not unfrequently the part that seemed healed again becomes exulcerated; while the neighbouring parts, which are about to receive the disease, grow tumid and hard, and change from a blackish hue ; the disease chiefly attacking the legs." In this passage the words fluid and vesicles are by Celsus named ImP°^°;fn pus and pustulae ; but that he hereby meant vesicles, and an icho- ceisus.'sy, rous fluid, the - ter ; and secondly, because in the ignis sacer, which, as we learn Gre^,. from Thucydides and Lucretius, was a symptom in the plague of * De Medicirma. Lib. v. Cap. xxvm. Sect. 4, 236 cl. m.] H.EMATICA. [ord. is. Gen. VI. Athens, the former has given us

^vy.raimi, or vesicles, as the pecu- Xeml" liar character of the eruption. " Yet the body," says Thucydides, vcsicuiarc " Was not outwardly very hot to the touch, nor pale ; but reddish, e^hem" livid, and efflorescing with minute phlyctccna? (vesicles) and ulcers ;''* which Lucretius has thus forcibly rendered. Et simul ulceribus quasi inustis, orane rubore Corpus, ut est, per membra sacer quoin diditur ignis. Wide-tidg'd with purple dye, and brandish'd o'er With trails of caustic ulcers, like the blaze Strew'd by the holy fire. Henceignis It is perfectly clear, then, I think, that the ignis sacer of the etyfhcma. Roman writers, was an erythema, chiefly vesicular, and sometimes gangrenous. It is also perfectly clear, that the present, like the preceding, species of erythema is the result of local or general de- Medical bility, and requires warm and active local applications, and a tonic treatment. ^^ bracing regimen. By later writers, however, the term is some- times more generalized, and, like pestilence, i3 employed to denote other affections than the genuine ignis sacer, though making an approach to them. Where the skin is slightly broken, and the acrid fluid oozes through the minute openings, the vesications should be frequently dusted, as already recommended under the second species, with chalk, or starch ; or, where the latter is too harsh and drying, with a mixture of equal parts of starch and finely levigated cala- mine ; carefully abstaining from all oleaginous or other applications that have a tendency to augment the relaxed state of the fibres. Found as a j have observed that the vesicular erythema is found, at times, as symptom or . . . *, . ' ' Bequei in a symptom in plague ; it is also occasionally found in the one or complaints. omer °f lts varieties, as a sequel on the exhibition of mercury in irritable habits ; and, under this form has been occasionally denomi- nated by authors erythema mercuriale, and hydrargyria, as we shall have occasion to notice still further when treating of syphilis. * Hist. ii. 50. cl. in.] SANGUINEOUS FUNCTION. [ord. u. 237 SPECIES V. ERYTHEMA ANATOMICUM. ERYTHEMA FROM DISSECTION. INFLAMMATION WITH LANCINATING PAINS ABOUT THE AXILLA. SHOOTING DOWN THE CHEST, USHERED BY SEVERE RIGORS AND ANXIETY ; SUCCEEDING RAPIDLY TO THE DISSECTION OF A FRESH CORPSE, WITH A PUNCTURE OR ABRASION ON THE HAND OF THE ANATOMIST : BLUSH A DEEP CRIMSON WITH A SPONGY FULNESS. CHIEFLY OVER THE PECTORAL MUSCLE : FEVER A TYPHUS. In our opening remarks on the present order of inflammations <|en* ^i- we adverted to that diffuse and ulcerative kind which is often found Diffusivo to take place in the cellular membrane, though rarely limited to this flamUmation. texture, from a variety of apparently slight causes, under a peculiar condition of the organ locally affected, or of the idiosyncrasy, or of the habit or manner of life. These causes are very numerous and Common in themselves of very different character, notwithstanding the simi- merous" larity of effect which they often superinduce. Some of them are ofcauscs- a mechanical, others of an animal origin ; some are general, others specific irritants ; but in every instance the cause, when first glanced at, is so seemingly minute that nothing but an established experience of the fact, from a redundancy of repetitions, could induce us to predicate so serious and oftentimes fatal a result. Among the more common of these causes are venesection ; the exposure of a pricked or pimpled finger to the fluids of a recently dead subject; the bite of a venomous serpent; the application of various secreted irritant, or chemical acrids to an abraded part of the cuticle ; and a small superficial but jagged wound made by a flesh-hook, or other mechanical instrument. Now all these causes, with the exception of the bite of a venom- Uut usually ous serpent, or other animal, are perpetually taking place without Co™setitu- any mischievous effect whatever. And hence it is obvious that ^"*^on unless there be some kind of aberration from the common law or coincides powers of health in the part affected or in the general frame of the w" l m' individuals that occasionally suffer from the application of such causes, and thus evince an exception to the ordinary course of natnre, there could be no mischievous effect at any time. Of the peculiarity of this aberration or morbid susceptibility of impression we know little or nothing. Intoxication seems to have been a pre- disponent in a few instances, but as even this has not uniformly acted, there must even at the time be a something independent of such an excitement, how much soever it may serve as an auxiliary. Yet although the symptoms issuing from such causes brought into The ^^' ■a state of activity, evince both in their local and constitutional such cau?^ though 23b CL. III.J ILEMAT1CA. [ORIL II. Gen. VI. Spec. V. Erythema anatomi- cum. Erythema from dis- section. often similar, in some of them differ essentially ; particularly wheie dis- section is a cause, as also in the bite of the more venomous serpents. The. former peculiarly entitled to attention. Anatomic erythema long ob- served hut not much noticed till of late. Its fre- quency within a few years. General characters. occasional discrepan- cy The cause differently accounted for. Hypothesis of simple irritation ; of putrefac- tion ; of a specific virus. The second the weakest and least adequate; though still adopted by Mugcndie and other high autho- rities. march a striking degree of resemblance as well as of uniformity in their descent from case to case ; yet they are often not without a considerable degree of anomaly and discrepancy of character, with the exception of those which proceed from the apparent contagion of a recently dead body during dissection or from the bite of the more venomous serpents. The former affection is peculiarly entitled to our attention from the undeviating tenour of its progress, the fre- quency of its occurrence, and the wonted fatality of its termination ; and an inquiry into its nature may possibly lead us to a somewhat better comprehension of the character of diffuse cellular inflamma- tion from the venom of the more poisonous serpents. The writer has hence given it, for the first time, a distinct, and as he believes, a deserved place in nosology, and trusts that the name he has assigned to it will meet with the approbation of the profession. The effect itself has been long observed, and occasionally adverted to, sometimes indeed loosely described, though it has not till of late very minutely engaged the attention of pathologists. But the repeated cases that, within little more than the last two years, have occurred in England,* Scotland, and Ireland, and have been sepa- rately reported by authorities of high reputation, have in the present day fixed the attention of the public upon the subject and given an interest to it that will no doubt lead to much clearer views than we are yet in possession of. The third volume alone of the Dublin Hospital Reports contains three cases of this kind, communicated by Dr. Colles, ;t and the first volume of the Transactions of the Me- dico-chirurgical Society of Edinburgh, not less than eleven com- municated to, or drawn up from personal observation, by Dr. Dun- can, junior : J in all of which the leading characters are the same ; and particularly in the diffuse blush and spongy feel in the integu- ments of the side, ind the typhous career of the accompanying fever : the chief discrepancy being m the degree of pain or inflamma- tory action in the vicinity of the pricked or abraded part which formed the inlet to the disease. But while the fact is thus generally admitted, the immediate cause has been very differently explained ; some writers have ascribed the inflammation to simple irritation in a constitution or idiosyncrasy of peculiar excitement; others to the irritation of a putrescent fluid ; and others again to a specific virus. The weakest and most inadequate of all these hypotheses is the second, or that which supposes the inflammation to proceed from an absorption of some part of the fluids of the body in a state of putrefaction. Yft it is the hypothesis stdl adopted by many patho- logists of established name, nnd especially by M. Magen«lie, if we may judge from his account of the fue of Professor Leeler, who died, as he fells us, " ;n consequence of the absorption of putrid miasms, which took place by a slight abrasion on one of the * Case of Dr. Pett, communicated by B. Travers, Esq.—Case of Mr. Newby, by Dr. Nelson, Medical and Phys. Joura. Feb. 1823. lb. Aug. 1823.—Case of Mr. Rainer, by Dr. Barlow. Edin. Medico-chir. Trans. Vol. i. p. 563. t P^tal Consequences resulting from slisrht Wounds received in DissccUon: p. 201. Dubl. 8vo. 1822. r * Cases of Diffused Inflammation, &c. v- 492. 524. and 563, Edin. 8>0. l«n' CL. Ifl.] SANGUINEOUS FUNCTION. [ord. ii. 239 fingers of the right hand."* It is an insuperable objection to this Orzn. VI. tene that the disease has occurred in almost every instance upon the Eryfhema dissection of a fresh body, and very rarely after putrefaction has anatomi- taken place: frequently indeed when the examination has been Erythema made within twenty-four hours, and in the case of Dr. Pett within ge°™0n.B" twelve hours, after death. " All the cases," says Dr. Duncan, insuperable " which I have observed, or of which 1 have had accurate re- tD0bJit.c,10n ports, except that of Mr. Whitlaw, and No. xvn. occurred after the examination of recent bodies, before they were interred"! It putrefac- is highly probable indeed that the process of putrefaction destroys the tion probn- specific virus, and consequently takes off its effects ; and such is the the specific expressed opinion of Dr. Colles :J and that in the few cases in virus' which local or constitutional symptoms have followed after the dis- section of a putrid body, it has rather been from the action of the putrid matter as a simple acuant on an irritable constitution, than from any specific influence. Dr. Duncan's two cases of affection when the body was putrescent, affords a striking confirmation of this opinion, instead of opposing it; for the first patient is described as being of a nervous irritable temperament, and the second, as being of scrophulous habit. Under such and similar circumstances, even mechanical and Hypothsm* chemical irritants, and diseased secretions of various kinds, though irritants0 otherwise sufficiently innocuous, are often found to excite not only examine!. local but diffuse inflammation, and a sympathetic fever that has sometimes ran so high as to prove dangerous and even fatal; the symptoms, indeed, being often a pretty close copy of those charac* terizing the disease before us. And hence many pathologists of the present day, chiefly from the difficulty of detecting a specific virus, have ascribed all the cases of anatomical erythema to the same cause of simple irritation in a frame thus constituted. But, in the first place, the disease before us has an essential dif- Objected to ference from all the other sources of inflammation in the manner of cause'of its onset, and in the state of the affected part. While all the rest *"• symP- . . .r , . „. . toms com- OPEN WITH LOCAL INFLAMMATION, Originating at the point Of injury ; pared with the inflammation spreading thence visibly towards the shoulder or erythema axilla, and followed by fever and constitutional disturbance as the anatomi. result of the local mischief; the anatomic erythema commences herlce a w WITH FEVER AND CONSTITUTIONAL DISTURBANCE, while the inflam- ^s'rrfust'be mation first shows itself about the shoulder or axilla ; the local point admitted. of injury remaining little if at all affected by inflammatory action. There is often indeed, a severe and lancinating pain, which darts upwards from such point; but, except in a particular description of cases, which we shall notice presently, there is no inflammation worth noticing, even when the pain is altogether intolerable. And, secondly, the plurality of individuals who have frequently Specific vi- been affected at the same time, as well' as with precisely the same f"om0,he0ua train of symptoms, and who have propagated the disease to their plurality 0f attendants, leads us, almost irresistibly, to the same conclusion of a Ifec'ted «'" the same * Precis Elemcntaire de Physiologic 2 Tom. 8vo. Paris, 1817. J.'me> or, t Trans. Medico-chir. Soc. Edin. Vol. i. p. 665. 'XV t Dublin Hospital Reports, Vol. in. nt suprn. £40 cl. in.] 1LEMATICA. [ord. n- anatomi cum. Erythema from dis- section. Additional illustration gen. VI. specific source of impression as in otlier cases of propagable conta- ErytnemT' gion. The same subject that gave rise to the complaint, which ter- minated fatally in Dr. Dease, originated it also, though not to a fatal extent, in Mr. Egan.* The cases of Mr. Blyth and Mr. Young, narrated by Dr. Duncan,! were in like manner derived from a com- mon dissection, as were those of Mr. Hercey, Mr. Hennen, and Dr. Dumbreck, communicated from the same authority ; in each of which, also, one of the anatomists fell a sacrifice, while the others were fortunate enough to recover. The following, forming another proof, from the pen of Dr. Dun- can, is perhaps still more to the point. " Dr. Cumming, a medical practitioner in this city, was present 30th September, 1821, at the dissection of a young woman who died from puerperal fever. Took no share in the dissection, except introducing a fresh thread into the needle which was employed in sewing the body, and was not aware of an abrasion, or having punctured himself in the act of threading. About eight hours thereafter, felt an uneasy sensation in the middle finger of the left hand, at the inner side of the flexure of the first joint; when, on examination, there was discovered an angry pim- ple. Passed a restless night; towards the morning had a severe rigor, to which supervened symptoms of pyrexia." The disease became established, and though its progress was less rapid and decisive than general, the patient expired on the eleventh day from the attack. The case, however, is here particularly selected, because it appears that a female who was employed to wash, in the evening after the above dissection, a towel that, in the course of it, had been used instead of a sponge, scratched her finger with a pin which. was left in it, and received the same disorder, in a milder, indeed, though still a very alarming degree ; but from which she ultimately recovered. It is unnecessary to accumulate examples. Whatever be the difficulty of conceiving the existence of a specific virus generated shortly aft^r death, and before putrefaction takes place ; it is far more difficult to withhold our assent from such an explanation, or to account for such effects upon any other principle. It may perhaps, in a slight degree, assist the pathologist in his future inquiries into this obscure subject, to observe that we have ground for believing that a new and active compound of some kind or other is constantly forming antecedently to the process of putre- faction, at the moment the living power, as well in plants as in ani- mals, is ceasing to exist, and a play of affinities commences, which saccharine this power has hitherto restrained. In plants this usually appears in ^"med'in the form of a saccharine principle, perhaps a saccharine acid; piaiits'as among mankind in that of a phosphoric acid, and often, from its decays. combination with other elements, of a phosphorescent light. This es^enuight ^s particularly the case with those animals that have a peculiar in animals power of emitting, and, perhaps, of secreting light while alive, as the glow-worm, the lantern-fly (fulgora,) and the cancer fulgens, among insects; among shell-worms, the phola, medusa phosphorea, and Other ex- amples un necessary. Physiologi- cal illustra- recently rtead only * Dublin Hospital Reports, Vol. in. ut supra. * Trans. Medico-Chir. Soc. Edin. Vol. I. ut supra. ma cl. m.] SANGUINEOUS FUNCTION. [ord. h. 241 various mollusca?; and among fishes, most that inhabit salt-water.* Gen. VI. All these are found to pour forth a succession of light after their Jryfheml* death, till putrefaction commences, but no longer. Yet something anatomi- of the same kind seems also to take place in various other animals Erylhen, under certain circumstances ;—perhaps in all. M. Cuvier tells us {™g0£* that M. Percy, who, during twenty-five years of war, had under his issuing care more than a million of wounded, and had often been obliged to [ulfaceof dress wounds in the dark, had frequently observed a phosphorescent wounds. light to issue from them, especially when extensive and dangerous, and where the living power was at a very low ebb. And he found, also, that the best way of rendering this emanation visible, is that of applying an aqueous fluid, as in the case of reviving the phospho- rescent light of the recently dead animals we have just noticed. " In one instance," says he, " a vivid light, a true ignis fatuus, existed for more than six days over the wound of an officer who had been dressed with compresses, wetted with pure water only."t I pretend by no means to say that the new and active, but viru- ™?0'IJlus" lent and contagious material, formed, perhaps always in the human, how far and apparently in other animal bodies, on the cessation of the living aPi)licable' principle, and when the laws of chemistry hitherto held in subjec- tion by the operation of this principle, now begin to assert their sway is of either of the kinds I have thus adverted to ; I have only endeavoured to draw the attention of the physiologist to the sub- ject, by showing that some peculiar and extraordinary compounds of a very diffusive and active kind are assuredly formed on the immediate termination of life, and to urge him to a search after compounds that have not hitherto been explored. Be the contagious material, however, what it may, it appears to The Tjrus pervade equally all the fluids of the decomposing body, whether ail the natural or morbid : for the disease has followed where the punc- dissected'116 tured hand has been merely immersed in genuine pusf that has body- flowed from an abscess of the stomach or some other viscus, as well fied!mp '" as where it has merely come in contact with the lubricating lymph of serous or mucous membranes ; and, as already observed, where it has only touched a towel or a sponge employed in wiping up the fluids, or other materials that have required removal in the course of an examination, or even a thread wetted with the same and pressed through the eye of a needle. Nor does the character of the contagious material appear to J3"6^0^ depend in any degree upon the nature of the disease of wbich the the nature subject submitted to dissection has died. It has followed upon cases "fou^X-" of dropsy, of pulmonary affection, of enteritis, of puerperal fever, of |?x3eem )U, aneurism, and of Cesarian section.§ So that the nature of the pre- fied. ceding disease has little connexion with the virus as the process of putrefaction. The ordinary progress of the complaint cannot be better described ££§£" f/ * Hulme, Experiments, &c. on the Light which is spontaneously emitted from various bodies. Phil. Trans. 1800. t Analyse des Travaux de l'Academie des Sciences de Paris pour 1819. X Case of H. Callow, Esq. Surgeon of the 16th Regiment of Foot. Lond. &c. Phys. Journ. Aug. 1823. p. 123. § Duncan's Cases in Trans. Medico-Chir. Sot. Edin. ut supra; as also p. 566. VOL. II —31 2\2 cl. iij.j ILKMATIOA. [ord. ir. Gen. VI. Spec.V. Erythema unatomi- cum. Erythema from dis- section. Erythema- tic blush a pathogno- mic symp- tom. Swollen parts sometimes crepitate. Sometimes extreme pain in the punctured spot, but without inflamma- tion. Nature of the fever. Fatal issue. Sometimes more fa- vourable. Prognosis in such than by copying the sufferings of Professor Dease. His demonstra- tion took place on a recent subject on February 13, 1819, at one o'clock. He awoke early the ensuing morning with severe rigors, sickness, and acute pain in the left shoulder. On the next day a slight fulness was observed above the clavicle along the left side of the neck, which could not bear the slightest pressure. On the day succeeding a colourless swelling was noticed about the axilla, which first suggested the real nature of the complaint: and on examining the hand there was found by Dr. Colles the mark of a slight scratch with a superincumbent vesicle. He appeared to improve a little for a day or two, though full, florid, and crimsoning erythema occu- pied the side in the region of the pectoral muscle, extending down- wards. On the morning of the nineteenth he showed delirium, and a vesicle appeared on his fore-arm, which remained stationary to the last. By the next day the erythematous swelling had extended over the entire side of the body from a little below the axilla to the hip ; and the swollen part became studded pretty thickly with indu- rated papula?; the delirium being more confirmed. On the twenty- first the inflammation completely involved the axilla, and on its poste- rior edge an abscess seemed to have formed though there was no fluctuation. At this period the opposite or right arm exhibited an intumescence on its anterior part, occupying about a hand's breadth of the flexor muscles, which was punctured on the same evening and discharged about a tea-spoonful of serous fluid, but without relief; and within an hour or two afterwards, being the eighth day from the accession of the disease, he expired. The pathognomic blush that spreads over the region of the pec- toral muscle has a peculiar feel that is not easy to be described ; it yields to pressure like a quagmire, or piece of sponge ; and is hence called boggy by Mr. Lizars,* and doughy by Dr. Colles.t In the case of Dr. Pett it was found by Mr. TraversJ to crepitate, a secre- tion or extrication of air having apparently taken place. There is often a considerable degree of uneasiness in the punctured or abraded spot which has proved an inlet to the virus, sometimes, indeed, amounting to an agonizing and intolerable pain, though without any visible show of inflammation, or too slight to be regarded. The accession of the fever is usually accompanied with great anxiety and dejection of spirits, and often an unwonted irritability of temper. The nervous and depressing character of the fever is indeed obvious from the first, and the patient rarely rallies into afty degree of hope or composure where it proceeds to a fatal termination. In very many cases, however, its issue is of a happier kind ; and where this occurs, sometimes, about the eighth day, a gentle diapho- resis or diapnoe lubricates the harsh and burning skin, a sound and refreshing sleep succeeds, the pain and inflammation diminish, and the patient advances to recovery in a straight path. But more gene- rally an effort is made to form lodgments of imperfect pus, bloody serum or grangrenous ichor, often of all these combined, in particu- * Trans. Medico-Chir. Soc. Edin. Vol. i. p. 496. ! Dnblin Hosp. Reports, Vol. in. ut supra. I orirt. Med. and Fhys. Joitrn. IVh 1823. p. KB section. uL..ai.f SANGUINEOUS FUNCTION. 'uiiu. u 240 lar parts of the affected side, most commonly indeed in the axilla ; Gen- vi- which swells into an enormous bag, and, if not opened by art, bursts t'^eu^' spontaneously and discharges the complicated and pent-up fluid to "natomi- an amount of several pints ; the whole of the cellular membrane Eyt'i.cma on the affected side being broken down into the general mass, with ftoindis- numerous sloughs and skeins of fibres detached from the adjoining muscles and thrown out in loose bundles. The cure is long, and doubtful, in proportion to the range of the ulceration, and the extent of the gangrene : and the patient is often so much reduced as to be Occasion- in danger of falling a sacrifice from hectic fever or some other f1.!0*nratality secondary affection. But when he has reached this stage he gene- secondary rally succeeds in the end, though the skin over the injured part is efl considerably shrivelled from the loss of the cellular texture beneath, and often attached to the subjacent muscles. Such is the progress of the disease when the contagion meets A peculiar with a habit or constitution favourable to its mischievous action, and idlosy" which yields at once to its influence. But, as in other contagions, l™y° %r so in the present, we perceive a striking diversity in this respect, the virus to The habit or idiosyncrasy of most anatomists fortunately renders guceh habits them altogether unsusceptive of its impression, and they escape from not com- its arrest. And hence, in all probability, the reason why but few hence very comparatively are ever affected with this fearful complaint, though "suc™!™Uii handling dead bodies for years, and with hands chapped or punctured in various points. There are others who seem to possess constitutionally a modified [jjBOme protection, though they cannot escape altogether ; in whom the idiosynaa- virus finds a less easy course of absorption, and, by being delayed in pyar?ina1j!|y its progress towards the axilla, opens its assault at the point of con- protects. tagion, becomes concentrated, and spreads its chief brunt in that the disease quarter. In this case the disease commences with local, instead ofinsucU with constitutional symptoms, and the latter are even at last rather a Commences sympathetic sequel, as in numerous cases of simple irritants, than a Instead" of diacritical part of the disorder. The punctured hand or finger is not conwitu- only vehemently painful, but swells and becomes considerably in- 10na y flamed ; the inflammation, characterized by heat, redness, pain, and enlargement, gradually shoots up the fore-arm ; and if not checked in its progress ascends to the shoulder, and fixes itself in the axilla, or spreads still further into the side of the chest. But the virulence = as much as if itself were primarily affected. If we contrast contrasted these species of inflammations with those that attack parts not very of'other86 essential to life, but with such a degree of violence as to produce parts less cstrntisl to Inilamma- tory symp- toms vary in different organs. Inflamma- tion of the ttiain. Inflamma- tion of the heart. Inflamma- tion of the stomach. Inflamma- tion of the Winter, on Blood, &c r>. VL. III.J SAi\G(JIi\fiOVS FUNCTION. j.OJRi). II. 2.51 universal sympathy and affect the vital functions, we shall find that Gen. VII. Hi the latter the pulse is fuller and stronger than common ; and the & blood is pushed further into the extreme arteries. The attack ™a<""w usually commences with rigor ; the patient then becomes somewhat *""* roused because the action of the part is roused, and the effects on the constitution are not yet such as to impede the operations of the vital organs. Much, however, will still depend upon the nature of the parts, whether active as muscles, or inactive as tendons ; as also upon the situation of the same description of part, and especially upon the character of the constitution : for if the last be extremely irritable and weak, as in many women who lead sedentary lives, the pulse may be as quick, hard, and small, even at the commencement of the inflammation, as in inflammation of the vital parts. The blood, moreover, may be sizy, but will be loose and flat on the surface. Having premised these general remarks, we are the better"pre- pared for examining the relations which the numerous species be- longing to the present genus bear to each other; and satisfy our- selves with a more summary account of several of them than would otherwise be necessary. These species are as follow:<— 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. EMPBESMA CEPHALITIS. ---------OTITIS. PAROTITIS, PARISTHIMITI&-. LARYNGITIS. BRONCHITIS. PNEUMONITK. PLEURITIS. EMPBESMA CARDITIS. ■ PERITONITIS. ---------GASTRITIS. --------- ENTERITIS; ---------HEPATITIS. --------- SPLENITIS. --------- NEPHRITIS. ---------CYSTITIS. ■--------- HYSTERITIS, --------- ORCHITIS. INFLAM5IATION OF THE BRAIN. ------------- OF THE EAR, MUMPS. QUINSY. INFLAMMATION OF THE LARYNX. CROUP. PEHIPNEUMONY. PLEURISY, INFLAMMATION OF THE HEART. -------------OF THE PERITONAEUM. --------------OF THE STOMACH. -------------OF THE BOWELS. ■ OF THE LIVEB. -------------OF THE SPLEEN. -------------OF THE KIDNEYS. ----,----■----- OF THE BLADDER. ---- OF THE WOMB. ----OF THE TESTICLE? lii>v. CL. ItL HiiMATTOA. I ORD. JI SPECIES 1. EMPRESMA CEPHALITIS. [INFLAMMATION OF THE BRAIN. PAIN IN THE HEAD Gen. VII. Sfec. I. General pathologi- cal re- marks. AVERSION TO LIGHT ; FACE MORE OK LE? FLUSHED ; CAUMA. Disease may com- mence in membranes or the sub- stance of the brain. Original seat how distin- guishable. The pathology of cephalitis, or inflammation of the brain, is, in some degree, obscure and difficult, from the difference which occurs in several of its secondary or concomitant symptoms; occasioned partly, perhaps, by the difference of its exciting cause, partly by the particular portion of the organ that is primarily or chiefly affected, and partly by circumstances which seem to baffle all research. From this occasional difference of symptoms some nosologists have en- deavoured to establish as many distinct affections, and have hence multiplied a single specific disease into a considerable number of distinct species, and even genera, and treated of it under a fearful host of distinct names : and hence the disease before us has been described, not only under the term cephalitis, but under those of phrenitis, paraphrenitis, phrenismus, sideratio, siriasis, sphacelismusr and typhomania, calentura, and a great many others, which have bur- thened the medical vocabulary, and perplexed the medical student. The disease may commence in the meninges, or membranes of the brain, or in the substance or parenchyma of this organ : and if it were to confine itself strictly to the part first affected, instead of spreading from one part to another, there would perhaps be no great difficulty in determining, from the symptoms before us, its direct and actual seat; for while membraneous and muscular inflammation before the access of gangrene, is accompanied with an acute and rousing pain, great heat, and a pulse considerably and permanently quickened, parenchymatous inflammation is rather distinguished by a heavy, and often a stupifying, pain, a slight increase of heat, and a pulst irregularly quickened, sometimes sinking even below its natu- ral standard.* Now both these conditions are occasionally found in different cases of cephalitis; and we may hence infer that in the one instance the disease is seated chiefly, if not altogether, in the meninges, and in the other in some part of the substance of the brain itself, thus presenting to us the two following varieties :— « Meningica. Phrensy. Brain-fever. Pain in the head acute ; into- lerance of light and sound; cheeks permanently flushed; eyes red ; watchfulness: de- lirium ; pulse rapid. Hunter, on Blood, he. p. 288, 26? < t. m.} ;SANGUL\E01jS FUNCTION. [oRd. Sj. 2o^ 3 Profunda. Pain in the head obtuse; cheeks Gek. VII Deep-seated inflam- irregularly flushed; pulse ir- £*£%£ mation of the brain. regularly frequent; eyes ob- Cephalitis. Acute Dropsy of the lique; sleep heavy but unquiet, Sob'S Head. and occasionally interrupted brain- by screams. Chiefly common to children. The above clear and distinctive marks, however, by which the Tjj,eav"|„ two varieties are separated from each other in exact cases are not run into often to be met with ; as each, for reasons already given, is apt to each other assume something of the character of the other. And hence they £"* ^£e> have hitherto escaped the attention of almost all our nosologists, cieutiy even of those who have subdivided inflammation of the brain into "otologist*. the greatest number of distinct genera or species of disease ; whilst Vogel expressly declares that all the most acknowledged symptoms of inflammation of the brain are equivocal, not only as to a distinc- tion of one morbid part from another, but as indicative of inflamma- tion of any part; and Dr. Cullen asserts in a note subjoined to his T)r0eateend _ot generic definition (for he advances the disease to the rank of a genus, rally by and a genus too without a species or a specific character,) that Cullcn* there are no symptoms capable at all times of distinguishing, with certainty, inflammation of the brain from inflammation of its menin- ges. On which account he deviates from the more complicated ar- rangements of Sauvages, Linne'us, and Sagar, and includes several of their genera in his own definition, which runs in more general terms as follows: "pyrexy severe; pain of the head ; redness of the face and eyes; intolerance of light and sound; watchfulness; fierce delirium or typhomania." There is so much correctness in this remark of Dr. Cullen's, not- withstanding the error of his arrangement, that the present author yielded to it in the first edition of his Nosology, and introduced cepha- litis, not indeed as a naked genus without a specific character, but as a single species without enucleating its varieties; or, in other words, without treating of deep-seated inflammation, constituting acute in- ternal dropsy of the brain, separately from inflammation of the head generally. It may, perhaps, be doubted, whether acute dropsy of the Expediency brain ought to be regarded as an idiopathic inflammation at all, and present sub- consequently whether the present is the proper place for it; but the diviBion; reasons which will immediately be advanced will, I trust, settle this point completely. And, as, upon a closer attention to the subject, notwithstanding Dr. Cullen's remark, I am induced to think that there are cases in which parenchymatous or deep-seated inflammation may be distinguished from meningic, I have so far deviated from the first arrangement as to give these distinctions under the form of the above varieties. I admit, nevertheless, with Dr. Cullen, that there are no symptoms ^^^ capable at all times of distinguishing, with certainty, inflammation of maikg can- the substance of the brain from inflammation of its meninges; and UeVaS'* only contend that the distinction may be drawn in certain cases in which the disease is simple, and the characters strong and unmixed ; 2U ul. m.} HJL1AIATIGA. [okd. u. Gen. vii. and strikingly indicative of membranous or parenchymatous inflam- EmTresma" mation, according to the general rules just laid down upon the subject. Cephalitis. It is possible, indeed, that meningic inflammation may occasionally tionTnho be still more limited, and exist chiefly or altogether in one of the Arachnitis membranes alone, as the arachnoid, whence some pathologists have xvhat."' '8' set down arachnitis as a sub-variety of the meningic form : but as such minute derivations can never be supported by pathognomic symptoms, nor lead to any practical utility, I cannot but prefer the example of Professor Frank, and indeed of most of the Italian patho- logists, in rejecting them, to that of Pinelle and other French wri- ters* in introducing or retaining them. These I believe that a simple and unrestricted appearance of inflamma- ?oVl£bir tionis more frequently to be traced in meningic than in profound or moro parenchymatous cephalitis; or, in other words, that in primary in- inemenningic flammation of the substance of the brain, the meninges are more dis- deep-seated posed to partake of the affection either by continuous action or sym- cephahtis. pathy, than the substance of the brain is in primary inflammation of Whence the meninges. And hence those nosologists that describe but a universally single species, or genus of this disease, as it has been often though described: incorrectly denominated, as Vogel, Cullen, and Parr, lean chiefly to the meningic variety, and define it by characters of great vehemence or acuteness, so as in reality to limit themselves to this variety alone. Yet as the symptoms do not always nor even most frequently mount up to this aggravation, in consequence of the disease more commonly originating, or being more commonly seated, in the substance of the brain itself than in its membranes, they have all been dissatisfied with their respective definitions; and instead of enlarging or modi- fying their terms to meet the distinctive phaenomena as they vary ac- cording to the seat of the disease, have endeavoured to apologize for their own inaccuracy, by representing these phaenomena as irredu- cible and anomalous. and given The first variety, therefore, exists in the judgment and even in character'*1 tne description of all writers, who, where they have not entered into of the more minute subdivisions, have given it as the general character of disease. ., , . „ ° ° the complaint. foeaBSnat- ^e ex^stence °ftne second variety, or, in other words, the pro- ting the priety of regarding what has hitherto been denominated acute or in- vMienty. ternal hydrocephalus as a variety of cephalitis, requires to be ex- amined somewhat more at length. regarded as ^e absurdity of the usual arrangement of internal hydrocephalus, belonging and of contemplating it as belonging to the ordinary family of drop- to dropsies. sjes wjtn wmcn jt has scarcely a common symptom, has long been felt by pathologists, and is directly noticed both by Sauvages and Cullen. But the question is, if we remove it from its usual situation, where are we to place it ? if we do not regard it as a dropsy, in what light are we to contemplate it at all ? and how are we to regulate our treatment of it ? The professor ofMontpellier tells us that, ac- cording to its symptoms, it is to be ranked in the comatose, spas- modic, or some other tribe of diseases: distin :•'«■! v importing that, in * Recherches sur l'lnflammation de l'Arachnoide, &c, Par P. Ducbatelet, M.D. &c. etl. Martinet. M.D. 8vo. Paris, 1821. cl. ni.] SAXGL" INEOUS FUNCTION. [ord. ii. 255 his own opinion, he could, not refer it to any single division in his Gen. VII. very extensive classification. Dr. Cullen's reply is, that it is an evi- j,®™;; dent and idiopathic species of apoplexy, and ought to take its place p^jj'* under that genus: and he has hence distinguished it by the appellation tio^of the apoplexia hydrocephalica, and in this manner assigned it " a local Ho'w'far an habitation and a name." In reference to this assignment he ob- apoplexy. serves, however, that, in a nosological work, it is difficult to collate exactly diseases that in their progress assume a changeable form, and hence to allot a perfectly fitting place to hydrocephalic apoplexy. " Yet I prefer," says he, " placing this disease under the head of apoplexy, to placing it under that of hydrocephalus (dropsy of the head;) first, as it differs extremely from the symptoms of sensible (external) dropsy of the head; and next, as in its proximate cause, and at length in its symptoms, it bears to apoplexy as near a relation as possible. Dr. Cullen evidently regarded the effusion or dropsy in the ventri- t^e8teft|cectof cles of the brain as a mere effect of the disease, rather than as the for the disease itself; yet the drowsiness, or heavy sleep, or whatever else causES there is a-kin to apoplexy, and which he contemplated as the proxi- mate cause of the disease, and consequently as the disease itself, is a still more remote effect than even the effusion, for it is probably the mere result of such effusion. In truth, it is only necessary to run over Dr. Cullen's specific definition of this disease, to see how very little it has in common with apoplexy. This definition is as follows: " apoplexy arising gradually: affecting infants, and the age below puberty,^*/ with lassitude, feverishness (febriculd), and pain of the head ; afterwards with a slower pulse, dilatation of the pupil, and somnolency." The definition includes two stages of disease, if not two distinct diseases, a primary and secondary : and it is only in the second stage or secondary disease, the mere result of the first, that it bears any analogy to apoplexy. The first and leading symptoms are evidently those of pyrexy, First and which is therefore the fundamental part of the disease ; and had not symptoms Dr. Cullen been in some degree influenced by system, he would pyrec,,c' probably have coloured these symptoms a little more highly, as he might have done without any departure from the truth. And hence, By whom while Dr. Parr, Dr. Young, and a few others, have adhered to Dr. an8 inflam-8 Cullen's view of the subject, the great body of pathologists have ma,ion- been dissatisfied with it, and have correctly carried internal hydroce- phalus over to the class of pyrexies, and regarded it as a fever or an inflammation. Thus in Dr. Macbride's table it occurs as a nervous fever, under the title of febris continua, nervosa, hydrocephalica: and more simply under that of febris hydrocephalica, in Professor Daniel's edition of Sauvages; whilst Dr. Quin of Dublin, Dr. Withering, Dr. Rush, Dr. Golis, Professor Martini, and a host of other writers of authority, have contemplated and treated it as an inflammation,—an inflammation of the brain,—and consequently a cephalitis, in the lan- guage of Dr.Coindet of Geneva Cephalite interne hydrencephalique ;* * M§moiresur l'Hydrencephale ou Ce'phalite Interne Hydrencephalique, par J. F, ^oindet. M.D. MGdicin en chef des Hospices de Geneve. Geneva. 1818. 2b6 et. ui.j H.EMATICA. Lord. u. Gen. VII Spec. I. Empresma Cophalitis. Inflamma- tion of the brain. the inflam- matory fevor not always acute, and rapid : still more lately by Dr. Porter Proofs de- rived from •dissection. in that of Dr. Golis wasaerschlag,* or water-stroke, from its violence ; the fever being regarded as a mild and somewhat irregular cauma, and the effusion into the ventricles of the brain as a mere effect of the inflammation. This is not the only instance, indeed, in which cauma assumes a mild character. In various other species of empresma it is often found to do the same, of which the reader will find an interesting example under the species laryngitis, a few pages further on: and ot which every practitioner is meeting with daily instances in pneumo- nitis, and especially in inflammation of the parenchyma of the lungs producing suppuration. The general organ of the brain, however, seems to have less irritability than almost every other organ when in a state of health, and we often find it to be little irritable in a state of lesion; since nothing is more common than for a bullet, or the broken point of a knife, sword, or other weapon, to be forcibly driven into it, and buried there for weeks, months, or years,! in one instance eleven years,!, not only without danger, but sometimes with little inconvenience. In the third number of the Medico-Chirurgical Journal, there is an excellent paper upon the subject before us, by Dr. Porter of Bristol, which commences with a very correct pathological view of the dis- ease, minutely coinciding with the present arrangement, and con- firming this view by a variety of strongly marked and well selected cases. And I am glad to avail myself of Dr. Porter's authority in following up this second variety of cephalitis, into a distinct and ex- tended illustration. In few words both varieties not only evince symptoms of inflam- mation during the progress of the disease, but anatomical proofs of the same upon dissection after the disease has terminated fatally; in the meningic subdivision the complaint commencing in and being ordinarily confined to the meninges or membranes of the brain, the blood-vessels chiefly affected with inflammatory action being the me- ningic branches of the external carotid ; and in the deep-seated sub- division the complaint commencing in and being ordinarily confined to the posterior part of the brain, the blood-vessels chiefly affected being minute branches of the basilary artery. It is nevertheless pos- sible, and appears often to become a fact, from the anastomoses that are occasionally found between different arteries of the brain, from the continuous spread of morbid action from neighbouring sympathy, or from some unknown cause, that either variety may pass still deeper or wider into the substance of the brain, and make an approach to- wards the other; and hence the mixt, anomalous, and even contra- dictory symptoms, by which the specific character is sometimes dis- tinguished^ a striking example of which, but too long to be quoted, is to be found in the Edinburgh Medical Commentaries.il * Praktische Abhandlungen iiber die vorziiglicheren Krankheiter des kindlichen Alters. Band. i. Wien, 1815. | Gooch's Cases. Hoegg. Diss. Observ. Medico-chir. Jen. 1762. j Majanet, Jonrn. de Med. Tom. xli. 65. lb. Tom. xx. 653. § J. P. Frank, De Cur. Horn. Morb. Epit. Tom. n. p. 48. Mannh. 8ro. 179<> |! Vol. tx. p. 164. ci. m.j SANGUINEOUS FUNCTION. [ord. ii. 257 "In three cases," says Dr. Sagar, " I have found suppuration of Gbn.VH. the brain after death ; in each of which the patient during the pro- EmTrosma gress of -the disease breathed sonorously but without stertor."* cephalitis. Whether, in the case of effusion between the membranes, the fluid be tionTfthe" confined, where the disease commences in the meninges, to the space brain' between the dura mater and the arachnoid tunic, and where it com- mences in a contiguous part of the brain, to that between the arach- noid tunic and the pia mater, as asserted by Dr. Porter, 1 have not been able to determine. We may hence explain why the symptoms of irritation and oppres- Hence sion should so much vary as we find they do in different cases; anomalies why there is sometimes no delirium and at other times a considerable exi)Ia,nr'! degree ; why the delirium is sometimes furious and impetuous, con- stituting the delirium ferox of medical writers; why in other instances it is mute or muttering, designated by the phrase delirium mite; why there should occasionally occur examples of that comatose or heavy stupor to which the Greeks gave the name of typhomania; and why the pain and pyrectic symptoms should vary from great acuteness to a mere disquieting head-ache and slight increased ac- tion : as also why, in a few cases, there should not only be found j*^"'^, suppuration, but examples of that mollification, or softening of the de cerveau. brain, the Ramollissement de cerveau, of M. Rouchoux,t and other French writers, which is more frequently traced in apoplectic sub- jects, and of which we shall have to treat when discussing the dis- ease of apoplexy. Phrensy is not often found as an idiopathic,complaint, at least in «E-Oepha- this country ; though it is a frequent attendant upon other diseases, gica. as synochus, worms, various exanthems, trichoma, hydrophobia, Brafn-U'veT. injuries of the brain, and severe grief. It sometimes makes a near Diagnostic*. approach to mania, but is easily distinguished by the nature of the exciting cause, where this can be ascertained, the abruptness of the attack, and the violence of the fever ; added to which there is in phrensy, for the most part though not always, a hurry and confusion of the mental powers, a weakness and unsteadiness of mind, which is rarely or perhaps never to be met with in genuine mania. It sometimes, however, runs into mania, of which Stoll has given a singular instance in a chronic case that continued for nine weeks before it assumed this change. J The remote causes are those of inflammation in general applied gemote to the organ affected ; such as sudden exposure to cold after great heat; cold liquors incautiously drunk in the same state ; inebriation and especially from spirits ; exposure of the naked head to the rays of a vertical sun ; violent passions of the mind ; obstructed menstrua- tion ; accidental injuries ; suppressed eruptions of various kinds ;§ and various kinds of poison. From some of these causes the inflammation assumes a chronic Sometimes character; is slow in its progress, and obscure in its symptoms. The chronic9 symptoms moreover, however connected with a morbid consent in character * Syst. Morb. Syropt. Cl. xi. Ord. hi. Gen. xii. t Dictionnaire de Medicine, Tom. il. Pans, 1822. I Rat. Med. Sect. in. p. 179. 5 Frank, ut supra, Tom. it. p. 61. Vot,. 11.—33 258 ci.ni.5 H.EMATICA. l<>m>. u Gen. vil. other organs, generally point to the brain as the seat of lesion ; and 8I rC' h' consist of cerebral compression or acute pain in the head, irregularity Hti." nSniS- in the pulse, and some kind of paralysis. M. Lallemand, who has &sy. industriously collected a multitude of anomalous cases of this kind, Brain-fever, observes that where the inflammation runs into suppuration, an effort is usually made by nature to form a sack or barrier for its limitation: but that even this effort is often in vain, and still adds to the fatal issue, as the new membrane frequently becomes thickened, and creates a fresh source of irritation.* Remedial The cure of phrensy must be attempted in the same manner as treatment. that of inflammati0n in general, or rather as the cure of inflammation by resolution ; for resolution is the only means by which a cure can be effected in this caso. Copious and repeated bleedings must here therefore hold the first place ; and the nearer the blood is drawn from the affected organ the better chance it gives us of success. The temporal arteries and the jugular veins have hence been recom- mended as the most effectual vessels to open; but for various reasons it is better to begin with drawing blood liberally from the arm, and afterwards by a free application of leeches to the temples. The head should be shaven as soon as possible, and kept moist with nap- kins wrapped round it dipped in cold vinegar, or equal parts of water and the neutralized solution of ammonia ; or, which is still better, with ice-water : all which is preferable to blistering, which is too apt to increase the morbid excitement, and has the authority of Hip- pocrates, who was in the habit of applying cold epithems, not only in inflammation of the brain, but even of the abdominal viscera.t The bowels should be thoroughly evacuated, and even stimulated at first by calomel alone or mixed with jalap, and afterwards kept open by cooling saline aperients: and nitre should be given in moderate quantities, repeated as frequently as the stomach will bear ; which is often considerably assisted by the tincture or infusion of digitalis. The chamber should be cool and airy; and no more light be admitted than the eyes can endure without inconvenience. Sometimes I have said that furious delirium, though generally laid down as a disttubance pathognomic of this variety of cephalitis, does not always occur ; intellect an(*in a very stron£lv marked case in which I was consulted several inastrated. years ago, the mental powers were not much interfered with. The patient was a lady of delicate habit, about thirty years old, who had caught cold by lying on an Indian mat, spread on the lawn, in the midst of a hot July. The first symptoms were those of inflammatory fever, with an acute pain in the head, which was not so much at- tended to as it ought to have been. I did not see her till the second or third day of the attack, when she had been bled only once, and that not very freely; though the bowels had been freely evacuated. At this time the pain in the head was intense, with an intolerable acuteness of hearing and sight, insomuch that the slightest light and 30und, even the humming of a fly, were insupportable. The face was flushed ; the eyes swollen ; the head externally hot all over as a furnace ; whilst a violent throbbing or thumping pulsated within. * Recherches Anatomico-Pathologiquej sur l'Encephale et ses Dgpendances I,etrre quatneme, 8vo. Pans, 1823. ' t Ilcpt Nrjsw, p. 484. cl. m.j SANGUINEOUS FUNCTION. [ord. u. 259 Free bleeding now, though repeated till the system was weakened to Gen. Vll. its lowest ebb, produced little or no refief. The hair was immediately a e* cv cut close to the head, and the entire scalp covered with napkins tho- phaiitis roughly wetted with ice-water, and renewed every half-hour, by which plenty!8' time they became quite hot. This afforded some relief, as did also B*aiDfover' a large bladder about half filled with pounded ice, and folded over the head like a night-cap. The fever, however, maintained itself, with little intermission, for a fortnight, during which time I advised the temporal artery to be opened once, and leeches applied to the temples several times ; the bowels were kept sufficiently loose ; and nitrate of potash, tincture of roses, lemonade, grapes, and other cool- ing medicines, were chiefly depended upon. As the weakness increased the mind wandered a little for a few minutes at a time, but never totally, nor without being easily recalled; but every attempt to sleep produced, at this period, the most horrible ideas, accompanied with cold sweat and syncope on waking ; even though the miserable dozing had continued only for a few minutes. This distressing state was relieved by ten grains of the compound ipecacuan powder, which produced quiet sleep for several hours. But opiates had hitherto uniformly disagreed with the patient's con- stitution, and did the same now, throwing out a rash over the entire surface of the body, that produced an intolerable itching, and was accompanied with a deadly nausea at the stomach; and this too, after the first dose, without any relief to the state of the head. They were tried in various forms, but had constantly the same effect; and we were obliged to relinquish them. Hyoscyamus and other narco- tics were substituted, but proved of no service. Camphor, taken freely both in pills and solution, allayed in some degree, the horror of the sleeping ideas ; and as the fever began to subside, cascarilla, with sulphuric acid, appeared also to be serviceable; at the same time Madeira wine was allowed in small quantities in acidulated barley-water. Nothing, indeed, but gentle stimulants rendered the sleep supportable; for without these no sooner were the eyes closed, than the pulse became quicker and feebler, cold sweats succeeded, the most frightful and agonizing train of ideas usurped the brain, and the patient woke and fainted ; evidently proving that the debilitated brain was now nearly torpid and incapable, without adventitious ex- citement, of secreting a necessary supply of sensorial fluid. And, as this was not the case during wakefulness, we have a clear proof also that the stimulus of the will answered the same purpose at this period. This distressing affection ceased only by very slow degrees, and merely in proportion as the system acquired strength. Some- thing of the same kind, however, was long felt after eating, at which time the sensorial power being peculiarly concentrated in the sto- mach to assist the process of digestion, every other organ was in a state of comparative exhaustion. It was, indeed, many months be- fore the brain recovered its habitual ease of action, and was free from all inconvenience. Q Profound or deep-seated cephalitis, or, as it is more commonly £^J;e called, acute or internal hydrocephalus, so far as examinations gojoda.^ after death may be depended upon, is almost always accompanied ccnb(lntiB, 200 cl. w.] HifcMATICA. [ORD. II. Gen. VII. with effusion into the ventricles of the brain ; on which account in- flSB*ce.1' deed the name hydrocephalus has been applied to it, though most phaiitis " incorrectly ; for I cannot but agree with Dr. Porter that it has no Coated other symptom in common with chronic or idiopathic hydrops ce- into.rnaii?' REBRI' and t,iat sucn a generalization has been a cause not only o" acute' of much confusion in nosology, but of much mischief in practice : !he heyadf and hence Dr. Coindet, while he retains hydrocephalus for the latter, proposes, as already observed, to distinguish the former by the name of hydrencephalus. Sometimes This disease is sometimes found in adults, but mostly in young Iduits.'but subjects, and chiefly from early infancy to seven years of age, parti- infasnu.in ofljuiy in those of a fair complexion. After seven years the disease is comparatively rare. niagnos- Tne symptoms commence obscurely, and are those of irritation produced by worms : as irregularity, and especially costiveness in the bowels; listlessness; impatience; knitting the brows into a frown ; heaviness of the head, which organ the patient is always de- sirous of reposing in a chair or some other place ; irregular fever ; and, occasionally, violent and deep-seated pain in the sensory shoot- ing from temple to temple, or across the forehead ; frequently ac- companied with sickness. Sprightliness, vivacity, and good-temper sink into dulness, the brightness of the eye becomes dim, and the colour of the cheek vanishes, the child walks unfirmly, as though stepping over a threshold, and often staggers as if drunk.* The pulse is irregularly quick; the sleep unquiet, and interrupted by screams ; and the eye has a look peculiarly oblique or squinting. These three last symptoms are usually regarded as pathognomic. The eye, however, instead of taking an oblique direction, is some- times turned upwards: but either change is the result of spasmodic action ; the pupil is often at first contracted, but at length unalter- ably dilated.! The pyrectic symptoms appear chiefly in the evening; but sometimes at other periods, for in this respect there is a strange and unaccountable anomaly; and as the disease advances they in- crease. The head is hot to the hand though without any flush ; a severe pain is felt in the forehead, sometimes shooting back to the nape of the neck, or alternating with pains in the limbs, or with co- licky gripings, and the stimulus of light becomes highly painful. Shortly after which many of the symptoms are apt to assume deceit- fully, for a few hours, perhaps a day or two, a milder character ; but the pulse evinces less power, the limbs become emaciated, stupor supervenes, occasional convulsions, more or less general, follow, and death very speedily closes the scene. Sance S° jmP°fing « the apparent improvement at times that Dr. Golis of improve- candidly tells us, in two instances he dropped his unfavourable prog- ment- nosis, and thought the little'patients on the point of recovery But a relapse after thirty-six hours in the one, and forty-eight hours in the other, took place and was speedily followed by death t I have thus given a brief sketch of the symptoms that principally mark the progress of this disease in all their versatility; and it is this vl. m.j SANGUINEOUS FUNCTION. [ORD. II. 261 versatility that has produced thQ chief differences of opinion that Gen. VII. have been entertained concerning it, to which we have already ad- pS^c«-1' verted. phaiitia The first symptoms are unquestionably rather those of irritation oee^'stateii than of compression, as is obvious from their resemblance to those ^era'af8' of invermination. The venous system in children, indeed, and espe- or acute1 cially the veins of the head, are not disposed to plethora, which is tdhePheadf rather a characteristic feature of advanced years; nor does the small Tne fir8t quantity of water which is often found in the ventricles seem adequate to inflamma- the violence of the effect; and we have hence very strong grounds .'"^ose for supposing that the collection of water is only a secondary disease, of oppres- dependent upon some previous idiopathic affection in some part of secondary. the brain ; and that affection, as Dr. Rush has long ago very ably shown, an inflammation. It has indeed been observed in opposition Examina- to this opinion, that acute hydrocephalus is less frequently to be met opposite with in strong and vigorous, than in weak and sickly children, dropsy °Pjnion- being here, as in other species, far more commonly an effect of debi- lity ; whilst it is in strong and vigorous children alone that we have reason to expect inflammatory action in the brain, as in any other organ. Bleeding it is admitted has been serviceable at times, but we are told that it has often been unproductive of any benefit what- ever ; and that it is possible to account for its occasional utility by other means than its taking off inflammatory action, as by simple removal or diminution of venous congestion. Yet we have already observed that venous congestion is not commonly a disease of in- fancy, but of later life ; that the first symptoms are those of irritation; that post-obit examinations have very generally shown an inflamed state of the arteries ; and that the fluid accumulated is not sufficient in many instances of itself to account for the symptoms by which the disease is characterized. In the progress of the complaint there is often a very singular ?)J|^ty irregularity in the quickness of the pulse, which seems to be always of the pulse. varying and untrue to itself; insomuch that if we count it several times in succession, we may chance to find it now eighty strokes, now a hundred, now a hundred and twenty or thirty strokes, and immediately afterwards not moro than eighty or ninety in a minute. The duration of the disease is equally uncertain ; commonly, per- Duration of haps, it runs on from three to six weeks, before it proves fatal; but disease. it will sometimes destroy life in a fortnight, or even a week. Qr. Coindet has occasionally known the patient sink in two or three days.* We have already observed that the substance of the brain has more generally evinced proofs of inflammation and other mischief • than the membranes ; though not unfrequently the increased vascu- larity and turgescence have extended from the parenchyma to the surface. As the existence of effused fluid is not necessary to the disease, it varies considerably in quantity when it is found; as a Amount of mean measure however, it may be stated at five or six ounces. effU8efi. Most modern pathologists concur with Malpighi and Haller, in hold- * Memoire sur l'Hydrencephale, &c. ut supra. GeBeva, 1618. 2b2 cl. in.J HJSMATICA. [0BD. U. Gen. VII P E. Ce- phalitis profunda. Deep- seated cephalitis. Internal, or acute dropsy of the head. Sometimes connected with a scrofulous habit. Therapia. Generally accordant with that for the pre- ceding variety. Temporal artery sometimes opened with great success. Mercury externally and inter- nally in large doses. ing that it is incoagulable ; but Pechlin, Lapeyronie, and a few au- thorities of the present day, have denied this. The disease is often connected with a scrofulous habit, and has sometimes formed a fatal metastasis to phthisis. The mode of practice, in consequence of this discrepancy of opi- nion, has been extremely undecided : whilst many practitioners are so despondent as to fear that every plan is equally unavailing. It has fallen to the author's lot, however, to see several patients recover both in infancy and verging towards adult age, who had all the characteristics of the disease, and were unquestionably labouring under it. Contemplating it as a variety of cephalitis, he has uniformly pur- sued the general plan recommended under the preceding variety, and to this practice he can only ascribe whatever degree of success he has been fortunate enough to meet with. Blood should be drawn freely from the nape of the neck by cup- ping or leeches : the head should be shaven, and napkins dipped in ice-water, or vinegar and water, be applied to the posterior part of it, and be changed every hour or half hour. The bowels should be freely purged with calomel, or calomel and jalap : and the jalap should be toasted to render it less disposed to excite sickness ; an easy diapnoe should, if possible, be excited and maintained on the skin ; the chamber should be large and well ventilated ; and when- ever it might be right to stimulate the bead, epithems of neutralized ammonia should be preferred to blistering. The value of digitalis is doubtful; when used early it has seemed serviceable, but it should be avoided in the second stage of the disease, unless, indeed, it be employed as, by Dr. Golis, to smooth the passage to death, by di- minishing the violence of the convulsions that usually precede it. In later life than infancy, where it has been necessary to draw blood repeatedly, I have occasionally prescribed opening the temporal artery with great success : for a small quantity, as six or eight ounces of blood, drawn in this way, will often answer the purpose of double or treble the quantity abstracted from the arm. In a young lady of nineteen, labouring under very prominent symptoms of this disease, I found the violent and deep-seated pain in the head cease instantly; and the pulse sink from seventy to forty-four, as soon as a teacup full .of blood only was taken away in this manner. . Mercury employed both externally and internally, in a quantity sufficient to excite a ptyalism, has also been used in many instances with great success, both among adults and infants, but particularly among the latter. Dr. Percival gives the history of a child of his own, aged three years and a quarter, in which a perfect cure was ob- tained by this, and nothing else. In forty-eight hours signs of amendment appeared, and in six days the child was well; during which time thirteen grains of calomel had been taken, and seven scruples of strong mercurial ointment had been rubbed into the legs* Dr. Dobson of Liverpool employed quicksilver in the same double plan, and asserts that he found it equally useful, and most strikingly * Edin. Med. Com. Vol. vr. p. 224. a,, ra.] SANGUINEOUS FUNCTION. [ord. n. 263 so in the following case. Four children of the same family had evi- Gen. VII. denced this disorder in succession ; three had fallen victims to it pi^ce- ' under a different treatment: one between three and four years old, ph^B. was subjected to the mercurial plan of calomel and inunction. In Deep" a' forty-eight hours a ptyalism was excited, the symptoms abated, and ^phallus. the child recovered.* Dr. Golis prefers the internal to the external internal, or use of mercury, as far more active and to be depended upon. He ^"psy of gives it in free doses, and observes, " that an infant of a year old tne head" and under will bear a much larger proportion without diarrhoea or griping, than those of four, five, six, or even eight years of age." And hence to the former he often prescribes eight or ten grains in the course of twenty-four hours. If diarrhoea or griping be pro- duced, it should be remitted. With Golis ptyalism has proved a rare effect.! In adults the ordinary proportion is ten grains of calomel and a drachm of strong mercurial ointment every night. Under this treat- ment various cases of success are recorded in the Edinburgh Medical Journal. SPECIES II. EMPRESMA OTITIS. EAR-ACHE. IMPOSTEME IN THE HEAD. SEVERE PAIN IN THE EAR ; TENDERNESS UPON PRESSURE ; DEAFNESS OR CONFUSION OF SOUNDS. Tins is usually a distressing rather than a dangerous disease ; but Gen. VII. the fever is sometimes violent, and delirium and even death has been CauSg;. a consequence. It is often produced by cold, and is hence fre- quently a local catarrh : and is still more commonly, perhaps, occa- sioned by some exotic substance which has accidentally entered into the ear, as a small piece of ragged bone,:J a cherry-stone,§ a worm, an insect, or the larve of an insect, as of an ant, a spider, a fly, or a cricket; of all which we have a variety of curious histories in medi- cal journals.|| In these instances the disease is confined to the ex- Jj^6™ ternal ear : but from many of the ordinary sources of inflammation flammation it often exists within the tympanal cavity ; whence, too, the inflam- Eternal matory action has extended to the brain, or affected it by sympathy.1T ear: but ,J , , ii**/*i' 4.1 sometimes In this case the membranes and lining of the inner organ are coated internal, with coagulable lymph, pus, or both ; while even the temporal bone *$££$• * Edin. MeJ. Com. Vol. vi. p. 224. t Golis, ut supra. I Hagendorn, Cent. I. Obs. 64. § Fabric. Hildan. Cent. in. Obs. 4. II Stalpart Van der Wiel. Maget. Journ. de Med. Tom. lxiv. Moebnng, Obs. 21. Saroml. MedicinischenWabrnehmungen, B. viii. p. 37. IT Case of Inflammation and Abscess of the Brain, attended with Disease oi the Ear. By John O'Brien, M.D. Trans. King's and Queen's Coll. Dublin. Vol. u p. 309. 8vo. 1824. 264 cl. m.] HLEMATICA. [ord. n. Gen. VII. 0f the affected side has become carious. An instance of this last kind is related by Dr. Powell in the Medical Transactions. The patient was a young gentleman of sixteen, who had been attacked with otitis once or twice before. The pain was intense, but the inthehead,pujse never exceeded seventy-two: yet the disease proved fatal. The intellect was at no time disturbed.* The disease therefore offers two distinct modifications, and is so far correctly arranged by M. Itard. Spec. II. Empresma Otitis. Ear-ache. Imposteme a Externa. External Imposteme. j3 Interna. Internal Imposteme. External ear highly irritable, lining membrane, when examined by a bright light, red and tumid. Hemicrania, sense of weight in the head: roughness about the mouth of the Eustachian tube : tonsils often enlarged. a E. Otitis externa. External Otitis, or Imposteme in the head. Sometimes becomes chronic, and is called otorrhoea. A hissing or tingling sound accompanies both varieties, but is most painful in the latter. M. Itardf believes both to proceed chiefly from cold, and to possess much of the nature of a catarrh : but in dividing them into two distinct sub-species, a catarrhal and purulent, he ramifies very unnecessarily ; for, let the exciting cause be what it may, the purulent is only a subsequent state to the pre- ceding. The external otitis generally suppurates in a short time, and then iiore completely forms what is vulgarly called an imposteme or impostiiume in the head, a term corrupted from aposteme; the discharge, which is usually yellowish, puriform, fetid, and somewhat bloody, flows from the external auditory passage in a greater or less abundance, according to the extent of the inflammation. It com- monly diminishes in about a fortnight or three weeks ; when the fluid becomes thicker, and to the eye, and even the smell, caseous. It then ceases, and is succeeded by a copious ceruminous secretion, which passes off without any injury to the sense of hearing. This is the ordinary course : but it sometimes runs into a chronic state, and especially where there is a morbid diathesis from struma,. syphilis, or variola ; and under such circumstances it becomes often tedious and unmanageable, and is accompanied with a thickening of the tympanal membrane, and an obtuseness of hearing. In some cases, however, the otorrhea or chronic state takes the lead. This is mostly'the effect of cold, and is in fact an otitic catarrh. The discharge from the ear is at first perhaps, not attended to, and, from particular circumstances, occasionally ceases for a time ; but only to show itself in any incidental excitement with renewed violence. The discharge differs in different individuals in its consistence, co- lour, and the peculiarity of its smell, though the last is always offensive ; it is at first mucous, then purulent, and at length consists of a thin sanies; in which last case, connected with the specific * Vol. v. Art. xvi. p. 212. t Traite des Maladies de l'Oreille et de 1'Audition. 2 Tom. Paris, 1821. Par J. M.G. Itard, M.D. &c cl. in.J SANGUINEOUS FUNCTION. [oiu>. n. 2G5 fetor that issues from a carious bone, there can be little difficulty in Gen. Vir. determining that some of the small bones of the ear or even the tern- f eE°6u"*, poral bone itself is affected ; which, indeed, are at times thrown out externa. in minute fragments. M. Lallemand, who has ably treated upon fn'ttsTor this subject, observes that " the morbid secretion is apt to alternate JjX'Xaa- with attacks of rheumatism in other organs, catarrhous vesicae, leu-' corrhcea, and various other complaints.* The most dangerous me- tastasis is that to the membranes or substance of the brain ; which M. Lallemand conceives occasionally produces death so soon, that no trace of such a transfer is to be ascertained on dissection. The general remedies for inflammation are here to be resorted to; Trtatmci • and particularly warm, narcotic fomentations, and a dry atmosphere. Blisters behind the ears have often afforded relief; and for the same reason stimulant errhines and sialagogues: which, by evacuating the mucous follicles of the Schneiderian membrane, and the salivary glands, produce an influence on all the neighbouring parts,-and often on the whole of the vessels of the head. And hence head- aches, ophthalmies, and pains in the ear, are in many instances equally relieved by these applications, and were often employed by Dr. Cullen for this purpose.! Where the case is chronic, setons or some other protracted drain should never be neglected. When worms or larves of insects are the irritating cause, a few drops of oil of almonds introduced into the ear will readily suffocate them. The internal otitis, inflammation or imposteme of the tympa- ? E 0titis , .,.,... r , r '. interna. nal cavity may commence either in the lining membrane, or in the internal membranes which cover and connect the minute bones, or even in °nposte°rne the mastoid cells ; it is soon, however, apt to spread from its pri- »n the heari mary seat to every adjoining part, so as to implicate every division or recess of the cavity of the tympanum : and unless the inflammatory action is soon mastered, suppuration must necessarily ensue, and it rarely happens that the tympanal bones are not involved in this severer process. In some cases in which their articulations or other connecting mediums are destroyed, they drop away as soon as the tympanal membrane becomes so far ulcerated as to allow them a passage. Occasionally, however, a kind of adhesive inflammation either between the articulating membranes, or the bones where the former are destroyed, may effect an ancylosis, and render them quite immoveable. How far, under these circumstances, the organ of hearing may |n™fB^ be destroyed must depend upon the extent of the disease, and the of hearing parts that have been actually involved in it. If that portion of the j^y^. organization which merely assists in conveying the sound, has been alone affected the hearing will not necessarily or altogether be de- stroyed ; and hence the malleus and incus, or two outer bones, are sometimes lost while the sense of hearing is still preserved in a suf- ficient degree of perfection for ordinary purposes; the sonorous vibrations being afterwards conveyed through the tympanum, a<- • Recherches Anatomico-pathologiqnes sur l'Enc€phale «>t ses Dependant? Lettre quatrifme. 8vo. Paris, 1823. t Mat. Med. Vol. 11. p. 436—442 VoT II-—3 > 2G6 i l. hi.] H/EMATICA. [ORD. II. Gen. Vll usual, along its panetes to the stapes, and by the vestibular fenestra ?P/ o,■£' to the labyrinth. But if these last have participated in the ulcer- '.'.unm.. ative process, and especially if the stapes be detached with the other owiSr bones, the vestibule laid open, the sac eroded, and the water which Tmpostemc it contains have escaped, the destruction has extended to the sentient ,n the head. ^ ^ ag tQ ^ conveying part of the general organ, and the loss of hearing will be irreparable on the side on which the mischief has occurred.* SPECIES III. EMPRESMA PAROTITIS. MUMPS. GAINFUL UNSUPPURATIVE TUMOUR OF THE PAROTID GLANDS, OFTEN EXTENDING TO THE MAXILLARY : CONSPICUOUS EXTERNALLY ; FRE- QUENTLY ACCOMPANIED WITH SWELLING OF THE TESTES IN MALES, AND OF THE BREASTS IN FEMALES. Gen.VII. The parotid glands are subject to a troublesome, and sometimes Spec. III. fataj phiep-mon, which we have already noticed under the name of How diners i = ' . «, . . , c from paro- phlegmone parotidea. I he inflammation before us is altogether ot indon!'les' a different kind ; it is more extensive, more painful, and rarely tends to suppuration. In our own country it is vernacularly called mumps. and in Scotland branks. ocscrip- The tumour, though sometimes confined to one side of the neck, more usually appears on both: it is at first moveable, but soon be- comes diffused to a considerable extent. It increases till the fourth day, and often involves the maxillary glands in the inflammation ; is evidently contagious, and often epidemic. After the fourth day it gradually declines ; and for the most part there is but little pyrexy, or need for medical aid ; avoiding cold, and a brisk purgative or two Sympathy being all that is called for. The sympathetic action of the testes ustes and ano< tne mammae is most conspicuous towards the decline of the in- rnammce, flammation And, in many instances, it is by no means an unfa- nfeans vourable sign ; for it has been occasionally found that where the unfavoura- sympathy has not been manifested, or the glandular swelling has been suddenly repelled, the symptomatic fever has been greatly ex- acerbated, delirium has ensued, and even death has closed the scene. Where there is any danger of such a result, the swelling should if possible be brought back or sustained by stimulant cataplasms or blis- Sometimes ters. Dr. Hamilton has in several cases observed this sympathetic alternant. mfluence operating alternately : and mentions more than one instance in which after a very considerable enlargement of the testicle, upon the cessation of the disease, this organ entirely wasted away, inso- much that the tunica vaginalis became an empty bag.t * Edin. Med. and Sitrsr. .Tnprn. No t.xxiv. p. 90. + Edin. Trans. ITT' cl. m.j SANGUINEOUS FUNCTION. [ord. 11. 267 In advanced life parotitis is sometimes apt to run into a chronic Gen.vii. form, accompanied with very mischievous symptoms ; in which state l^esm"' it is denominated a malignant parotid. This is more especially apt Parotitis. to take place in females when menstruation is on the point of easing, Moi?gPnant and the general action of the system labours under some disturbance. Pftrotid- The tumour should, if possible, be carried off by leeches and cool- How ,0 bo ing repellents: for if it proceed to suppuration, which it tends to trcated though very slowly, the ulcer rarely heals ; usually degenerating into a foul offensive sore, that sinks deeper and spreads wider, resisting all medical treatment and at length undermines the constitution, and destroys the patient. Vomits frequently repeated have in this case been found highly serviceable ; and those of the antimonial prepa- rations are to be preferred to ipecacuan. They maintain a longer action, and determine more effectually to the surface, or rather to the excernents generally. In a case in which a diseased condition of the parotid gland formed only part of an enormous tumour in a patient aged forty, Mr. Carmichael removed the whole by the knife, and the patient recovered with a slight partial paralysis of one of the muscles on the affected side.* SPECIES IV. EMPRESMA PARISTHMITIS. QUINSY. REDNESS AND SWELLING OF THE FAUCES : WITH PAINFUL AND IM- PEDED DEGLUTION. This is the squinsy, or squinancy of our old writers ; the cynanche, Gen> Y^. or angina of medical books. Paristhmia from irapot and io-fyt«s, literally synonyms." morbus faucium, or throat-affection, is the term employed by Hippo- crates, and is only varied to paristhmitis, in the present system, in consonance with the general termination of all the species belong- ing to the genus before us. The term was used among the Greeks, as on the present occasion, in a specific sense: though the later Greek physicians gave different names to its different varieties : and hence we meet with cynanche, synanche, and parasynanche; the common signification of all which is angina or strangulation, while the prefixes cy- sy- and parasy- are of doubtful meaning, as I have farther observed in the preliminary dissertation to the Nosology. Aetius attempted to justify cynanche, but Ccelius Aurelianus, and Paulus, used synanche after Celsus. The Latins employed angina in the same extent as Hippocrates did paristhmia ; quinsy is used in a parallel latitude among ourselves. Sauvages conjectures, and there is some ground for the opinion, that the synanche of the Greeks was the common quinsy of the present day, the paristhmitia tonsillaris of * Trans, of tbo King's and Queen's College, Dublin, Vol. n. p. Wl. 8™. 1824 26$ cl. m.j HiEMATlCA. L0*D- "• '"T- the system before us ; their parasynanche, the quinsy of the pharynx, Rm^sma* paristhmitis pharyngea; and their cynanche, croup, or empresma Paristhmi- Broncklemmitis. Quinsy presents itself to us under four varieties ; the common inflammatory sore-throat; the ulcerated or malignant; the sore throat that peculiarly attacks the pharynx ; and inflammation of the esophagus. Gen. Quinsy. a, Tonsillaris. Common Quinsy. Inflammatory sore throat. <3 Maligna. Ulcerated ; or Malignant sore throat. y Pharyngea. Pharyngic Quinsy, $ CSsophagi. Quinsy of the Esophagus. Swelling of the mucous membrane of the fauces, and especially of the tonsils ; redness florid ; fe- ver a cauma. Redness crimson; with ulcera- tions covered with mucous and spreading sloughs, of an ash or whitish hue: fever a typhus. Frequently epidemic; generally contagious. Found often as a symptom in rosalia, or scarlet fever. Redness florid, and especially at the lower part of the fauces: deglutition extremely painful and difficult: fever a cauma. The impediment to deglutition felt below the pharynx, with a cir- cumscribed pain, and rejection of food when it reaches the seat of obstruction. ath'*ai> *u ^iC FLH:iT variety or common quinsy, the swallowing is, for tonsuiaris. the most part, greatly impeded: and the speech, and sometimes quinsly°n even tne respiration rendered highly troublesome : the mucus is ex- Uenerai creted sparingly, and consequently there is a considerable clammi- ness in the mouth ; and the pain sometimes spreads to the ears. The disease is never contagious, and, though violent while it lasts, is comparatively of short duration. It terminates by resolution, or suppuration ; hardly ever by gangrene ; though a few sloughy spots sometimes appear upon the fauces. Oanses. The usual cause is cold ; and it is hence found most frequently in spring and autumn, when vicissitudes of heat and cold are most common. It is supposed to affect particularly the young and the sanguine—but, in my own practice, it has occurred as often at other ages and in other temperaments. W hen it has been re-produced several times within short intervals of each other, it is apt to estab- iish a peculiar diathesis or habit, so as to be excited readily and by very slight occasional causes. Treatment. If attacked by a medical process early, much benefit has been derived from astringent and acid gargles, and vapours inhaled by any simple machine for this purpose. Blisters to the throat or behind the ear, ought also to form a part of the curative plan; and if bleed- vl. m.j SANGUINEOUS FUNCTION. [orv. u. 269 ing be had recourse to, it should be by scarification or leeches ap- Gen. VII. plied to the tonsils or fauces. An early use of leeches I have often f EEp'a-IV' found highly successful, and can distinctly corroborate Dr. Cramp- "stbinitii ton's remark, that leeches fix far more readily on moist internal sur- commo™' faces than on the skin. Dr. Crampton, by way of caution, passes quin8r- a thread of silk through the lower half of the body of the leech,* but I have never found this necessary. Cooling purgatives, and a low regimen should also enter into the general plan of treatment. If suppuration cannot hereby be prevented, the better way will be to Process in expedite this termination by the steam of warm water, or water im- £uration.Up" pregnated with the leaves of rosemary or chamomile; and where the fluctuation is clear to the touch, if the abscess do not of its own accord break readily, it ought by all means to be opened with the lancet. In a few instances the suppuration has pointed and broken exter- singular n 11 • • i i c iij.ii • n termina- nally, and tne termination has been favourable.! And occasionally, tions. from the extent and violence of the inflammation, there has been so much danger of suffocation, that it has been found necessary to make an opening into the treachea :J which has been done some- times as high as the larynx, and sometimes considerably lower ; and under both kinds of operation the patient has recovered.§ In the malignant or second variety, the inflammation passes at 0 e. Par- once into the ulcerative stage ; and is consequently characterized maligna8. by the symptoms stated in the definition: the sloughing often takes ulcerative, place rapidly, and spreads widely, and the fever is a typhus. This nantsore- variety is frequently epidemic ; generally contagious ; and found Frre°qa„;ntiy often as an alarming symptom in rosalia, or scarlet-fever. In its epidemic. idiopathic form it is usually ushered in with a sense of stiffness in the """P1*00, neck, accompanied with some hoarseness of the voice, and occasion- ally with symptoms of a coryza. It is in effect a quinsy, taking an Expiana- erythematic or erysipelatous, instead of a phlegmonous turn, in con-tion" sequence of the peculiar temperament of the atmosphere, or of the patient, or of some unknown cause. The sloughs at first appear whitish, or cinereous ; but soon be- Extensive come brown, and often black ; and spread over the whole of the [h° ulcera- fauces, and mouth, into the nostrils, and often down the esophagus ; lion* the ulceration has, also, sometimes passed up the Eustachian tubes and affected the ears. And, as the sloughs appear to carry conta- gion with them, on being swallowed they have communicated the disease through the entire range of the alimentary canal. The danger is hence very great if the ulceration cannot be check- Henceoften ed ; and it is peculiarly so to children and adults of relaxed and de- d.ngerous. licate frames. The disease makes its appearance most commonly in the autumn, though it has appeared in every season. The erythematic character is sometimes very striking, the intumes- Erythema- cence spreading widely yet limiting itself to the cellular tissue. ier some-" Even externally the throat is swollen, hard, and tender ; while such j^-^™1* is the constriction within that deglutition is impossible, and there is * Dublin Medical Reports, Vol. in. p. 229. t Sctienck, Lib. II. Obs. 36. t Ballonius, I. p. 182. Fernire, Journ. de Med. Tom. lxii. § Ficnus, Chir. Tract. iy. v. c. I. Musgrave. Phil. Trans. N. 258 270 cl. hi.] HiEMATICA. [ord. II. Gen. VII. great danger of suffocation. Dr. G. Gregory has given a well-mark- f e PaJ-V* ed instance of this modification, in a young woman in whom it ter- isthmitis minated fatally on the sixth day : and has referred to other cases of ufcewti've, a similar kind, and mostly with a similar result, from Dr. Kirkland, nant^orf- Dr. Wells and Mr. James. From its being chiefly seated in the eel- throat, lular membrane Dr. Gregory has given it the name of cynanche Cynnnche 17 i • * cellularis CellulariS.* wr?ethge°rry' ^ Cullen regards the eruption of scarlet fever as a pathognomic scarlet symptom of this disease ; but this is to confound two complaints Jeathogno- tnat are very clearly distinct, as we shall have farther occasion to ob- mic symp. serve when discussing rosalia, or scarlet fever. It is at present suffi- ces not cient to remark that, even in the opinion of Dr. Cullen himself, eoTnpan8- sor Frank,! is deeper seated than the preceding, though the inflam- Quinsy of matory blush often extends to the fauces. The food will in conse- phhea ®SB°* quence pass forward to the seat of obstruction, but no further, and by irritating the inflamed part produces a painful effort to vomit, which continues till by a severe struggle, which occasi nally reaches to the back-bone, the ingulphed morsel is dislodged and thrown back into the mouth. * Ramsey, Lond. Med. Journ. x.—Medicus, Beobachtungen, u. 505. t Practical Information oa the Malignant Sore Throat, &c. I De Cur. Horn. Morb. Epit. Tom. 11. p. 101. 8vo. Mannh. 1792, CL. III.) H^EMATICA. ORD. II. Gek.VII. Spec. V. Whether ever de- scribed till of late. Probably known to Mead and Hippo- crates. Closely resembles croup. Description. How dis- tinguished from croop. SPECIES V. EMPRESMA LARYNGITIS. INFLAMMATION OF THE LARYNX. PAIN AROUT THE LARYNX ; EPIGLOTTIS SWOLLEN AND ERECT ; BREATHING SHRILL AND SUFFOCATIVE ; GREAT ANXIETY ; DEGLU- TITION IMPEDED ; FEVER A CAUMA. It is doubtful whether this severe and dangerous complaint has ever been described till of late years. It seems to have been known to Dr. Mead, whose general account coincides with a disease noticed by Hippocrates. It is minutely and accurately detailed by Dr. Home, in his Principia ; and is the subject of several excellent papers in the Transactions of the Medico-Chirurgical Society, particularly by Dr. Farre, Sir Gilbert Blane, Dr. Roberts, and Dr. E. Percival. It is particularly and accurately described by Professor Frank.* The disease, as will be perceived by the definition, bears a consider- able resemblance in many of its symptoms to croup ; is highly acute, and destroys by suffocation in a day or two, unless very actively op- posed. Frequently, indeed, it destroys much sooner. Brassavoli mentions a case, which seems to have been of this kind, that proved fatal in ten hours :| and Schenck, another, in which suffocation and instant death were produced by a fit of vomiting, the spasmodic ac- tion having extended to the stomach or its auxiliary muscles.J It is produced by cold or the usual causes of quinsy, but has been often excited by too much exertion of the organ in singing, or public speaking. The disease makes its approach with the common symptoms of inflammatory fever, as chilliness succeeded by heat; the voice be- comes hoarse and indistinct; the breathing laborious, with a painful sense of constriction in the throat; the fauces present a Modena red colour, and are considerably swollen and turgid, the swelling ex- tending to the face and eyes, the latter not unfrequently protruding, as in cases of strangling; though occasionally the inflammation is confined to the larynx and no peculiar appearance is to be traced on the tonsils, uvula, or velum palati ;§ the pulse is quick and the tongue furred ; and every attempt to swallow is accompanied with great dis- tress ; the muscles of deglutition, and even those of the chest being thrown into severe spasms, threatening the patient with instant death from soffocation, and making him call out for air and an opening of the windows, It is distinguished from croup by the existence of a perpetual and ♦ Ut supra, Tom. II. p. 105. t Comment, ad Hippocr. de Rat. Vict. Acnt. Lib. iv. t Obs. 29. ex Triucavellio, Lib. u. § See Mr. Coekbnrn's Case, Edin. and Med. Surg. Journ. Apr. 1P23 cl. in.] SANGUINEOUS FUNCTION. [ord. u. S7ti voluntary hawking, rather than a forcible and involuntary cough, as Gem. VII. though to clear the passage by expectoration. It is also distinguish- £™*' ed from it by the nature of the expuition which is a viscid mucus, Lnryng.tis. rather than a coagulable and membrane-like exudation. The two {"onTf the diseases differ, moreover, in their proximate causes as considerably larytl,r' as in their symptoms. Laryngitis consists in a suppurative inflam- mation of the membranes of the larynx, extending backward to the membrane common to itself, and the esophagus, between which pus is often found lodged : while croup or bronchlemmitis is a peculiar inflammation of the trachea, extending through the bronchial vessels, and exciting on their internal surface the secretion just noticed of a concrete filmy material which threatens suffocation by filling up the opening of the rima glottidis. In the treatment of this distressing malady, our object should be Treatment. to take off* the inflammation by the most active means. For this purpose eighteen ounces of blood should be instantly drawn from the arm, and eight or ten from the throat by leeches; and the bowels should be thoroughly purged by calomel and jalap, or some other active cathartic. In connexion with this process many writers ad- vise the application of blisters, and the use of relaxant inhalations. But, in preference to both, I would recommend gargles of ice-water acidulated, and epithems of pounded ice applied externally. Profes- sor Frank recommends, as in bronchlemmitis, a free use of calomel, in the proportion of five grains at a dose to infants of two years old, two or three times a day, or three grains every three hours, till fifteen grains have been taken. If this plan do not at once succeed, no time is to be lost, and bronchotomy must be had recourse to. But whether the opening should be made in the larynx, or below it, must be left to the judgment of the surgeon to determine. In a few instances, however, this disease seems to commence with Sometime comparatively little violence ; and to run easily into a chronic form : m°iidiy°anris a case of which kind is described by Mr. Wood in the Edinburgh "8r^*8 a Medical and Physical Journal. The child, a female, was ten years form. old when she was attacked. The symptoms for the first three or IUu3trate''- four days were even so trifling that no attention would have been paid to the complaint but for the croaking noise made in breathing, and particularly during sleep, and which had a considerable resem- blance to croup. The disease advanced gradually and almost im- perceptibly, except by occasional exacerbations, with a pulse from eighty to ninety in a minute, till the twenty-eighth day, on the noon of which the patient ate with an appetite, and with tolerable ease. At this period a night exacerbation carried her off suddenly* and on examination, the larynx was found internally covered and nearly filled with coagulable lymph, which is said to have assumed a mem- branous form ; and hence approaching to the nature of the exuda- tion in croup. This constitutes the angina laryngea cedematosa of M. G. L. j^sj"^ Bayle, minutely described by him in a late foreign journal. The ex- cEfaulsa puition he represents as glairy rather than membranous. In the of Bay'fe< course of the chronic inflammation by which the disease is marked, nnd which produces the effusion, a few tubercles or caruncles are v'ol. II.—35 2?4 cl. hi.] HAEMATIC A. [°™- v. Gen. VII, Spec. V. Empresma Laryngitis. Inflamma. tion of the larynx. General march. Tracheitis of Frank. formed that render inspiration suffocative, yet interfere but little with expiration. A cough, as may be expected, is sometimes a con- comitant. This form of inflammation has generally been found to take place in debilitated habits, or after an exhausting fever or some other com- plaint. If the patient recover, it is usually in about three weeks : for the most part, however, no remedial plan succeeded at La Cha- rite, and the disease terminated fatally in about a month or six weeks. Tracheotomy was often tried, but rarely with success. On dissection, some degree of ulceration, or purulent discharge was commonly traced.* It ought to be observed that Dr. M. Hall and Mr. Liston have since succeeded with tracheotomy in several in- stances in our own country.t If the inflammatory action commence below the larynx, it is called tracheitis by Professor Frank ;\ yet the pain and struggle are here considerably less than in proper laryn- gitis, though they sometimes stimulate the signs of sternalgia, or angina pectoris. SPECIES VI. EMPRESMA BRONCHLEMMITIS. CROUP. BREATHING PERMANENTLY LABORIOUS AND SUFFOCATIVE ; SHORT, DRY COUGH; EXPECTORATION CONCRETE AND MEMBRANOUS; FEVER A CAUMA. GEH.VII. Spec VI. The bronchitis of various authors, and of the first edition of the pre- sent work. Name why changed. Hitherto erroneously arranged. In the first edition of the present work, as also in that of his vo- lume on Nosology, the author was induced to follow M. Swediaur, Dr. Young, and various other authorities, in denominating this dis- ease bronchitis ; but as the same term is used in a very different sense by various other writers, importing inflammation of the bron- chia? generally, though a sense hardly called for, as except in the present instance, such affection is usually a symptom of catarrh or some form of pneumonitis, he has been induced to change the name of bronchitis for that of bronchlemmitis ; which, as importing mem- branous or membrane-like inflammation of the bronchia?, from *W«C' a sheath or membrane" as in neurilemma, a sheath or mem- brane of the nerves, is expressly descriptive of that concrete or tubu- lar effusion which peculiarly characterizes the complaint. The writers on croup have given but one form of it, except what has been erroneously called spasmodic croup, a disease, of a different kind, which has already been described under the name of laryngis- mus stridulus. Properly speaking, however, there are two forms, * Memoire sur l'CEMeme de u G1 tt ou A ine L ge (Ederna(ellse N reau Journal de la Medicine. Janv. 1819. f Edinb. Med. and Surg. Journ. No. lxxvh. p. 56?. t De Cur. Horn. Morb. Tom. n. p. 107 ol. m.j SANGUINEOUS FUNCTION. |ohd. xi. 27b an acute and chronic, under which the present species shows itself, Gen. VII. and which may thus be distinguished as varieties : S^ema." Bronch- a -^ /» «• • i , lemmitis< cl Acuta. bense ot suffocation keen, and Croup. Acute croup. constrictive ; chiefly seated in the larnyx; respiration sonor- ous ; voice harsh; cough ring- ing ; great restlessness ; termi- nating in a few days. 3 Chronica. Sense of suffocation obtuse and Chronic croup. heavy ; chiefly seated in the Bronchial polypus. chest; cough severe, but inter- mitting ; extending to some weeks or months. The disease, in both varieties, usually commences with the com- mon symptoms of a cough or catarrh ; but essentially consists in a peculiar inflammation that spreads through different parts or even the whole range of the windpipe, from the larynx to the minutest ramifications of the bronchiae. In this extensive sense, the tube was import of called bronchus by the ancients; and I have hence preferred the formerly! term bronchlemmitis to that of tracklemmitis, or membranous in- p"egentthe flammation of the trachea, as such a term would imply a limitation occasion. of the inflammatory action to the upper part of the bronchus alone, to which it is not confined in either of the forms before us. The first variety, importing the common or acute croup, the « e. suffbeatio stridula of Dr. Home, who has the merit of having ear- lemmitia best called the attention of medical practitioners to it as a distinct &cuta- ... . . • i i n -i t'Ommonor disease, though it extends thus widely, usually commences in the acute larger parts of the tube ; during which a peculiar effusion is secreted, pg""^ that readily assumes a membranous form, and lines, not only the membrane- trachea above its divarication, but also its minutest branches, though secretion. the larger parts of the tube are first affected. When chemically Chemical examined the secretion appears to consist chiefly, if not entirely, ofc Ma the gluten, or coagulable lymph of the blood, diluted with its serosi- ty, and copiously combined with that peculiar substance of the blood, detected by the labours of modern chemistry, which, from its essen- tial tendency to concrete into a fibrous, and even a membranous texture, has received the name of fibrin. By what means the mucous secernents throw forth this peculiar effusion on this peculiar occasion we know not. It is said by some writers to be secreted on no other occasion, and by no other organ ; but this is unquestionably a mistake. There are few practitioners, %£$*% perhaps, of accurate observation, who have not found it discharged other pans at times from the intestinal canal; of which I have already given °/mthe ■*«- cxamples under diarrhosa tubularis; in which, as in croup, there is an inflammatory affection of the morbid organ, and a spasmodic constriction of the passage. In reality the effusion, distinct from the inflammation that gives %™££ rise to it, is not essentially different in its principles from what oc- of polypi. f.urs in genuine polypus, or that of the nostrils, and those polypous 276 (I.. ut,j H^MATiCA. [oRD. IT, <;en-.VH. Spec. VI. a E. Brou- clileinmitis acuta. Uommon nr acute croup. Whence croup has been named angina polyposa, but incor- rectly. Disease known in most parts ef the world at present; though not distinctly noticed till within the last cen- tury. Its "attack on children not easily accounted for. Rarely attacks them after twelve vears of Description concretions which are often to be found in other cavities: and hence Dr. Michaelisand some other writers have given to the dis- ease the name ofanginapo///po«a.* a term, however, inconvenient and, indeed, inaccurate, since angina, as commonly understood, im- ports inflammation of the fauces accompanied with difficulty of swal- lowing, neither of which are necessary or even accidental symptoms of bronchlemmitis. This disease appears in the present day to exist in most parts of the world, and in the American States is called hives, supposed by my distinguislied friend Dr. Hosack to be a corruption of the term heaves, and probably so named from the heaving or violent efforts of the mus- cles of the chest and abdomen which take place in breathing during its course. It is hence extremely singular that till within the last century it should either not have had any existence or not have been definitely noticed or described by medical writers : for Dr. Cullen appears to be perfectly correct in referring to Dr. Home as the first person who has given any distinct account of it.f It is also not a little singular that children should be chiefly sub- ject to its attack, at whose age fibrin is not peculiarly abundant, and whose blood contains comparatively but a small proportion of azote, which in fibrin is so large a constituent. These are among the many curiosities which the prying eye of physiology has yet to follow up: and much has it to accomplish before it will be able to explain them. Dr. Cullen asserts that acute croup seldom attacks infants till after they have been weaned ; and that there is no instance of its occurring in children above twelve years of age. As a general rule this remark holds, but the disorder is by no means unfrequent to in- fants at the breast, of which I had one example not long ago ; and it has been found occasionally in persons considerably above twelve years of age. Those who have once had it are more susceptible of it than before ; though the susceptibility gradually wears off as they grow older. It is found equally in midland regions and on the coast; but perhaps more frequently in low, marshy grounds, than in drier uplands. There is no unequivocal instance of its being con- tagious, though it seems to have been occasionally epidemic. It commences usually with a slight cough, hoarseness, and sneez- ing, as though the patient had caught cold and was about to suffer from a catarrh. And to these in a day or two, succeed a peculiar shrillness and singing of the voice, as if the sound were sent through a brazen tube. " At the same time," says Dr. Cullen, who has well de- scribed the progress of the disease, " there is a sense of pain about the larynx, some difficulty of respiration, with a whizzing sound in inspi- ration, as if the passage of the air were straitened. The cough which attends it is sometimes dry ; and if any thing be spit up, it is a matter of a purulent appearance, and sometimes films resembling portions of a membrane. Together with these symptoms, there is a fre- quency of pulse, a restlessness, and an uneasy sense of heat. When the internal fauces are viewed they are sometimes without any ap- pearance of inflammation; but frequently a redness, and even swelling appear: and sometimes in the fauces there is an appear- IJteAt&l Polyoma Ancfan Christ, Fred- Micnaell*. ISmo.-Aftrentor. 177f>. t De Sufforaf inite Sfridirta. ■ ' ci.. m.j SANGUINEOUS FUNCTION. [ord. n. 277 ance of matter like that rejected by coughing. With the symptoms Gen. VII. now described, and particularly with great difficulty of breathing, and f^B™-- a sense of strangling in the fauces, the patient is sometimes suddenly cniemmitis cut off."* To which I may add that the countenance exhibits great Common distress : the head and face are covered with perspiration from the °rr0ttucnte violence of the struggle; the lips and cheeks are alternately pale and livid. The essence of croup consists in the secretion of this viscid and Whence concrete lining, which is perpetually endangering suffocation. Dr. oAhe"56' Cullen does not dwell sufficiently upon this symptom ; but ascribes disease: the danger principally to spasmodic action, and represents the ac- companying fever, which, on his hypothesis, is also a spasmodic ac- tion, to be very considerable ; but spasm was with him, as we have £0Imlhge' sm already seen, a favourite doctrine, and his judgment was often warped by it. Dr. Marcus of Bamberg in Bavaria, who regards all fe- J,nra\n"*ra' vers as inflammation of some organ or other, and as entirely seated in the arterial system, regards croup also as a local inflammation alone, utterly independent of spasm, which neither exists here, nor in fevers of any kind : and attributes the danger to this symptom solely : which is the more extraordinary as he regarded croup to be a disease identic with hooping-cough, in which the spasm or con- vulsion is the most prominent symptom. That there is some degree bo^o( which lire of spasmodic action, however, as well as of fever, is unquestionable, present. though neither are very considerable : and the locality of the disease as well as the peculiar character of the inflammation, sufficiently distinguish it from catarrh, in which there is also some inflammation of the mucous membrane of the trachea, though of a common kind, and rarely limited to this organ. In children, however, it frequently treads close upon catarrh, measles, hooping-cough, and any other disease that has debilitated the powers of the lungs ; for as Dr. Mi- chaelis-observes, whatever tends to weaken or produce any degree of irritation in the lungs so as to occasion a preternatural secretion into that organ, may be considered as a predisposing cause of croup. Professor Dupuy of the Veterinary School at Alfort, gives an instance Communi.-. of its having been communicated in a village, in which it was epi- dogs! demic, to a dog, brought under his care from a mistaken idea that the dog was suffering from hydrophobia. During the progress of the disease he had the shrill, ringing voice of children labouring un- der it; and speedily died of suffocation. On opening the body, a false membrane was found in the larynx, of a reddish colour, which extended to the bronchia;; and the lungs were filled with an abun- dant serous effusion.t The cure demands a prompt and active attention ; and must de- The,c.ure • I , . . , . . must de- pend not so much upon searclung into and correcting the remote pend upon cause, or even counteracting the spasm, as in counteracting and re- th™mem- moving the membranous secretion, which is every moment in dan- hranous ger of producing suffocation; and especially in children, in whom which ' the natural aperture of the glottis is much smaller in proportion than endcafln^erg in adolescents ; and occasionally not more than a line and a half suffocatiixtiTei,, Xtvxa (pXtyfMCTi 7replt%o(MVX, " firm Not dig- mucus-like excrescences, surrounded with white phlegm."* But noticed till tne complaint does not seem to have been distinctly described, till warren's j)r. Warren's history of it in the Transactions of the College.! illustrated. The case by which he chiefly illustrates it, and which is here chiefly alluded to, is that of a young lady eight years of age, of a strumous habit, who was suddenly attacked with a difficulty of breathing, attended with a short, dry, and almost incessant cough; but without any pain in the side or chest. The symptoms diminished in the ensuing night, and the complaint appears to have been productive of little inconvenience for six weeks ; when it returned with addi- tional severity, with costive bowels, a white but moist tongue, and a pulse too quick to be counted. Bleeding, purgatives, and the oxymel of squills relieved her, but the breathing was still laborious; she had wasting night-sweats, and the pulse beat from a hundred to a hundred and twenty strokes in a minute for the ensuing twelve days, at the close of which period, she woke suddenly in the night and was almost choked in bringing up, by coughing, what Dr. Warren calls " a large polypous concretion." It came up without either blood or mucus, and instantly gave her great relief. For two months afterwards she seldom passed three days without coughing up masses of the same kind, but none so large: she was tolerably easy when sitting still or in motion in the open air; and though her pulse never beat less than a hundred and twenty strokes in a minute, she had a good appetite, gained some degree of strength and flesh, and entirely lost her night-sweats. She was now suddenly attacked at night with another paroxysm of distressful breathing, and a sense of suffocation, and in the morning threw up a larger membranous concretion than at any time antecedently, and in the course of the four ensuing days, a quantity quite as large as in the six preceding weeks. From this time the oppression on the lungs returned irre- gularly after intervals of five, eight, ten, or twenty days, always followed and always relieved by an expuition of the same concrete material; till at the close of a twelvemonth from the first attack, the patient complained of a pain in the right heel, an abscess formed there, and the os calcis was found carious. From this time the bronchial affection ceased, the breatliing was perfectly free and no more concretion was at any time thrown up. A De Morb. Popular. Lib. vn. Sect. xli. • Vol. i. Art. \vi. • l. m.] SANGUINEOUS FUNCTION. [ord.. u, 281 Dr. Warren conceived this concrete substance to have been an Gen. VII. inspissated matter secreted by the mucous glands of the bronchial f ™ Bill" vessels. But the existence of fibrin, as a constituent part of the chiemmitia blood, was unknown at the period in which he wrote ; and his plates chS' and description of the membranous matter expectorated, show evi- Broncnia? dently that, like that discharged in croup, and often from the intes- polypus? final canal, it was composed of this formative element intermixed fXtanco with gluten, secreted in layers, and affecting a tubular structure. «*peeto- " Some of these polypi,''' says he, "are of a much firmer texture ac^unteri than others, and bear shaking in water without breaking to pieces. n°urt?nCor.!t: Others are so tender that a very gentle motion in water breaks off«ctiy. a great many of their smaller branches. They are solid, composed of laminag, which are easily separated from each other, and are manifestly of a texture less and less firm as you approach the centre or axis, which consists of a white pappy mucus as thick as cream. I observed one, about the size of a quill, which was tubular. It seemed to consist of a few lamellas only." In connexion with the plan of treatment already pointed out, it is Treatment, highly probable that much benefit might, in this chronic form of bronchlemmitis, be derived from the use of mercury and fox-glove. And as a natural cure was obtained by a metastasis, or a morbid action excited in a remote organ, we have a strong invitation to follow in a like path ; and should endeavour to obtain a like benefi- cial result by the use of setons or caustics. SPECIES VII. EMPRESMA PNEUMONITIS, PERIPNEUMONF. INFLAMMATION OF THE LUNGS ; OBTUSE PAIN IN THE CHEST ; C0>- STANT DIFFICULTY OF RESPIRATION, ALLEVIATED BY AN ERECT POSITION ; TUMID, PURPLE FACE, OR LIPS ; COUGH, GENERALLY MOIST, OFTEN BLOODY ; PULSE USUALLY SOFT. Inflammation of the lungs has been described under so many Gem. Vll. names that it is scarcely worth while to give a list of them. The f^ym*' most common perhaps is peripneumonia, for which pneumonitis, employed first, I believe, by Bourgard in his Dissertation, published in 1754, is here substituted merely on account of the regularity of its termination. The disease, as above characterized, ia traced under the three following varieties :— # Vera. Fever a cauma; pain severe, little True Peripneumony. expectoration in the beginning. /3 Maligna. Fever a synochus or typhus; the Malignant Peripneumony. debility extreme from an early period. Often epidemic. Vol. IT—3^ >S2 cL.m.] 1LEMATICA. lord. n. Gen. VII. Spec.VII. Empresma pneumoni- tus. Peripneu- mony. a E. Pneu- monitis vera. Truo pc-ri- pneumony Uuiied by y Notha. Spurious Peripneumony. Great secretion and expectoration with a mild cauma. Occurring in weakly habits, and often con- nected with a catarrh. Distinctive characters. Yet some- times found concurrent. The first of these varieties, or true peripneumony, is, perhaps, the most common, and has been more generally treated of than the rest. Dr. Cullen has united inflammation of the parenchyma of the pie"riti£i,h lungs* which is here alone contemplated, with inflammation of their membranes : as believing that we have no means of ascertaining a difference from the course or concomitancy of the symptoms. and in this view of the disease he has been followed by Professor Frank, who however retains the term pleuritis, but limits it to what has occasionally been called bastard pleurisy.* It may be ob- served, however, that in pleurisy the face is comparatively but little flushed, and far less tumid ; that the pulse is harder; the cough less violent, and, from the beginning to the end, without expectoration ; the seat of pain also is here fixed: while in peripneumony, it shifts not only to different parts o£ the same side, but often from the one side to the other; and, when the lower part of the right lung is affected, is communicated to the liver, occasioning an uneasiness in the right hypochondrium, and accompanied with a yellow and copi- ous expectoration. It is most commonly the case, however, that some degree of pleurisy accompanies pneumonitis from continuous sympathy;! but then it is not idiopathic pleurisy, nor strictly pos- sessed of its symptoms. Percussion, if skilfully managed, will often ascertain the particular part in which the inflammation is seated, but the stethoscope will prove a still better diagnostic ; for the use of which the reader is referred to the treatment of phthisis in the ensuing volume. Inflammation of the substance of the lungs bears nearly the same relation to pleurisy or inflammation of the membrane that lines it, as profound or parenchymatous cephalitis bears to meningic. The two former, however, are somewhat more distinct and less liable to run into each other than the two latter, because one half the pleura, from its duplicature, is more remotely situated from the lungs and less connected with them. And I have hence followed the ordinary division, and treated of pneumonitis and pleuritis as distinct species, rather than varieties of one common species, which is the view taken of meningic and profound cephalitis. In both sets of dis- ease, however, the membranous is the more acute affection, evinces more violent and painful symptoms, and runs through its course more rapidly. And hence, in pneumonitis, as in deep-seated phrensy, the pulse is sometimes soft,}; the fever small,§ and the progress pro- tracted occasionally to twenty days or more.ll The causes of true peripneumony are those of inflammation in • De Cur. Horn. Morb. Epit. Tom. u. § 185. 8vo. Mannh. 179* T Morjeagn. De Sed. et Caus. Morb. Ep. Art. 18, 14. S7 I De CabalIis,Phanora. Med. 5 Clesrhorn n W » Stoll, Rnt. Med. P,r u. p. 376. Art. Nat. c£. vXy 6& "& More easily distinguish- able than inflamma- tion of the brain and its mem- branes. And why. Analogy between cephalitis and the diseases in question. •jl. ni.j ;SA.\GUL\EOlJS FLECTION. [ord. u. 283 general; particularly excessive exertion of the lungs, or cold, Gen. Vll. applied when the system is generally heated, to the skin, mouth, or f ^Prl" stomach. It attacks the robust and plethoric more frequently than monitis the spare and delicate; and appears most frequently in cold weather, Trueperi- or sudden changes from hot to cold. Repelled eruptions have Pnoumon>'' probably sometimes proved a cause ; and noxious exhalations cer- tainly. To the last we may refer the frequency of this disease in the outskirts of Mount Vesuvius, as remarked by Vivenzi ;* and on this account it is described by Baroniusf and Bovillet,J as endemic. Professor Frank observes that it is occasionally the result of worms or saburra in the stomach or intestines. The first symptoms also are those of inflammation in general; Deicriptiqr.. but there is usually more shivering, or cold fit, and the hot stage is proportionally violent; the head aches considerably, and the urine is high-coloured. The pain in the chest is rarely felt in any oppres- sive degree till these symptoms have continued for a day or two: though sometimes it is coetaneous. It is chiefly felt in a recumbent position, and more on one side than on the other. The cough is short, peculiarly distressing, and obstinate, the expectoration small, viscid, and discoloured, and sometimes little in quantity. The pulse is variable, in some cases hard and strong, in some soft or oppressed; but, with the advance of the disease, it becomes feeble, sometimes fluttering. Delirium is an occasional accompaniment, and is a highly dangerous symptom, except where it alternates with the pneumonic symptoms, in which case it augurs well. In favourable terminations the violence of the disease diminishes on or before the seventh day: if it increase beyond this, it commonly proves fatal. Peripneumony, like other inflammations, terminates in effusion, ]£™™f suppuration, or gangrene ; and it has also a termination peculiar pneumoni- to itself, which is that of hemorrhage from an increased vis a tergo.,,s- The most salutary mode is effusion, for the vessels hereby become Effusion relieved, and the secernents immediately add to the relief by com- favourable. mencing an increased action, and consequently an increased dis- charge of mucus. In consequence of effusion, however, we occa- ^J0100- sionally find adhesions take place between the lungs and the pleura ; adhesions and sometimes a collection of water in different parts of the chest; sometime* and not unfrequently a flow of blood, apparently from the mouths ^p3^ of the exhalants without any rupture of vessels, giving a bloody tinge to the sputum. This last has been often regarded as an Bloody ^ alarming symptom, but the alarm is altogether unfounded, for it ll0Cessariiy generally affords considerable relief. Indeed an hemorrhage itself «•«"«•»«"■ from the lung3 has not always been attended with fatal conse- quences : it has occasionally proved critical, and carried off the disease in a few days: though a hemorrhage from the nose, no un- usual attendant, is far preferable, as producing a like benefit with less risk. If the inflammation run into suppuration, the change is generally indicated by shiverings, with a remission of pain, and sometimes perspiration where there has been none before. If gan * Epist. ad Haller. iv. t Pleuropneumonia ann. 1633, Flaroiniam infestante. i»idi. Ia39. - Mfimojres sur les Pleitropnenmonies- Epidemiq'ies. p. MR 284 &. lu.j HAEMATIC A. [ORD. 11. Geh.VII. Spec.VII. a E. Pneu- monitis vora. True peri- pneumony. Treatment. Expectora- tion the best and most natu- ral eure. Bleeding according to the ge- neral habit and consti- tution. In some cases very copious. Sometimes local only. Laxatives and refrige- rants. Emetics. Full vomit- ing. Peschier's rrntimoniaj pfan. grene ensue, the pulse sinks, the debility rapidly increases, and the eyes are fixed with a ghastly stare. The best, the easiest, and even the natural cure of peripneumony is expectoration ; which, hence, ought to be excited, and en- couraged by all the means in our power. It forms the optima crisis of Stoll, though, as he adds, a crisis too rarely obtained.* Bleed- ing, by giving some degree of freedom to the distended capillaries, affords one mean of accomplishing this object; but if the patient's strength be considerably reduced, the strength of the capillaries will be reduced also, and they will be too debilitated for the increased action. It is, hence, necessary to measure the general habit and constitution of the patient, as also the situation in which he resides; for if he be in an open and mountainous region, and addicted to the pursuits of a country life, he will bear bleeding far more readily and freely than if he be the inhabitant of a crowded city, or accustomed to a sedentary life. In this case the bleeding should be prompt and copious, at least to eighteen or twenty ounces, and repeated twelve hours after if necessary; and as the disease occurs chiefly in robust constitutions, it is rarely that vengsection can be dispensed with. The chief evil is that the fever is apt, at times, to run into a typhous form, and assume the second of the varieties before us. And hence, where there is any doubt upon the subject, local bleeding, is to be preferred, whether by leeches or cupping-glasses, repeated according as the evacuation appears to be demanded. Laxatives and refrigerants are next employed with the same general view of taking off the entony of the arterial system. One of the most common, and, at the same time, most useful refrigerants, is nitre; which may be combined with the citrate of potash, or made to produce a more certain determination to the skin by the addition of camphor or of antimonial wine, or by a combination with the citrate or acetate of ammonia. Emetics have seldom been given except in an early stage of the disease, and then only as a gentle puke ; yet, from my own practice, I can recommend them when the disease has made a considerable advance: but they must be used boldly or so as to produce full vomiting, and the action of vomiting must be maintained for an hour, or even two: and in this way they will often produce a transfer of action of as beneficial a nature as the same process is found to do in purulent ophthalmy ; and will, at the same time, peculiarly stimulate the exhalants of the lungs to an increased secretion of mucus. M. Peschier of Geneva prefers for this purpose tartarised antimony to all other medicines of this kind : and depends upon it alone or nearly so, even discarding the lancet; for he gives it in large doses so as to purge as well as vomit. His usual quantity, at first, is, according to the age, from six or eight to fifteen grains dis- solved in six ounces of water, which is taken in divided doses, in any diluting drink, in the course of twenty-four hours. And under this plan he tells us that he cured all his patients, old or vouno;. *'HaJ. Med. in. 58 cl. in.] SANGUINEOUS FUNCTION. [ord. n. 2b-j without exception. He admits, however, the conjoint use of Gen. VII. blisters, which ought unquestionably to form a concomitant in the f"p^S* general plan ; and the obstinacy of the cough may be alleviated by mon'ths demulcents, or inhaling the steam of warm water. Opiates have tw peri- been tried in every form, but have never been found of decisive ^aSt benefit: if opium be used at all it should be in conjunction with Demui- gum ammoniac, or squills : but, upon the whole, either of these Sations. expectorants seem to answer best without opium. Dr. Saunders °P'um recommended the extract of the white poppy ; and that of the fui.ely use" garden-lettuce has since been tried upon the recommendation of J^"of Dr. Duncan ; others may have been more fortunate than myself, poppy; but, in my hands, both have proved altogether insignificant. den-lettuce. If the disease proceed favourably the pulse becomes slower and Prognostics. softer: the yellow, tenacious, and perhaps bloody sputum, is mixed with points of a whiter matter, which increases with the amendment of every other symptom; for the cough is less violent and straining, the breathing freer, the skin moister, and the tongue cleaner at the edges. If the progress be less favourable, the expectoration be- comes darker and more viscid ; the pulse lower, indistinct, and often intermitting ; a low, wandering delirium supervenes, with subsultus ; and the patient dies, apparently suffocated from the oppressed ves- sels no longer permitting an expansion of the lungs. When a salutary expectoration has commenced, it sometimes Accidental ceases suddenly from some unknown cause, or some irregularity in ev the mode of treatment. This symptom is alarming ; and every means should be instantly taken to bring the discharge back; such, particularly, as increased doses of the expectorants already How noticed, to which may be added the steam of vinegar, alone, or im-re,,eTed' pregnated with the essential oil of aromatic plants, as rosemary. And if a diarrhoea, which sometimes proves a very distressing con- comitant, should supervene, it will be best relieved by the pulvis cretae comp. cum opio. Inflammation of the lungs is, also, occasionally found as a symp- Found oc- tom or sequel in rheumatism, lyssa, or canine madness ; various ex- "othery anthems, as small-pox, measles, miliaria, and commonly in phthisis; dUorders' in which last it has a very frequent tendency to suppuration, as we shall have to notice when treating of this distressing complaint. The malignant peripneumony, contrary to the true or common P e. Pneu. inflammatory affection, is generally an epidemic, and may be easiest maligna. explained by describing it as an epidemic synochus or typhus* occur- p^Jpf,™"' ring in such situations, at such seasons of the year, or in such a tern- mony. perament of the atmosphere as has a tendency to excite inflamma- iCnSyn0Chus tion of the lungs. The debihty is often so extreme from an early writ,^^,> stage of the disease, that the pulse ceases on the pressure of the flammation finger ; and the vascular action is too weak to accomplish expecto- ?urn^ ration. It is supposed by many writers, and especially by Sarcone The debility and Ludwig, to be a pulmonic erysipelas, by which they mean an Bys^rne erysipelatous erythema: and they are probably right in their con- called a. jecture. Whence Planchon regards erysipelas as its proximate erysipelas * Pelargus, Medicinische Jahrgange i. i. p. 44. Tissot. sur I'Epidemie en Lau- sanne, &c 2St> cl. m.j H^MATICA. [ord.il Gen. vii. cause.* The symptoms are those already described, with a great !Pe pJe"' addition of sensorial debility, and consequently with increased la- monitis boriousness of respiration. The disease is usually fatal on the fourth Malignant or fifth day; and if the system be incautiously lowered by venesec- penpneu- tion or a laxative of too much power, it often takes place earlier; Ea"iy and has sometimes occurred within twenty-four hours after bleeding. Treatment. Our attention must here, therefore, be turned rather to the con- as £» stitutional disease than to the local affection ; and the plan recom- mended in typhus is to be pursued on the present occasion: for it will be in vain to attempt expectoration under circumstances in which the system will probably sink before the usual time arrives ^mSi nt *°r effecting i*« Camphor is here a medicine of considerable ser- stimu ants. ^.^ ^^ ^^ ^e ^^ ^ conjunction with the aromatic confection, and wine in large quantities. It should be taken freely in the form of pills, rather than in that of julep: though both may be employed P^Vusto conjointly. Even the bark has a powerful claim to be tried, and thJeUbrcath° that too in as large quantities as in putrid fever ; nor has it been ™s- found to produce difficulty of breathing. It may be advantageously combined with the aromatic spirit of ammonia, which of itself often proves a useful stimulus. If evacuations be necessary they should be obtained by injections alone. A light breathing perspiration, a free expuition, and a more animated appearance of the counte- nance, are among the most favourable diagnostics. y e. Pneu- The spurious or bastard peripneumony is usually allowed to no0^"* offer another variety of this disease; and is described under the Spurious name of peripneumonia notha by Boerhaave, Coze, and Sydenham. penpneu- r r. * , ., ,*. .- mony. It is, in many instances, little more than a severe catarrhal affection catarrh1t0 of the lungs, accompanied with great obstruction, occurring in habits and some- of a peculiar kind; and is hence denominated by many authors catarrhus catarrhus suffocativus, and by Professor Frank, catarrhus bron- tivusCa* chiorum.] It is characterized by great secretion and expectoration, by Frank, with a mild cauma ; and is chiefly found in those of advanced life, chiorum" or who have weakened their constitution by excesses. But judi- Sydenham, however, has properly distinguished this malady from tinguished" catarrh, notwithstanding the close resemblance it bears to it on from it by particular occasions. The following is his description of the dis- Sydenham. r _,. . . °. , , r„ . . , , , pescrip- ease :—" 1 he patient is hot and cold alternately, feels giddy, and complains of an acute pain in the head, especially when there is a teazing cough. He rejects all fluids, sometimes from paroxysms of coughing, and sometimes without: the urine is turbid, and of a deep red ; the blood appears as in pleurisy. The patient breathes quick and with difficulty ; complains of a general pain throughout the entire breast, and, as he coughs, discovers a wheezing to the attendants. The cheeks and eyes appear slightly inflamed ; the pulse is small, often intermitting ; and lying low, or on one side, is peculiarly distressing. Process of As the fever is here of no great moment, we may, with consider- able advantage, carry our local stimulants to a greater extent, and thus excite the lungs more actively to throw off the burden of mucus * Toiirn. <*> Med. Tom. xi.vi. p. 24. » De Cur. Horn. Morb. Tom. n. p>. 13P cl. in.J SANGUINEOUS FUNCTION. [oru. u. 2&7 with which they are overpowered. Squills, gum ammoniac, balsam Gem. VII. of Peru, and even some of the turpentines, may be tried, and will Je'pJS* mostly be found serviceable. The tetradynamia, as charlock, wild- mo?iti9 rocket, and mustards of various sorts; and the alliaceous plants Spurious will form useful auxiliaries in the plan of diet. Blistering is highly £"npn.eu" serviceable ; after which, as soon as the chest is a little unloaded, a Ex?2eto- regimen directly tonic should be commenced, by means of bitters, Sting. chalybeate waters, a moderate portion of wine, gentle exercise, ToPic pure air, and the irritation of an issue or seton: for a common resultreg,men of this disease is hydrothorax from atony of the absorbents of the chest. And hence, perhaps, more fall a sacrifice to some sequel of the disease than to the disease itself. SPECIES VIII. EMPRESMA PLEURITIS. PLEURISY. ACUTE PAIN IN THE CHEST, INCREASED DURING INSPIRATION ; DIFFI- CULTY OF LYING ON ONE SIDE ; PULSE HARD ; SHORT, DRY, DIS- TRESSING COUGH. As the proper seat of the preceding species is in the substance of Gen. VII, the lungs, or the pleuritic membrane that immediately lines its sur- how^S?' face, or in both, the proper seat of the present is in the surrounding tinguished membranes of the pleura ; and as these differ, the difference has monitisneu laid some foundation for several varieties ; of which the three fol- lowing may be noticed, as matter of curiosity, though the sub- divisions lead to nothing of practical importance, as the causes are nearly alike, and the same mode of treatment is applicable to the whole. « Vera. Fever a cauma : pain felt chiefly on True Pleurisy. one side : the inflammation com- mencing in that part of the pleura which lines the ribs. H Mediastina. Heavy pain in the middle of the ster- Pleurisy of the num,descending towards its ensiform mediastinum. cartilage : with great anxiety ; the inflammation from its symptoms being obviously seated in the medi- astinum. y Diaphragmatica. Painful constriction around the prsecor- Pleurisy of the dia; small, quick, laborious breath diaphragm. ing; manifesting that the inflamma- tion is seated chiefly in the dia- phragm ib5 cL.ur.j ILEMATICA [ord. u. Gen. vii. We have already pointed out the distinction between true pleurisy aSE!pieu- am* peripneumony; and observed that in the former the cough is ritis vera, dry and commonly without expectoration from the beginning to the ^ rue pieu- en^ contrary t0 wnat occurs m the latter ; that the seat of pain is fixt, instead of shifting from side to side; and that the face is far less flushed and tumid. It must be conceded, however, to Dr. Cullen, who has treated of these affections under one common defini- tion, that the general features of the two have a considerable resem- blance ; and, with the exception of expectorants, which in pleurisy are of little avail, the mode of treatment already proposed for the former disease, is the same that will be found necessary in the latter : the causes of both are alike, and as peripneumony rarely, though we have reason to believe sometimes, occurs without any degree of pleurisy, so it is commonly affirmed that pleurisy rarely occurs without some degree of peripneumony ; in both which cases it has been called a pleuro-peripneumonia. Like the latter, we also find the former an occasional symptom or result of typhus, catarrh, rheu- matism, various exanthems, and hypertrophy or enlargement of the heart.* The pleurisy, however, that is supposed to accompany rheumatism, is often an inflammatory affection of the intercostal or other thoracic muscles alone, since the pain is confined to the origin and insertion of the muscles. Where this has been accu- rately attended to, it has been distinguished by the name of bastard plturisy: and simply by that of pleuritis by Dr. Frank,! and those who have regarded genuine pleurisy as a mere modification of pneu- monitis, or peripneumonia. Dcscrip- Like the preceding species, true pleurisy commences with the usual signs of a febrile attack, as chilliness or shivering, succeeded by heat and restlessness. The pain is usually just above the short ribs, and, as already observed, the expirations are less painful than the inspirations. The pulse is hard, strong, and frequent; and though the cough is mostly dry and supprest, there is sometimes a bloody or puriform mucus spat up from the lungs, evidently proving that the substance of the lungs has participated in the inflammatory action. Termina- Like the preceding species also, pleurisy terminates in resolution, suppuration, and gangrene. The former is the ordinary and most favourable issue. The last occurs rarely ; but suppuration is by no means uncommon ; in which case, if the abscess do not point out- wardly, an empyema will necessarily follow ; and the formation of pus is indicated by a remission of the pain, one or more shivering fits, and, in some instances, a sense of fluctuation. This, however, is a termination far more common to pleurisy from external injuries, than from internal causes. Treatment In the treatment of pleurisy, as we have no advantage to expect from expuition, we may employ bleeding far more extensively, and with far less caution than in peripneumony. °ouidnrfe -Perhaps there is no disease in which profuse bleeding from a large * Original Cases, with Dissections and Observations, &c. by John Forbes M D p. 222. 8vo. 1824. ' "*'•" + De Cur. Horn. MorT». Epit. Tom. 11. p. 126. 8yo. Mannh. 1792. irofuse. CL. in.] SANGUINEOUS FUNCTION. [oki>. ir. 280 orifice may be so fully depended upon, or has been so generally Gen. vii. acceded to by practitioners of all ages and all nations. The only aE.vS5l question which has ever arisen upon the subject being, whether the tiB v"*- blood should be taken from the side affected or from the opposite. Jeurisy. The earlier Greeks recommended the former, the Galenists and Amuuatod Arabians, the latter ; and the dispute at one time rose so high that dispute the medical colleges themselves, not being able to determine the l!™b£odh point, the authority of the emperor Charles IX. was whimsically snould bo appealed to ; who, with much confusion to the controversy, died whimsical himself of a pleurisy before he had delivered his judgment. He, too,teferencc- had been bled, and his death was immediately ascribed to the blood having been drawn from the wrong side. At present from a know- ledge of the circulation of the blood, we can smile at these nugatory solemnities. It is possible, however, that there are some contro- versies of our own times that have as little ground-work, and at which future ages may smile with as much reason. The blood Pruritic drawn in this disease has a peculiarly thick, yellowish, tenacious corium, and is hence specifically distinguished by the name of the pleuritic corium or coagulum. With these exceptions the treatment of peripneumony and pleu- risy should run parallel. Purgatives should be used freely ; blis- Purgatives. tering the side is very generally beneficial after bleeding has been tried and repeated, and should be accompanied with diluents and Diophore- diaphorctics. Opium may also be employed with less caution than opiates. in peripneumony. And where we have reason to suspect suppura- in case of tion, warm cataplasms should be applied to the part to solicit an ti™nPhow external opening. If the abscess break internally it must be followed t0 proceed. by the operation for an empyema. The heart and pericardium are sometimes apt to associate in the # ?. PIe?i- morbid action, as well as the lungs themselves. This is particularly astina. the case in the second variety. Dr. Perceval, in his manuscript themedial- commentary on the Nosology, has given me a striking example of this tinum. .. / , , • 6V c b ■ .- • ■ *u • c Case of Dr. in a patient who complained of excruciating pain in the region ot percevai of the heart with dyspnoea, not at all relieved by copious and repeated Dut,lin* bleedings. After death a slight effusion was discovered in the peri- cardium : but the mediastinum was more inflamed than the mem- brane of the heart. The treatment of this variety ought not to differ from that of the preceding. The cerebrum is, however, still more disposed to associate in the J'it?^.u" morbid chain of action than the heart. And hence, when any of phmgma. the varieties of pleuritis, and particularly the last, are combined with P7eaurigy of an affection of this organ, and produce delirium, the disorder was the ^ that carditis, like pleuritis, has many signs in common with pneu- species.ns monitis ; which may readily be conceived from the vicinity and close connexion of the thoracic viscera with each other, and particularly from the very strong sympathy with which, as already observed, they co-operate. Dr. Cullen affirms, indeed, that he has often met with cases of carditis evincing no other symptoms than those of pneu- And hence monitis, and Dr. Frank concurs in the same testimony. It is probably Bome'nosL- on in*s account that Linneus has taken no notice of carditis in his logists. nosological arrangement. Vogel's definition is founded altogether upon this view, " Cordis inflammatio fere ut in peripneumonia." I have hence been at some pains to draw aline of distinction ; and I think it may be found in the symptoms now delivered as a specific character of the disease. We may add to these symptoms, that there is sometimes, though not always, great difficulty of breathing, generally some degree of cough but without expectoration, and a perpetual tendency to fainting; and that if deliquium takeplace, and ll. in.J SANGUINEOUS FUNCTION. [ord. u, .291 the patient do not soon recover from it, it proves fatal.* M. Portal Gen. VII. asserts that the organic pain is accompanied with an increase of f m*°;n*- heat, which often spreads to the surrounding regions. This is M. L»"i>iis. Portal's acute modification of the disease : but he also notices an JionTrtto obscure or latent modification, in which its symptoms are but little Modiitau- conspicuous, and whatever exists of them, are ascribed to some tio°ns 0f" other disease. The spirit, he tells us, is here suddenly subdued and Po,ta1' broken : the pulse is slow, soft, and feeble: there is little pain in the heart, and little or no palpitation. Fainting, nevertheless, is a fre- quent appendage, and is peculiarly apt to lead astray. This, however, can hardly be called an idiopathic disease. M. Portal has drawn his description entirely from post-obit appearances in those who have died of severe atonic typhus, or of plague : and observing, as M. Chicoyneau had before him, occasional proofs of suppuration and gangrene of the heart, he has inferred the previous existence of carditis, and has ascribed the almost instantaneous sinking of the patient to a rapid march of inflammation in this organ, notwith- standing it was not manifestly accompanied with its ordinary indications.t We are not in possession of any signs by which an inflammation No distinc- of the pericardium can be distinguished from that of the substance tom98ymp" of the heart, for here the stethoscope affords little aid : and hence fl|JnVm™io^" we cannot make a distinct species of the latter. Vogel and a few of the heart other writers have attempted it, but the boundary has not been cardiumf clearly drawn, and has never been of use. Upon dissection, adhesions have been occasionally found to a AdnesionB very considerable extent between the heart and pericardium, even detected where little inconvenience had been felt during life : and into this previous16 fact we are perhaps chiefly to resolve the declaration that the heart discomfort* has occasionally been found without any pericardium whatever. From all which we may, at least, collect that the extent of motion of these two parts on each other is not very great. A purulent kind And somxr- of fluid has at times also been detected on the outer surface of the lenffliid.'^ heart, without the slightest appearance of ulceration either of the heart or pericardium ; and as the same sort of secretion has often been traced, without ulceration in other cavities, Mr. Hewson, as we have already seen, first suspected, and Mr. Hunter afterwards endeavoured to establish, that this fluid is nothing more than coagu- lable lymph thrown forth from the vasa vasorum, but changed in its nature in consequence of passing through vessels in a state of in- flammatory action. And it was this discovery, and the hint thus founded upon it, that gave rise to the doctrine now so generally admitted, and apparently so well sustained, of a distinct secretion of pus, in many cases without ulceration. The causes of carditis are often obscure : where we can trace ^a,^"d them, they are for the most part those of pneumonitis ; and the mode of treatment needs not essentially vary. Dr. Frank gives an * Abercrombie, Contributions to the Pathology of the Heart. Trans, of the Me* dico-Chir. Soc. of Edinb. Vol. i. 1824." t Memoires sur la Nature et le Traitement de plusieurs Maladies. Par A. Parts' Premier Medicin de Boi, &c. Tome Quatrieme. 8vo. Paris, 1819-, 292 cl. m.j HjEMATICA. [0RP. II. Gen. VII. Si-ec. IX. Empresmu Carditis Tnfl.tmma. tion of the licart. Walls of the heart sometimes thickened. Exempli- fied. interesting case of violent carditis brought on by terror in a prisoner condemned capitally. It proved fatal, but on dissection was found not to be confined to the heart. There seems sometimes to be an increase in the action of the vessels of the heart, which, though short of inflammation, is suffi- cient to give thickness to its walls, and considerable magnitude to its general substance. And hence a frequent origin of enlargement of the heart. M. Bayle has published an interesting case which appears to belong to this kind of morbid structure. The patient was a young man of delicate constitution, and limited intellect. He was attacked in 1819 with mental derangement \ and in a few months afterwards seemed to labour under a general oppression in every organ, under which he died in a few days. The membranes of the brain were infiltrated and thickened : the heart was twioe and a half its natural size : the aorta and pulmonary artery, as well as various other vessels, gave evident proof of a direct inflammatory action.* SPECIES X. EMPRESMA PERITONITIS. INFLAMMATION OF THE PERITONAEUM. PAIN AND TENDERNESS OF THE ABDOMEN, ESPECIALLY ON PRESSURE OR IN AN ERECT POSTURE ; WITH LITTLE AFFECTION OF THE SUB- JACENT VISCERA, OR ABDOMINAL WALLS. Gen. Vll. The inflammation may be seated in the peritonaeal membrane Spec. X. fining the cavity of the abdomen, or in its extension to the mesen- tery or omentum. And hence Dr. Cullen has noticed the three following varieties:— The inflammation taking the general range of the perito- naeum ; pain extreme, often pungent, with little or no re- lief from stools. With a more sensible swelling in the region of the omentum. Pain deeper seated, and more immediately in the mesenteric region : external tenderness less than in the preceding varieties. Noticcu It is singular that Dr. Cullen, after distinctly characterizing this iw brevlf"' species in his Nosology, and following it up into three sub-divisions. >y " e' * Observations d'Arterite. Bibliotheque Medicale. Sept. 1821. Propria. Proper inflammation of the pe- .ritonseum. Omentalis. Inflammation of the omentum. Mensenterica. Mesenteric inflammation. CL. ni.] SANGUINEOUS FUNCTION. [obd. n. 293 i>ento- nseum. each of which, with him, forms a separate species, as the general Gen.vii. disease does a genus, sliould take no other notice of the entire ?*^IJ' complaint in any form, except what is expressed in the following P-rit«.ni«w. laconic remark: "Among the inflammations of the abdominal t'^oftto region, 1 have given a place in our Nosology to the peritonitis ; comprehending under that title, not only the inflammations affecting the peritonsj.im lining the cavity of the abdomen, but also those affecting the extensions of this membrane in the omentum and mesentery. It is not, however, proposed to treat of them here, because it is very difficult to say by what symptoms they are always to be known; and further, because, when known, they do not require any remedies besides those of inflammation in general." This remark is by far too sweeping. If the diseases referred to "^h™*™ have no specific symptoms by which they can be known, they have expedient. no more claim to be admitted into a system of symptomatic nosology than into a treatise of practice. Dr. Cullen is right in assigning them a place in the former ; and he is, therefore, neces- sarily wrong in banishing them from the latter ; and the more so, as the treatment ought, in some degrt-e, to vary from that of ente- ritis, to which his general observation seems chiefly to refer. The true peritonitis occurs, as we have already observed, as <*.?■ rerito- a symptom in puerperal fever ; and as we have treated of it at pr.B some length under that disease, it is i he less necessary to be minute a'Xiation in our account at present. Puerperal fever, indeed, is sometimes, oftheneri- though not quite correctly, made a variety of peritonitis : for it is HoTfM a disease of a peculiar kind, produced by peculiar causes, and is ,elaied t0 , i • . . . . " ii - puerperal only connected with peritonitis as the latter enters as a symptom iever. into its general character, and may hence take the name of puerpe- ral peritonitis, to distinguish it from idiopathic. In what light Dr. Cullen regarded puerperal fever does not appear from his writings, since common as the complaint is, it does not occur in any of them; which is the more extraordinary as his System of Nosology, which is not comprehensive enough to include many diseases, might easily have found a place for this. Dr. Carmichael Smith has well described the progress and effects of this inflammation in the following passage: " The symptoms oescrip. accompanying peritonaeal inflammation are fulness, tension, and a t,on' general soreness of the abdomen, with purging and fever. The pulse is remarkably small, quick, and thready ; and the slightest pressure on the part occasionally causes pain, sickness, and vomit- ing. Upon dissection there is found a kind of gelatinous exudation all over the intestines ; and the cavity of the abdomen is often filled with a turbid whey-coloured serum."* In the specific definition it is stated that peritonitis occurs " with JJSJ? little affection of the subjacent viscera or abdominal walls." In rounding effect it often happens that these are not at all influenced, and, iitt|e affect- whenever they are, it is only secondarily ; and hereby peritonitis is ed; sufficiently distinguished from puerperal fever. " If the perito- »d8 ^ Marm* naeum," says Mr. Hunter, " which fines the cavity of the abdomen, Hunter. * On the different kinds of inflammation. 094 cl. m.j 1LEMAT1CA. [obd. it. Gem. VII Spec. X. a E. Perito- nitis pro- pria. Proper in- flammation of the peri- tonaeum. Substance of different organs not equally consenting with their surrounding membranes. Illustrated. Objection of Portal- Causes. Treatment. inflames, its inflammation does not affect the parietes of the abdo- men ; or if the peritonaeum covering any of the viscera is inflamed, it does not affect the viscera. Thus, the peritonasum shall be universally inflamed as in the puerperal fever, yet the parietes of the abdomen, and the proper coats of the intestines, shall not be affected : on the other hand, if the parietes of the abdomen, or the proper coats of the intestines are inflamed, the peritonasum shall not be affected."* We hence perceive another proof that the membranous tunics of the different viscera do not hold an equal intimacy of action in every instance. And it would be interesting to follow up the discrepancy, and draw a scale of their readiness or inaptitude to sympathize with the viscera which they cover. The membranes of the brain, as we have already seen, are so peculiarly disposed to partake of the inflammatory action of the parenchyma, as to render solitary inflam- mation of the one or of the other a rare occurrence. In the lungs and in the heart the play of relationship is far less conspicuous, and in the viscera of the abdomen it rarely takes place. And it is owing to this circumstance that we are able so generally to draw the line between inflammation of the peritonaeum and of the intestines, from the pain being much more superficial in the former than in the latter case, and, in many instances, not accompanied with sickness or any other disturbance of the alvine canal. M. Portal is too httle disposed to admit of this distinction, and seems to think that idio- pathic inflammation of the peritonaeum is by no means a common disease, and that when it does exist, its manifestation is far from beihg clear.t But this is to render a general rule universal, and to sweep away from it the exceptions that chiefly establish its proof. The causes are those of inflammation in general, as cold, external injuries, and a morbid transfer of action ; and, in a few cases, sympathy with the adjoining organs, as in puerperal fever. The treatment is, in like manner, that of inflammation in general, particularly that of e. enteritis, to which the reader's attention is especially directed. Bleeding, both general and local, should be carried into effect copiously and with all possible speed; but purging, though at all times of service in inflammatory affections, is less imperiously demanded than in inflammation of the intestines; ex- cept where the peritonitis is puerperal, and the system affected generally : in which case we have already observed that calomel should be given liberally at the commencement of the complaint. Warm stimulant fomentations may be advantageously applied to the abdomen, and blisters in succession : but, after a very free use of leeches, I have found more benefit in applying a large folded flannel wrung out in simple hot water, or water impregnated with aromatic herbs over the whole of the abdomen, and letting it remain there for many hours or till dry, wrapped over with a broad calico or flannel swathe that surrounds the entire body. All we can possibly aim at, in applications of this kind, is a continuation of * On Blood, &c. p. 244. t Memoires sur la Nature et le Traitement des plnsieurs Maladies, Tom. iv. Sv*' Paris, 1819. a. in.] SANGUINEOUS FUNCTION. [ord. ii. 295 moist warmth, as in a common poultice ; and this is obtained more Gen. VU. easily, and with infinitely less fatigue to the patient or danger of a E. p'eri-' giving him cold, than in the ordinary way of applying fomentations, ^"'j-^ When the bowels have been well opened, opiates may be given with Proper in- freedom, and especially in union with ipecacuan or antimonials to of1^™ p'eri" determine to the surface. tonamm. When the inflammation commences or is seated in the omen- f^^6"' TUM or EPiPLooN,'the pain is more limited, and points rather towards omentaUs. the superior and middle region of the abdomen, a little above and S^TSfthe below the navel; though it sometimes inclines to the right or left omentum. hypochondrium. The peritonaeum itself does not readily pass into J^,"0* a secretion of genuine pus ; and still less so the omentum, which, suppurate. where ulceration takes place, generally evinces a foul and sanious secretion. Sauvages gives a striking example of this in a woman, [JJjj^^ who was at first attacked with an acute lancinating pain in the umbi- vages. fical region ; and had a tumour formed towards the right hypochon- drium about the size of a man's fist, which by degrees occupied the whole abdomen. By an application of emollient cataplasms, the pain and general swelling were diminished in the course of three days ; but a fluctuation in the abdomen was next detected, like that of an ascites ; in consequence of which, a trochar was introduced into both sides of the abdomen, and a putrid ichorous fluid was dis- charged, which induced the operator to enlarge the opening ; when sloughs of the omentum, already separated, came away with an intolerable stench, and with about two pounds of what Sauvages calls ichorous water. But the skill of the surgeon was overpowered by the disease, and the patient fell a victim to it.* The mesentery has but a small degree of sensibility, and hence, y j^f^ as well as from the greater depth of the seat of the disease, mesen- senterica. teric inflammation is only discoverable by pressure. If the affec- tVon'oftto tion be strictly mesenteric, the symptoms are mUd and gentle ; but mesentery. this is a rare case, and chiefly occurs when the glands are obstructed, and any accidental irritation is applied to them. Most commonly it ^"^ t . is catenated with inflammation of the spleen, liver, or intestines. The with other chief point of tenderness or pressure is the navel; though in the comPlaints- commencement of the disease the pain seems to shoot upwards from the back ; the bowels are often obstinately confined.! The medical treatment will be the same as in hepatitis, or Treatment. splenitis : though bleeding, in general, effects but little benefit. * Nosol. Med. Class in. Ord. m. xvi. t J. P. Frank, De Cur. Horn. Morb. Epit. Tom. 11. p. 188. 8vo. Mannh. 1792. 296 cl. in.] 1LEMATICA [ord. it. Gen. VII. Spec. XI. Hypothesis of Brous- sais. All essen- tial fevers forms of gastro- enteritis. This sub- ject already examined. Origin of Broassais's hypothesis. The fre- quency of gastritis and similar inflamma- tions at Paris as Combined with fever. The cause not accu- rately known. But the fact con- currently proved. SPECIES XI. EMPRESMA GASTRITIS. INFLAMMATION OF THE STOMACH. BURNING PAIN AT THE PIT OF THE STOMACH, INCREASED ON SWAL- LOWING : REJECTION OF EVERY THING ; HICCOUGH ; EMACIATION ; OPPRESSION AND DEJECTION OF MIND ; FEVER A SYNOCHUS. If to this species we add the ensuing, or empresma enteritis, we shall have a general type of fever, according to the doctrine of M. Broussais, and that which is commonly received in the present day throughout France : for we have already observed that this cele- brated teacher regards fevers of all kinds as an inflammatory affec- tion of some part or otlier of the alimentary canal; or, to give a close copy of his own words, "all the essential fevers of authors," says he, u may be referred to gastro-enteritis, simple or compli- cated ; and all the acute examples of this inflammation, in its aggra- vated form, proceed to stupor, typhomania (fuligo), lividity, feti- dity, and prostration ; and represent what have been called typhus, putrid or adynamic fever, or those in which the irritation of the brain is considerable, whether it amount to inflammation or not, whether it produce delirium, convulsions, &c, or take the name of malignant, nervous or ataxic fevers."* Having already entered into the question whether fever be essen- tially dependent upon inflammation of any particular organ, as the head, the alimentary canal, the liver, or the pancreas, for all have had their respective advocates, and having pointed out the pathog- nomic distinctions between idiopathic fever and organic inflamma- tions, it is not necessary to return to any detailed consideration of this subject. But we ought to add that there seems more founda- tion for M. Broussais's opinion in France than perhaps in any other country ; since inflammatory affections of the alimentary canal, in some part or other of its length, or under some modification or other, often indeed a -companied with ulceration, appears to be more common in Paris than in any otlier town or region in Europe, or perhaps in the world. To what cause this is owing has not been very clearly pointed out; the diet is perhaps chiefly concerned ; the water has also been denounced; but there are various auxiliaries which are not so easily detected. The fact however admits of no question ; for the observations of MM Prost, Petit, Serres and others concur in proving that by far the greater number of febrile attacks in France, whether sporadic or epidemic, are combined with some modification of gastritis or ente- * Examen des Doctrines M€dicales et des Systemes de Nosologic, &c. Par J. F. V. Broussais, Prof, de Med. exxxvm. cxjixix. cl. m.j SANGUINEOUS 1'UNCTION. [ord. u. 2U7 ritis, and very generally show symptoms of diarrhoea and dysentery. Gen.VII. But that even in Paris itself, idiopathic fever and inflammation of 1^5' the alimentary canal are distinct diseases, has been sufficiently o^triiis. established of late by the valuable post-obit examinations of M. An- ™nTihl dral; which have been conducted upon a very extensive scale for the sTe^riai express purpose of settling this disputed question. This excellent Paris fever and indefatigable investigator has been selected by M. Lerminier, tiZT™' physician to the hospital of La Charite, for the purpose of providing ?ho(i?n.to, cases and dissections for a valuable system of Clinical Medicine fromta-** which he is preparing for the public. In pursuit of this branch of SoToVthe study he has been particularly attentive to the state of the aliment- alimentary ary canal through its whole course in patients who have died of especially fevers of almost every type and modification; and he has found that p^g**]; although, as already observed, this organ, in some part or other, has tive to the often given proof of inflammatory action, yet that, occasionally, SJaTncd there has been no such effect whatever, and very frequently none byhim' sufficiently violent or extensive to become the cause of dissolution, or even of any serious evil to the living frame. In thirty-eight indi- viduals, eleven only presented traces of gastric inflammation, suffi- ciently distinct to warrant the opinion that they had influenced the symptoms observed during life. In thirty persons red patches, erup- tions, or ulcers were found in the small intestine ; but in fourteen only did these lesions appear to bear any proportion to the severity of the symptoms. In the great intestine the alterations were more rare, and less vehement than in any other portion of the canal. On comparing the lesions observed in the three great divisions of Compars- the canal the following results were obtained. In five patients the of patients entire tube was exempt from every lesion of consequence. In seven JocajTyr: others they appeared too inconsiderable to exercise any influence on affected the state of the disease. And where the affection was more strictly jutie, or and manifestly inflammatory, the effects were extremely diversified. B«arceIy at In some cases were found eruptions of varied form and character, character occasionally running into ulceration. In other cases the mucous flirtation membrane was studded with large patches of inflammation, and the diversified. subjacent cellular tissue was advancing to a gangrenous state. In several instances the ulcers were detached and assumed a carbun- cular appearance.* In most of these examples there can be no question of the exist- General ence of idiopathic gastritis or enteritis : but the simple fact of.the existence of numerous instances of fever, and fever too so violent as to prove fatal, without any such accompaniments, together with the certainty that inflammation and even gangrene of particular parts of the alimentary canal are, in numerous instances, effects instead of causes of fever, are a sufficient ground for regarding fever and inflammation either of this or any other kind as distinct diseases, and prove a complete subversion of M. Broussais's hypothesis. Inflammation of the stomach may be either of the adhesive or the J$£eM erythematic character; the latter is the more common ;t and the according * Clinique Medicale, ou Choix d'Observations, &c. publiee par G. Aadral, Fils, nature^ Doct. en Med. Premiere Partie. Fievres. Paris, 8vo. 1823. theinttam- f J. P. Frank, De Cur. Horn. Morb. Epit. Ton>, 11. p. 25fA matron Vol. II.—38 29a cl. m.j ILEMATICA. [ORD. II. Gen. VII. species hence offers us two varieties with considerably different ISSriS' symptoms; which are chiefly, indeed, the result of the peculiar Gastritis, nature of the fever that accompanies this inflammation, already tio/ofthe stated to be a synochus, or fever commencing with caumatic, but stomach, terminating in typhous, symptoms. For this kind of fever it is not difficult to account. We have often had occasion to state, that the stomach is the common centre of sympathy; it is also an organ of acute sensibility ; and it is hence impossible for it to suffer from inflammatory action without suffering severely, and without ex- tending its affection very widely. The natural consequence is, that there must be great, and general, and sudden debility, and the fever, though commencing with excess of action, may soon lead to total atony, and fatal consequences. ec Adhaesiva. Adhesive inflammation of the stomach. p Erythematica. Erythematic inflamma- tion of the stomach. Ueneral re- marks and pathology. General causes. The pain very acute ; the fever violent. With an erythematous blush extending to, and visible in the fauces ; pain more moderate; fever less violent; pulse low and quick. Dr. Cullen seems to have been the first writer that distinctly pointed out the nature of these two varieties, which he has unne- cessarily advanced to the rank of species, and later writers have jus- tified the expediency of a distinction. This distinction, as already remarked, is produced by the nature of the accompanying fever; and consequently, in a considerable degree, by the nature of the constitution in which the disease occurs. The fever is perhaps in every instance a synochus, the cause of which we have just stated ; but, while in a firm and robust habit the febrile course has, compa- ratively, but little tendency to pass from the entonic action with which it commences, into a dangerous languor and atony, in relaxed and irritable habits it is apt to run into this stage almost from the first, and the synochus degenerates rapidly into a typhoid character. In both varieties the causes are alike ; as external or internal cold suddenly applied in a heated state of the stomach, acrid substances, or excess in eating. The acrid substances chiefly recorded are jalap and other drastic purgatives taken in excess ; oil of vitriol; corro- sive sublimate; and very large doses of nitre, or quantities swal- lowed by mistake, as an ounce, or an ounce and a half, of both which we have an example in the Journal de Medecine.* It is also said to have sometimes been produced by a severe paroxysm of cololi- thus ;t and occasionally to have followed upon trichosis Plica, the matted hair of Poland.} A sudden chill by swallowing cold water or some other fluid on a heated frame has been a frequent cause: * Laflize, Tom. lxxi. Souville, Tom. lxxiii Iei.C1757?hmied' Pr* dC iEgr° inflammatione ventriculi demortuo calculi*, &c I De la Fontaine. Cliirurw>. "■ Gen.VII. Spec. XI. o E. Gas- tritis adhse- siva. Adhesive inflamma- tion of the stomach. Remedial process. Treatment in the event of suppura- tion. P E. Gas- tritis ery- thematica- Erythema- tic inflam- mation of the sto- mach. Explained by Mr. Hunter. tion, whatever be the progress. Yet the march of the disease is not always thus quiet or deceitful; for it is often preceded by many or all the ordinary concomitants of dyspepsy, as acidity, eructations, flatulency, and oppression of the stomach after eating ; often indeed accompanied with emaciation and debility, and not unfrequently with hajmatemesis ; by which last signs it is chiefly to be distinguished from idiopathic indigestion. The death however is commonly sud- den, within a day or two or even a few hours, from the cause just stated. M. Chardel* has given various examples of this form. M. Gerardt and Dr. AbercrombieJ others. Gastritis in its acute form has often been represented in a more dangerous light than it deserves to be : for in neither variety under this modification is it frequently attended with fatal effects under ju- dicious treatment. In the true adhesive form copious and repeated venesections have been very generally recommended, and have often been found of the highest advantage, particularly in robust and vigorous habits. To be, however, of any decided avail, this plan of treatment should be commenced early: for the fever is so apt to pass into a typhoid form, that, after the first two or three days, too much inroad will generally have been made upon the constitutional strength to allow the use ofthe lancet. If acrid poisons, or excess of eating, be the cause, an emetic should be administered: but otherwise this, as well as all other stimulants, should be avoided. Gentle cool- ing laxatives, a blister applied to the pit of the stomach, mild nutri- tive drinks, nutritious injections, and, if the pain or sickness be ex- treme, doses of a drachm ofthe syrup of white poppies, and perhaps about five grains of nitre in an emulsion of gum arabic or spermaceti, will generally be found the most successful plan. It is, however, ex- tremely difficult to get any medicine to remain on the stomach ; and hence the best preparation is that of pills. If suppuration should follow, and the abscess burst, a milk diet with the mildest food, and in small quantities at a time, is the only plan to be pursued. If a gangrene take place, all further exertion will be in vain : and we may deter- mine its presence by a sudden cessation of pain, coldness about the praBCordia, and languid or intermitting pulse, which are its sure at- tendants. Under the chronic form we have just noticed, Dr. Aber- crombie has found sulphate of iron in the proportion of two or three grains three times a day, a valuable and decisive remedy, and it is well entitled to attention.§ Upon the erythematic variety the following remarks of Mr. Hunter are too valuable to be omitted : and they are the more valu- able as they apply to disorders of other internal cavities besides the stomach. " There is," says he, " an inflammation which attacks internal canals which is classed with the erysipelatous ; but how far it is the same I do not know. It is certainly not the suppurative. Whatever it is, it may be considered in some of its effects to be in direct opposition to the adhesive and suppurative inflammations : for where the adhesive most readily produces adhesions, there the erysi- pelatous does not, as in the common cellular membrane ; and where * Ut supra. - Edin. Med. Rnd Snrp. Joittn- Yol. xxi. t>".T t Des Perforations Suontanees de l'Estomac ft Ut supra. cl. hi.] SANGUINEOUS FUNCTION. [ord. ii. 301 the adhesive seldom takes place, excepting from extreme violence, Gen. Vll. there this inflammation (if erysipelatous) has a tendency to produce ^Gas-' adhesions, as in canals or outlets. It also opposes, in some degree, <'itis erv the suppurative, in being backward in producing suppuration even Erythema- in those places where suppuration most readily takes place, such as Hfjj^o," canals and outlets ; for there, as above observed, it more readily thesto- throws out the coagulating lymph. Whatever the inflammation raach' maybe, it is certainly attended with nearly the same kind of consti- tutional affection. The fever in both appears to be the same, viz. accompanied with debility, languor, &,c."* The erythematic inflammation of the stomach comes on more in- Dp°gnos' sidiously than the adhesive ; and is best characterized by the inflam- matory colour ofthe fauces, for it usually spreads to these, and the lowness and rapidity ofthe pulse. The inflammation often extends through a great part of the alvine canal as well as the esophagus ; and, after a subsidence of the sickness, produces diarrhoea, and mu- cous discharges from the bowels. It is sometimes so gradual and tardy in its progress as to produce little fever, or even local disturb- ance, for many days or even weeks. De Haenj has repeatedly re- ferred to this sort of gastritis, and Hennings has described it more at length.f If this variety of gastritis be excited by acrid or poisonous sub- p^"^1 stances, a brisk emetic should be exhibited with as much speed as possible ; and afterwards such antidote as the character of the poison may point out: opposing acids to alkalines, and alkalines to acid erosives, and the most active stimulants to narcotics. When the cause is internal, mild, diluent, and cooling drinks are to be employed freely. The infusion of roses will often prove one of the most ser- viceable medicines we can make use of; blisters should be applied and repeated, and the bowels kept cool by laxative clysters. Inflammation of the stomach is also found in the one or the other ^""{Je*'80 of its varieties, as an occasional symptom in aphtha, measles, small- occasions. pox, and other exanthems: and, perhaps, in repelled herpes, sca- bies, and similar eruptions. We may here observe that the pancreas is also sometimes, {•■^a™frJ^ though rarely, affected with inflammatory action ; and that in this pancreas. case the symptoms are a combination of empresma Gastritis and e. Hepatitis. There is pain and distention in the epigastrium, with fre- quent vomiting. There is also a defined tumour seated higher than the liver, and generally more polarized, but always accompanied with some degree of jaundice from its pressure on the bile-ducts. The affection often yields to depletion by cupping, brisk purgatives, and blisiering.§ * On Blood, &c. p. 270. t Rat. Med. Part vi. ix. Xiv. passim. j Beschreibung der Kennzeichen und Kunder Entziindung des Magens und der & Inflammation and Enlargement of the Pancreas. By Edw. Perceval, M.D. &c. Trans. Kirig's and Queen's College, Dublin, Vol. n. p. 128, 1824. QQ2, cl. in.] ILEMATICA. [ord. ii. SPECIES XII. EMPRESMA ENTERITIS. INFLAMMATION OF THE BOWELS. GRIPING PAIN IN THE BELLY ; TENDERNESS. AND VOMITING : FEVER A SYNOCHUS. Gen. VII. In inflammation of the stomach the pain is seated higher, and is Sp. XII. rather burning than griping; this last, also, has usually some degree tritis. unguisied of hiccough, and great dejection of mind : neither of which belongs from gas- to inflammation of the intestines ; and it is by these characters that the two are to be distinguished from each other. Stoll adds, that intestinal inflammation is also accompanied with a suppression of urine ; but we cannot rely upon this as a specific symptom. Our opening remarks upon gastritis, in respect to the nature of that disease in France, apply to the present as well. Enteritis, also, exhibits two varieties : » Adhaesiva. Adhesive inflammation of the bowels. /3 Erythematica. Erythematic inflamma- tion ofthe bowels. Why ac- companied by a syno- chus. General causes. a E. Ente- ritis adhas- siva. Adhesive inflamma- tion ofthe bowels. Description Pain very acute, fever vio- lent ; vomiting frequent; and costiveness obstinate. Pain more moderate; fever less violent; little vomit- ing, and diarrhoea instead of costiveness. Of these varieties the former is more frequent in this species, as the latter is in the preceding.* The causes of both, as also of the accompanying fever, being a synochus, may be understood from the remarks already offered upon gastritis ; the intestines partaking in a very considerable degree of the character ofthe stomach. To the causes enumerated under gastritis may be added some na- tural or accidental organic mischief in some part or other of the in- testinal canal, as ventral, inguinal, or other hernias, or introsuscep- tions of various kinds ; or infarctions from coprostasis, scybala, or enterolithus. The plica polonica, or matted hair, is said by De la Fontaine to be a cause of this species, as other writers affirm it to be of gastritis. The progress of the first variety usually commences with a sense of coldness or shivering, and an uneasiness in some part of the belly, at first remitting or intermitting, but gradually acquiring permanency, and rising into an acute pain. The pain now spreads over the whole abdomen, which is tense and tender to the touch. * Frank, ut stiprA. Tom. u. § ccxxxvm. p. 250. *:l. in.] SANGUINEOUS FUNCTION. [ord. u. 303 though less so than in peritonitis ; there is great flatulencyaccom- Gen.VII. panied with occasional spasms that shoot backward to the loins, S a E. Ente- adhrc- usually obstinate costiveness, and unconquerable vomiting, though »tis a sometimes diarrhoea and tenesmus. The pulse is small, hard, and Adhesive frequent, but has sometimes been soft: the tongue dry; thirst i"0flna™fmtho extreme ; urine high-coloured, small in quantity, and discharged bowels. with difficulty ; the breathing is laborious ; and from the contrac- tion of the abdominal muscles the patient is perpetually bending forward.* If no beneficial change takes place, all these sypmtoms become aggravated; instead of feculent stools, there is an ineffec- tual straining, with a small mucous discharge ; and with the increase of the retching the feces burst through the valve of the colon, and are occasionally thrown up fron> the stomach. At length the torture suddenly diminishes; and the patient appears to have obtained relief: but his pulse intermits, his face grows pale, his extremities cold, convulsions succeed, and he sinks in death. The general termination, therefore, when unfortunate, is that of Prognostic* gangrene ; for it is rarely that the inflammation runs into a suppura- tive state. If in the course of the first two, three, or even four days, a free feculent discharge can be procured from the bowels, the vomiting and pains will gradually diminish, the pulse abate in quickness, and the patient be on the way of recovery. In treating this complaint, it is hence of the utmost importance to Curative procure free evacuations, for the cure depends almost entirely upon our success in this respect. Yet the difficulty is often very great, and increased from the tendency of the stomach to reject whatever medi- cines are introduced into it. Most practitioners commence with v"°™*£ bleeding, which they urge very copiously, and repeat every six or far useful. eight hours, according as the pulse will bear the lancet. The remarks we have made upon this practice under gastritis, will apply to the present species. If the disease occur in a patient of a hardy and vigorous habit, and particularly if we have an oppor- tunity of employing venesection within the first day or two, we shall commonly find it of essential service : but if we do not succeed, we shall assuredly hasten the stage of gangrene, and abbreviate the term of remedial operations. And hence, unless free bleeding can be in what employed early, and the constitution evinces a tolerable portion of chievo™. vigour, there is no inflammation in which the lancet is less likely to be serviceable, or may become more mischievous. To local bleeding, even under the conditions we are now supposing, there is less objection ; but we have less chance of benefit by it than in peritonitis. From the first, therefore, we must attempt cathartics. If the sto- ^"^ mach will retain the milder, as castor oil, neutral salts, or senna, ;h»n harsh, these are by far the most adviseable; as our object should be to c^V diminish instead of increasing the irritation of the intestines. But power. in the first species this is rarely the case; and we must hence, without loss of time, apply to those that are more acrid ; as calomel in combination with the colocynth pill: assisting their operation by * m« 3SV-Tir, III. 49T. SO- siva. Adhesive inflamma- tion of the bowels. But acrid purgatives not neces- sarily aug- mentive of inflamma- tion. Explained. Opiates when to be given. CL. III.J HiEMATICA. [ORD. II. Fomenta- tions, blis- ters, and epithems. Copious injections of warm water. Singular rally ofthe constitution when apparently sinking- How in such case to be assisted. injections frequently repeated, and in as large quantity as the bowels will retain them. It does not necessarily follow that the irritation of these more acrid purgatives will add to the inflammatory irritation ; nor do we always, or even commonly, find any such effect. For, firstly, the operation of the two irritations is very different; and by exciting the former we may even diminish or take off the latter by a transfer of action, in the same manner as we take off inflammation from any other organ by the application of a blister to some neighbouring part. Secondly, the direct effect of the cathartic is to restore a natural action, the peristaltic action of the intestines, which is the direct effect of the inflammatory action to oppose. And thirdly, we ■ find, in fact, the beneficial influenee of such a practice, not only generally, but almost uniformly, and are incapable of accounting for it upon any other principle. Opiates would be desirable through the whole course of this disease, but that in their general intention, they add to the costive- ness if given alone, and retard the effect of purgatives if given in conjunction with them. Nevertheless, if, after copious bleeding, the costiveness should be intractable, and the flatulency and spasmodic pains very distressing, it will be better to trust for a few hours to two or three grains of opium alone, and withhold the purgative plan for the present. For the costiveness is chiefly the result of spasm : and if we succeed in allaying the spasmodic action, a cathartic will answer readily; and sometimes the bowels have been moved, even by the tranquillity alone which the opiate has produced. Fomentations and blisters to the abdomen form a regular course of the therapeutic plan ; and have, no doubt, been occasionally serviceable ; but, like local bleeding, they are less so in the present disease than in peritonitis. And where fomentations are adviseable, I prefer the epithem of a folded flannel wrung out in hot water, and confined with a swathe, as already recommended in peritoneal inflammation, to all other fomentations whatever. Injections of warm water alone, forcibly thrown up the rectum in as large a quantity as the bowels can be made to contain, are more- over often found of essential benefit, and are generally to be preferred to the warm-bath, which, by adding to the debihty, has accelerated the approach of gangrene. After the bowels have been freely emptied, diaphoretics, and especially combined with opiates, will be the best plan we can pur- sue ; and, if the stomach become quiescent, the patient should drink freely of diluents. There is a singular fact, noticed by Rhodius,* which sometimes occurs in this disease, and is peculiarly worthy of notice, as sustain- ing our hopes to the last: and it is this ; that occasionally, in the extreme moment of a seeming mortification, a sudden revolution takes place, and stools are evacuated; and this, too, after the extremities have begun to grow cold, and an apparently deadly lan- guor has overpowered the frame. In such case, we must snatcli + Cent. ii. Obs. 89. ul. m.j SANGUINEOUS FUNCTION. [ord. 11. 303 the patient from impending death by a free use of wine, and warm Gek.VH. generous cordials; closely attending, at the same time, to a copious as£"ff discharge from the bowels, of which, with the liberal plan now recom- "tis'adh*- mended, we need not be afraid, and which we should be extremely Adhesive cautious of checking by opiates. mflam- From the less threatening character of the symptoms, as they thfCrers-. show themselves in the erythematic variety, this affection, as ?itif e?yX- Rothboel has well observed, often exhibits a fallacious appearance, ■«a,ica and is misunderstood.* And it has hence been described on the ucYntw continent, under the names of occult, apyrectic, and anodyne! ente- [he'boveia ritis. " Saepe," says Professor Frank, " nee febris in pulsibus umbra ; ardor, dolor ad intestina aut nullus, aut certe non vehemens ; nee fere ulla tam diri morbi phaenomena observantur."| Its real nature, however, is as we have explained it above : and from the debility superinduced, ascites has occasionally followed rapidly. It has been well ascertained that the seat of this variety is sometimes in the external coat of the intestines ; and it is said, by some writers, that this is the most common seat. It is not easy to determine upon this point: nor always, at its commencement, whether the inflam- The two mation be of the one variety or of the other, the modifying causes npt'aiways being, in some constitutions, and some seasons of the year and tern- J? be d's- peraments of the atmosphere, so nicely balanced as to leave the at first; course doubtful. A case of this kind occurred to me in July, 1805, in a healthy and active young gentleman, thirteen years old. The abdomen was tense and tender, the intestinal canal painful through the greater part of its extent: the pulse quick, and moderately full; the skin very hot and dry; the blood, when drawn from the arm, without any butty coating ; the sickness incessant, with deep anxiety and oppression. The greater part of these symptoms indicated the adhe- sive variety ; but as the morbid signs increased, the stomach evidently partook of the affection, and shortly afterwards an erythematic sloughing appeared in the throat on the fourth day from the attack, evincing the real nature of the inflammation, and that it had extended up the whole of the esophagus. On the sixth day the patient died. Bleeding, which was repeated within about twelve hours, did not in this case, prove of any benefit; though it may be justified from the mixed character of the disease. But in distinct and simple examples of erythematic inflammation, it ought, unquestionably, to be abstained from: and acids, and the milder tonics, and bitters, as infusion of roses, cascarilla bark, and cinchona, supply its place. We have said that in enteritis there is less pain and tension to the fmki^ten touch than in peritonitis. It is singular that at times there should be able. little or none whatever on pressing the abdomen. " Gastro-ente- Broussok. ritis," observes M. Broussais, " exists without any painful point, when the inflammation is not vehement in the stomach and duode- num : and pressure of the belly does not produce uneasiness. "§ * Dissert, sistens Observationes circa fallaciam siguorum in Inflammationibus A6- dominalibus. Hafn. 1776. t Ploucquet, Initia. Vol. v. 108. J De Cur. Horn. Morb. Tom. n. p. 254. § Examen des Doctrines Medicates et des Systemes de Nosologic Prop, cxsxvi l>ar F. J. V. Broussais. Vor IJ.—39 306 c*. m.j 1LEMAT1CA. [our*, n. Gen. vii. m. Petit speaks nearly to the same effect, though he modifies the pSE. En!*- opinion ; affirming that if the belly be pressed a little deeply at its ,itis erythe lower part, especially toward the right between the spine of the rSc'ma- ileum and the navel, the patient is sensible of pain, and at times mation o£ makes complaint of the pressure, and exhibits the same by his coun- the bowels tenance."*—Yet even in ulcerations of the mucous membrane there Andrai. is not always much uneasiness. "Nothing," says M. Andral, "is more common than an absence of every kind of pain in cases in which numerous ulcerated spots cover the inner surface either of the ileum, or ofthe caecum, or ofthe colon; while we frequently see patients complaining of sharp abdominal pains where the gastro-enteric mucous membrane is not inflamed."! compara- The last of these writers has lately favoured the world with a iesion"in °f valuable and extensive range of examinations into the state of the daTtyeonfthe anmentary canal in patients who have died of gastritis and enteritis ; alimentary and we are hence enabled to arrive at some calculation of the com- cana1' parative frequency of inflammatory action in different parts of the canal. Ulcerations, he observes, may take place in every part, from the cardiac orifice to the anus : but they are not in all places equally common. They are rare in the stomach, and still more rare in the duodenum and jejunum : they are very frequent in the lower third of the small intestine ; and they are again less frequent in the .Reduced to different parts ofthe great intestine. These conclusions are drawn from the following table, comprising seventy-one distinct cases of disease : In 10 individuals ulcerations were found in the stomach. 1------------------------------------duodenum. 9------------------------------------jejunum. 38------------------------------------lower part of ileum. 15 ■------------------------------------caecum 4 ————---------------------------ascending colon. 11------------------------------------transverse colon. 3 — ■■--------------------------------descending colon. t ——--------------------------------rectum. I ri.nguiar I have said that enteritis is sometimes a result of hernias. It has pr'oducUon. a^soi occasionally, been produced by a forcible protrusion of a part of the intestinal canal through the anus ; of which a singular instance is given in the Medical Transactions, in a paper communicated by Dr. Latham :§ the part of the prolapsed intestine was very consider- able, and the injury was occasioned by the passage of the wheel of a cart over the loins ; a portion of the mesentery was protruded with that of the gut; gangrene supervened to the inflammation, and the prolapsed mesentery and intestine were cut off above the line of gangrene ; the latter to a length of not less than fifty-seven inches, measured by a string applied to the outward surface. The patient, who was a boy, recovered ; had motions regularly from the truncated extremity of the remaining intestine ; and was able afterwards, to walk twelve or fourteen miles a-day. He had no power, however, of restraining his motions so as to postpone the evacuation. * Traite de la Fievre Entero-Mesenterique, &c. p. 131 t Clinique Medicale, on Choix d'Observations recueilles, a la Clinique de M. feWES ,Cm \ ^T1*.1 d? la C^^ &* par G. Andrals, Pile, b.M. 8ro Pans, 1823, t Andral, ut supra. § Vol. iv. Art. xxjv cl. in.] SANGUINEOUS FUNCTION. [okd. ii. 30? SPECIES XIII. EMPRESMA HEPATITIS. INFLAMMATION OF THE LIVER. TENSION, SORENESS, AND PAIN IN THE REGION OF THE LIVER ; PAIN ABOUT THE RIGHT SHOULDER : FELT ESPECIALLY WHEN LYING ON TIIE LEFT SIDE ; SHORT, DRY COUGH. Inflammation of the liver, which may in general be sufficiently 9ENi-Y//' known by the above characters, has also two varieties, dependent upon its more rapid and violent, or more tardy and obscure march. a. Acuta. In which the above symptoms are Acute inflammation clearly marked, and the charac- of the liver. ter of the disease is decisive. £ Chronica. In which the specific character is Chronic inflammation obscure ; and the existence of ofthe liver. the disease suspected from a previous exposure to its causes, in connexion with an occasional recurrence of the pathognomic symptoms, accompanied with a slight degree of fever. Sauvages, on the authority of Amati, has given an erysipelatous, or, as it should rather be, an erythematic variety of this disease, as Lommius has, likewise, done of pneumonitis : and Frank has fol- lowed Sauvages: but the parenchymatous viscera do not seem to be subject to inflammation of this description, as Dr. Cullen has correctly observed ; and as has been since confirmed by the remarks of Mr. Hunter which we have already quoted. Dr. Frank has also fo™^ affirmed that next to the lungs and the brain there is no organ more t?ry affec- frequently affected by an hereditary taint than the liver ; and that he tIon- has witnessed families suffering in consequence of such a predispo- sition as well in the acute as in the chronic form of inflammation.* The acute variety commences with the ordinary symptoms of ^a^ visceral inflammation ; dullness, succeeded by heat, frequent pulse, Acute in- and a furred tongue : the bowels are irregular, mostly costive ; the of7hm*-™ evacuations little tinged with bile, the urine often saffron-coloured ; the skin is dry, the thirst extreme, with occasional sickness. No physiologist has yet been able to explain the cause ofthe pain JJ^JJj^ so generally felt in the'right shoulder. It is however sympathetic of other affections of the liver, as jaundice, orchololithus, as well as of hepatitis ; and hence it should seem to be produced by almost any * TV Cur. Horn. Morb. Tom. 11. p. 2fi* 30$ CL. Ml.J 1LEMAT10A. [ORD- 11 Gen. vii. morbid excitement of this organ, whether from inflammation or the al'. He"a. obstructionof gall-stones. The cough, which is often very distressing, utis acuta. is easily accounted for from the vicinity of the diaphragm to the flammation seat of disease, and its sympathy with the liver. The sickness of ofthe liver. t|ie stomach is from the same cause. Not always The disease is sometimes accompanied with a jaundiced colour niedwfth of the skin ; and Sauvages and Sagar have made such a colour a 6kjm"ndiced specific symptom ; but it is not always that the bile regurgitates, and hence, such an appearance ought not to be enumerated among the pathognomic characters. which is Even where it exists it is not a distinct symptom of hepatitis ; for, mo°nCtom' t0 say nothing of proper jaundice, the feces, as Dr. Latham has well other affec- observed, may be light-coloured, and the eyes, skin, and urine pe- culiarly yellow, from the pressure of an indurated pancreas upon the bile ducts, and an obstruction of their course. And hence Dr. Latham imagines that an enlargement ofthe pancreas has sometimes been mis- taken for hepatitis, and a diseased ovarium still more frequently. On which account it demands a very nice examination of the liver and a pretty tolerable assurance to ourselves, that, before we can speak with decision, there is no enlargement of either of the other organs. causes.0 ^ie ordinary remote causes are suddenly suppressed perspira- tion, especially from currents of cold and damp air, and excess of spirituous potation : though often the cause is too obscure for de- tection. Proximate Dr. Saunders, and with some plausibility, suspects the acute variety conjectured is owing to an inflammatory state of the hepatic artery, and the chro- aerBS:aun" n*c to a ^e state °*" ^e vena Portse- Winslow ascribes both to an by wius- inflamed state of the ramifications of the vena porta;, which, in his brCuiien: opinion, constitute the seat of the disease ; while Cullen refers us to the hepatic artery alone, and limits the seat of inflammation to its Heberden. extremities. Dr. Heberden does not incline to believe that the liver is primarily affected, but only influenced by a phlogistic diathesis, or preceding inflammatory fever. of mem™ If the inflammation originate in the membranes, the pain, as in branoos most other cases of membranous affection, is peculiarly puno-ent, affection: jjke that of a pieuritjs . tne fever js severe? t},e tension very consider- able, the pulse frequent, strong, and hard; the urine generally high Scpaaffec-* co!oured- When the substance of the liver is primarily affected, the tipn. " pain and pyrexy are far less acute, and especially at first; but they increase with the progress of the disease, or, in other words, as it extends to the membranes, the pain not only darting to the rio-ht shoulder, but sometimes as far as the throat and clavicle. P/ognostics. Where the symptoms are most severe, and we have reason to sus- pect that the disease is confined to the membranes, the duration is often short, and the termination is in most cases that of resolution But when less active, and seated in the parenchyma, it generally tends to suppuration ; and if the convex side of the liver be the part affected, a tumour is visible externally, the cough becomes aggra- vated, and there is a difficulty of breathing. If adhesions have nre- breathing. If adhesions have pre- ntstothe skin, and the abscess opens on the surface ; but if it break internally it generally proves fatal bv ceded the suppuration, the pus points to the skin, and the abscess opens <.l. m.j SANGUINEOUS FUNCTION. [ord. ii. 309 inducing a hectic, though sometimes, in consequence of fortunate Ge\Yiiil adhesions below, the abscess discharges itself into the hepatic duct, aS£. Hepa- and the pus is carried off by this channel. It has, occasionally, by ««'s '&&&. the same means, made its way into the stomach and intestines, where damnation the abscess has been very large. In which case, however, immedi- °ftheliver* ately upon the bursting of the vomica, the patient throws off, by sick- ness or by purging, a large mass of most offensive matter, often fill- ing the whole house with its noisome smell, and dies in a few hours. In like manner, the pus has occasionally formed an empyema in the thorax : and, in a few instances, has been discharged from the lungs. The progress to a state of gangrene is sometimes very rapid, and g™|rreBnseof especially in the swamps of the East and West Indies. Dr. Chis- Bometimes holm gives a striking example of this in a gentleman who being fapi ' " heated and profusely perspiring after violent exercise, lay down and slept in this state in a current of cool air. He awoke soon after in the most excruciating torture in the right hypochondrium, and with great tumefaction of the whole abdomen. In two days he was dead." The liver was found greatly enlarged, and reduced in many parts to a state similar to that of rotten cork.* The disease sometimes terminates in scirrhosity ; in which case fe°||Jf^amee88 the induration bears an extent in some measure proportioned to the in schir- range of the preceding inflammation, and may often be felt by ap- rU08Ity- plying the hand to the region of the organ. This, however, is a more frequent result of the second or chronic variety. In order to induce acute hepatitis, it is necessary that the organ m™3Jyfound of the liver, at the time of attack, should be in a state of at least among the moderate health and vigour ; for it is in this condition only, that in- [°b,eS|>e-d flammation running through its regular stages can take place ; and ^mates hence the acute variety is found far more frequently in temperate, than in intertropical climates ; and in the latter more frequently among new comers than among those that have been long habituated to the climate, and whose livers have been weakened and relaxed by the greater heat of the sun : " Among the men of the eighteenth illustrated. regiment," says Mr. Christie, who was stationed at Trincomale, and had the care of the entire garrison in 1798, "I found for the first six or eight months, the disease was much more frequent, much more violent in its symptoms, showed more tendency to suppuration, and was more sudden in its crisis, than with the Company's European troops, who had been long in India, although the latter were the most debauched. Among the natives hepatitis does not ofter occur ; out of a thousand native troops, I did not, in the course of three months, meet with more than two cases of liver-complaints, which is comparatively a very small proportion."! There is, however, a *™* striking distinction between the state of the bowels as affected by affected in this disease in hot and in temperate climates. In the latter it is rarely t°mpe"ate we have any diarrhoea, and often an obstinate costiveness, the eva- climate* cuations being mostly untinged with bile. In the former, from the higher degree of irritation that prevails, and the greater extent of its range, a bilious flux is so frequent as to be almost a pathognomic * Climate and Diseases of Tropical Countries, p. 64. 8vo. London, 1822. t Letter to the Editor of the Medical and Physical Journal, May, 1798. 310 cl. 111.] H/EMATICA. [ord. ii. Gen. VII. Sp. XIII. a E. Hepa- titis acuta. Acute in- flammation ofthe liver. Remedial process in temperate climates. Bleeding. Purging. Mercuria) course. To be of use in hot climates, should produce ptyalism. Blisters. Diaphore- tics. Treatment in case of suppura- tion. symptom ; and as the gorged vessels are apt to give way from debi- hty, this is sometimes intermixed with blood. In our own climate, bleeding at the commencement of the disease is generally found serviceable, and ought to be prescribed as speedily as possible ; certainly before the fifth day ; and be repeated, gene- rally or locally, as the violence of the symptoms may require, and the strength of the constitution allow. Frank advises leeches to the hemorrhoidal vessels or to the hypochondriuni; but the lancet is alone to be depended upon in letting blood. Free purging, with calomel and Epsom salts, should immediately follow ; and mercury be at the same time introduced into the system by the stomach, or by inunction, or by both. From the costiveness that usually accompanies the disease it is rarely necessary to unite the mercury with opium ; though where it irritates the bowels, the latter should unquestionably be given ; as it should also to allay the cough, where this symptom is very distressing and prevents sleep. The mercurial course, as recommended by Sir James M'Grigor,* should be steadily persevered in, not only in hot climates but in temperate, till a salutary change has been effected, or salivation has been freely excited. It will often be found, however, that the patient will bear a long continuance of the mercurial plan without any affection of the mouth ; and will gradually and insensibly improve under it; the soreness and tension subsiding, the cough diminishing, the pulse becoming slower, and the heat and dryness of the skin yield- ing to a pleasant moisture ; all which are prognostics of a favour- able issue. In hot climates, however, little benefit is obtained from mercury till it has produced ptyalism : while, such is the still greater degree of torpitude under which the absorbents, as well as the ex- cretories of the liver labour, that it is often almost impossible to excite this effect by the boldest practice. " I have myself," says Dr. J. Johnson, " taken calomel in twenty grain doses, three times a day, without experiencing the slightest inconvenience from the quan- tity ; nay, I often found large doses sit easier on the stomach, and occasion less irritation in the bowels than small ones. At this time too I was using every exertion, by inunction, to forward the ptyalism, yet it was several days before I could produce any offect of this kind."t The application of large blisters over the hypogastric region in succession is recommended by most practitioners, but I have not found them successful; and have evidently derived more benefit from fomentations, epithems, and the warm-bath. Diaphoretics should certainly form a part of the curative process; and they combine admirably with the mercurial treatment ; particu- larly the antimonial preparations. Cooling, diluent, and even acidu- lated drinks, should be taken copiously ; the diet consist chiefly of light arinaceous foods ; and the chamber be well ventilated. If, from sudden shiverings, and remission of the quickened pulse, we have reason to believe suppuration has taken place, columbo, the mineral acids, and above all the bark, where it can be retained. * Medical Sketches, passim. t Influence of Tropical Climates, &c. Third edit. p. 174, •x. m.] SAAGUINEOUS FUNCTION. [ord. u. 311 sliould be given freely ; the cinchona, at least in the proportion of Gen, VII. from half a drachm to a drachm, five or six times a-day ; and this ,s|' ££ whether the abscess be likely to burst externally or internally, and if tjtis acuta. the former, the direction should be encouraged by maturating cata- nWallon plasms, and the abscess be opened as speedily as possible. The dis- °f,neliver' charge is sometimes very considerable in quantity, and amounts to several pints ; the pus is occasionally found pure, but more generally intermixed with coagulable lymph or some viscid, yellow fluid. It is at times lodged in different sacs, and hence subsequent tumours ensue, and subsequent openings are necessary.* It is not always, however, even after suppuration has taken place, ?««some- that the abscess must necessarily open in any direction ; for the fol- absorbed lowing case will show that when we have full reason to believe such wilh a result has occurred, the fluid may be carried off by absorption, and 8U°Ce the organ be restored to a sound state. In the middle of February 1821,1 was requested to meet in con- Case sultation Mr. Patten, and several other medical practitioners of high K!h"r0 respectability, at Professor Gregory's of Woolwich Common, whose ThTatuck son, eight years of age, had, for nearly three weeks t.een labouring at first under a considerable degree of fever, accompanied with a mixture of obscur0, symptoms that gave no mall degree of obscurity to the real nature of the complaint. The bowels were at this time obstinately costive, Description! the pulse at a medium of a hundred and thirty strokes in a minute, but varying from ten strokes above to ten below ; there was a short, dry, distressing cough, and a slight difficulty of breathing ; yet no observable pain about the right shoulder : the skin was nearly of its natural hue ; the motions, when procured, rather less yellow, and the urine rather more so than in common health ; the nights were without rest, and very fatiguing. The result of the symptoms had hitherto induced an idea of mischief in the chest; but finding, on Pronounced examination, that there was a considerable degree of tension and hepatitis. tenderness in the hypogastrium, rather verging towards the right, and connecting these signs with the preceding, I had no hesitation in pronouncing the disorder to be hepatitis, and the opinion was unani- mously adopted. As the pulse, from the length of time the disease had now con- Progress tinued, would not allow of general bleeding, twelve leeches were in- ment.reat stantly applied to the region of the liver ; an active cathartic was prescribed, and the patient put upon a course of calomel and anti- monial powder, of the former of which he took three or four grains a-day ; with an opiate at night. And, after the application of the leeches, a large flannel wrung out in hot. water, was applied over the whole of the abdomen, and confined with a calico swathe, in the manner already recommended in peritonitis; the warmth and mois- ture being rendered permanent by a renewal of the hot-water as soon as the flannel became dry, though it rarely required to be changed oftener than two or three times in the twenty-four hours. The ap- plication was peculiarly grateful to the patient. By this process a very favourable impression appeared to be made Favourable * Recueil d'Observation de Medicine des Hopitaux Militaires, &c. Art. par M. Poucher. Tom. n. 4to. P»ri* 312 cl. in.] HiEMATICA. [ORD. II. Gen.VII. Sp. XIII. a E. Hepa- titis acuta. Acute in- flammation of the liver. Fresh ex- acerbation, with ascites. Violent shivering-fit and hectic sweats. Symptoms diminish. Renewal of the symp- toms. Case explained. Found by Chisholm, rintaeiou*- on the disease from the first; the pulse sunk to less than a hundred and twenty, and sometimes to less than a hundred ; and cough was less troublesome, the nights more refreshing, and the patient was able to retain more food. One of the most obstinate symptoms was the costiveness, which no ordinary aperient, even though aided by injections and the use of the calomel, was capable of alleviating ; and which was only occasionally relieved by a combination of ex- tract of jalap with that of aloes or gamboge, or both. In about a fortnight, however, all the symptoms became more vio- lent ; the pulse rose to a hundred and forty, the cough was more troublesome ; the tension over the abdomen was more general, and there was an evident fluctuation over the whole abdomen, indicative of ascites. The fomentation was omitted, but the calomel was con- tinued, and elaterium, gradually increased to three grains at a dose, in conjunction with the same quantity of extract of jalap, was given as a purge. In no proper proportion, however, did it operate as such ; it sometimes produced a watery evacuation or two, but never to any extent, and occasionally excited vomiting. It was omitted, and the digitalis, in union with the infusion of roses doubly acidu- lated, was given in free doses together with the calomel. At this time a violent shivering-fit took place, which made the teeth chatter ; the pulse seemed rather to remit in rapidity, but the night was passed in hectic perspirations. Suppuration had no doubt commenced. The digitalis and calomel were omitted, a strong in- fusion of columbo, acidulated with equal parts of nitric and muriatic acid prescribed in its stead ; the right hypochondrium was covered over with a large plaster of the emplastrum ammoniaci cum hydrar- gyro ; animal food was enjoined, and a small quantity of wine al- lowed. All the symptoms once more diminished : the tension and perspiration subsided, the fluctuation was lost, the cough ceased, and the nights were refreshing. The patient continued to amend about a fortnight, when the morbid symptoms again returned, though in a slighter degree, and seemed to show that some other part ofthe liver was now affected. The former treatment was resumed ; leeches, succeeded by an ammoniac-mercurial plaster, were applied to the part affected ; calomel was given in the proportion of two grains a-day, but the tonic regimen, in the debilitated state of the patient, was not relinquished. In a few days this plan also was found to produce a beneficial effect: every symptom again subsided ; and the little patient, in about three months from the commencement of the disease, was restored to perfect health. It is clear that in this protracted and complicated case the liver was successively attacked with inflammation in different parts ; and that, had the whole advanced to suppuration, and opened externally, there would have been distinct sttcs or abscesses in succession to each other. And it appears also, from the history of the symptoms, that the first and last inflammations were carried off by resolution ; and the second by suppuration, the pus being absorbed, and the cavity healing without exposure. Dr. Chisholm found this disease on one occasion contagious. It was at Grenada in the winter of 1786. in districts peculiarly exposed cl. m.j SANGUINEOUS FUNCTION [ord. ii. 313 to the influence of chilling northerly winds, and possessing large Gen. VII. tracts of marsh. The disease was lamentably inortiferous, though ?£. He!"' the symptoms were insidious rather than violent. It usually destroy- "ti3 ucuta- ed in the course of six days—and the deaths were calculated at one namm^fon in every six.* of tlie i»ver. In chronic hepatitis all the specific symptoms, as already ob- 0 p. Hepa- served, show themselves obscurely. The pulse is something quicker nil0aCh'°" than usual, and there is an obtuse pain in the region of the liver ; a,™^" but such as would not perhaps be noticed if it were not inquired into of the liver. and the organ pressed upon, and connected with a sudden quick ^"'P1*0'" expiration after an attempt to inspire deeply ; and there is also an indistinct uneasiness generally, though not always, about the right shoulder : all the symptoms becoming exacerbated at a certain period of the day, commonly about four o'clock in the afternoon. But in conjunction with the proper hepatic symptoms, the most obvious are those of dyspepsy and atrophy; the appetite fails, the stomach is- capricious, the animal spirits flag, and the flesh wastes away. The bowels are generally costive, and the stools often clay-coloured, though not always ; and there is usually a sallowness on the skin. The disease slowly advances to suppuration, or terminates in a scirrhous induration ; but in many instances, and especially after a habit of hard eating or drinking, is the index of a broken-up consti- tution. Excess in eating and drinking, or indeed in any other voluptuous- Exce^ ness, is the common cause of this variety of hepatitis in temperate regions; though it sometimes follows upon obstinate quartans. It is, however, a more frequent affection in hot climates, where, as already observed, it is far more apt to occur than the preceding va- riety. And it is on this account we see so many persons returning annually to our own country from the East or West Indies, with en- larged livers, irregular fever, indigestion, costiveness, fulness in the right hypochondrium, white stools, yellow complexion, dry cough, disturbed sleep, and dejected spirits ; occasionally some of these symptoms being wanting, and occasionally others. In all such Treatment cases the organ is torpid, debilitated, and irritable, and the cure '"JesT" must depend upon our ability to give it fresh tone and vigour. The general congestion is most effectually removed by smaller doses of calomel than advised in the acute variety, so as to produce an alter- ant effect, and gently excite the sluggish secernents into a state of renewed activity. Though here also ptyalysm is aimed at in hot cli- mates, yet in a milder degree than in the acute variety. And, in conjunction with these, we are to employ warm aromatic bitters; and, where they agree with the stomach, the mineral acids. Dande- lion, as recommended by Boerhaave, and Bergius, has often been found serviceable. Dr. Pemberton paid much attention to its virtues, and had often seen it of decided advantage in incipient scirrhosities of the liver and other abdominal organs ; and strongly recommend- ed it in doses of half a drachm of the extract twice a-day.t We cannot, however, always depend upon this preparation, and hence* * Climate and Diseases of Tropical Countries, &c. p. 66. 8?o. Lond. 182?, t Treatise on the Diseases of the Abdominal Viscera. Vol.. II.— 40 114 Gen.VII. Sp. XIII. ft E. Hepa- titis chro- nica. Chronic in- flammation of the liver. in slighter t-ases. Effects of a scirrhous infarction. Extensive and dan- gerous he- morrhages. Useful instead of dangerous in the acute variety. Distinction of Hippo- crates unfounded. ,V III.] 1I.EMATICA. [OKD. II. as a general rule, it will be more adviseable to employ the decoction. Where there is an evident tumour on the right side a seton should be introduced over it. In slighter cases, which have nevertheless compelled a return from India after a residence of eight or nine years, 1 have found all the symptoms vanish before a steady use of Plummer's or the blue-pill, taken every night for a month ; and the Cheltenham air and waters, for the same period of time, afterwards. Where a chronic inflammation of the liver has terminated in a scirrhus of the whole organ or of a great part of it, the blood is obstructed in its circulation, congestion takes place in other organs, and we often meet with very extensive hemorrhages from the lungs, nostrils, stomach, or anus. These discharges are rarely, perhaps never, of service in chronic cases, and only contribute to weaken the system. But in acute cases, constituting the first variety, by diminishing the phlogotic action, they are often of very essential use, in inflammation of the spleen as well as of the liver ; and may per- haps be regarded as critical. Boerhaave* has quoted, upon this subject, the remarks of Hippocrates and Galen, in confirmation of this fact; but they seem to have laid down an unnecessary distinc- tion in contending that the hemorrhage from the nose, in order to be critical, must take place kcct evSvaptuv, or in a direct line ; in other words, from the right nostril in inflammation of the liver, and the left in inflammation of the spleen ; for we have numerous examples of benefit in both affections from which side soever the blood has issued. SPECIES XIV. EMPRESMA SPLENITIS. INFLA3IMATION OF THE SPLEEN. HEAT, FULNESS, AND TENDERNESS IN THE SrLENIC REGION ; WITH PAIN UPON PRESSURE. s*xrv ^F tne usc °^tue sP*een' as observed in the Physiological Proem to General " the first class, we know little or nothing. It secretes no peculiar fluid mfce'wUh1 excePt what serves to produce a change in its own blood, which is the use of of a dark livid colour, and coagulates with difficulty. It is common- ly supposed to be an organ auxiliary to the liver ; and it is unques- tionably subject to all its ailments ; voluptuous living, however, and even the heat of a torrid sun, affect it less ; but obstinate tertians and quartans more, and render it sooner congestive and scirrhous. Inflammation of the spleen, together with the symptoms given in the definition, is accompanied with the usual pyrectic signs; and often with a pain extending over the whole of the abdomen, but par- ticularly in the left side, and shooting from the diaphragm to the left * Van Swieten Comment. § 923-4. Hippocr. in Prognostic. Tom. vm. p. «1S. Galen, de Crtsibtis. lib. m. cap. iv. the spleen. Description. ul. ux.J SANGUINEOUS FUNCTION. [okd. u. 3lb shoulder. There is also not unfrequently a dry, short cough, and Gen. VII. sense of constriction in the pnecordia, sickness or nausea, and a dis- ImpiS charge from the rectum of black or livid blood, from a rupture of Splenitis. some of the splenic vessels. {"o^ofule The common causes of inflammation of the spleen, are the same JP^ and as those of the liver; and the treatment needs not essentially vary, treatment" as the progress and terminations of the disease are not different. In India, where it is more common than in temperate climates, the na- tive practitioners use acupunctures and scarifications. The splenalgia, or pain in the spleen, of many writers, is for the Spionaigia. most part a slight attack of this disease with some small degree ofwba1' fever : and parabysma splenica, is a frequent result of both. In this last stage the organ has been sometimes extirpated, either partially or wholly, without injury to the general health.15 SPECIES XV. EMPRESMA NEPHRITIS. INFLAMMATION OF THE KIDNEYS. pain In the renal region ; FREQUENT micturition ; VOMITING : NUMBNESS OF THE THIGH ON THE AFFECTED SIDE ; RETRACTION OF THE TESTICLE. The general causes of this species are whatever obstructs the (|EN^r' flow of the fluids in the vessels of the kidneys ; as a wound, contu- General sion, tumour, strain of the muscles of the back that press on the causes- kidneys, excess of horse-exercise, various acrids conveyed to the kidneys by the course of the circulation. It is, however, most fre- AIo8t,y a quently met with as a secondary disease, resulting from calculous disease?0 matter blocking up the tubuli uriniferi, or from calculi formed in the pelvis of the kidneys, and obstructing that cavity or the canal ofthe ureters, concerning which we shall have to treat under the genus Lithia, embracing calculous concretions in the urinary passages. The symptoms enumerated in the specific definition are sufficient Symptoms to indicate the presence of nephritis, though the numbness and re- traction of the testicle are common to calculi in the ureters or body of the kidney, even when there is little inflammation present. In J?"*^*^ the case before us, however, the skin is usually hot and tlry, the body t>«m other costive, and motion, and even an erect position, is accompanied with nffoCtlons considerable uneasiness. By the last sign we may distinguish the disease from an inflammation of the ,psoas, or almost any other adjacent muscle ; while the immediate seat of pain separates it from colic, even when it is attended, as it is occasionally, with ventral gripings. * Eph. Nat. Cur. Dec. i. Ann. iv. v. Obs. 164. Ann. vii. Obs. 150. Valisncri Opp. in. p. 128. cl. ni.} HAiJMATICA. [ord. il Gen. VII. Where the disease is violent, the urine is discharged in small quan- E^fp're^ma tity, and of a pale hue. And hence, if the urine become higher Nephritis, coloured, be secreted in a larger proportion, and be at length thick tiMof'the and mixed with mucus, a gradual relief may be expected to follow, Tro^'tics an(*tne cure w^*be e^ecte<^ by a copious flow. The disease some- times passes off also by a metastasis. But if the symptoms be pro- tracted beyond the seventh day, and there be stupor or heaviness in the organ, instead of acute pain, with frequent returns of chilliness and shivering, we have reason to expect that an abscess will ensue : in case of in which event the pus may be discharged into the pelvis of the kid- tion^^d ney, the abdomen, or, in case of adhesions, externally through the disSiar»ed integuments and the skin. The first is the most favourable issue, D ' next to that of resolution ; the last is often succeeded by a cure, but an evacuation of pus into the cavity of the abdomen rarely." In some instances the suppuration has been so considerable as to de- stroy the substance of the affected kidney entirely, and leave nothing but the external membrane. Yet there are cases in which a patient has recovered even in this state, and the office of secretion has been performed by the sound kidney alone. Sometimes Gangrene occasionally ensues, and is indicated by a sudden re- lnsues.ne mission or cessation of pain ; after great violence of vascular action ; accompanied with cold sweats, a sinking pulse, discharge of black urine, and the other symptoms of approaching dissolution. Treatment In attempting a cure of nephritis, we should commence with co- pious bleeding ; and in this case we may most conveniently employ cupping-glasses, applied to the region of the kidneys. Saline pur- gatives should follow ; and then oleaginous or mucilaginous emul- sions, with small doses of nitrate of potash, or tincture of digitalis. The last has often proved highly serviceable in taking off the arterial action that maintains the inflammation, and at the same time in augmenting the urinary secretion. The loins should, at the same time, be covered with a large folded flannel wrung out in hot water, and confined as already described in the casp of peritonitis ; and copious emollient injections should be frequently thrown up the rectum, and suffered to remain there as long as the patient may be able to retain them. The rest of the treatment and regimen should be that of inflammation in general. cl. hi.] SANGUINEOUS FUNCTION. [obd. 11. SIT SPECIES XVI. EMPRESMA CYSTITIS. INFLAMMATION OF THE BLADDER. PAIN AND SWELLING IN THE HYPOGASTRIC REGION ; PAINFUL OR OBSTRUCTED DISCHARGE OF URINE ; TENESMUS. The bladder is often irritated and inflamed by viscid substances <*^C™' that pass into the circulation, and particularly by cantharides, ar- idiopathic dent spirits, and terebinthine essences or balsams. Idiopathic j^n not*" inflammation is not a frequent disease; yet it occasionally occurs common. as the bladder is subject to the common causes of inflammatory affec- tion : and it takes place both in its exterior serous coat, and internal mucous membrane. If the lower part of the bladder be chiefly affected, the pain will Distinctive extend to, and take the course of the perinaeum. If the seat be in c a'ac e' the neck of the organ, there will be a retention of urine with a constant urgency to evacuate; if in the fundus, the urine will flow stUlatitiously, and without ceasing ; the bladder will give a feeling of being constantly full; and the patient will be perpetually and fruit- lessly striving to empty it. In this affection there is usually great restlessness and anxiety, with cold extremities, vomiting, wildness of the eyes, dehrium, and other marks of great general irritation: the Disease disease runs its course with rapidity, and subsides, or destroys the fapSdiyf patient, in a few days. It terminates, like all other inflammations, most favourably by andtermi- resolution. But if this do not take place, it passes on to suppura- {iousiy. tion or gangrene ; the diagnostics of both which are those already noticed in the preceding species. If sup[juration take place, the pus may be discharged by the urethra, which is its happiest outlet; or it may follow the course of the ulceration, am! be emptied into the cavity of the abdomen ; or, if adhesions have been formed with the subjacent cellular membrane, it may work its way in a sinuous direction and find an opening in some part of the perinasum. Of the last two terminations the first is almost always fatal; and the second is extremely troublesome and tedious, though a cure is usually effected at last. Repeated bleedings, aperients, and relaxants, with copious emol- Treatment. lient injections, suffered to remain in the rectum as long as possible, form the chief part of the^ plan of cure. Blood should be drawn both generally and locally, and a large bladder about half full of warm water be kept constantly over the pubes. The warm-bath has also been frequently of essential service. When the urine is actually suppressed, it is usually evacuated by a catheter : but I would stre- Elastic nuously recommend instead of this, a siphon formed upon the plan purm?"" of that employed by Mr. Jukes for the stomach, and already de- 318 cl. m.j HiEMATICA. [ord. u Gem. VII. scribed under dysphagia constricta,* with an elastic bottle attached Emprwma to its outer end, and a stop-cock adapted to it ; so that, being intro- cystitis. duced in its contracted or vacuum-state, it may readily be converted «onaofmthe into a powerful suction-pump by merely turning the valve. This bladder. instrument may also be rendered of great importance in another way ; for by charging it with an emollient or anodyne fluid, when the bladder is empty, we may get such preparations to come imme- diately in contact with the inflamed surface of the bladder, in any degree of strength that may be advisable. SPECIES XVII. EMPRESMA HYSTERITIS. INFLAMMATION OF THE WOMB. PAIN, SWELLING, AND TENDERNESS IN THE HYPOGASTRIC REGION; HEAT, PAIN. AND TENDERNESS IN THE OS UTERI : VOMITING: PULSE RAPID. Gen. VII. This species offers us two varieties, according to the condition of Sp. XVII. the organ at the time of attack : Simplex. Simple Inflammation of the Womb. Puerperarum. Puerperal inflammation of the womb. The organ unimpregnated. Pain permanent, circumscribed, throb- bing : fever a cauma. The organ having lately suffered childbirth. Pain less acute,less circumscribed; flow of urine difficult: fever a synochus or ty- phus. aE. iiyste- The first of these is produced by cold or any of the other ordi- piex.3"" nary causes of inflammation, and terminates in resolution, suppura- fl'mmatio"n ^on' scirrhus, or gangrene. The most ordinary termination is that of the of resolution : the next that of scirrhus, sometimes running into can- womb. cer. jJQtn wnjcn are far more common to women who have never been impregnated, than to those who have had families, but rarely appear before menstruation from the natural quiescence of the organ in this Distinctive state.t The concomitant symptoms vary according to the part of symptoms. t^e organ in which the inflammation is seated. If this be chiefly in the fundus, the greatest distress of pain, heat, and throbbing, will be above the pubes; if the posterior part be chiefly affected, the loins and rectum will principally sympathize, and there will be a troublesome tenesmus : if the inflammation attack the anterior part, the bladder will participate in the ailment; the urine will flow with difficulty, but there will be a perpetual desire to pass water : while * Class i. Ord. i. Gen. in. Spec. i. t J. P. Frank, tie Cur. Horn. Morb. Epit. Tom. n. § 222, p. 217. cl. in.] SANGUINEOUS FUNCTION. [ord. h. 319 if the sides of the uterus or its ovaria be chiefly inflamed, the pain 9 ^^5* will dart clown the interior of the thighs. „ e Hy«te- All the ordinary means already noticed for subduing inflammation, "tu«■»-.■ both general and local, should here be put into effect without loss simple in- of time, as venesection, aperients, emollient injections both into the „fI}1n^at,on rectum and uterus itself, and fomentations or epithems to the hypo- womb gastrium. The disease is sometimes cured by a metastasis, and sometimes by a sudden flow of the menses, with hemorrhage or genuine blood. The second variety, in which the symptoms are alike, but less fit^-^'e" acute, is usually, though not always, a result of suppressed lochia, perarum. or violence sustained during labour, particularly from the use of Jfa- instruments ; the inflammatory action from this cause often extends tjonof the down the vagina which is hot, reddened, tense, and tender to the touch : and sometimes the same effects descend so low as to be mani- fest externally. Bleeding is here to be avoided ; and the inflamma- tion to be attacked with gentle laxatives, diaphoretics, and, where there is much irritability, camphor and opiates ; fomentations and injections being employed at the same time. It is a singular but well ascertained fact, that the spleen, from JJjKjJft some unknown cause, is peculiarly apt to sympathize with the action of the of the womb, and at times, to run into an equal degree of inflamma- ^morbid1 tion, suppuration, or even gangrene ; and especially in females of a uterus. high nervous temperament. And so common is this fellowship of action, that most of the cases of diseased spleen related by Mor- gagni, are accompanied with an account of some mischief existing in the womb or its appendages. It is, however, to M. Gastellier of JK?.*? the Hospice de la Maternite, at Paris, that we are chiefly indebted teiiier: for a knowledge of this peculiar sympathy, and especially in the case of uterine inflammation after child-birth. "La rate," says he, " en a ete" souvent frappee, mais une fois entr' autres elle a ete entierement detruite, entierement fondue : il n'en restoit aucune trace, si non un foyer de fluide sanieux, dans la region, et en place de cet organe." This passage from M. Gastellier is quoted by Dr. Ley, in a case ^DrTey. of a similar kind which lately occurred to himself in the Westminster Lying-in Hospital, and is given in the Medical Transactions of the College.* In this case, the preceding labour seems to have been perfectly natural and without any difficulty whatever. On the third day afterwards the disease seems to have commenced, indicated by intense pain over the whole of the abdominal region, with a slight sense of fulness, but without any considerable degree of tension. The patient sunk suddenly seven or eight days subsequently, and at a time when she was supposed to be in a state of improvement. On examining the body, the peritonaeum and intestines exhibited little morbid affection of any kind ; and the disease was found Umited to the uterus and spleen : the peritoneal covering of both was slightly inflamed, but the internal structure of both had under- gone a very extensive destruction. The whole surface ofthe uterus. * Vol. v. Art. xx 320 cl. m.] HJEMATICA. [ord. n. Gen.vii. when stripped of its tunic, was found to have assumed a gangrenous p e. Hyste- appearance, was extremely irregular, of a dark, livid hue, and gave rit.s puer- forth a highly offensive vapour. The texture of the spleen was so perarum . . ,. n r J •* Puerperal changed as to resemble an extremely soft piece ot sponge, and its " oTthe Ce^s were n^ec* w^tn an intimate mixture of pus and grumous blood. inflamma- tion womb SPECIES XVIII. EMPRESMA ORCHITIS. INFLAMMATION OF THE TESTICLES. PAIN AND SWELLING OF THE TESTICLES ; NAUSEA OR VOMITING; DEPRESSION OF SPIRITS ; PULSE QUICK, SOMEWHAT LOW. Gen. VII. Inflammation of the testicle has generally been expressed by HernULVtm- ^G aDsur(l an^ unmeaning name of hernia humpralis; which, how- moraiis, ever, in its earliest use, applied to only one stage of the disease, namely the suppurative, and imported an abscess or collection of pus in any part of the scrotum ; and in this sense the expression Empyocele, occurs in Heister and Dionis : being precisely synonymous with the what. empyocele of the Greeks.. I have revived the Greek term orchitis, not only as being far more precise, but as accordant with the general termination of the specific names of the diseases appertaining to the present genus. Progress of The inflammation seems commonly to commence in the tunica wease. vagma]jSi and to pass secondarily into the substance of the testis. Dr. Swediaur contends that the testis never swells in the first instance, Gauses. and that the disease always begins in the epididymis. The causes are irritation or external injuries. The most common irritation is Treatment, venereal virus. Bleeding, laxatives, and cold lotions, with a sus- pensory bandage, form the curative process. Yet we have already observed that, when all local applications have proved ineffectual, the inflammation has been removed by vomits, in consequence ofthe close sympathy between the testis and the stomach. This was a frequent practice of Mr. John Hunter,* and especially when the inflammation was the result of a syphilitic taint. It was successfully employed for the same purpose, and is hence strongly recommended by Rhazes,t and is a common mode of treatment on the continent, particularly in Germany ;| after which opiates are Peculiar often had recourse to, as well externally as internally. It may be between7 worth remarking that the affinity or play of action which thus pre- the h°* a va^s Detween the testis and the stomach, does not appear to be the testis:an common bond of union that is exhibited between the stomach, as the general centre of sympathy, and most other parts of the system ; but a fellowship of a peculiar kind, and which, in fact, does not ter- * On Venereal Diseases. t Continent. Lib. zi. f Althof, Practische Bemurkungen, &c. Girtanner, Venerische Krankheiten, &c ul. ia.j SAiNGUINEOUS FUNCTION. |oru. u. 321 minate in the stomach, but extends to the upper extremity of the Gen. VII. alimentary tube, and exercises a very high degree of influence over |m|™- the parotid glands, as is well known in e. parotitis, and has been Orchitis. already noticed in discussing that disease. In treating of e. hyste- uonTita ritis, I have had occasion to glance at the existence of a like sym- p^'ioiof pathy between the uterus and the spleen : and the physiologist who affinities0 has time for such pursuits, and judgment enough to guide him to a oS""" correct discrimination, would be engaged in no unthrifty employment <«gan». if he were to follow up and arrange, in a regular classification, these specific and mysterious relationships which single organs hold with single organs, and which are subordinate to the general harmony of the entire machine. GENUS VIII. OPHTHALMIA. OPHTHAIMY. INFLAMMATION OF THE EYE. PAIN AND REDNESS OF THE EYE OR ITS APPENDAGES : INTOLERANCE OF LIGHT J FLOW OF TEARS OR OTHER DISCHARGE. Ophthalmia, from the Greek term itpicc^a, " oculus," is obvi- Gen.VIH. ously of very extensive import, and, from its radical signification, ge^'ranm- may be applied to any morbid affection of the eye, unless limited by JJTJ? fi • Common consent. Now, although a sort of common consent has been given, so as to restrain the term to inflammatory action, such consent has not been universally acceded to ; and hence ophthalmia has been used in very different senses by different writers. Thus How under- Sauvages, Linneus, and Sagar, employ it as expressive of any ache differ,? of the eye, without reference to pyrexy or inflammation. Among writers. all these, therefore, it occurs under their class dolores, and runs parallel with cephalalgia, or cephalaea, ache or pain in the head. By Vogel, Cullen, and Macbride, it is limited to inflammatory affec- tions of the eye ; the two former arranging it as a genus, and the latter as a species. By Dr. Parr and Dr. Young it is also arranged as a species, and limited to phlogotic action ; the second deno- - minating it ophthalmitis, consonantly with the common termination of names importing inflammatory diseases of a particular descrip- tion of internal membranes and organs. In the present system ophthalmia assumes a middle rank : it is its meamug limited to inflammatory action accompanied with organic pain, but tent wut is arranged as a genus. It might possibly have been placed as a species under the preceding genus, empresma, in which case it should have been written as Dr. Young has written it, ophthalmitis: but it has various characters peculiar to itself, as well in regard to it* Vor II.—4! $22 cl. m.j 1LEMAT1CA \p™>- " Gen.VIIL symptoms, as to the particular parts of the organ affected, which ra£lhal" seem to entitle it to the rank of a distinct genus. And thus ex- oph'thaimy. plained, its real meaning will be found in the generic definition ; tio^of'the the symptoms of inflammation common to the order, and entering °rc' into the ordinal definition, being always understood as a part of the generic character. For the diseases affecting tlje sense of vision, and unaccompanied with inflammation, the reader must turn to the ensuing class neukotica, order n. in volume iv. Disease There is, perhaps, no disease in Dr. Cullen's First Lines that is Joriflnd" treated of so slightly and unsatisfactorily as ophthalmy. He gives tyVeated"" only one idiopathic species, into which he resolves all inflammatory of byacui- affections of the eyes that are not symptomatic of other complaints ; len' and he considers this merely as modified into two varieties, from the inflammation being seated in the membranes of the organ, or on Toodif- the edge of the lid. When we compare this abbreviated view of pienck/ the inflammatory diseases of the eye with Dr. Plenck's methodical arrangement of its ailments altogether, and behold the latter enume- rating not less than one hundred and nineteen genera, comprising very nearly six hundred species, although a regard to our own ease may dispose us rather to take part with the abbreviating spirit of Dr. Cullen than the discursive genius of Dr. Plenck, still it is im- possible for us not to perceive that the former has been too summary in his arrangement; and, if we follow up his arrangement into his Diseases of therapia, too summary in his therapia also. It is true, indeed, that s?neeythe since Dr. Cullen's time, .the maladies of this organ seem to have iWe* 'he mcreasedi and this too, in one at least, perhaps more than one, of its writers. most virulent and fatal affections, as the contagious purulent ophthal- my ; but then this addition has taken place, also, since the arrange- ment of Dr. Plenck, who would otherwise, no doubt, have found the means of extending his list by the invention of new genera and species, to nearly a hundred more maladies of the eye ; so as to have treated us with a catalogue of nearly seven hundred, instead of six Better ar- hundred, distinct diseases of this single organ. Professor Beer has ofnSeer.Dt m a considerable degree simplified and abbreviated the catalogue of Dr. Plenck, and has treated the subject with more clearness and discrimination than perhaps any other author whatever : but even his divisions will bear epitomizing with advantage; for the distinctions are often too refined, and sometimes even fanciful.* Proposed After no small degree of consideration, it appears to me that intospecie=. ophthalmia, or inflammation ofthe eyes, may embrace all the dis- eases that belong to it, as a genus, under the five species of inflam- mation of its coats generally ; inflammation of the muscular fibres of the iris ; inflammation of the internal surface of the eye-lids associating with that of the globe ; inflammation of the tarsus or edge of the eye-lids ; and the chronic inflammation which is often found a sequel to most of these. + Lehre von den Augenkrankheiten als Leitfaden zu seinen 6ffentlkhen Vorlmn- ?en entrrorfen, &c. 2 vols. Vienn. 1817. cl. m.j SANGUINEOUS b'UNCTION. [oun. n. S2o 1. OPHTHALMIA TARAXIS. LACHRYMOSE OPHTHALMY. GEN.VHL 2- ---------- I1UDIS. INFLAMMATION OF THE IRIS. mfa. 3.----------PURULENTA. PURULENT OPHTHALMY. ffimma- 4. ---------- GLUTINOSA. GLUTINOUS OPHTHALMY. tion of the 5. ---------- STAPHYLOMA. PROTUBERANT EYE. 6.----------ECTROPIUM. EVERTED EYE-LID. 7.----------ENTROPIUM. INVERTED EYE-LID. SPECIES I. OPHTHALMIA TARAXIS. LACHRYMOSE OPHTHALMY. INFLAMMATION CHIEFLV SEATED, OR COMMENCING, IN THE SCLE- ROTIC TUNIC OF THE EYE-BALL : INCREASED SECRETION OF TEARS. This is the common inflammation of the eyes produced by cold, ^p^1"' dust, or any other external irritation, as excessive light, vivid colours, Expinnn-' blows, or wounds ; and has been often called, and with great pro-,10n' priety, lachrymose ophthalmy, as the morbid secretion chiefly excited is that of tears. By Paul of iEgina it was named taraxis, from ixeovrro, "to disturb, confuse, tumultuate," in allusion either to the violent action that takes place, or the confusion of the objects presented. And as the Greek name has been very generally con- tinued by medical writers, and especially those ofthe Continent, to our own day, I have employed it in the present system, to distinguish the species before us. It occurs under two varieties as follow : K Mitis. The inflammation limited to the Mild Lachrymose surface : the pain passable : the Ophthalmy. head not affected. S Acuta. The inflammation extending to the Acute Lachrymose lower part of the eye-ball: and Ophthalmy. sometimes commencing there : the pain burning : the tears per- petual and acrid, with intolerable head-ache. The first variety is a very frequent disease in most countries, but "J^'ii*. particularly in those exposed to sudden changes in the temperature Mildly of the atmosphere. It is the sclerotitis of Professor Beer. Clouds ophthaimy. of dust, in dry seasons, are another common cause ; as is also an expo- CauseB- sure to smoke, or other acrid fumes or exhalations. A strong incessant glare of light, or of vivid colours has also not unfrequently proved a source of affection ; but perhaps less frequently so than an undue use of wine and ardent spirits. The disease commences with the appearance of a network of red n««.pt,m.. $21 vl. ui.j ILEMATIt A |obd. Lt Gen.VIH. blood-vessels in the sclerotic tunic, and particularly at the angles of aaiv ' the eye : and it is by its commencement in this tunic, the nature of MMrismili8' tne discharge, which is serous, the character ofthe inflamed vessels lachrymose which are very small and distinct, and the colour of the inflamed ophthalmy. surface which is rosy or carmine, rather than scarlet-red, that this species is chiefly distinguished from purulent ophthalmy which has its seat in the conjunctiva. The eye-lids are often swollen and ten- der, the fine membrane that lines their interior is turgid with blood, and there is a feehng as if gritty particles had insinuated themselves under the lid, accompanied with great heat and a pricking pain. If the inflammation commence in one eye it will generally extend to, and sometimes alternate with the other ; and during sleep a gluti- nous fluid is secreted which collects towards the angles, and some- times so closely cements the eye-lids, that it is with difficulty they are opened in the morning. Progress. In ordinary cases, this milder modification of ophthalmy runs its Treatment, course in four or five days, and ceases spontaneously, or is easily removed by local applications, and particularly astringent lotions, as cold water or solutions of alum, zinc, or lead ;* though, in irritable habits of a particular kind, relaxants and anodyne fomentations prove most successful. And even when the first are employed, it is always best to wash off the adhesive fluid that glues the eye-lids together during the night, with a little warm water in the morning, before a free use of them. ft o Tar- in the second variety, constituting the chemosis of Plenck, and AXcute ' produced from the same causes as the preceding, the symptoms o^hVifaTmy0 ^om tne ^rst assun,e great violence ; the inflammation passes rapidly Description, from one part ofthe ball to another ; a keen darting pain penetrates frequently to the bottom of the socket, accompanied with a burning heat, and intolerable head-ache ; the temples often throb, and the Heicoma. pulse is quick. If an ulcer ensue it forms what was called helcoma Shat.' °y the Greeks, or onyx if in the cornea. Under either of these Epiphora, varieties the disease will sometimes become chronic from neglect, and be distinguished by a permanent and distressing flow of tears which has been called an epiphora ; and, if such flux become acrid, Xeroph- it lays a foundation for an ectropium, or blear-eye.t If the chronic what!"1' inflammation be without tears, it was called by the Greeks xeroph- thalmia. Treatment. The most active measures are here necessary from the earliest commencement; for, from the violence of the inflammation, ulcera- tion may take place internally or externally, and the pupil be irre- trievably lost. Copious bleedings by leeches or cupping-glasses, are usually recommended from the temples ; but the former may be employed with inconceivably more advantage if applied directly to the inflamed tunic, by placing the patient with his back to the light, and gently everting the lower lid. We learn from Dr. Crampton that this method has been pursued with almost universal success in the most severe cases in the Royal Military Infirmary at Dublin ;| and it has the great advantage of not being followed by * Janin, Beobachtungen iiber das auge, &c. Berl. 1776. t Frank, De Cur. Horn. Morb. 11. 62. I Dublin Medical Reports, Vol. in ul. ni.J SANGUINEOUS FUNCTION. [ord. ii. 62b that erysipelatous affection which so often succeeds when leeches Gen.VIII. are applied on the external surface of the eye-lids, or even to the / a t»£ temples. Large and repeated general bleedings carried on to syn- A™tacuta> cope will also frequently be found successful ; and if the blood be lachrymose taken from the temporal artery, the success will be still more cer- °Phthaln)y' tain : though less so than when taken locally as above recom- mended. Brisk purgatives should at the' same time be employed, and blisters applied behind the ears, but not to the temples, as they often spread their own irritation from this quarter to the eye itself. The room should be kept moderately dark, but cool and airy; and astringent lotions, chilled by ice or frigorific mixtures, be constantly applied to the forehead, temples, and eye-lids, by folds of linen suc- cessively wetted for the purpose. I have known, however, the vomiting plan, which I shall have to Free notice under the third species, employed here also with very great often wfhiy advantage, and in some cases where every other plan had failed ; beneficial- and I find the same practice had recourse to with like success in a Confirmed very strongly marked case, published by Dr. Robert Dobson of practice. Kirkham ; who tells us that at that time, 1773, there was a rumour of the utility of emetics in some inveterate cases of this kind, not- withstanding the general prejudice against them, from their being supposed to add to the congestion of the head. The patient, whose illustrated 1111 jit c from a ease history he describes, was a young woman, aged twenty-two, ot a by Dobson. delicate habit. The attack was sudden, and produced a total ina- bility of sight in the right eye. The tunica albuginea, and indeed the whole globe of the eye were preternaturally enlarged, and the former in a considerable measure'covered with deeply inflamed red vessels ; the cornea being greatly distended, and the crystalline lens apparently protruded, by an accumulation of fluid, through the pupil so as to be in contact with the inner surface of the cornea itself, possessing an irregular and unequal form. The eye-lids were very much swollen and glued together ; the admission of light and air was insupportable; and followed by a copious discharge of acrid tears; and the whole was accompanied with excruciating and incessant pain, entirely preventing sleep, and sometimes so intolera- ble as to induce fainting. The left eye was similarly affected, but in a less degree. Copious and repeated bleeding from the temples, blisters, purgatives, shaving the head and cold applications to it, and all other means that could be thought of, had been tried, but to no purpose. As a doubtful and desperate remedy, a tartar emetic mixture was prescribed of which the patient was to take a large spoonful every hour till it vomited or purged her. The second dose both vomited and purged ; after this at bed-time, she took a grain and a half of Thebaic extract with two grains of ipecacuan. She passed a quiet and composed night, and enjoyed more sleep, and slept far more comfortably than she had done during all her ill- ness. The tartar emetic mixture was continued the next day in smaller quantities, and in a few days more she recovered her former health and strength.* * Edin. Med. Com. lit. p. 411. 326 cl. m.j UiEMATICA. [ord. II Gen.vih. Where the inflammation is a mere symptom or concomitant of B oETar-' some other disease, it can only be removed by a cure of the origi- axis acuta. na| malady. And this is not unfrequently the case : for it is often Acute la- . J ? ■-,• ■ 1 i • j chrymoso dependent on a strumous, or syphilitic habit, or a suppressed Where'a°'v" blenorrhcea : on a disordered state of the stomach, liver, or some symptom of other digestive organ, and especially in hard drinkers ; on an abuse co.opiaintr of mercury as a medicine ; and on various affections of the teeth.* toebeatter H" tne inflammation be produced by an influx of sand or gravel, particularly or spiculae of flint or iron driven into the external tunic, every such Tieaunent'' foreign substance must be carefully removed with as much speed as when idu>- possible: but it will be generally found that the pointed and prick- ing pain caused by the incursive substance will remain for some time after its removal, and induce in the patient's mind a strong belief that it is still fixed in the membrane. We have various examples of an extraction of spiculae of iron forcibly driven into the eye, by the application of a magnet.t When the inflammation becomes chronic the vessels of the con- junctiva, and even those of the cornea are often greatly debilitated pterygium, an(j reiaxed, and a caligo or glaucoma is a frequent result. Some- times also a few filmy bands of vessels shoot from the external or internal canthus, and by uniting form a fine filmy membrane that spreads in a conic or pyramidal form towards the cornea ; and to this has been given the name of pterygium.J SPECIES II. OPHTHALMIA IRIDIS. INFLAMMATION OF THE IRIS. INFLAMMATION COMMENCING IN THE IRIS ; COLOUR CHANGED TO GREEN OR REDDISH ; FIBRES LESS MOVEABLE, AND SHOOTING DENTIFORM PROCESSES INTO THE PUPIL ; PUPIL IRREGULARLY CON- TRACTED AND GRAYISH. Gen.VIII. Dr. Schmidt of Vienna, to whom we are chiefly indebted for an The iritis' accurate description of this species, has denominated it Iritis;§ and of Schmidt; under this name it has of late years been described by many practi- namehnot ca^ sur?eons m our own country. The termination, however, is classical, unclassical, and if the derivative be retained, it should unquestiona- bly be iriditis, instead of iritis ; but ophthalmia iridis is better, as the disease is very clearly a species of a connexive genus of diseases rather than a distinct genus itself. It is the more singular, how- ever, that iritis should have ever been used by its inventor, as the * Beer, Lehre von den Augenkrankheiten, Band. i. Wien. 1818. t Morgagni, De Sed. et Caus. Morb. Ep. xm. 22. Weber, Wurkunr des kiinst- hchen Magnets in emem Augenfeler, p. 18. Hanov. 1767, 8vo. Phil. Trans, p. 164. X Guthrie's Lectures on the Eye, p. 127. 8vo. 1823. 8 Ueber Nachstaar nnd Iritis Nachstaar operationem. Wien. 1801. cl. m.j SANGUINEOUS FUNCTION. [ORD. II. 32* Germans have long employed the more correct relative compounds Gen.VIII. of iridotomia, iridectomia, and iridodwalvsis £vf>cl1' mi . , ft . "**#*"/*""• Ophtha'mia I lie exact change of colour which the inflamed iris assumes, first i""'"- in its less, and then in its greater circle, depends upon the peculiar u^nT'he colour it possessed when in health. If this were grayish or blue, ^rWd the morbid hue will be green ; if brown or black, it will be reddish, change of The grayish or cloudy appearance of the pupil is produced by the accounted secretion of coagulable lymph which spreads over it in a fine flake for like a cobweb. If the inflammation do not yield to the curative pea7anceP" treatment, a yellowish-red tubercle forms in some part of the sur- «ocrcoutltei1 face ofthe iris, commonly where the greater and less circles of the Piogress of rnembrane meet; it enlarges, projects still forwarder, and is dis- mSilcS'to" tinctly seen to be an abscess, which at length bursts and discharges jyra" its contents into the anterior chamber. The inflammation now diminishes, the pus and blood, if any be thrown forth, are absorbed ; and the disease subsides, but with a total loss of vision ; for the iris »pd l0i» »f remains permanently expanded, with an utter inability of motion, v""on' and the pupil is closed or rather filled up by the grayish or ash- coloured web or membrane already noticed. The most frequent cause of this distressing affection is the ope- Usuai ration tor the cataract; in which an irritation is often excited either by endeavouring to press out the lens through too small a wound in the cornea ; by suffering some pieces of the lens to remain in the posterior chamber ; or from too frequent an exposure of the internal surface to the air by unnecessarily raising the flaps ofthe cornea. And the disease was hence, in our own country, till of late, most absurdly denominated secondary cataract. The disease, called synizesis or closed pupil, is a frequent result, though, as it often proceeds from other causes, it seems more expedient to describe it in another part of this work.* Like several other species of ophthalmia, this also occasionally Occasional shows itself during the existence of a syphilitic train in the system. caU9e'> And where a patient is labouring under an arthritic diathesis, and is accidentally affected by a common ophthalmy, this species is apt to be engrafted upon it. It is also an accompaniment of several cuta- neous eruptions, especially those connected with an abuse of mer- cury. The medical treatment is both local and general. The first Medicai 111 --/.i i ii -ii treatment, should consist in freely emptying the vessels by venesection, leeches, Local. and active purgatives : blisters are then to be applied successively to the temples, behind the ears, and on the nape of the neck. Cold local applications are quite useless ; and the only admissible col- lyrium is a fomentation of the eye with water made as hot as the patient can bear it, which will often mitigate the violent pain ; the eye being carefully wiped dry after using the application. The general treatment ofthe disease consists in the introduction General. of mercury into the system. This is particularly insisted upon by Mr. Travers, who has written a valuable article upon the subject. Whether it be a primary affection, or connected with other diseases. • See Cl. iv. Ord. ii. Gen. i. Spec x. Vol. ir. 32« cl. m.J HiEMATlCA. [ORD. 11. Gen.vih. even with syphilis, or induced by the action of mercurial prepara- Ophtha'hnVa tionsi he estimates this as almost a specific remedy.* With this iridis. remedy he unites the external use of belladonna, as affording the tionTf'the most effectual means of warding off those evil consequences which '"*• are chiefly to be apprehended, closure of the pupil, and effusion of coagulable lymph from the irritated organ. inflamma- Mr. Travers distinguishes also inflammation in the iris from that irTshowdis- in the cornea, by regarding the latter as suppurative, and leading to ftor^thaf an a^scess' an'J tne former as adhesive alone. And he tells us that of the inflammation of the cornea so strictly maintains this character, that cornea. • f lt Spreaci to tjje ir\s^ aruj m tnis case become merely secondary, it still preserves its adhesive power. Sometimes This species is also sometimes a concomitant of cutaneous erup- tant or tions, decidedly not syphilitic ; and especially of those produced by otJJer1 of a very extensive use of mercury; constituting what has been de- affections, nominated by some writers erythema mercuriale, and hydrargyria, as we shall take occasion to notice under syphilis. In the syphilitic or arthritic affection, however, a particular atten- tion must be paid to the primary disease, since otherwise no local remedies can be of any avail. SPECIES III. OPHTHALMIA PURULENT A. PURULENT OPHTHALMY. INFLAMMATION COMMENCING IN THE CONJUNCTIVE TUNIC ; THE IN- TERNAL SURFACE OF THE PALPEBR.E ASSOCIATING IN THE INFLAM- MATION OF THE EYE-BALL : COPIOUS SECRETION OF A PURULENT FLUID. Gen.VIH. As the conjunctiva forms the primary seat of this species, it has pec. I . Deen name(ji though not very classically, conjunctivitis by Professor Beer. The old Greek term chemosis would be a better appellation. It offers four varieties that are peculiarly worthy of notice, though one or two of them are of more importance than the rest: they are distinguished from the preceding species by the bright scarlet hue of the inflamed vessels, and by their following the movement that is given by the finger to the eye-lids. » Epidemica. The disease epidemic ; inflam- Egyptian ophthalmy. mation rapid and destructive, producing irritating granula- tions on the inner surface of the palpebral: head-ache in- tolerable : often succeeded ■ Surgical Essays, &c. I. passim, cl. m.j i «g SANGUINEOUS FUNCTION. [ord. ii. 32S by delirium ; at times remit- 9EM-V?!!- t'. Spec. UI. T, r len1. Ophthalmia P iVletastatica. Apparently produced by a sud- p«»uienta. Metastatic ophthalmy. : den suppression of catarrhal, ophlhXy. blennorrhoic, or other morbid discharge ; the secretion of- ten greenish. y Intermittens. Marked by irregular intermis- Intermittent ophthalmy. sions nearly allied to the epi- demic variety. Probably pro- duced by a peculiar miasm generated in marsh-lands. £ Infantum. Appearing suddenly and with- Purulent ophthalmy of infants. out any ostensible cause in new-born infants : the palpe- brae florid, and peculiarly tu- mid. The first or Egyptian variety, is that concerning which so j*°- vu^\ much has of late years been written by French and English sur- mica.e geons and physicians; which proved so extremely destructive to oj^ffiny. the armies of both nations in their respective expeditions to the banks of the Nile ; and the real nature and cure of which have been ?![atm'e of , n 1 f • tmJ disease very recently discussed with no small degree of acrimony in our and mode own country, but at the same time with much benefit to the public, ofrecent611* from the facts and the ingenuity which the controversy has brought discovery. to light. There appears little doubt, however, that it has occasion- ally existed even in our own day, in ships of war, antecedently to the expedition to Egypt, of which Sir Gilbert Blane has given two examples,* though it does not seem to nave been a subject of much attention at the time. This disease was at first ascribed to the minute and glassy spi- How , , v . . Accounted culae of the sands of the Egyptian plains. But it has since been for at first. sufficiently traced, either to a peculiarymiasm generated in marsh jjj°*" lands or to sleeping on damp or swampy ground, with insufficient covering, and surrounded by a moist atmosphere. And as these causes exist in other parts of the world than Egypt, the disease has been since detected in other parts as well: and as we shall pre- sently remark, appears to have been known and attended to in former times as minutely as in the present. A peculiar miasm, however, formed in hot and swampy soils, is J^'5^6 perhaps the ordinary cause ; there may be others as in thocase of miasm tbo fever, but this seems to be the most certain and obvious. " The reolCftUs9* true cause of the disease," says Dr. L. Frank, " i9 to be found in the atmosphere, and consists in a principle peculiar to the air of Egypt." He afterwards supposes this, but with little reason, to consist of muriatic acid. Such a cause, however produced, must Epidemic necessarily render the disease epidemic ; and the pus, as in one or ["P"^1" two of the succeeding varieties, secreted apparently from the seba- specific contagion * Select Dissertations, &c. p. 215. Vol, 11.-4? 330 cl. in.] HtEMATICA. [ord. u. Gen.vih. ceous, or rather the mucous follicles of the tunica conjunctiva (for a"p'u".1' M. Bichat is probably right in regarding the conjunctiva as a mucous icnta epide- membrane) is impregnated with a specific contagion ; and hence Egyptian the disease is propagated with great rapidity between those who ophthalmy. come m contact with each other by sleeping together, or using the Received same towels. I have known it caught by a surgeon's assistant merely in consequence of syringing the eyes of a patient, a part of the dis- charge having, from the force of the syringing, spurted into one of his own eyes, which was for some days in a state of danger. Symptoms The general symptoms and progress of the disease are those greli*0" already noticed in the definition. From the violence of the morbid action, the eye-lids soon become excessively tense and edematous, sometimes inseparably closed, with the edges drawn inwards, and sometimes gaping with the edges broad, turgid, and everted. The secretion of pus and tears is prodigious ; and the pus is discharged ophthuimo thus freely even when there is no ulceration ; on which account rh*'a°r" Professor Beer has proposed to call this species ophtlialmo-blennor- rhaza. But an ulceration often takes place, and sometimes during the first night of the attack. It commences usually in the cornea, which, from the onset of the disease, looks more or less muddy, or is studded with white spots. The ulcerative progress is sometimes checked before it spreads over the whole disk of the pupil, and, in this case, the sight is partially preserved. But, very frequently, it makes a rapid and irresistible advance over the entire cornea, lays open the iris, and works its way to the membranes, and even to the cellular substance below : in consequence of which the aqueous, and a part of the vitreous humour escape, the iris protrudes, and more or less adheres to the ruptured cornea, and the eye loses its figure as well as its power of vision. The pain, through the whole pro- gress, is intolerable : in the eye itself there is a sense of scalding or burning, and an agony in the head that drives the patient mad. "I have seen," says the younger Dr. Franks " the bravest soldiers cry like children for a whole night: and have heard them declare that they would readily allow the affected eye to be torn out if they could hereby get rid ofthe pain.M* Effects In some cases the symptoms are less violent, and gradually sub- fees wotant. s^e without ulceration, in three or four days ; and especially where the disease has been actively opposed by the process we shall have to notice presently. But innumerable granulations have, by this time, often formed upon the conjunctiva of one or both eye-lids, and a destructive irritation is hereby still kept up, which becomes a secondary source of blindness. Treatment The earliest mode of treatment pursued by the French, as we adopted at jearn from tne account of Dr. Antonio Savaresi, as well as of Dr. L. Frank, consisted in little more than the general treatment of the common acute ophthalniy; as local bleeding, drawn, however, from the jugular vein or temporal artery, blisters, saline purgatives, anodyne lotions, and a low diet. The bleedings do not appear to have been very copious. And yet the first writer tells us that by * De Peste, Dysenteria et Ophthalmia .-Egyptiaca, 8vo. Vienn. cl. nr.J SANGUINEOUS FUNCTION. |okd. ii. 331 this process alone he was so fortunate, that out of a thousand, or Gen.VIIT. thereabouts, who were confined m the French military hospitals in J"^?"' Egypt under his care, not more than two lost their sight completely,lei?^ epide- though some others suffered the loss of one eye. Egyptian In the hands of our own army-practitioners the plan of treat- Not^one^" ment thus limited, completely failed of success : and the bleeding, rally sue which was almost solely depended upon, was carried, from the first ^ough day of the attack, and repeated for several days afterwards to as carried to great an extent, not only as fainting, but as life itself would allow, extent. The first accounts we had of this practice seemed to show that it was in the highest degree successful :* but later experience has not justified the representation, and the extensive lists of blind pensioners at this moment supported by the Chelsea and Greenwich hospitals, are a sufficient proof that the success of the evacuating plan was considerably exaggerated. A free abstraction of blood by leeches applied to the conjunctive tunic itself, does not appear to have been tried till of late by Dr. Crampton, in the Dublin Hospital, where it seems to have been of very decided advantage when employed in its first stage, though it is insufficient afterwards. The late Mr. Saunders was in consequence induced to turn his ^rt0bve" attention upon its full stretch to this most acute and maddening saundnrs: disease : and he was the first in the present day to discover that the "hr°ddit3^t" blindness which is so apt to follow, even after the first attack of theinflam- virulent inflammation has subsided, proceeds from the friction upon ^s""la of the transparent cornea, of initumerable irritating granulations, as he two stages. denominated them, thrown forth from the surface of the tunica con- junctiva that lines the interior' of the palpebral, and which become a new source of inflammation, less violent indeed, but as fatal in its effects ; and the disease has^hence been very correctly divided into two stages, that of primary and that of secondary or apparently granulating inflammation. 'Mr. Saunders endeavoured to cut the Mnnage- disease short in its first stagb by exciting nausea, and maintaining first stage'L it for a considerable period of time so as to lower the living power, and hereby take off the inflammatory action. And where the dis- °™jesst*' ease had proceeded to what he called the granulating stage, he removed the minute caruncles from the tunica conjunctiva by cut- ting them off with a pair of scissors, and afterwards applied a solu- tion of nitrate of silver to prevent their sprouting again. Sir Wil- in both .... -ii f • 1 u .U cases tur- liam Adams appears very essentially to have improved upon botn therim- plans. Instead of the nauseating process employed in the first stage, £rd°avmds b-v he boldly prescribes active* and powerful vomiting continued for eight or ten hours by giving two grains of tartar emetic at first, and continuing one grain every half hour afterwards through the whole of this period ; by which violence a change of action, or new but more manageable excitement is often produced in the eye, and the disease is stopped in the course of ten or twelve hours from its onset. Though, as observed under the first species, the benefit of leeches h^J\o applied to the affected tunic or conjunctiva itself is so striking and the con- considerable, that it ought not lo be superseded by the emetic pro-Junctvn- * Account of the Ophthalmia which has appeared in England since the return of the British army. By J. Veitcb, M.D. 332 cl. m.j IliEMATICA. [ord. ii. GekVIII. Spec. III. n O. puru- lenta epide- mica. Egyptian ophthalmy. Sulphuric acid. Emetics long known to be useful in ophthal- my ; and employed, but upon a different principle. The pla- darotiis of the Greeks; or mulberry eye-lid of earlier English surgeons; cess. Nor should it be forgotten, that in this first stage the disease has been often subdued and granulations prevented from forming by the use of sulphuric acid applied to the conjunctiva, as we shall have occasion to mention in the everted eye-lid. In the feeble practice pursued too generally by the physicians to the French Egyptian army, emetics were as little resorted to as venesection. Dr. L. Frank disapproves of the former, and affirms that the latter, as well as purging, is always hurtful. Opium was chiefly relied on as a general remedy and a stimulant ointment of butter of antimony, and the red oxyde of mercury as a local applica- tion with aromatic vapours. The opium was given largely, some- times a grain an hour for twenty-four hours together. Where the second or granulating stage has commenced, Sir William Adams slices away by a knife the diseased surface of the conjunctiva, instead of the granulating points alone ; by which the morbid action is destroyed not only with less pain, but far more radically and effectually ; and he afterwards employs a solution of alum instead of a solution of nitrate of silver, as the latter is hereby rendered unnecessary ; not to mention that the agony it excites is often intolerable, and that a new inflammation has followed in some instances almost as dangerous as the,„original inflammation itself. Emetics, indeed, have long been occasionally made use of as a mean of relieving inflammation in the eyes; but not in the par- ticular kind before us, nor perhaps $, any time of the inflamma- tion with the precise object in view, proposed by Sir William Adams. Stoll, for instance, employed them successfully in periodic ophthalmies ;* and Dobson, as already observed, in ophthalnries of a like chronic kind, accompanied with nervous debility ; the bark being interposed between their repetition.! The nearest approach, however, to this practice which I have met with on medical records is Dr. Dobson's case, already noticed under acute taraxis. Yet though the emetic plan carried to this extent, and employed for the express purpose just stated, does not appear to have been had recourse to in this form of ophthalmy till our own day, it has been very clearly shown by those who have critically and histori- cally examined into the subject, that this very affection was long ago known to the world, and has been rationally as well as success- fully treated in different ages. As the Greeks were much better acquainted with Egypt than ourselves,, it is hardly to be supposed that it could have escaped their notice, and it has hence been sug- gested, with much probability, that it is. referred to by them under the term pladarotis ; J while it is ingeniously affirmed by a learned critic of our own day to have been described by the old surgeons of our own country under the expressive appellation of the mulberry eye-lid.§ There can, however, be no question that the ophthalmy before us was well known to them under whatever name described ; and that even the granulations of the second stage as they are in- correctly denominated, and which are rather enlarged and indurated ? Nat. Med. Part n. p. 102. f Med. Coram. Edinb. Vol. hi. p. 444. I Galen. Isag. 215. c. 6. Vol. v. fol. 1642. ' 5 fcjuarterty Journal of Foreign Med. Vol. I. p. 403. tx. m.j SANGUINEOUS FUNCTION. [ord. ii. 333 crypto? ofthe conjunctiva, had not only been noticed by them, but GenVIII. were even removed by some of the most approved methods of ScfpuS' modern surgery : since it is expressly recommended by Read who '<««« «pi- flourished nearly a century and a half ago, that, " if they be thick and Egypton gross they must be cut away dexterously with the point of a lancet, $£*$£*• and afterwards let the place be touched with a little fine salt, alum, of Read. or copperas-water. '* This, however, is not mentioned with a view of deducting from the merit of Mr. Saunders or Sir William Adams; since the practice, and even the name of its original inventor, seems to have been long lost sight of in the annals of chirurgical science, and consequently the revival of such a practice, and a detection of its benefits are as much a discovery now as it was in the time of Read. In the second or metastatic variety, the inflammation of the f°- Puru* eye is produced by a transfer of action or secretion from some tastatica" other organ ; as on a sudden suppression of the discharge that takes 2^1*^, place in the nostrils during a catarrh, or in the urethra from vene- How real infection. produced. The mucous membrane that lines the ball of the eye, and is a Resem- duplicature of the tunica conjunctiva, has a near resemblance to between those which line the urethra and the nostrils, and all are easily muc°UB • , . ' .' membranes. excited to a very copious secretion of purulent matter. T his m Sympathy effect is the immediate cause of the purulent ophthalmy in each of its of acuon" varieties. And it is not therefore very extraordinary, as we are per- petually meeting with examples of a transfer of action in almost every other part of the body, that the mucous membrane of the eyes should occasionally become the seat of a metastasis or transferred action from organs that so nearly partake of its nature :| and it is still less wonderful that such an effect should occur where the whole system is impregnated with syphilitic virus; a subject of inquiry, however, that belongs rather to the genus syphilis, than to the pre- sent place. The symptoms, under such a translation, are those of the Egyptian Symptoms ophthalmy ; the disease is often as violent and dangerous, and re- treatment.0 quires to be treated in the same manner. I have noticed this variety upon the concurrent testimony of St. Yves, Scarpa, Mr. Bell, and Dr. Edmonstone, to which may be added the authority of Dr. Plenck, who has two distinct varieties under the names of ophthalmia catarrhalis and o. gonorrhoica. It should at the same time be The «*«»- observed that some very respectable practitioners still entertain variety doubts upon the existence of a variety produced by any such means; someteprac- and are inclined to ascribe the disease, whenever it occurs, to a con- titioners; veyance of the virus of the organ primarily affected to the eye by means of the finger, or of a handkerchief. These doubts, however, guffi^0"1 appear to be founded rather on hypothesis, and an indisposition to reason. believe that the conjunctive tunic ever secretes mucus, or that there is any such thing as a consent of parts between the respective mem- branes before us, than on any actual disproof. The variety seems * Short, but exact Account of all the Diseases incident to the Eyes. Loud. 2d edit, p 96 1706. See also Quarterly Journ. of Foreign Med. ut supra. t J, P. Frank, De Cur. Horn. Morb. Tom. ii. p. 67. 334 cl. m.] HLEMATICA. [ord. ii. CBN.Vffl. to be Supported by incontrovertible experience : and M. Scarpa has f aCpuru-' pointed out a striking difference between the transfer of gonorrhoea lentame- to the eye by a consent of parts, and the infection of this organ Metastatic by an accidental communication of its virus ; the disease being in DfettoctTo'n.the latter CJlse always far milder than in the former. I was lately of Scarpa consulted by Mr. G. of Great Russell Street, who had been long the^ymp- labouring under an ophthalmy that had assumed a chronic and less toms of violent character, and which appeared to be very much ofthe pre- metastatic . ' ../. . . • , 1 1 i 1 * • and acci- sent variety. His former life had been irregular : and he had twice ophthalmy before had a clap suddenly cease upon a severe inflammation of the from vene- eye. I had no reason to suppose that the present inflammation was The variety the result of such a transfer : but as he had been for some weeks and^iius- attended by a surgeon of considerable eminence, who had already tratod. exhausted, although in vain, nearly the entire treasury of medical resources, I could not avoid observing that as there existed so close a sympathy between the mucous membrane of the eye and that of the urethra, probably the most speedy and effectual means of carry- ing off the present inflammation would be some accidental irritation of the urethra. No steps were taken to effect this; and I was, therefore, the more astonished at finding about three days after- wards that such an irritation had accidentally occurred, accompanied With a considerable flow of purulent fluid from the glans : and I was peculiarly pleased to find that from this time the ophthalmy be- gan to diminish, and that a complete cure was effected in about a week. y O. puru- jn tne THIRD variety, or that marked by regular intermis- lenta inter- . ' . mittens. sions, the inflammatory symptoms are less violent than in either of ophtha'imyf the preceding. Its cause is uncertain : and it has been suspected Cause by some writers to originate in a particular kind of marsh-miasm operating upon a particular diathesis ; and by others, to be con- Ophthaimia nected with a syphilitic taint. It is the ophthalmia periodica of Sf pienck. Plenck. The cure is to be attempted during the interval; in which treatment a n'ee exhibition of bark has been usually had recourse to, though where a vitiated habit is suspected, sarsaparilla, or the inner bark of the elm in decoction, or the solution of arsenic, might be tried with a better chance of success. e o. puru- The fourth vauiety is called by Mr. Ware the purulent oph- famum. thalmy op new-born childken,* and by Professor Frank, ophthal- ophtilaimy m'a v^omatorum,\ and*is at times as rapid and alarming as the of infants. Egyptian ophthalmy. Its cummon cause is cold ; though as it Causes. occurs far more generally in particular seasons of some years than of others, it is highly probable that a peculiar temperament of the atmosphere may form a predisposing cause. It usually makes its Description, appearance within the first week or fortnight from birth. The eye- lids look red, and swell rapidly to such a size that it is difficult to separate them without pain. A discharge of a yellow purulent fluid soon succeeds, which, upon opening the lids, will be found to cover the entire globe of the eye. And from the forcible pressure of lid against lid, both are greatly thickened, and not unfrequently * Remarks on the Ophthalmy, Plorophthalray, and purulent Eyes of new-born Infants. Edit. Sec. 1814. t De Cur. Horn. Morb. Epit. Tom. H. in loco. cl. m.j SANGUINEOUS FUNCTION. [ord. ii. 335 everted. The disease is usually unconnected with any other disor- Gen.VIH. der ; though Mr. Ware informs us that it is occasionally accompa- f 0E>fS* nied with eruptions on the head and other parts of the body ; and tanta in- sometimes with signs of a scrophulous constitution. pa"ruiTnt At the moment of writing the first edition, two infants of highly ftg respectable families, and who had had every possible attention paid illustrated". to them, living not many doors from each other, were just recover- ing from an attack, which had seized them about a fortnight after birth. The discharge of pus or purulent matter was prodigious from each ; both the eyes of both infants were in great danger : three of the four eyes were ulcerated on the cornea on the third or fourth day, and in one of the eyes the ulceration spread so com- pletely over the pupil as entirely and irrecoverably to destroy the sight. Much of the best medical and chirurgical advice that this metropolis can afford, including that of ophthalmic surgeons, was had recourse to in either instance. The author was one of those consulted in the one case, and was privy to the proceedings in the other. I cannot say that either in these or in any other instance that has Treatment. fallen within my own range of practice, I have seen all the benefit pho^ataoT from the use of Bates's powerful and stimulant astringent, known by "ates- the name of aqua camphorata, which Mr. Ware ascribes to it, I often m- have known it, at times, check the discharge, but do almost as much andVmU-n mischief from the pain it excites, and the irritation produced by very «*»«»«»• long fits of restlessness and crying, which are sure to follow. In consequence of which, moreover, neither the mother nor the nurse can summon fortitude to use it half so often or half so effectually as they ought: at times on this account alone, I have sometimes been compelled to relinquish it. Yet, even where it has had a fair trial, I have not generally found it successful. In most of the cases, however, related by Mr. Ware, the inflam- mation was less violent than in those just adverted to, and had con- tinued for some weeks, and assumed a chronic character: and, under such circumstances, this pungent application may certainly be had recourse to with more propriety, and a fair expectation of benefit. The plan that has proved most effectual, in my own course of Solution of observation, is, to syringe the eyes thoroughly, so that the whole of ferabiein the purulent discharge may be washed out with a solution of alum ^"other" in water, in the proportion of not less than a grain to an ounce : to means. continue this syringing three times a-day, to keep the bowels open, scarify the gorged vessels of the conjunctiva where it can be done, or apply leeches to their under surface, and surround the forehead lightly and loosely with folded linen, wetted with a lotion of an ounce of the liquor ammonise acetatis mixed with seven ounces of water, and kept cold in a bucket of ice. The child, in order to ^'^inoua receive the full benefit ofthe solution ofUlum, should have its head how to"be laid flat between the knees of the operator, with the face upper- aPP>iet*- most: the lids should be separated from each other by the fingers, or if necessary, as it almost always is, by the assistance of a blunt 'ilver spatula, or some other blunt instrument, and the point of the 336 cl. in.] HiEMATlCA. [ORD. II. Gen viil. syringe loaded with the astringent lotion should then be introduced f a piiru-* between them, and convey its contents all around : the syringing lenta in- being repeated till the whole of the collected matter is washed away. purulent The pain produced by the use of this solution is trifling, and the or'infantaf cnu!d ceases to cry almost as soon as the operation is over. Where an If, when the inflammation begins to subside, an ulcer be detected detected, a on any part of the cornea, and especially if it be over the pupil, a solution of solution of nitrate of silver, in the proportion of a grain to an ounce nitrate of 1,11 1 , • 1 • 1 , • a silver. of water, should be dropped into the eye night and morning alter Hp°p^etj,,e the syringing is over, and the eye be kept open for about half a minute, so that the solution may not be wiped away suddenly by the closing of the lids, but may fairly lie upon the ulcer and float Sulphate of over it for this period of time. The sulphate of quinine should also with"au- be given dissolved in a small quantity of water, to as great an extent danum if as the infant can bear it; and if looseness be produced, it should be checked by a drop or half a drop of laudanum in each draught. Pf U8\'atu Prussiate of potash is also a very good astringent for contracting the in the form area of the ulcer, and expediting the healing process ; and may be men"01"1* useQl instead of the solution of the nitrate of silver in the form of an ointment, by means of the unguentum cetacei. By a careful per- severance in this process I have not only seen ulcerations on the cor- nea heal speedily, but in one or two instances, without leaving any cicatrix to impede the vision, even where the ulceration has been seated over the pupil. SPECIES IV. OPHTHALMIA GLUTINOSA. GLUTINOUS OPHTHALMY. THE INFLAMMATION CHIEFLY SEATED ON THE TARSUS, OR EDGES OF THE EYE-LIDS ; ITS SEBACEOUS GLANDS SECRETING A VISCOUS AND ACRID FLUID THAT GLUES AND ULCERATES THE EDGES, AND IRRI- TATES THE EYE. Gen.VHI. This is the psorophthalmia of Plenck and Mr. Ware ; and con- Spec. IV. sjsts m an inflamed state of the small sebaceous glands, whose ducts l tie paor- . . ... /.. .. ophthalmia arranged in a row on the edge of each eye-hd, pour forth a viscid ancTware'. matter that incrusts and hardens; and, during sleep, when the lids D«scription. have been for some time in contact, glues them together so firmly, that they cannot be separated without many a painful effort. This matter, instead of being mild and lubricant, as in health, is now not only viscid but acrimonious and erosive ; whence the eye is irritated, and the edges of the lids ulcerated; and the complaint is apt to be- come chronic, and will sometimes last for years, or even for life, Causes. The disease is not unfrequently produced by small-pox and measles; occasionally by a taraxis or common lachrvmose oph- ■ l. m.j SANGUINEOUS FUNCTION. [ord. ii. 337 thalmy from cold or any other causes, and in a few instances, though Gen.VIII. rarely, from a sty. Sometimes it appears to be the result of a Sjhth'aimia scrophulous or venereal taint. Giutjnoaa. It is best attacked, and perhaps only to be cured, by such local opffimy. stimulants as may excite a new action or inflammation that may be Treatment- more manageable. The practice of M. St. Yves was here very bold; he touched the ulcers on the edge of the eye-lid with lapis infernalis, and thus cauterized the morbid surface. The unguen- tum hydrargyri nitratis, or the older form entitled unguentum hydrargyri nitrati, has of late been used with equal success, and with far less danger of injuring the ball of the eye ; and if the in- flammation have spread from the tarsus to the ball itself, this also may be illined with the same application. The best way of using which is, not that of a pencil-brush, but of letting a drop of it fall into the eye, melted for the purpose in a small silver spoon held over a candle. Or a drop of spirits, as vinum opii, ether, or Riga balsam may be allowed to fall into the eye in the same manner, and be repeated daily. SPECIES V. OPHTHALMIA STAPHYLOMA. PROTUBERANT EYE. ENLARGEMENT OF THE BALL OF THE EYE ; PROTUBERANCE OF THE CORNEA ; SIGHT DIM OR ABOLISHED. THE'term strapiiyloma is derived from vrxtpvXvt, " uva," a grape, Gen.VIII. from the resemblance of the tumour to the pulpy and semitrans- origin'of" parent appearance of this fruit. Richter seems first to have pointed £°m1pecifio out the real nature of this disease ; which, from the difference of its Real cause and prominent symptoms, may be considered as affording three ?rawd by varieties: Eichter; x Simplex. From increased secretion of the Simple protuberant eye. aqueous or other humour: pupil transparent. (3 Purulentum. From flow of pus from an ab- Purulent protuberant eye. scess in one of the membranes : pupil cloudy. y Complicatum. Complicated with an enlargement Complicate protuberant of the lachrymal gland ; or a eve rupture of the iris, and its pro- trusion upon the cornea consti- tuting a grape-like tumour: sight abolished. Plenck, who makes staphyloma a genus, and, as we have already g$«™v observed, multiplies the diseases ofthe eyes almost without end, has pienCk vOL II.—43 eM1'5 338 cl. iii.j HiEMATiCA [ORD. II. Gen VIII. Spec.V. Ophthalmia Staphy- luma. I'rotubcrant .ye. roduciblcto the present. Exophthal- mia, what; ophthal- moptosis ; ptosqfiridie. Explana- tion. t O. Sta- phyloma simplex. Simple pro- tuberant eye. llydroph- ihalmia, what. ft O. Sta- phyloma purulen- tum. Purulent protuberant eye. y O Sta- phyloma complica- tum. Complica- ted protu- berant eye. Uauses. several otlier subdivisions which are easily reducible into some one of these ; as he has also several other genera which do not essen- tially differ from the present, as exophthalmia, ophthahnoptosis, and ptosisiridis. The staphyloma, therefore, embraces all morbid collections ol fluids or other materials, within the cavity of the eye, producing a displacement or protuberance of the anterior part of the eye-ball, and, in most instances, a protrusion of the transparent cornea from its being the weakest part of the eye ; sometimes, indeed, a partial protrusion into the sclerotica or opake part of the eye, in conse quence of acute inflammation. The first variety has occasionally been called hydrophthalmia, or dropsy of the eye, as being formed by an increased secretion of the aqueous humour, or a torpitude of the absorbents that should carry off the fluid when secreted in its healthy proportion. Where it is from the first accompanied with a slight pain, we have reason to infer a continuance of augmented action, and, consequently, the first of these causes ; where there is no pain, which is usually the fact, the second, in which case the torpitude is commonly a sequel of inflammation. In the second and third varieties the pain is frequently severe and shoots backward into the head, attended with constant restless- ness, heat, and other febrile symptoms, and at times with a sense of tension and fiery sparks, which frequently continue, not only till the sight is lost, but till the eye bursts of itself, or its contents are dis- charged by an opening. In some cases instead of a fluid there is an accumulation of a medullary fungus, or pulp, that by continual pressure equally destroys the organization of the eye, and fills up a great part of the globe. This is chiefly found among children of delicate health, and, in a striking instance recorded by M. Panizza, was found connected with a morbid and mollescent state ofthe brain, and a diseased condition of the mesenteric glands. The child, about six years old, after having lingered for many months, at length died insensible and soporose.* The causes are for the most part internal, producing, as just observed, inflammation and abscess, which break down the mem- branous septa by which one part of the ball is so curiously divided from the rest, and throw the whole into confusion, with an increase of effused fluid. They are sometimes, however, dependent on external violence; and in a few instances are resolvable into severe strains from vomiting,! the hooping cough,| or vehement muscular action.§ The disease is often connected with a morbid state of the retina in the fungous staphyloma, and is generally supposed to originate from this affection. M. Panizza, in the case just quoted from him, ascribes it to a strumous diathesis. o*."4",11^1?210^ Anatomico-pathologiche sur fungo Medullar* dell'Occhio, &c. Favia, 1821.—Guthrie, Lectures on the Operative Surgery of the Eve. 8vo. p. 166. del Yelik Paris'1722 "' °bS' 194>~^int Yves> »«™« Traite des Maladi«s X Layard, Phil.'Trans. Vol. I. 1758. » Procbaaka. Mohrenheim. Weiherischen Bevtrasrer. B. 1L i;l. m.j ?>ANUUI\EOUS FUNCTION. [ord. n. J3n the first brush, as first recommended by Janin, and afterwards by Richter. It rarely happens, however, and especially in the second variety, gero"„mcnl that the use of the eye can be preserved, and hence, says Mr. Bell,t ^""'y- our chief objects in general are to abate the violence of the pain, rarefy to be which is ofien very severe, and to remove that deformity which an ^ed^?e: enlargement of the eye is always sure to produce. The last inten- usually the tion belongs to the art of surgery. For the first, blood-letting, 0or?ig,"o!:n" blisters, cooling applications to the eye and opiat s, are principally ab?ntea^° to be depended upon in the commencement of the disorder. But, remove the if these and similar means do not prove effectual ; if suppuration j£r°;hnei,y- take place, and the pain still continue severe, nothing will more cer- fiist, «- tainly afford relief than taking away the painful distention of the c°acu*n** eve by making an incision into the ball, and thus evacuating the con- ^;;enha)] tents: as has been*recommended indeed ever since the time ofanddis- Co-lsus. It is sometimes necessary, as in dropsies of otlier mem- SoSf."3 Lrancs, to repeat the puncture, as the effused fluid is apt to re-accu- J^J* mulate.J Some practitioners have repeated the operation to the advantage. fifth time, and effected a radical cure at last. A singular instance of this disease, produced apparently by mus- ™5jferof Tyre tm t OT^ an(* hung down over tbe cheek to tne upper »P- The coats second ' were greatly discoloured, all the vessels turgid, the sight totally lost, variety. an(J the humours appeared like fluctuating pus. An incision was made, the accumulated fluids were discharged, a great portion of the eye extirpated, and the remaining part reduced within the orbit; Reproduced the wound soon assumed a healthy appearance. But the patient by catching navmg caught cold before it was healed, a second inflammation ensued, a new and very large cyst was formed, filled with a trans parent fluid, and constituting a very protuberant dropsy. This, on being punctured, discharged a large tea-cupful of the accumulated liquid. The cyst, consisting apparently of a part of the sclerotic tunic which had been left, collapsed, and the next day was easily Favourable removed ; when the wound healed without further inconvenience or ermi a 10 . disfigurement than that of appearing to have the eye closed. Treatment. When, in the third variety, the pain and protrusion are pro- variety, duced by an enlargement or tumour of the lachrymal sac, nothing but an effective and early removal of the morbid growth can save the vision, the eye-ball, or even, perhaps, the life itself. SPECIES VI. OPHTHALMIA ECTROPIUM. EVERTED EYE-LID. EVE WEAK AND WEEPING, WITH SLIGHT BUT CHRONIC INFLAMMA- TION ; TARSUS THICKENED, AND RETRACTED, WITH A PERMANENT REDNESS ON ITS VERGE. Gen.VIII. This species is usually a relic or sequel of some one of the pre- pec. VI. cedjug^ m consequence of ill-treatment or neglect ;* and may be contemplated under two varieties : or, according to M. Scarpa, two species: x Lippitudo. The ciliary edge red, thickened, and Blear-eye. highly irritable, the retraction sim- ple ; conjunctiva unexposed. 0 Nudum. The upper or lower tarsus completely Naked ectropium. everted, the conjunctiva exposed, and turgid, with red vessels. Smarts. The blood-vessels visible in that part of the conjunctiva which covers the inside ofthe eye-lids, are far more numerous than those * Vetch, on Diseases of the Eye, 8vo. 1820 ll. in.] SANGUINEOUS FUNCTION. [obd. ii. 341 observable in that part of it which covers the globe of the eye. And Gen.VIII. hence the reason that in various species of ophthalmy the interior of oJifthkiSi the eye-hdis peculiarly apt to become turgid, and very highly inflamed ; Ectn.Pium. and, from turgescence, thickens at its edges, and is often so consi- e^iiid! derably everted as to expose a very large portion of the conjunctiva. And if these effects of inflammation be not duly attended to, both °ri?jndof the thickening and eversion are apt to remain and become perma- 'PP',U nent; nor is this all, for the exquisitely tender membrane ofthe eye-lid, constantly exposed to irritation from cold, sharp winds, dust, a strong light, and excoriating tears, especially those of an epiphora or chronic taraxis, increases in tenderness, is never free from some degree of inflammation, and at length becomes highly vascular, florid, fleshly, and carunculate, and exhibits a very hideous deformity ; the everted eye-lid sometimes adhering and being ce- mented to the cheek by abrasion and the inosculation of new vessels. The disease, under both varieties, is the result of debility. In the « o. Lippi- commencement of the blear-eye or vascular turgescence, running nieai-eye. parallel with the first modification of Mr. Guthrie,* and the first Treatment. species of Scarpa, the vessels should immediately be scarified with Scatifica- a lancet so as to be disgorged of the blood with which they are llon" loaded ; and it will be sometimes expedient to repeat the scarifica- lion several times, for the operation itself produces a new and more healthy action, and gives a disposition to contractility. The edge stimulants and interior of the thickened tarsus should then be attacked with gents?"'"" gentle stimulants and astringents ; as cold or ice-water, a solution of alum, zinc, lead, or camphor ; illinations with the best brandy, vinum opii, or the nitric oxyde of mercury, in the form of the Col- lege ointment, or any of the other stimulants enumerated under the last species. Repeated blisters to the temples have also been very misters generally employed ; but I have frequently found them entirely fe'ctuVi!'*"" ineffectual. Where additional secretion from a neighbouring organ Spuige-fkx is desirable, it may be obtained more successfully by the use of the tiilftemp'ie, thymalaea Monspeliaca, or spurge-flax, the daphne Cnidium of Lin- more use_ neus. Small circular pieces of its bark, soaked for about an hour in vinegar, may be applied to the temple of the affected side, and renewed every ten or twelve hours. It excites a serous discharge, and consequently produces increased action without blistering or irritation. The SECOND VARIETY, Or EVERTED EYE-LID, when of long P.O. Ectro- standing, is accompanied with a hard or horny cicatrix ; in which Nudum. case the only cure seems to be that recommended by Sir William Jrf0,ijjudmEc' Adams, of cutting out with a pair of scissors a strip ofthe tarsus in Treatment, Ae form of the letter V ; afterwards separating the eye-lid from the "horny * cheek whenever it adheres to it; and, finally, supporting the lid now cicatrix. raised into its proper place, and confining the edges of the cut eye- lid, brought into a state of juxta-position, by a proper bandage.! The divided edges heal by the first intention ; and the cure is often completed in a fortnight, with a restoration of the eye-lid to its healthy form. * Lectures on the Operative Surgery of the Eye, p. 54. 8vo. 1823. t Practical Observations on Ectropium. &c. Chap. t. 2V2 cl. in.J HiEMATlCA. [ord. ii Gen.vih. This ingenious operator has recommended the same process for p aEct^o- the simpler and earlier stages of everted eye-lid, or where there is no i'ium hard or horny cicatrix, but a morbid turgescence of the internal Nuked membrane ofthe eye-lid, often accompanied with granulations ; yet wheTiuiD' as Mr- Guthrie has given ample evidence after Beer,* that in both simple. these cases, a skilful application of a very small portion of sulphuric acid.1"' ' acid to the internal conjunctiva, upon the end of a probe, will of itself suffice to effect a cure, will destroy the minute caruncles, and produce almost any degree of contraction throughout the extent of the eye-lid, even to that of an inversion of the ciliary edge, if car- ried too far,t the operation just noticed should be reserved for the extreme stage of a hardened cicatrization :—that stage indeed which Scarpa contemplated as nearly, if not altogether, irremediable. SPECIES VII. OPHTHALMIA ENTROPIUM INVERTED EYE-LID. TARSUS DRAWN INWARDS, CILIARY HAIRS BENT AGAINST THE CON- JUNCTIVA, AND PERMANENTLY IRRITATING AND INFLAMING IT : FIXT REDNESS OF THE INTEGUMENTS. Gen.VIII. This disease has been distinguished by various names, as ptosis, synonyma." phalangosis, and trichiasis, but is now chiefly known by that selected inscription. on the present occasion. The evil it produces is the reverse of that just described, and consists in an internal traction of the tarsus above or below, in consequence of which a perpetual irritation is produced in the conjunctiva, by the friction of the hairs of the eye-lid thus thrown out of their natural line of growth. The inflammation is in time communicated to the cornea, which becomes opake, and is fre- quently ulcerated. When the disease has acquired a chronic state. the integuments appear redder than usual, the eye-lid is thickened, the conjunctiva is contracted at its commissures, and the tarsus as- sumes an unnatural curvature. Treatment Various plans have been devised for the cure of this defect from ""various the time of Celsus, or rather of Hippocrates. Of these the chief plans. nave consisted in a careful attention to remove, and if possible pre- vent the future growth of hairs, either by pulling them out, or de- stroying their roots by sulphuric acid ; a removal of a fold of thle skin, and producing an artificial retraction by drawing the extre- mities of the wound together by sutures or strips of adhesive plaster, as recommended by Scarpa; and lastly, an entire removal of the edge of the eye-lid, including the cilia, as proposed by Jaer, and since performed with little variation by Mr. Saunders. * Letare von den Augenkrankheiten. Band. u. p. 144. Wien. 1817. + Lectures on the Operative Surgery of the Eye, &c. p. 56. 8vo. Load. 1823 cl. in.J SANGUINEOUS FUNCTION. [ord. u. 346 Of these methods the first, which is the simp'rst, rarely if ever, GknVHI. as Beer has justly observed, produces a permanent cure ; while the §"£22. rest either do not succeed or are peculiarly unsightly in the issue. Entropium. To remedy these evils Mr. Guthrie has lately introduced an ope- %m ration which, though in some respects more complicated than the ^loT' preceding, seems completely to succeed, and with little or no dis- method.8 figuremeiit. Its principle consists in taking off all contraction, by slitting up the eye-lid at each angle, and then producing a sufficient degree of permanent retraction, by taking away a small slip of the a fleeted tarsus as near the edge as may be, and afterwards uniting the edges of the wound, as already noticed, by ligatures.* GENUS IX. CATARRHUS. CATARRH. INFLAMMATION OF THE MUCOUS MEMBRANE OF THE FAUCES, OFTExS EXTENDING TO THE BRONCHIA, AND FRONTAL SINUSES J INFARCTION OF THE NOSTRILS ; SNEEZING ; AND, FOR THE MOST PART, A MUCOUS EXPECTORATION, OR DISCHARGE FROM THE NOSE. Catarrh is a Greek compound, and imports "defluxion," from **??* *■£• x.xtx, denoting, as stated in the table of significations to the affixes the generic and suffixes of medical terms in the Nosology, " augmented action,"'term" and 'pta, " to flow." Catarrhus, however, like ophthalmia, has been Different used in various senses and latitudes by different authors. Schneider plied to it. and Hoffman show a disposition to extend it to inflammation of the mucous glands in general; and Parr, enticed by such an example, has made it a genus for including not only what is commonly under- stood by catarrh, but the cough of old age (which he admits is with- out pyrexy,) croup, dysentery, phthisis, cystirrhoea, leucorrhcea, gonorrhoea, and one or two others. This is the widest acceptation of the word. The narrowest is that of the old pathologists, who thus distinguished between three separate terms which are now regarded by many writers as synonymous : Si fluit ad pectus, dicatur rheuma Catarrhus ; Ad fauces, Bronchus ; ad nares, csto Cortza. This couplet is, perhaps, founded upon Galen's account of these affec- t^°g^8e"d tions ; but it does not follow up the Greek distinction into all its by the ramifications ; for the Greek physicians, as Galen himself tells us, cfreeks- * Lectures on the Operative Surgery of the Eye, &c. p. 33. 8vo. Lond. 1823.— Quadri, Annotazionc praUche sulle Malattie degli Occhi. Napoli, 1819.—Trovers, Svrnpsis of the Diseases of the Eve. 1810 —Beer, Lehre, &c. ut supra. su Gen. IX. Catarrhus. Catarrh. How deno- minated by Celsus; his subdi- CL. UI.j ILLMATioA. oRD. 1.1. Listinctions of Suu- vagea: compared with the arrange- ment of Cullen. Significa- tion in the present pvstem. had also a further, supply of names for the defluxion when it fixed itself chiefly in other parts of the neighbourhood; as acinus, when the uvula was the seat of affection ; antiad.e, when the tonsils; and paristhmia, when the attack was common to the fauces. For all these Celsus employs the Latin term gravedo, between which, however, and coryza he observes that there is a manifest difference. It is this difference which I have endeavoured to support in the pre- sent system ; in which coryza, treated of under our second class as an affection of the vocal avenus, is made to import nasal defluxion without pyrexy. Celsus takes no notice of the term catarrh ; for in his day catarrh was changed by the later Greek writers in catas- TAGMUS. Sauvages has only deviated from the rule contained in the above Latin couplet by omitting bronchus and employing catarrhus in its stead, and rheuma in the stead of catarrhus ; so that with him rheuma imports a cold, or febrile defluxion of the chest; catar- rhus, the same affection of the fauces, and adjoining organs ; and coryza, the same malady of the head or nostrils. Cullen has regarded rheuma, coryza, bronchus, and catarrhus as synonymous terms, scarcely indicating varieties of the same disease. The arrangement of Dr. Cullen, moreover, did not allow him to place bex, tussis or cough, any where else ; and being obliged to yield to the force of necessity, he has made cough also a synonym of catarrh, and has treated of it under this genus. It is here the present system differs from Dr. Cullen, as it does likewise in sepa- rating coryza from the list of phlogotic affections. Cough is not necessarily a pyrectic or inflammatory disease, though it may be occasionally a symptom of such disease. Cough therefore, under the Greek term bex, we have already considered, as well as coryza. under the second or pneumatic class ; where they will probably be allowed by most nosologists to occupy more correct and natural posts than in the present place. Catarrh, thus explained, embraces the two following species : 1. COMMUNIS. 2. EPIDEMICUS. COLD IN THE HEAD OR CHEST. INFLUENZA. Under neither of these species can catarrh be regarded as a danger- ous or very serious disorder, unless neglected or treated improperly; or unless it occurs with great severity in persons of delicate lungs or possessing a consumptive diathesis ; in all which cases its result may be very mischievous, and lead on to pneumonitis, bronchlem- mitis, phthisis, or dropsy of the chest, though in itself, and separate from such concomitants, by no means alarming. 'i. m.j SANGUINEOUS FUNCTION ^ord. u- 24b SPECIES I. CATARRHUS COMMUNIS. <£OLD IN THE HEAD OR CHEST. FEVER SLIGHT ; MUCOUS DISCHARGE CONSIDERABLE. This is the pose of old English writers, a term precisely synony- ^EN* **• mous with the gravedo of Celsus, which is also employed in the synonyms! earlier medical works of our own country. To pose is still used in the sense of to stupify, and the real meaning of posie is a " narcotic charm," and hence a nosegay of tranquillizing odour inducing repose or sleep. The common symptoms of this species are a sense of Description. fulness in the head, and of weight over the eyes, which are inflamed and lachrymose. The nostrils are obstructed, and pour forth a thick acrimonious ichor, which excoriates the skin as it descends, accom- panied with frequent sneezing. The voice is hoarse, the fauces sore, and the lungs loaded, often producing a troublesome cough. Its usual cause is suppressed perspiration from cold ; whence Dr. Causes. Cullen conceives that cold is the constant and only cause, and would in every case be detected to be such, were men acquainted with, and attentive to, the circumstances which determine cold to act upon the body. From the similarity between the fluid exhaled from the skin and that from the lungs, he conceives that, whenever the former secre- tion is obstructed in its flow, it is transferred to, and passes off with the latter ; the cough being produced by the stimulus of the increased action, and exhalation. There seems, however, to be, in many cases at least, something Some»hing . ,. • , |. . • .ii "ore than more than this ; for neither cold nor suppressed perspiration will cold as a account for every instance of common catarrh. There are few "i^ea.a* practitioners, perhaps, but have sometimes known persons thus affected who have been bed-ridden from chronic lameness or some other cause, and have had their chamber warmed night and day by a fire. Some ladies always catch a cold in the head on quitting the town for the country ; and others on quitting the country for the town. Something must therefore depend on the actual state ofthe constitution at the moment; and something upon the variable quality of the atmosphere : and a change in both frequently perhaps con- curs in producing the affection of a common catarrh. Where the attack is slight, medical aid is not often sought for or pr"r*e^f needed. A few days of domestic repose in a warm but not a close atmosphere, diluent drinks, with an abstinence from animal food, and vinous or other fermented liquors, a sudorific posset at night, with an additional blanket thrown over the bed to encourage perspi- ration, usually succeed in carrying off the complaint. But if there >be a sense of oppression on the chest, or of fulness in the head. Vor. II.- 44 * 346 cl. in-J ILEMATICA. [oRD. II Co!d in the head 01 r!. .-st. Gen. XI. wjth the ordinary signs of fever, venesection should be had recourse Srhul* to, and a smart purgative immediately afterwards, while the preceding communis, process is stilUcontinued. If the cough should be troublesome h" at night, it will be best allayed by a dose of Dover's powder, which will Take off the irritation, and determine to the surface. Catarrh is also found occasionally, as a symptom, in measles. small-pox, worms, dentition, and rheumatism. SPECIES II. CATARRHUS EPIDEMICUS. INFLUENZA. THE ATTACK SUDDEN; GREAT HEAVINESS OVER THE EiES; FEVEE STRIKINGLY DEPRESSIVE; EPIDEMIC. Gen. IX. This species differs chiefly from the preceding in the abruptness if.fw dis"" of its incursions, the severity of its symptoms, and very generally in tinguished the rapidity of its transition. It probably also differs in the nature of preceding its remote cause, which we shall briefly inquire into after attending species. to jts diagnostic character. Description. It commences, according to D. J. C. Smith, who has accurately given us its progress as it appeared in 1781 and 1782, with the usual catarrhal symptoms, in conjunction with others that are far more distressing to the patient, and often not less alarming to the phy- sician ; such as great languor, lowness and oppression at the prae- cordia; anxiety, with frequent sighing, sickness, and violent head- ache. The pulse is peculiarly quick and irregular, and at night there is often delirium. The heat of the body is seldom consider- able, particularly when compared with the violence of the other symptoms; the skin is moist, with a tendency to profuse sweating : the tongue moist, but white or yellowish. Sometimes there are severe muscular pains general or local; at other times, erysipelatous patches or efflorescences on different parts of the body, which, in a few rare instances, have terminated in gangrene and death. From the onset, for the first twenty-four or forty-eight hours, the symptoms are extremely violent, far beyond the danger or duration of the dis- temper. For the most part it attacks the healthy and robust; chil- dren and old people either escape entirely, or are affected in a slighter manner. Pregnant women, however, are disposed to mis- carry, and the flooding is in some cases fatal. Patients also subject to pulmonic complaints suffer much from the cough, difficulty of breathing, and other peripneumonic symptoms, which occasionally lead on to dissolution.* Such is the general progress of influenza in most ofthe periods in * Medical Communications. Vol. i, p. 71. cl. hi.] .SANGUINEOUS FUNCTION. [ord. n. 347 which it has shown itself. But in every period its symptoms have Ges- J*- considerably varied in severity in different individuals. In many catarrhus' instances, they have scarcely exceeded the signs of a common cold ; ^'Jf™^"9' in others, the pleuritic pain has been very acute, or the head-ache Symptoms intolerable, shooting up to the vertex with a sense of splitting; the severity in pulse has been a hundred and forty, and often considerably more, in different a minute, with incoherency or delirium from the first night. Yet cases of real danger are very few ; and the violence ofthe disease is over frequently in forty-eight hours; sometimes in twenty-four. Those who have suffered appear to be insusceptible of a second Sometimes attack during the continuance of the epidemy, though they have no by great indemnity against the next that may appear. In many cases, how- j^bHUy. ever, the general debility induced on the system does not terminate with the catarrh itself, but remains for weeks, perhaps for months, afterwards, and is sometimes removed with great difficulty. The disease has been known and described from the time of Hip- Disease de- i i-ii ^ i .1 l scribe J by pocrates to the present day : and is dwelt upon at great length by ihe Greek Sydenham, who regarded it in the autumn of 1675 as a general cough „"'*",;. produced by cold and moist weather, grafted upon the autumnal garded by epidemy, and varying its symptoms ; whence the fever, which had y Cl hitherto chiefly attacked the head or the bowels, now transferred its violence to the thorax, and excited symptoms which had often a semblance to those of genuine pleuritis, but in reality were not so, and demanded a different and less evacuant treatment; the patient being uniformly made worse by copious and repeated bleedings : though a single moderate venesection was often useful, and in a few instances a second: beyond which Sydenham always found it mischievous to proceed. And in proof that this was the real nature of the case, he observes that " these catarrhs and coughs continued to the end of November, after which they abated, but the fever still remained the same as it was before the catarrhs appeared ;" meaning that it then returned to its essential character : " although," he con- tinues, " it was neither quite so epidemic, nor accompanied with quite the same symptoms ; since these incidentally depended upon the catarrhs." Influenza, however, as we shall have occasion to show presently, J^'.y .„ has not only occurred in the autumn, but in every season ofthe year, opidu/y: whether hot. cold, damp, or temperate; and when there has been apparently no other constitutional distemper with which it could unite itself. The chief returns of the disease which have been remarked f*™^; in this country since the above of Sydenham are those of 1732, 1762, 1775, 1782, and 1803; the duration of the epidemy was in every instance from a month to six weeks. That the disease is an epi- demy, cannot be doubted for a moment : yet this is to advance but ^ «J|« a verv little wav towards a knowledge of its origin or remote cause ; nature of J x**.**.»v »» j o /» • i * u * epidemics for we have still to inquire into the nature of epidemies, their b'ul litlll. sources, diversities, and means of diffusion ; often, as in the case of known. spasmodic cholera, in the very teeth of periodical winds and other meteorological phenomena that we might fairly conclude, if we did not know the contrary, would irresistibly oppose their progress, or disintegrate their principles, and consequently abolish their power. 348 cl. in.] HiEMATlCA. [ORD. II. Gen. IX. Spec. II. Catarrhus cpidemicus. Influenza. Still further examined as to probable causes. Influenza how ac- counted for. Sometimes traced to Uie first of the above causes. More ge- nerally to the second. Dr. Sydenham, with the modesty which peculiarly belongs to him- self, and always characterizes real knowledge, freely confesses lus ignorance upon the subject, though he is rather disposed to ascribe them to " some occult and inexplicable changes wrought in the bowels of the earth itself, by which the atmosphere becomes conta- minated with certain effluvia, which predispose the bodies of men to some form or other of disease;" while Hippocrates, who had pursued the same recondite subject with the same indefatigable spirit upwards of two thousand years before, resolves them with a devotional feeling which would do honour to the philosophy of the present day, but which the philosophy of the present day has not always evinced, into a present divinity, a providential interposition : for such, as Galen informs us,is the actual meaningof his TO ©EION,* and not some unknown and latent physical principle of the atmos- phere, as various expositors have conceived : " non enim quaecunque causas habent incognitas ct abditas divina vocamus ; sed ubi admi- rabilia videntur duntaxot."t An epidemy, however, or state ofthe atmosphere capable of pro- ducing any general disorder, whether originating specially or in the ordinary course of nature, may depend upon an intemperament, or inharmonious combination of the elementary principles of which it consists, or upon some foreign principle accidentally combined with it, and which has of late years more especially been called a miasm or contamination. It is possible that both these may be causes of different diseases ; and, in this case, the term epidemy might be more correctly limited to those which issue from the first cause than from the second : and Dr. Hosack has endeavoured thus to limit it. But as it is rarely that we can distinguish between the two, and especially as the term has been very generally applied to diseases arising from both sources, itis not worth while to alter its common signification. In the disease before us, many writers have endeavoured to trace it to the first of the above causes, and particularly to the atmosphere's being in a state of negative electricity ; and M. Weber, fully con- fiding in this cause, has recommended, somewhat whimsically, the use of socks made of the most powerful non-conductors, as oiled- silk, or paper covered with sealing-wax, as a certain prophylactic.]: Others, without undertaking to determine in what the atmospheric intemperament consists, have regarded it as a mere exciting cause of catarrhs, or, in other words, as merely rendering the body more susceptive of the ordinary causes of this disease, and hence con- verting a sporadic into a general distemper. More commonly, however, catarrh as well as other epidemics ha? in modern times been contemplated as dependent upon the second of the aerial causes just adverted to, namely the existence of a spe- cific miasm, or morbid principle of a peculiar kind in the atmos- phere, distinct from any change in the combination of its proper elements :§ and hence, Professor Frank, after adverting to the " in + De Prognont. Lib. I. f Comment, in Progn. Hipp. t Rahn. Briefwachsel, rait seinen chemalignen, Schulern. Band. u. Zurich, 8ro. § See especially De Merten's Observ. Med. Tom. n. 4. and Simmons, I.ond. Mrd Tonrn. 1788. P. iv. ll. m.j SANGUINEOUS FUNCTION. |okd. n. 349 ambiente nos aere mutatio," adds, "• non sine magna latentis contagii Gen. IX. suspicione."* There is much, indeed, to support this opinion ; for cmrrhus in many cases, as in intermittent and remittent fevers, we can mani- epjdcmicus. festly trace such an origin ; and, as we have already shown that contagions and miasms are often identic or nearly so, the former may be brought forward as abundantly confirming the same view. This identity, or approach to identity, between contagions and Ttlentityof miasms, is closely connected with the present subject, and must be andtae'°n a little examined into for its clearer elucidation. miasms In treating of the origin and laws of febrile miasm, we observed that it is of two distinct modifications, or proceeds from two distinct sources :f that in its ordinary course, it first appears as the result of a decomposition of dead organized matter operated upon by the common auxiliaries of putrefaction : but that afterwards, " during the action of the fever thus produced, the effluvium from the living body is loaded with miasm of the same kind, completely elaborated as it passes off', and standing in no need ofthe decomposition of the effluvium for its formation ; under which form it is commonly known by the name of contagion.'' I may now add, that as primary febrile miasm is not the only miasm generated in the atmosphere, so it does not seem to be the only miasm that gives rise to contagion : that both are very nume- rous in their kinds, and that specific contagions are, though perhaps not always, yet far more generally, a result of specific miasms pro- duced as above. This seems especially to be the case in respect to Doctrine influenza ; for though most individuals labouring under it are evi- ,Tnuenza! dently affected from an atmospheric taint, many, as we shall show ^^nco J , .. r„ . J , r influenza presently, appear as in the case of remittent or typhous fever, to produced receive it from personal contagion : nor is there, in fact, any reason gf0n0,„fi" why a puriform discharge from the mucous membrane of the nostrils miasm. may not be contagious, as well as a puriform discharge from the mucous membrane of the eye-lids in ophthalmy, or from the ure- thra in blenorrhcea, or, as we shall shortly have to notice, from the rectum in dysentery. Among dogs and horses we perceive the illustrated same disease, in many instances highly and extensively contagious, Japes in and accompanied with so violent a degree of fever as to be peculiarly ^maie dangerous, especially to the young of these kinds. In South Ame- rica, in particular, this affection is so violent that half the dogs pupped there are supposed to die of it while sucklings. Whence Distemper in common language it is called emphatically the distemper, though dogs, what. vulgarly, the snaffles, or rather snuffles, from the state of the nostrils. In nosology it is commonly called catarrhus caninus. Generally speaking, specific miasms and contagions capable of fJ^jj'^ affecting one kind of animals, are incapable of affecting any other one kind of kind ; or at least rarely extend their influence any further. In a few *™$*ls ~ febrile pestilences, quadrupeds and birds seem to have been fellow- attack sufferers with mankind, as we have already had occasion to notice under epanetds malignus, or malignant remittent fever. But this is not common ; and in some instances is well known to have * De Cur. Horn. Morb. Epit. v. p. 118, 119. * VoJ. ii. Class ii. Ord. I. p. 45.—Remote Cause of Fever. 350 cl. m.j 1L4SMATICA. (okd. ir. Gen. IX. depended upon the general dearth of a country, or the insalubrity cauurim"' ofthe preceding harvest. A few ofthe exanthems, as cow-pox, are epidcmicus. capable of propagation from one species to another ; but the greater iLstrated. number of them are not, or only with great difficulty. When a putrid fever has broken out among a ship's crew, the live stock has never been known to suffer from it: and it has happened occasion- ally, when large numbers of sheep and hogs have been stowed in a ship for the purpose of exportation, sometimes the former have been attacked with infectious fever, and sometimes the latter ; but the sheep have never communicated it to the hogs, nor the hogs to tin sheep, nor either of them to the ship's crew. " It seems to be a general law of nature," observes Sir Gilbert Blane, " at least among the mammalia, that accumulation and stagnation of the exhalations Glanders of the living body produce disease. The glanders of horses arise from°con- onty m large stables, and the distemper of dogs in kennels. During centratod the American war, it was proposed to send live sheep from England of their"1 across the Atlantic. In a few weeks, in consequence of being own kind crowded ina ship, they all died of a febrile disorder."—" In the sheep af- expedition to Quiberon in 1795, several horse-transports had their liko,eCausem hatches shut for a length of time in a storm, by which means eight and with horses were suffocated. Those which survived became affected with tion. the glanders soon after they landed. Professor Colman saw twenty of them under this disorder ; a considerable number had been pre- viously destroyed."* It does not appear that in either of these instances the respective disorders were communicated from one genus or species of animals to another. That the catarrh before us possesses not only an epidemic cha- racter, but is dependent on atmospheric influence, is established by such a cloud of well known proofs, that it is hardly worth while to give examples. Of a dozen persons in perfect health in the same room, ten have often been attacked as nearly as possible at the same time. In the influenza of 1782, three families, consisting of seventeen persons, arrived on the same day at an hotel in the Adel- phi all in perfect health. The next day they were all affected with the symptoms of the reigning disease.'! In an hospital, containing a hundred and seventy persons, more than a hundred were, on one occasion, attacked within twenty-four hours ; and few of the re- mainder escaped afterwards. We have said, however, that the middle-aged, the strong, and the robust are affected soonest, and suffer most severely, while the young and the old are less susceptive of its influence. In proof of this, we may advert to the fact that healthy and well disciplined soldiers suffer peculiarly. In 1782, this was especially the case at Aberdeen : at Dublin there were, at the same period, seven hun- dred soldiers confined under it in their barracks at once, and incapa- ble of doing their duty ;{ while at Utrecht the number amounted to not less than three thousand. On the contrary, out of seven hun- * Med.-Chirurg. Trans, iv. 89. 475. t Med. Trans. Vol. m. p. 59. f Dr. Hamilton, Mem. Med. Soc. of Lond. 178? , r. loung make a nearer approach to the general opinion of Dr. Cullen than any other nosologist that I am acquainted with. They regard the disease as an inflammatory affection ; but seem to differ from Dr. Cullen in believing it to be essentially and at all times contagious : the former limiting himself to the expres- sion that it is generally so; the latter, that it is often so. The earlier nosologists, however, have laid little or no stress on g^lmi- ' ither the pyrectic or the contagious character of the disease; and ters pay no hence in Sauvages, Linneus, Vogel, Sagar, and Macbride, it occurs ^possess" as a genus under the division, not of fevers but of fluxes, without any ing«onta- - .• e c ■ .... . J gion or notice ot fever or contagion except as a distinctive symptom in some fever. of their species. .The practitioners in warm climates, and even the monographic Dl*Pate i i- • i . n i tot continued a id clinical writers ot our own country to the present moment, are among as little agreed upon the subject of a specific contagion. Pringle, ™°puwd Hunter, Harley, Balfour, and Chisholm, contend strongly for the writers. existence of such a principle—the last of whom asserts that " few diseases are more apt to become contagious."j Johnson, Ballin- gall, Bampfield, and Dr. L. Frank, either deny it altogether or have not met with any instance of it in their own practice. So in the Howie"r late alarming attacks ot this disease in Ireland, it was not regarded late in as contagious at that time at Cork, by Dr. Barry,J or at Limerick Ireland- by Dr. Perston :§ while Dr. Halloran, practising also at Cork,|| observes that it was obviously contagious on many occasions ; Dr. Poole that it was contagious at Waterford ;1I Mr. Dillon that it was the same at Clonmell ;** and Dr. Cheyne, to whom we are indebt- cheyne. ed for the best as well as the most extensive clinical history of this disease that has ever been communicated, that it was at Dublin in some cases contagious, and iii some not: being decidedly so when When con- connected with continued fever; and uncontagious in its simple wheunu*? form, or when combined with an intermittent, tt This last opinion appears to be most reasonable : or at l^ast most This view harmonizes with the present author's experience upon a pretty ex- w°ith°t"itn tensive survey, and especially when the disease has been epidemic *°*"£*cef or endemic. Insomuch that he has felt himself authorized in con- General eluding that as '• during the action of fever produced by marsh- miasm, the effluvium from the living body becomes loaded with miasm of the same kind completely elaborated as it passes off, and standing in no need of a decomposition of the effluvium for its formation ;''|| so, during the action of pyrectic dysentery or dysen- teric fever, the effluvium from the living body becomes loaded with the same kind of miasm or atmospheric contamination that, primarily * Part. I. Book v. Chap. n. Sect, mlxxv. t Climate and Diseases of Tropical Countries, p. 54. 8vo. 1822. X Dublin Hospital Reports, &c. Vol. in. p. 10. 0 lb p 21. i! H»- P- 9- ^ Ib- 1'- 7- lb- P- 5- + + Ut supra, p. '-• H See the present Vol. Corol. 6. p. »5 corollarv. 856* Gen. X. DyBenteria. Dysentery. Bloody- flux. VL. 1U. ILL MATIC A [OllD. Principle parallelled in influen- 'ronic Dysentery of Ireland, &c. Dublin, 1822. | Observations on Simple Dysentery and its Combinations. 8vo. 3 Medical Reports, &c. p. 18. vl. m.j SANGUINEOUS FUNCTION. [okd. ii. 357 It is not always that the disease under this shape is a sequel of Gen. X. acute dysentery, and especially among those who have predisposed tylZl™.' themselves to it by an antecedent life of intemperance. Dysentery ™ody has on this account, of late years, by many writers both at home and i" this form abroad, been divided, as a genus, into the two species of acute and JS2i chronic, the pyrectic form being contemplated as a variety of the primary. acute division ; and as there seems good reason for such an arrange- ment, we shall now proceed to examine it under these two species : 1. DYSENTERIA ACUTA. ACUTE DYSENTERY. 2.---------CHRONICA. CHRONIC DYSENTERY. SPECIES I. DYSENTERIA ACUTA. ACUTE DYSENTERY. FECES DISCHARGEn WITH DIFFICULTY, MOSTLY IN SMALL QUANTITIES, AND ALTERNATING WITH THE MUCOUS OR BLOODY DEJECTIONS ; PAIN OR TENDERNESS IN THE ABDOMEN : TERMINATING WITHIN A MONTH. We have already observed, that the atmospheric temperaments Gen. X. chiefly calculated to produce severe bowel complaints are those ofjf^f• *' summer and autumn: when the liver is excited to a larger secretion complaints of perhaps more pungent bile, from the greater heat of the weather; fluent* In the skin is exposed to more sudden transitions from free to checked sumrne^ perspiration ; and the exhalations that rise so abundantly from tumn; marshes and other swamps, too often give an epidemic character to the atmosphere, and lay a foundation for intermittent and remittent fevers : and we may hence see why dysenteric and other bowel affec- vvhy ie« tions, like intermittents, were far more common in our own country nowThan about a century ago than they are at present; the soil being more f°rmer,y- generally drained, and the atmosphere less humid. We have here also sufficient ground for local and general affec- and hence tion, and may readily see how it is possible, from the operation offnthe^Lme one of these causes singly, or of two or all of them jointly on an seasons. irritable state of the intestines, for all or any of the local symptoms to be produced which enter into the generic or specific definition of the disease before us ; as also how it is possible for these symptoms alone or to be combined with fevers and other disorders of various kinds and ^ J^ various degrees, so as to render the complaint peculiarly complicated diseases. and dangerous ; though we have not yet been able to find out what are the precise causes that, operating locally, produce the distinctive symptoms of dysentery rather than those of diarrhoea, cholera, or any other irritation, or spasmodic action of the intestinal canal. This may, perhaps, sometimes depend upon idiosyncrasy, sometimes upon accident, and, in the severer cases, upon contagion or a spe- cific miasm. 3d# cl. in.] UiEMATICA. |OKD. K Gen.X. Spec. I. Dyscuteria acuta. Acuto dys- entery: General beat of the disease. Sometimes one part more af- fected than another; and hence disputes concerning its imme- diate seat. Ordinary exciting cause, sup- pressed perspira- tion from cold. Its action illustrated by that of rheuma- tism and catarrh. The symptoms, however, already noticed sufficiently point out the general seat of the disease : the tormina or griping pains, the region most affected by them ; and the costiveness or nodules of feces that are dejected, the existence of spasmodic constriction in or about the colon or the upper part of the large intestines. And while such is the state of the canal above, the excessive straining or tenesmus, accompanied with a discharge of simple or bloody mucus, shows, as distinctly, the existence of great irritation in the sphincter or its vicinity. In some cases one of these parts is more affected, and in some another ; and hence the origin of most of the disputes con- cerning the precise spot of the disease, which have long occupied so much of the attention of the medical community. The ordinary exciting cause, however, of acute dysentery, under all its varieties of fixation, there can be little question, is suppressed perspiration or a sudden chill applied to the surface, acting in con- junction with the predisposing cause of an atmosphere varying rapidly from heat to cold and from moist to dry ; but by what means this exciting cause operates upon the larger intestines rather than upon any other cavity, or produces the symptoms of dysentery rather than those of diarrhoea, cholera, or cholic, we seem to be incapa- ble of determining. We perceive, however, in the events of every day, that sudden chills on the surface are possessed of a revellent power, and throw the action which is lost on the skin on various internal organs, and especially on cavities of mucous membranes, which, in consequence of this excitement, become inflamed, and pour forth an additional secretion. Such is especially the case in rheumatism and catarrh, both which terms are derived from the same Greek root, and import defluxion. And from thiscommon character the three diseases have by some pathologists been conceived to be so much alike, that dysentery has been regarded as an intestinal rheumatism by Coelius Aurelianus, Akenside, Stoll, and Richter ; and is actually set down, by Dr. Parr, as a species of catarrh, in his nosological classification. We also see why dysentery, like catarrh, may be either sporadic or epidemic ; as also why, in each case, it may be either slight, and pass off without any serious evil, in a few days, or accompanied with great inflammatory action and continued fever : thus giving ri^r to the two following varieties : x Simplex. Simple acute dysenterv, Feces often discharged without considerable pain ; of a natural quality and affording ease : abdominal tenderness unheeded. Stools frequent; in every way di- versified, both in colour and consistency : severe pain in the abdomen; fever considerable. mostly a synochus. These are the two varieties Under which acute dysentery is de- sTrFenham. scribed by Sydenham, who indeed limits himself almost entirely to a Pyrectica. Pyrectic dysentery. Dysenteric fever. Thus ar- cl. m.j SANGUINEOUS FUNCTION. [ord. n. 359 these forms of the disease, since though he notices the second spe- Gkn. X. cies or chronic dysentery, he merely glances at it in a kind of post- rfv^ueria script to his chapter. Yet his description concerning both these is ^u,a-d so accurate, and the author is not afraid to add, his general mode of emery. y" treatment so judicious, that we shall find in the prosecution of this subject, both have been supported by the concurrent practice of the most approved pathologists from his own day to the present. As the local inflammatory action is more usually traced in the cr°'?"1i1tis '•olon than elsewhere, Stoll, and various other writers have fixed ail. upon this intestine as its proper seat; and hence Dr. Ballingall has distinguished it by the name of colonitis. A nearer approach how- ever to the present general arrangement will be found in Mr. Bamp- field's valuable treatise,! though the complicated subdivisions of Sauvages seem to be here unnecessarily revived and imitated. It has been already observed that in dysentery although the ^"^^ primary seat of inflammatory action is the intestines, yet the tunc- and liver tions of the skin and of the liver are from the first, as well as ,aheesaemea throughout the whole course of the disease, considerably disturbed time. by sympathetic excitement. The liver, however, suffers in many instances not only on this account, but from a continuous spread of the inflammatory action through the medium of the biliary ducts, and becomes injured in its organization as well as in its function. Some pathologists, as Dr. Chisholm, conceive that they can trace this ex- tension ofthe inflammatory process to the liver by particular symp- toms, as a fixt pain at the stomach, a constant heat-ache, and fre- quent dejections at the commencement of the disease ; and they jjj£j££y have consequently given us a distinct division of it under the name of chis-' of hepatic dysentery. It is sufficiently ascertained, however, that °ra' the structure of the liver has been often considerably affected and even destroyed, when neither these nor any other peculiar symptoms have presented themselves ; and hence it is a distinction which can be made no use of. A frequency of dejections at the commencement is rather an anomalous fact than a pathognomic sign : while as to the other two indications it is admitted by Dr. Chisholm himself that they are " apparently not characteristic symptoms ;" in other re- spects, says he, u the disease does not seem to differ from the idio- pathic or common dysentery." Some writers, however, as Piso| formerly, and Dr. James John- son in our own day,§ have carried this view of the subject considerably farther than my late learned and venerated friend Dr. Chisholm ever intended ; for they have boldly reversed the general opinion that has Doctane prevailed, and especially since the days of Sydenham, and contended ^erf«™ that the liver itself forms in every instance the primary seat ot the set/of • disease, the intestines being only affected secondarily. Whence the dj^« latest of these two distinguished authors has ventured a scon at the that of sy- pathology of Sydenham, " who," says he, « it is our firm belief d<*tam- never examined a dead body after he left his academical studies ;— t Aa^i2&T»ti^P«2S55il Dysentery, more particularly as it occum in "** g£!5£ la Nature, fee. des Maladiesacconirag- *« de Dysenterie, 1623, ^Influence of Tropical Climates, &c Ldit. m. p. 197. 360 cl. m.j HiEMATICA. Lord, ii Gen. X. Spec. I. Dyeentcria acuta. Acute dys- entery. Sydenham illustrated. Shown to be in coin- cidence with the best opin- ions and at least he has given us no indication of pathological knowledge in any of his works."* I value Dr. Johnson's friendship, and have an equal value for his talents, but I cannot concur with him in thus tearing from the tern pies of an illustrious countryman the wreathes of honour he has so deservedly earned, and which have been bestowed on him by our best foreign as well as domestic judges, from Boerhaave and Sauvages. in the middle of the last century, to the younger Frank in the pre- sent day. His language indeed is tinctured with the prevailing errors ofthe humoral hypothesis, which at that period it was impos- sible altogether to avoid, and which is again rising into notice in some quarters ; but sifted of this, his pathological doctrines are those of the present day, to which in the main they have given rise ; and better stand the test of dissection than those of Dr. Johnson himself. " His observations," says Dr. Bostock, will be commonly found to be correct, although his hypotheses are too often fallacious."t These " observations" teach us in a few words, that dysentery is an inflam- matory affection of some part of the larger intestines, which in its idiopathic and milder state, subsides without serious evil in a few days; but which, occurring in the autumn, is apt to associate itself with whatever febrile epidemy is then prevalent, to become a far more important and complicated malady, and to ravage over a much larger field of organization ; the fever aggravating the dysentery, and the dysentery the fever ; while, not unfrequently a metastasis ensues and the fever is thrown upon the intestinal canal, and expends its violence topically: during which vehemence of action a peccant material (the contagious principle of Dr. Cullen,) is elaborated in the constitution and thrown out on the surface. To oppose all which, he lays down a therapeutic plan which evinces an equal de- gree of judgment; and consists in bleeding, purging, diaphoresis, and opium ; in other words in taking off congestion, and inflamma- tory action, in allaying irritation, and restoring to the circulatory system its proper balance. It may perhaps be said by some modern writers that he did not always carry these principles far enough. Possibly not in every instance: but this must altogether depend upon the severity of the disease. And we have a proof, in his own success, that he carried them far enough in general; while his great merit consists in the establishment of such principles ; and in squaring a correct line of practice to a correct pathology. It may also be objected that calomel does not appear to have entered into his list of deobstruents. That he did not use it among other cathartics, shows, evidently, that his cathartic catalogue might have been im- proved ; but to have employed it as a sialagogue, and to have depended upon curing the disease, almost exclusively, as his loudest opposers have endeavoured to do, by ptyalism—however valuable such a process may be in a few instances— would not I fear have added to his reputation or increased the number of his followers. Had the animadversion, indeed, which I have thus felt it my duty to notice been delayed but a few months, it is most probable that it * Medico-C hiring. Rev. Mar. 1823, p. 880. t Elementary System of Physiology. Vol. i. p. 448. 8vo. 1824 CL- III.J SANGUINEOUS FUNCTION. [ord. ii. »J61 would not have been advanced at all. For whilst the learned writer Gen. X. who has made it, had already to struggle with perhaps a majority of £™£ the most judicious tropical writers, in denying the existence of con- «• tagion at all times, and regarding the very opinion as absurd ;* he c\Zy. ys* would have found in the admirable treatises on dysentery which have ?£".£!?*[ since been furnished us from Ireland, not only that this opinion, as day! already observed, seems to have a firm foundation under particular circumstances ; but that his favourite doctrine that the liver is the primary seat of the disease, is completely unhinged ; as also that his favourite plan of treatment has as little succeeded here, as it did in India under Dr. Ballingall, or as Dr. Frank informs us it did in his hands in Egypt during the occupation of that country by the French army. The diagnostics of the first variety, or simple acute dysentery, aD- acuta unaccompanied with the prevailing fever of the season, are thus Simple* accurately laid down by Sydenham : dysentery. " But frequently there is no appearance of fever ; for the host of Diagnostics gripings take the lead and the dejections follow. The gripings are ham; " always severe, and a sort of painful descent of the bowels accom- panies every evacuation. The discharges are chiefly mucous, but an excrementitious stool sometimes intervenes without considerable pain. The mucous stools are generally streaked with blood ; but in some cases there is no such appearance through the whole course of the disease. Nevertheless, if the stools be frequent, mucous, and accompanied with gripings, the disorder may as justly be called a dysentery as if blood were intermixed with them." These constitute the ordinary symptoms of the simple variety. And to the same effect Dr. Cheyne, t; when dysentery was uncon- Ho£d1*: ... „ i-i , v. . scribed by nected with continued fever, which apparently was often the case, cheyne. there was nothing peculiar in its origin. The patients generally assigned cold, damp, fatigue, hardships, indigestible food, as the causes of their disease, which began with confinement ofthe bowels, chills, pyrexia, tormina, unsatisfactory stools and tenesmus."t It is correctly observed by Dr. Chisholm, that, " when after the straining has continued for a few days, the stools are intermixed with blood, the blood never thoroughly combines with the slime or mucus so as to produce a uniform colour,"^ but as Sydenham observes, " ap- pears distinctly or in streaks." It is remarked by several of the practitioners in India, and espe- Bampfieid. cially by Mr. Bampfieid, that the dejections are more frequent during the night and especially towards morning than at any other period of the twenty-four hours : and that the attacks and relapses of the Said to be disease are more common at new and full moon than at any other Jo^'m by period of the lunar revolution : and the influence of the heavenly lfluuneanrcien- bodies is referred to as the cause of these peculiarities. The remark does not seem to be sufficiently established ; but if it should here- after be found to hold generally, Mr. Bampfield's intermediate mode + Influence of Tropical Climates. Edit. hi. p. 223. t Medical Reports of the Whitworth Hospital House of Industry, containing an Account of Dysentery, &c. By J. Cheyne, M.D. &c. Dublin Hospital Reports, Vol. in p 18. i Climate and Diseases of Tropical Countries, p. 64. Vol. H.—46 3t>2 LJL. 1II.J 1LEMAT1CA LORD. D. acuta simplex. - Simple acute dysentery This doc- trine ex- plained. Gen. X, 0f accounting for such influence is somewhat soberer than the limrif- S*KC:J: diatc action more commonly brought forward. "The periods, says he, " of dysenteric attacks and relapses I have observed to be more common at the plenilunar and novilunar periods, than at the interlunar intervals. But whether the increased attraction of the moon, at the change and full, has any direct power in producing diseases, I believe will never be satisfactorily determined : and, not- withstanding the ingenious hypothetical explanations of Dr. Balfour. Dr. Darwin, and others, I am induced to conclude that it has only an indirect influence or power by the changes which it occasions at these periods on the atmosphere and winds : for the prevalence of fresh winds, strong gales, and showers of rain has been observed to be much greater at these periods ofthe moon, than at the interlunar intervals. And these, by checking perspiration, produce effects in the constitution excitive of many acute diseases, which have been in part ascribed to the direct agency of lunar attraction in the fluids of the body, by supposing that it decreases the gravity and diminishes the stimulus of the particles of the blood."* Progress of In its most favourable course, the symptoms gradually subside in ihe disease. ft weejc or ten jays, and sometimes even sooner, the skin becoming soft and moist, and the circulating fluid recovering the natural free- dom of its current. If the symptoms augment, all the local mischief of ulceration and gangrene follow, which we shall have to describe presently, or the disease will become chronic In the second variety or dysenteric fever, as it is called by many writers, all the preceding symptoms are highly aggravated, P D. acuta pyrectica. Py Pyrectic Dysenwnc ant* otners are superinduced by the action of the fever itself. fever. When chiefly occurs. The preceding variety may occur at any season of the year, though, for reasons already stated, the disease under every form, is most frequently to be met with in the estival and autumnal months : it is very rarely, however, that the pyrectic variety is to be found in any other than these two seasons ; nor even in these unless there be some endemic or epidemic fever prevailing, with which dysentery can combine. Apt to com- Of its readiness to do this, and even to convert almost all the any pre- other diseases of the season into its own form, so forcibly pointed fever.' out by Sydenham, the late ravages in Ireland have furnished us with illustrated, the most undeniable proofs. " The bilious fever of the autumn," says Dr. Cheyne, " continued till near the termination of winter, con- sequently it existed as long as the dysentery was prevalent in the hospitals in the House of Industry, or the symptoms were often ex- changed for those of dysentery, the irritation from the mucous mem- brane of the stomach and small intestines probably extending to the large."! And again, " dysentery was sometimes converted into fever, while, vice versa, fever was converted into dysentery :—In short, these forms of disease were convertible the one into the other; so that the opinion of Sydenham, that dysentery is a febris introversa or turned in upon the intestines, received support from our observa- * Practical Treatise on Tropical Dysentery, more particularly as it occun in the East Indies, &c. By R. W. Bampfieid, &c. 8vo. 352. 1819. * Dublin Hospital Reports, Vol. in. p. 17, i thatdysen- otner diseases, and especially fevers, or to convert them into its own tery is a nature, that many pathologists of considerable name have regarded jjomfo'the'r it as nothing more than fever with a peculiar " local mode of action," complaint to adopt the language of Dr. Jackson. And they hence endeavour Jackson. to show, that when dependent upon a cause of endemic fever, it is often intermittent; when dependent upon a cause of contagious fever, it is contagious ;J and when dependent upon a cause of ty- phous fever, it is malignant or putrid ;—in the language of Dr. m"grB\dnal Balfour, as applied to the dysentery of India, a "putrid, intestinal, remitting remitting fever.''§ {jeav,efou°> Most of the French writers of the present day describe dysentery Often a as essentially an atonic or adynamic disease, and hence peculiarly at0ny. apt to fall into this last form ; and Dr. L. Frank represents this as • the form it assumed with little deviation among the French Army in Egypt, and believes it to be the ordinary form of hot climates.|| And we can hence see, where there is much fibrous debility with ^^wlth but little fever, and especially where this is produced by poverty of scurvy of diet, that it may occasionally connect itself with that kind of scor- MiUwnk butic affection which has lately appeared among the convicts of the Pcniteutia- Milbank Penitentiary, and lay a foundation for such a form of the The dysen- disease as was long ago denominated dysenteria scorbuticaby Cirigii bcurt,iaCaC0T and Brambilla,1T and has been distinguished by the same name in cirigii and our own day, by Mr. Bampfieid.** The last writer, indeed, gives us [nfi»mina- also an opposite modification of the disease under the name of |»rrJ '^en- dysenteria infiammatoria, which the reader will now have no diffi- culty in accounting for after this general view of its accommodating power. In the pyrectic variety, therefore, the fever is found to vary ac- *J««»|e cording to the diathesis or surrounding circumstances. The func- described. tions of the liver and skin are disordered from the commencement, and continue so till the termination. In the dysentery at Dublin, in J^Sm the autumn of 1818, the skin was obstinately dry, hot, and pungent; Dublin. and, "judging," says Dr. Cheyne, " by the appearance of the stools, ^ the biliary secretion was often suspended for many days."tt Scybala |^ye^ar were here never found in the discharges, nor often in the intestines ; discharged * Dublin Hospital Reports, Vol. in. p. 10. t lb. p. 16. 1 Jackson Hist, and Cure of Fever, Endemic and Contagious. Part I. Ch. »H. \oa * °n Sol-lunar Influence, p. 17. ^Iirnnsnlt lix T. H. p. 135. 1T Phlegm. Tom. n. p. 337. S*C^J!;dT«atieoPn Tropical Dysentor/.&c. 8vo. 1819. + t Chevne, ut supra, p. 2.'. db'l CL. 111.} 1LEM.VT1CA. [own. ii Gen. X, Spec. I. ft D. acuta pyrectica. Pyrectic dysentery. Their occasional formation accounted for. Dejections complicated of all ma- terials. Progress of the disease. Sometimes pure blood discharged. Sometimes gangrene. and they by no means appear so frequent as have been represented by many writers ; insomuch indeed, that it has of late been doubted by some authorities, whether they are ever to be traced at any time. or in any country. Dr. Johnson has freely imbibed this doubt :* Dr. Ballingall tells us that "it is comparatively a rare occurrence in India :f while Dr. Chisholm speaks of them, on the contrary, as an ordinary symptom, and particularly adverts to the case of one patient under his care, who, " on the tenth day of the disease, after a paroxysm of excruciating torture, attended by cold sweats and deliquium, spontaneously discharged at three evacuations a quantity of scybala sufficient to fill a common sized chamber-pot."f There is hence no reason to question their occasional formation, notwith- standing they are rarely to be traced on many occasions in the dysentery of any climate : their production indeed is easily accounted for from the spasmodic constrictions which so often run through a very considerable range of the intestines ; and there is hence, prima facie, more reason for anticipating than for not expecting them. Mr. Pack, who had formerly witnessed them in the Medi- terranean, was surprised at not meeting with the same appearance at Kilkenny, in the epidemy of 1818, and could not avoid adverting to the dissimilarity of the disease in this respect in these distinct quarters. § The patient on going to stool, whatever be the discharge that ensues, has always a feeling of something remaining in the bowels which ought to be dejected ; while the dejections themselves, accord- ing to the extent and violence of the inflammatory action and its effects, evince every combination of materials: being, in consisten- cy, watery, like beef-washings, slimy, mucous, purulent, bloody ; in hue, drab-coloured, like flummery, bright-green like conferva, and, after opium and calomel, deep-green; sometimes pitchy,|| and ex- tremely fetid ; and sometimes loaded with shreds of detached mem- branes ; while occasionally a feculent motion is thrown down, of a natural colour, and nearly of a natural spissitude. Meanwhile, to adopt the description of Sydenham, the strength is much exhausted, the animal spirits dejected ; there are all the signs of an ill-condi- tioned fever; intolerable sickness and excruciating pains, and a deadly coldness of the extremities. Insomuch that the disease in many instances, and especially when unskilfully treated, endangers the patient's life much earlier than in most other acute diseases. But if the patient should escape death in this way, still numerous symptoms of a different kind succeed. Sometimes in the progres?- of the disease, instead of the membranous shreds which are usually mixed with the stools at the commencement, pure blood, unmixed with mucus, is profusely discharged at every evacuation, which of itself threatens death, as manifesting an erosion of some of the larger vessels of the intestines. Sometimes a fatal gangrene seizes the ♦Johnson, Influence of Tropical Climates, &c. p. 223, et passim. t Practical Observations on Fever, Dysentery, and Liver Complaints, &c. 2d edit. r ??'J.?23' * Climate and Diseases of Tropical Countries, &c. p 56. § Dublin Reports, &c. ut supra, p. 20. (1 O'Krien on Acute and Chronic Dysenterv. p. 5P. cl. 111.] SANGUINEOUS Fl NCTION. [okv. ii. 365 intestines in consequence of the inflammation being aggravated by Gen.X. an afflux of hot acrid matter to the affected parts. Towards the / "£„£ close of the disease aphthae frequently affect the interior of the pyre'ctica. mouth, and generally foreshow imminent death. djSy. These symptoms are confirmed by practitioners in every climate. APhthae- Dr. Chisholm, alluding to the aphthae that so frequently precede the Aptbs. final stage, observes, very justly, that they are produced by an ex- r^Tby tension of the inflammation from the intestines to the stomach, and Chiahoim. even the fauces ; during which, instead of an increased secretion of mucus, there is an increased " exudation of lymph which assumes the appearance of little granulated masses, under and around which inflammation discovers itself with a bright florid colour."* The rapidity with which acute dysentery, when connected with ^g*1)^ fever, rushes on to destruction, more so indeed than in most other acute diseases, is particularly noticed by Dr. Cheyne, who ascribes the fatal issue in this case to the violence of the fever itself rather than to the proper dysenteric symptoms : though he adds, that some- times sudden death ensued from an escape of the contents of the intestines into the cavity of the peritonaeum, in consequence of ulceration.! The afflux of hot acrid matter alluded to by Sydenham is not .Af?ux ?.f i i ■ i /• ii- i • t i ■ i hot acrid unfrequently derived from the liver, and indicates a very morbid con- matter. dition of this organ ; and to the same effect Dr. Johnson ;—" We sometimes see a partial ill-conditioned sweat on the surface, which is productive of no benefit: while from the liver an occasional gush of vitiated bile, like so much boding lead, throws the irritable intes- tines into painful contortions, and then the tormina and tenesmus are intolerable."! There is occasionally, at this time, a formation Sometimes of black vomit, the stomach discharging frequently a dark fluid, vomit. with a precipitate like coffee-grounds.§ Dr. Chisholm observes that the signs which chiefly show us that Whether the disease has extended to the liver are, a " pain at the pit of the catlvenof stomach, and a head-ache, a considerable anxiety at the prsecordia, 1(1^$™ and a sensation as of a continued pressure in the right hypochon- driuni, with frequent stools, composed of a fluid like the washings of raw meat."|| But he admits, as we have already noticed, that these are not idiopathic, and consequently are not to be depended upon for this purpose. They prove, however that the disease has made an extensive inroad upon the constitution. Yet there are not Sometimes unfrequently signs that it has extended still further, and that the lungs affected^ themselves are affected, not merely in their function, but in their structure : for the respiration, observes Dr. Cheyne, was sometimes suddenly suppressed in the advanced stages ; there was pain in the chest, a teasing dry cough, showing a translation of the disease to the lungs; an exudation of puriform mucus in the cavity of the bronchia, being detected on dissection.If " A harsh, dry, opake, dirty-looking skin ; a florid, clear, var- JjJ»{ P"*- nished tongue ; vigilance ; a hollow eye, and pallid, wasted, faded * Climate and Diseases of Tropical Countries, p. 62. f Vide supra, p. 20. I Influence of Tropical Climates, ut supra, p. 194. S Dublin Hospital Reports Vol. m. p. 32. II Vhx supra, p. 59. V Sunr:., p. 25. 366 cl. m.] II.EMATICA. |ord. ii- Gen.X. Spec. I. ft D acuta pyrectica. Pyrectic dysentery. Mortality often dreadful. Post-obit examina- tions. Chief seat of disease in the intestines. Affected in various ■ways. Disease long and severe when the coats are thickened. This effect chiefly in the colon. cheek ; pains in the knees ; cramp in the legs ; fits of dyspnoea ; tendency to edema and ascites—belonged to the more advanced stage, but not to the last; which was characterized by extreme emaciation, supine posture, involuntary stools, a thin reddish secre- tion, flowing without check; sordes on the teeth ; hiccough, ten- dency to delirium ; difficulty of swallowing ; thread-like pulse."* The mortality is often dreadful. At Clonmell, in 1818, where however it was far less severe than in many other parts of Ireland, Mr. Dillon calculated the deaths at one in ten ; at Cork, during the same year, Dr. Barry estimated it at one in three at the least. " I never," says he, " witnessed so fatal a disease." And to the same effect, in general terms, Dr. Cheyne, while practising at Dublin : " I had often witnessed obstinate cases of dysentery, but I had not formed an adequate conception of the horrors of that disease, until I saw the patients who were congregated in the wards of Whitworth Hospital." Post-obit examinations were made in the dissecting room of this hospital upon a very extensive scale, and gave evident proof, first, that the primary and chief seat of the disease was the in- testines ; though the liver often participated in the general lesion; and, secondly, that the intestinal canal was very variously diseased, according to the length or severity of the attack, or the peculiarity of the patient's constitution. In some cases the canal was prodigiously distended ; in others the coats were greatly injured, but without any thickening; in others again they were considerably thickened, as well as otherwise dis- eased. Where distention prevailed, the small intestines were, in a few instances, found to be not less than seven, and the large not less than nine, inches in circumference. Where the intestinal coats were without incrassation, the inflam- mation of the mucous membrane was sometimes still very extensive, and reached from the stomach to the rectum ; being however more obvious as the larger intestines were approached ; though occasion- ally this last intestine was still pretty sound for three or four inches above the sphincter. The mucous membrane was sometimes in- creased in vascularity without abrasion, or ulceration ; sometimes covered with coagulable lymph ; sometimes simply abraded of its epidermal coat; sometimes partly ulcerated, and irregularly exposing the muscular coat; the intervening portions being of a natural appearance. Where the intestinal coats were thickened, the mischief seems to have been generally more severe ; the internal surfaces were often rugous as well as ulcerated, exposing the muscular fibres more ex- tensively, which often hung in shreds as if sphacelated. The pro- cess of thickening, moreover, belonged to the more protracted cases, and often measured the duration of the disease.! This incrassation is traced chiefly in the colon, which Dr. Chis- holm has found sometimes a quarter of an inch thick and full of * Supra, p. 23. + Medical Report. &c. p. 28. 34. ' l. m.j SANGUINEOUS FUNCTION. [okd. ii. 367 minute abscesses, and small steatomatous excrescences.* These last Gen. X. appearances are particularly noticed by Dr. Cheyne, but described /"£,£ differently ; " they are not," says he, " small ulcers, but minute pin- pyrectica. holes formed out of the enlarged ducts of mucous glands ; they were dysentery. found very numerously, but especially in the rectum, and lower part of the colon." By Dr. Baillie they are described as excrescences resembling warts.f " The livek," says Cheyne, " in a majority of cases was sound, Liver com" but often otherwise. In two cases there were abscesses ; and in many sound but great sanguineous congestion."\ To a like effect Dr. O'Brien, ^£olher" writing from the same capital at a later period : " Generally," says he, " the liver was unaffected ; though the gall-bladder was always distended with deep-brown, or dark yellow bile."§ But these ap- pearances were particularly observed by Dr. Chisholm in the West Indies, thus again harmonizing the nature of the disease in climates of different temperatures. " Where the colon was thus diseased it was prodigiously distended with air. All the rest of the intestinal canal wa3 healthy, the liver was equally so, but the gall-bladder was of a most uncommon size and full of yellow bile."|| The same undeviating show of mischief in the intestinal canal, with only an occasional appearance of morbid structure in the liver occurred to Dr. BallingaU in India, and to Dr. L. Frank in Egypt: so that the real source of the disease can be no longer a matter of doubt. " The dissection of every subject," says the former, " who died of dysentery in the regimental hospital of Penang (with one solitary exception,) proved the disease to consist entirely in an inflammatory affection of the large intestines, without a trace of disease in the structure of the liver."IT The medical treatment of Dysentery has given rise to much Medical warfare of opinion. Not however in slight cases of the simple acute disease ; for such usually give way in a short time to the ordinary evacuants and sedatives. "In cases," says Dr. Cheyne, " not Practice of attended with much fever or pain, and in the first few days of dis- cheyne- ease, a purgative in the morning, ten grains of Dover's powder in the afternoon, and again at bed-time, with low diet, restored many."** Sydenham generally commenced with bleeding, gave an opiate at ^/den" night, and a pretty active purgative in the morning ; the purgative consisting of a drachm and a half of rhubarb, two drachms of senna, with half an ounce of tamarinds infused in a sufficient quantity of water, with manna and syrup of roses. The purgative was repeated twice every other day, in every instance followed up with an anodyne of sixteen'or eighteen drops of his own potent laudanum after every purge, to take off whatever additional excitement the purgative might produce ; and he constantly gave the same anodyne with a * Climate and Diseases of Tropical Countries, p. 56. t Morb. Anat. Fascic. iv. PI. m. p. 73- X Medical Report, &e. p. 36. § Observ. on the Acute and Chronic Dysentery of Ireland. Dub. 1822. II Climate and Diseases, &c. p. 57. ...«•..• n flPrSal Observations on Fever, Dysentery, and Liver Complaints, &c. By GeorgeBaUmX M.D. F.R.S.E. &c. Second Edit. 8vo. Edinb. 1825. ** Medical Report, &c. p. 42. 368 cl. m.j 1LEMATICA. |_ouu. u Gen. X. Spec. I. Dysenteria acuta. Acute dys- entery. Medical treatment. His princi- ple not easy to be improved upon. How far bleeding advisable. How far calomel: and mer- curial fric- tion, so as to produce ptyalism. Great con- flict of opi- nion on this subject. warm diaphoretic every night and morning even on those days when the aperient was not employed. Where this was insufficient the sedative was repeated every eight hours to the amount of twenty-five drops at a dose, and a perspira- tion was still further attempted to be promoted and maintained by drinking freely of whey or the white decoction, and the use of warm emollient injections ; the perspiration being continued for at least twenty-four hours at a stage, the only beverage allowed in the mean- while being tepid milk. He tells us that the tormina and bloody stools usually gave way after the third or fourth injection. But where the morbid secretion ran into a chronic character he varied the form and intention of the injection ; and with a view of introducing a new and less unhealthy action, compounded it of half an ounce of Venice turpentine dis- solved in a pint of cow's milk, which was thrown up daily ; thus anticipating, in a very considerable degree the modern practice of obtaining the same effect by the balsam of copaiba, which is only u terebinthinate of another kind. The principles of this practice it is not easy to improve upon ; though they have since been modified and often extended with con- siderable advantage. As a general rule the lancet was had recourse to with too much timidity ; though its present indiscriminate and lavish employment forms an extreme that ought equally to be avoided. Where the fever is considerable, the pulse hard and full, and particularly where there is much general pain and tension over the belly, indicating an inflammatory diathesis, blood should be drawn copiously and with all possible speed, and repeated as long as the same symptoms may require; for here we have no time to lose ; the inflammation may run rapidly into gangrene, and the patient sink from mortification or loss of blood in a day or two ; perhaps in a few hours. There is nevertheless no disease that requires the exercise of a sounder judg- ment upon this point than dysentery ; as the fever, if not typhous from the first, has a general tendency to pass into this type ; and the inflammation is perhaps of the erysipelatous kind. In his cathartic plan Sydenham would have been considerably aided by the use of calomel; of all the purgative deobstruents the most valuable ; and the more so as exercising its evacuating power over all the secernents of the body. It has of late, indeed, been very extensively employed in a very different way, and for a very different object; that I mean of curing by a specific action upon the immediate seat of inflammation; being persevered in for this purpose in doses of from five or ten to twenty or twenty-five grains two or three times a day ; assisted, where there is much torpor ofthe absorbents, by mercurial friction, and continued till ptyalism is pro- duced, which, as in the case of yellow fever, is the alleged test that the constitution is sufficiently loaded with it, and that the disease i> about to give way. It is impossible to contemplate the conflicting opinions which are given us respecting this mode of treatment by the monographic writers on tropical diseases without astonishment: and the onlv ll. m.j SANGUINEOUS FUNCTION, (okd. ii. 361* mode of reconciling them is, to suppose that the constitution is very Gen. X. differently affected by the use of mercury, under different circum- D%Enct;rf; stances ; and that while in some epidemics and sporadic cases it acuta. produces all that benefit which a priori we should expect generally, tS%?** in others it entirely fails, or even proves mischievous. Dr. Jackson, MedicaI Dr. Balhngall, and Mr. Bampfieid feel justified in employing calomel merely as a purgative ; while the second, though he regards it as of the highest importance in chronic dysentery, found even ptyalism itself unsuccessful in the acute form. t Dr. Johnson esteems it of high importance as a purgative, but of the utmost moment as a sia- logogue. He unites it occasionally with bleeding, with anodynes, with diaphoretics, or with all; but each of these is subsidiary to its powers, and may often be dispensed with.* Mr. Cunningham, late surgeon to the Sceptre, in the East Indies, boldly employs it alone, and regards every thing else as impeding its course. He does not even stand in need of alvine aperients of any kind, and prefers scruple doses to smaller proportions, because it does not in this form so readily excite the alvine discharge, so as to be carried out of the system by stool: and administered in this way, he fearlessly asserts, and the tables of his practice seem to justify his assertion, that " it is an almost certain remedy for dysentery, in hot climates at least." And, finally, for it is not worth while to pursue the discrepancy further, Dr. L. Frank assures us that in his practice the large doses of calomel given so generally by the English surgeons in India, proved dangerous in the French army in Egypt; and that the plan most successful in his hands was that laid down by Sydenham, which consisted, says he, In removing irritation by gentle aperients, the use of emollient injections, mucilaginous and diluent drinks, diaphore- tics, and laudanum. Laudanum. The boldest part of Sydenham's plan indeed was his free use of Free use of this last medicine. Even this, however, has been occasionally car- denhanT ried further in our own day : but it should be recollected that Syden- ham's liquid laudanum, was much stronger than the present officinal tincture of opium, his dose of twenty-five drops ofthe former being just equal to forty drops ofthe latter, provided the drops were ofthe same bulk ; but as this is not the case, the laudanum of Sydenham, measured by drops, must have been of more than double the strength of that of the present day : and his three doses of twenty-five drops in the twenty-four hours, have equalled at least a hundred and sixty drops of the latter. And hence, even as he employed it, there can he no doubt of its having, in very numerous instances, proved a powerful and efficacious medicine. Sydenham, however, employed it as a cordial and diaphoretic as well as a sedative ; so as to take off that fearful depression of the animal spirits by which dysentery is so peculiarly characterized, and to give a breathing moisture, and consequently a refreshing coolness to the parched and burning skin, as well as to allay local irritation ; his chief auxiliaries for the last purpose being diluents, tepid injec- tions, and the warmth of the bed. Modern practice has greatly {$««£, * Influence of Tropical Diseases, &c. p. 202 Vol. II.--47 610 CL. ill. ILEMAT1CA. [uKD. II. Gen.X. Spec. I. Dysenteria acuta. Acute dys- entery. Medical treatment. Kinetics. Dover's powder. Host mode of adminis- icring' Dover's powder. Flannel swathe. Singular sudorific plan men- tioned by Darwin. improved upon this plan, by combining some relaxant with the opium ; and, in many instances, by premising an emetic, which, independently of its often exciting a perspiration which nothing else can accomplish, has the additional benefit of emulging the meseraic or mesenteric vessels by the act of vomition. The antimonial pre- parations form the best emetics for this purpose, whether the glass of antimony, at onetime so powerfully recommended by Sir George Pringle,* tartarized antimony, or Dr. James's powder. Sir George Baker, Dr. Adair, and Dr. Saunders, concurred in strongly recom- mending the emetic tartar as a diaphoretic or relaxant; the first alone, the second with calomel, and the third with opium : all which, nevertheless, have in our own day, often yielded to Dover's powder, which is'certainly entitled to a very high degree of praise for the present purpose. Much, however, of the benefit to be derived from Dover's powder, as a sudorific, depends upon its proper administration, and the care taken to co-operate with its influence by a proper adjustment of clothing. For this purpose Dr. Cullen lays it down as a rule, that it should be given in the morning, when the ordinary sleep, or term of sleep, is over ; " For sleeping," says he, " though not incompa- tible with, is commonly not favourable to, sweating." This, how- ever, would be, in many instances, to lose much time ; and we must always begin as soon as we have it in our power. There is more importance in another part of Dr. Cullen's course, that no drink should be taken into the stomach till some degree of sweat breaks out, lest the powder should be thrown up by vomiting. Beyond which he recommends that the covering on the body generally should not be more than is merely consistent with the intention of sweat- ing ; in many cases not more than is ordinarily made use of; but that some considerable addition should be laid over the feet and legs ; and that if the sweat should not, by these means, extend to the extremities, boiled bricks or bottles filled with warm water should be applied to the soles of the feet: and further, that, as the heat and perspiration advance, if the patient feel himself too hot and rest- less, whatever additional covering has been put upon the body gene- rally, and even a part of what has been put upon the lower limbs, should be withdrawn by degrees. He also advises that the patient should, from the first, be wrapt in a flannel shirt and laid between the blankets alone, by a removal of the linen sheets, so that he may be surrounded by nothing but a woollen covering. Mr. Dewar's recommendationf of a broad flannel swathe or cumberband bound round the abdomen, is, however, better entitled to practice, as it affords support as well as warmth: on both which accounts Sir James M'Grigor tells us he has found it very useful.! Dr. Darwin amuses us with a singular mode of producing the same result, and one which, if continued long enough, might pro- bably prove as powerful a revellent as any of those already noticed. but which we should not always recommend, nor find our patients * Edinb. Med. Essays, Vol. v. Art. xv. t Observations on .Diarrhoea and Dysentery, as tho?e Diseases appeared in the Bri- ■Ni Amy in Egvpt in 1607, i Sledico-Chir. Trans, vi. 433 ex. m.j SANGUINEOUS FUNCTION. [ord. ii. 371 disposed to carry into eftect. " Two dysenteric patients," says he, Gen. X. " in the same ward of the Infirmary at Edinburgh, quarrelled and ny^teria whipped each other with horse-whips a long time, and were both acuta. much better after it."* ^ydys' If the flux of blood, or any otlier morbid material, continue to be f^i. considerable, and especially if there be still an intermixture of sanious Astringent's grume and shreds of membranes, evidently proving vascular disin- and ,onK'8' tegration and the approach of gangrene, astringents and tonics must enter into the plan of treatment. And in this case great benefit has been obtained by the mineral acids in union with sulphate of zinc, or with opium. The former combination was a favourite medicine with Dr. Mose- ley, who, of the mineral acids, preferred alum, and varied the pro- portions according to the strength or age, the degree of costiveness or of hemorrhage, of the patient: sometimes giving two or three grains of each at a dose, to be repeated three or four times a-day; where the hemorrhage is considerable, increasing the alum ; and where feculent evacuations were required, diminishing it or even omitting it altogether. The preparation is valuable as it unites a Their vu- p i i,. • i • i • i » .. , , . tue in com- powerfuf metallic tonic, which is a true character ot the sulphate bination. of zinc, with an acid which has the singular virtue of proving astrin- gent to the sanguineous and secernent system, while it produces little effect upon the peristaltic motion, and by some physiologists is thought rather to quicken it. Dr. Adair employed alum alone ; but it is greatly improved by the addition of the white vitriol. Dr. Jack- son recommends either, or both conjointly : and both himself and Dr. Moseley employed injections at the same time, composed of a solution of acetate of lead, and apparently with great benefit. A like beneficial effect, however, has been derived from uniting JJv™^ fhe mineral acids with laudanum. The sulphuric, though the plea- laudanum. santest to the taste, is more apt to irritate the bowels than the nitric. But the best mode of giving the latter, is, by combining it with mu- riatic acid in the proportion of two thirds of the former to one of the latter, imitating hereby the chrysulea of Van Helmont, or the aqua regia of later chemists, the nitro-muriatic acid of the recent day, in doses of two drops of the nitric, one of the muriatic, and ten minims of laudanum, intermixed with infusion of roses or that ofthe more powerful astringents, logwood, catechu, and gum kino. I have em- ployed this medicine with peculiar advantage, not only in dysenteric, but in many other loosenesses, and hemorrhages of the bowels, increasing the proportion ofthe acid or the laudanum as the urgency of the symptoms require. When, however, the thirst is considerable, and acidulous drinks £— are called for, we may for this purpose use the sulphuric acid as the most grateful; though in this case the citric acid will usually be pre- ferred, and the patient may be allowed to exercise his choice. Yet the one or the other of the above compounds should be continued without any alteration in consequence of such a beverage. 4« the disease declines, there will often be found a very consider- }%™£. nic debility; ♦ Zoonom, Cl. n. i. 3. 19. 3T2 CL. III. IL'EMATICA. oKli. »l Gen.X. Spec. I. Dysenteria acuta. employed from the first; but injudi- ciously. able degree of debility, and a chronic diarrhoea, with occasional dis- charges of blood from the excoriated state of many of the minute blood-vessels ofthe mucous membrane of the intestines, or perhaps entery.ys" from a simple relaxation of the mouths of the capillaries. And in Medical tnjs situation, and especially where the disease has assumed a highly treatment. ' i J . 1 »«■ • ut r to be op- malignant character, many of the bitters of the Materia JVledica, as SittMsnnd the cinchona, columbo, simarouba, or extract of chamomile ; and, acids. perhaps, the nerium antidyscnterium of Linneus, may be resorted to. Have been in connexion with acids, with great advantage. They have indeed occasionally been given from the first; and in a few very slight case? and very infirm constitutions the practice may have succeeded ; but as a general rule of conduct it is highly rash, and has rarely been tried without repentance. Some of them may have a power of sti- mulating the intestinal canal; or, in large quantities, this, as con- jectured by Dr. Cullen, may be a power common to all of them; but their chief virtue is that of increasing the tone, and they cannot therefore be employed at the commencement of the disease, when the fever is severe and the constriction rigid, without certain and essential mischief. In the decline of the disease, however, we may take our choice. In conjunction with this process, the very great tenderness of the interior of the larger intestines, from erosion or abrasion, will often, for a long time, demand peculiar local attention; and demul- cent or bland oleaginous injections, as the infusion or oil of linseed, or olive-oil with a little wax and soap dissolved in it, together with a grain or two of opium if there should be much pain (the whole not to" exceed three or four ounces in quantity,) will often be found ot great assistance, as well in affording present ease, as in forwarding the expansion of a new cuticle. Opium alone in the form of a small pill or suppository, as recom- mended by many practitioners, will be generally found too harsh ; and, where there is much tenesmus, it will be impossible to retain it. The only mode in which I have found it useful in this way is to rub it into an impalpable pulp with a little of the oil or butter ofthe cocoa- nut, and to mould it into small pastiles of a sufficient consistency to bear the touch. In long protracted and chronic cases, lime-water drunk freely, has occasionally also proved useful. The coat of the intestinal canal is here, however, sometimes very considerably thickened and indu- rated. And in such cases the best remedy we can have recourse to is mercury. Houlston recommends such a course to be persisted in to salivation.* Libavius commenced his mercurial plan with mer- curial ointment, t Stoll, on dissection, found in several instances, the affected intestines thickened, indurated, rigid, yet without ulcer- ation ; and sometimes evidently marked with chronic inflammation.J The liberal and experimental practice pursued at the Dublin and various other hospitals in Ireland during the late severe attacks of epidemic dysentery, and its general though often discrepant effect Bland in jections often requisite' Opiate pastiles. Lime-water in chronic cases- Recent treatment in the Dublin and other hos- pitals of Ireland. * Observations on Poisons, &c, * Rat. Med. Part ni. p. 277. t Hornungr, Cista, p. 2 cl. m.] .SANGUINEOUS FUNCTION. [ord. ii. 373 may be appealed to in confirmation of the mode of treatment thus Gen.X. far laid down. SrEC- *■ Such was the fatal ravage of the disease that no one plan hitherto nwfal""* devised offered more than a very unsatisfactory success ; and hence emery." almost every plan was tried in its turn. Medical 17, .. , treatment. 1' rom the treatment by mercury much was at first expected ; and Mercury in many cases it seems to have been of use : but it " did not sue- ge^rVuy'of ceed," says Dr. Cheyne, " so well as I expected. Calomel tried in <">vantage: every proportion and distance of time often failed with me and my colleagues."* And he adds shortly afterwards, " Mercury could sometimes not be depended upon, and did not relieve in numerous instances ous. where the mouth was affected ; and sometimes seemed to increase the disease."! And even where the symptoms distinctly pointed out ®hVg"i™J!ere a morbid organization of the liver, the result of this treatment was was affect- unsatisfactory. "Mercurial frictions," says Dr. Cheyne, " wereed" tried in all the forms over the region of the liver ; but the advantages were not so extensively beneficial as I had reason to suppose from finding that in every dissection the liver was in its structure more or less destroyed."! Venesection and opium seem to have been more beneficial. " The lancet," he further adds, " has repeatedly afforded great tern- £f ™°jf*f porary relief where ulceration seemed to have taken place ; and the nnd local relief proved permanent from blisters, mild aperients, and anodynes. BHstersf Where the lancet was not allowable leeches were also highly use- aperients, ful."§ Free venesection we are told, in another place, often dynes. procured a large feculent stool, where even purgatives failed. In conjunction with a blister it often removed even the alarming symp- tom of dyspnoea when timely applied. || Dr. Cheyne's sheet-anchor seems to have been opium, and to this ^ufmot he shows as strong an attachment as Sydenham, who only preferred benefit. the liquid to the solid form of this medicine, as he expressly tells us, on account of its more easy sub-action. Dr. Cheyne, however, carried his practice here, as well as in bleeding, to a considerably larger range, at least in severe and alarming cases. " The mercu- rials," says he, " with opium sometimes seemed to answer : but in future I should chiefly depend upon opiates in doses of four or five grains, as this seemed chiefly to arrest the progress of inflammation, diminished agony, and sometimes proved of permanent benefit." IT In less violent assaults, he at length fell back still more fully into J^u.^ the practice of former times. " In the middle stages," he tells us, still further " I preferred to the treatment by mercurials, the old proceeding; T$ff in venesection, purgatives (chiefly the saline :) bath in the evening ; dia- cases. phoretic at night. This was frequently successful in an early stage." The blood drawn on the first use of the lancet was from thirty to forty ounces or more ; which was repeated as often as necessary. With the saline aurgative was often intermixed emetic tartar, to act on the stomach as well as on the bowels ; and to these were added, in more violent cases, emollient injections and, as already observed, blistering. * R* port, &c. ut supra, p. 41. t lb. p. 45. J lb. p. 89 fc lb. p. 47. II lb. p. 26. V lb. p. 44 374 cl. hi.] 1LEMATICA. [ord. II. Gen. X. Spec. I. Dyscnterhi acuta. Acute dys- entery. Medical treatment. Terebinthi- nate clysters of use. Injections of nitrate of silver and acetate of lead. Astringents. Cremo of tartar did not suc- ceed. Additional means. Castor oil, so highly prized by many writers, rarely acted kindly. and very frequently aggravated the tormina and tenesmus. It suc- ceeded best when united with opium. Generally speaking, injections did not answer so well as was expected. The most successful were the terebinthinate clysters—the Venice turpentine of Sydenham being merely exchanged for the oil of turpentine or the balsam of copaiva. The local action was hereby frequently changed and meliorated. And we are distinctly told that even the griping property of castor oil was softened instead of aug- mented by combining it with the rectified oil of turpentine. The other kinds of injections chiefly employed, were diluted solu- tions of nitrate of silver, and acetate of lead : the last united with opium. This combination was in high repute on account of its decided success in various cases. Dr. Barker has since improved upon the principle, by giving to the joint materials the form of pills ; under which modification it seems to have been still more effectual. The ordinary astringents, in addition to the above, were the chalk mixture or infusion of catechu combined with laudanum. Creme of tartar, long since recommended by Selle,* was put to the test with great freedom ; and the more readily as Dr. Home, among other virtues, has extolled its power of resolving obstructions and bringing down bile.t In a few instances it seems at first to have been serviceable ; but it was not able to maintain its reputation. In protracted cases the medicines chiefly had recourse to were Dover's powder, small doses of ipecacuan and calomel. The treatment where the disease ran into a chronic form we shall have to notice presently. SPECIES II. DYSENTERIA CHRONICA. CHRONIC DYSENTERY. STOOLS FREQUENT, LOOSE AND FECAL: OFTEN WITH LARGE DE- JECTIONS OF PURE OR GRUMOUS BLOOD, AND ESPECIALLY WHERI: THERE IS SEVERE TENESMUS ; MORBID PROGRESS SLOW, AND INSIDIOUS ; MOSTLY WITH HECTIC FEVER. Gen. X. Spec. II. How dis- tinguishable from the preceding species: though sometimes produced by it. Sometimes a primary rrraladt. The genuine symptoms noticed under the preceding species are. for the most part, rapid and violent: and, when they have run through their course, if the constitution generally, or the alvine organs more particularly, be reduced to a state of extreme debility and relaxation, the disease, instead of yielding to a return of health, is extremely apt to pass into the present species of dysentery. But it not unfrequently happens that the causes of the disease are of feeble power, and slow though persevering in their mode of 1 De Cnr. Morb. p. 167. Clin. Experim. p. 383 cl. m.j SANGUINEOUS FUNCTION. [ord. ii. 375 action ; or that the organs on which they operate locally, are already Gen. X. in an infirm or undermined state, so as to possess scarcely energy i>y*nteria' enough to evince any vehemence of excitement; and in either of chnrr°0nmcca- such cases chronic dysentery is produced without the intervention of dysentery. acute, and becomes a primary malady. These causes are chiefly a repeated exposure to a cold damp air, Causes. and especially in warm weather, by which the perspiration of the skin becomes frequently and suddenly supprest; and an habitual irritation of the alvine canal, by a daily indulgence in highly stimu- lant food, and particularly spirits. In this species the inflammatory action is always passive or atonic ; illustrated. and it spreads insidiously from one organ to another, in consequence of its being for a long time but little regarded, till all the viscera subservient to the digestive process are implicated in a common chain of disease ; and especially the liver, which is usually, indeed, in a state of great irritability and weakness from the first; as are also the mesenteric glands. Hence the symptoms must vary according to the progress the ^"epdtob^a disease has made, and the extent of the structural injury from a accidents. simple relaxed state of the bowels, producing diarrhoea, uniformly accompanied with a greater or less degree of tenesmus, to a perma- nent ulceration, pouring forth purulent matter, or a more compound colluvies, sometimes watery like the washings of raw flesh, some- times coagulated like dirty cream, and sometimes black and tena- cious as pitch ; and in most cases intolerably fetid.* Occasionally, indeed, there is a dejection of sordid pus in considerable abundance, in consequence of the bursting of an abscess that has been long forming in the liver or some other organ, and has discharged its contents immediately or intermediately into the intestinal canal.t And we may hence see abundant cause for those colliquative sweats, dry distressing cough, and other symptoms of hectic fever, which so frequently accompany dysentery in this form. Chronic dysentery may therefore, in its simplest and mildest state, JJJjfJftSJ, be regarded as a gleet of the larger intestines ; produced, as ure- |^|enre^* thral gleet is, by a morbid relaxation of the mucous glands of the part affected, and accompanied with that sort of irritation which is the usual cause of increased secretion in debilitated organs. If the irritation be of any considerable extent over the intestinal w'h™a canal, the peristaltic action is often permanently excited, and we produced. have then an obstinate and weakening diarrhoea, pain at the pit of the stomach, with loss of appetite, and other dyspeptic symptoms. If the same irritation ramify, whether by sympathy or continuous action, to the liver, we often find this organ also stimulated to a very considerable excess of secretion ; when there is a frequent flow of bilious fluid from the rectum, sometimes nearly pure, but more generally depraved, and intermixed in its passage with other mate- * Observations on the Acute and Chronic Dysentery of Ireland. By John O'Brien, M.D. p. 58. Dublin, 1822. t Practical Treatise on Tropical Dysentery, more particularly as it occurs in the East Indies, &c By R. W. Bampfieid, &c. p. 3. Lorn). 8yo. !819. 376 cl. 111. j HiEMATlCA. [OKU. Li dissections. Gen.X. Hals ; constituting that variety ofthe disease which by practitioners DyTcnle"" in tne Easthas Deen often denominated bilious or hepatic ilix.* chronica. J\0t unfrequently, however, the discharge from the rectum is pure tymtery. and depraved blood, instead of being pure or depraved bile : the be!Matic0r relaxet* and debilitated capillaries of the organs chiefly affected, flusf10 pouring forth this fluid in great abundance by anastomosis, or a gangrenous erosion destroying the tunics of much larger vessels, Bloody and exhausting them of their living current And in this case the flux' disease is correctly denominated bloody flux. Sometimes In the late epidemic dysentery in Ireland, Dr. O'Brien included duration/" all those cases under the present species which ran on to a longer period than six weeks, and were accompanied with little or no fever. The most numerous sufferers were the aged and infirm, who had previously laboured under diseases of the liver, or some other abdo- minal organ. in an ad- From the extensive range of the morbid action, the impoverished stageoften state of the constitution, and consequently its difficulty of rallying, fatal. }t is not often that a patient recovers from this form of the disease when it has once passed from its mild or simple stage into a severer or more complicated course : and on this account Dr. L. Frank has asserted that it is essentially more fatal than the acute species. Post-obit Post-obit dissections have given nearly the same appearances as we have already noticed ; there is abrasion or ulceration of the mucous membrane of the intestines :—the colon is very generally found thickened and contracted through its whole extent, but parti- cularly in its lower flexure. The smaller intestines are rarely traced in a state of ulceration ; but patches of a deep-red colour are found in scattered plots, and especially on the ileum. The liver is not always affected in its structure, though more frequently than in the acute form : the gall-bladder is usually distended with deep-brown or dark-yellow bile, evincing a paresis or obstruction in the cystic duct. Therapia. The therapeutic intentions are here to change the nature of the morbid and irritable action; to diminish the exhausted dis- charges ; and to give tone to the languid and impoverished frame. Calomel For the first purpose the most effectual medicine we can employ with opium. js calomei? either alone or intermixed with opium. "If, in treating of the acute form of flux," says Dr. Ballingall, " I have refrained from an indiscriminate, and, as I conceive, unmerited commenda- tion of this powerful medicine, it is only in hopes of being able to urge its employment with double force in the form of disease now under consideration ; and to recommend an implicit reliance on it in the cronic form of flux; to ascribe to it an almost unlimited power in this disease ; and to express an opinion that it will seldom disappoint our most sanguine hopes." Its effects in India, where torpitude and congestion are more frequent and more excessive than in cooler climates, seem to give a full sanction to this unqualified recommendation, and authorize its employment in large doses. In our own country, though very far from affording universal success. * Curtis, on the Diseases of India. cl. ixi.j sanguineous function. [ord. h. 377 it is of pre-eminent importance ; but as it requires a long perseve- Gen. X. ranee in its use, it will be found an error to load the system with it ^U "' suddenly. In Ireland it was most beneficially employed in the form chronica. of the blue pill, combined with opium and a minute appendage of SSSSy. emetic tartar. Treatment. Here, too, the terebinthinate preparations may frequently be had Tcrebinthi- recourse to with some confidence of advantage ; as may also, for rSs?1'8" the same purpose of improving the local action, the essential oil of turpentine and the balsam of copaiva. As an aperient, oil of castor ou of cas- may generally be employed with less excitement of griping than in mMaperT the acute form : but whatever laxatives are had recourse to, they en,»- should always be of as mild a character as possible ; and hence rhubarb in combination with small doses of calomel, or Epsom salts, is often found preferable to castor oil. By keeping the bowels free from irritation in this gentle manner we indirectly check the morbid discharges of whatever kind by which the disease is so peculiarly distinguished. And where more direct Astringents. and powerful means are necessary, the compound chalk mixture with opium, various preparations of kino or catechu, or the acetate of lead, in solution, or pills, as already noticed, may be had re- course to. The diet should at the same time be equally bland and nutritious, met. composed chiefly of milk, as recommended by Sir John Pringle, or of vegetable mucilages, as rice, arrow-root, sago and salep. And When con- as soon as the local irritation has manifestly subsided, a more cor- cordials ' dial and tonic plan should be entered upon ; animal food be al- and tomcs• lowed : the warmer bitters and metallic roborants be prescribed, as cascarilla, columbo, sulphate of zinc ; and such exercise and change of air as may best comport with the patient's constitution and sta- tion in life. Dr. O'Brien judiciously recommends him to try a Warm warmer climate if his home be the British isles, and a colder, if he be a resident between the tropics. In all situations he must be especially careful to avoid sudden changes of temperature, and particularly a cold damp atmosphere; and maintain a healthy excitement on the skin by flannel socks worn on the feet, and flannel swathing round the body. Vol II.—4b 378 cl. in. i HEMATIC A 1'vun. u. GENUS XL BUCNEMIA. TUMID LEG. i'ENsE, DIFFUSE, INFLAMMATORY SWELLING OF A LOWER EXfRL .IITV ; USUALLY COMMENCING AT THE INGUINAL GLANDS, AND EX TENDING IN THE COURSE OF THE LYMPHATICS. Genius n^w This genus is new to nosological classifications : but it is neces- to nosology, sary, in order to include two diseases which have hitherto been re- sary!'606'1" garded by most writers as totally unconnected, and treated of very remotely from each other ; but which, though occurring under very- different circumstances, are marked by the same proximate cause, in most instances affect the same organs, and demand the same local treatment. They consist of the following species : 1. BUCNEMIA SPARGANOSIS. PUERPERAL TUMID-LEG. 2. --------- TROPICA, TUMID-LEG OF HOT CLIMATES. the generic ^s tbe Present genus is new, it has been necessary to distinguish term. it by a new name ; and on this account the author has made choice of that of Bucnemia, from (iov, a Greek augment, probably derived from the Hebrew yi or nj.»3 "to swell, augment, or tumefy," a par- ticle common to the medical vocabulary ; and the Greek noun kvjj^sj. ;crus," or " the leg," literally, therefore, "bulky or tumid leer." SPECIES I. BUCNEMIA SPARGANOSIb. PUERPERAL TUMID-LEG. TllL TUMID LIMB PALE, GLABROUS, EQUABLE, ELASTIC, ACUTELt TENDER; EXHIBITING TO THE TOUCH A FEELING OF NUMEROUS IRREGULAR PROMINENCES UNDER THE SKIN ; FEVER, A HECTIC : OCCURRING CHIEFLY DURING THE SECOND OR THIRD AVEEK FROM CHILD-BIRTH. Spec?' * "AVE observed above' that the tumid-leg of child-birth lias Natural " mostly been contemplated as a very different affection from that of ofnthuion bot climates> a"d l*as rarely been treated of in connexion with ii. species Dr. Thomas, however, has been sensible of their relation, though main*. he has stiU placed them at a distance from each other. » The di? UL. IU.] SANGUINEOUS FUNCTION. [ord. ir. 379 ease," says he, " to which in my opinion it bears the strongest re- Gen. XI. semblance (meaning the species before us,) "is the glandular l™± affection so frequently met with in the island of Barbadoes."* It -Snosi.. is singular that, with this impression, so able a writer should still fumKg. nave regarded the latter as a species of elephantiasis, and arranged and described it accordingly. In the present author's first edition ot his Nosology the ordinary arrangement was so far yielded to as to place the two species remotely, though a distinction between elephantiasis and the tumid-leg was strongly enforced. The tumid-leg of lying-in women has been described by different Synonyms. authors under a variety of names, as phlegmatia dolens, phlegmatia lactea, ecchymoma lymphatica, and by Dr. Cullen, as anasarca serosa; few of which express the real nature of the affection, and some of them a source obviously erroneous. By Dioscorides it was denominated sparganosis, from c-nxpyxu, Delation " to tumefy and distend:" tumeo et distentus sum, as rendered by SteteJIE" Scapula; and, as the term is sufficiently expressive, it has been pre- ferred on the present occasion to any of the rest; and appropriated to the present disease, instead of being made common, as Diosco- rides has made it, to numerous other affections of the chest. By Dioscorides, and most writers till within the last twenty or causes thirty years, the swelling has been ascribed to a redundancy of milk, ™ooUdnand and a morbid deposition in consequence of such redundancy.uoublful- Mauriceau regarded it in like manner, as a depot or translation, and Puzos concurred in the same view ; whence the French practi- tioners call it to the present day, after Puzos, depot laiteux, or lait rSpandu; and the Germans milchstreichen. A minuter attention, to the subject, however, has sufficiently shown that this complaint has seldom any connexion with the milk : perhaps never. It has occur- red where the breasts have been destitute of milk, and where they have overflowed ; where suckling has been relinquished, and where it has been continued. It is not long since that I was consulted by a young woman labouring under it. who was suckling her infant without any complaint of the breast whatever. It is as little influenced by the state of the lochia as by that of the milk. It attacks women of all ranks and of all habits; the healthy and the diseased ; the lean and the corpulent; the seden- tary and the active; the young and the middle-aged. It also occurs at all seasons and situations ; and has never perhaps been known to appear in any other part of the body than the lower ex- tremities. My esteemed friends Dr. Hosack and Dr. Francis, of New-York, W';*"™, have, however, ingeniously contended that it has also been found jn the upper in the upper as well as in the lower limb, and in males as well as in g^ffirmed females : and they especially appeal to one case communicated to by iiosack them by Dr. Heermans of Ontario, which, could it be relied on, *;", as^also would go far to settle the question ; but as it appears to me that i»»g^ this like various similar cases that have occurred to the present cases author, was an instance of erratic or metastatic rheumatism rather doub"*u' « Modern Practice of Physic. Diseases of the Puerperal State. 380 ci.m.3 HA5MATICA. [ord. n. Gem. XI. than sparganosis, we are not at present authorized to deviate from BSucnemia the ordinary character assigned to the disease or to generalize it m "parganoL. the manner which this more extended view of its occurrence would uSSSfiS demand of us. Other local affections, indeed, make an approach to it, of which Dr. Denmark has described one that occurred in a male, which, however, he prudently avoids calling a phlegmatia dolens, contenting himself with saying that it resembled it; whde Dr. Davis, as we shall have to observe presently, seems to have mis- taken for this complaint an inflammation of one of the larger veins in the pelvis or its vicinity. Description. In about twelve or fourteen days after delivery, according to the common course of the disease, the patient complains of pain in the groin of one side, accompanied with the general train of pyrectic symptoms, but without the precursive shivering. The part affected soon becomes swelled and distended, the swelling usually extending to the labia pudendi of the same side, and down the inside of the thigh to the leg and foot; in a day or two the limb is double its natural size, is hot, exquisitely tender, and moved with great diffi- culty. It has not, however, the ordinary external signs of inflamma- tion, but is hard, smooth, glabrous, pale, and equable, except where the conglobate glands are situate, which are corded and knotty, as in the groin, the ham, and the back and fleshy part of the leg. There is, occasionally, an uneasiness in the loins and in the region of the pubes on the same side. The swelling has sometimes appeared as early as twenty-four hours after delivery, and sometimes not till five weeks afterwards. The accompanying fever, which is of a hectic form, usually declines about the fourteenth or twenty-first day, but in some cases runs on for six or eight weeks, and the patient becomes greatly emaciated. The first appearance of improvement takes place where the disease commenced about the groin, the pain and tumour gradually subsiding in this quarter, and the amendment spreading in a continuous line. Sometimes, though rarely, both sides are affected simultaneously, and, in a few instances, the sound leg has exhibited something, though a less degree, of the same com- plaint, as the diseased leg has improved. The improvement is very slow ; and, in many cases, the affected limb continues weak and of a morbid enlargement through life. Proximate The latest and best writers upon the subject, Dr. Whyte, M. Cas- bab'yT0 Par> ^r- Trye, Dr. Ferriar, and Dr. Hull, concur in deriving the morbid af- disease from some affection of the lymphatics of the distended side, tne Iym-° though they differ as to the nature of such affection. Dr. Whyte theaffecfed supposes it to be an extravasation from the lymphatic vessels limb; ruptured by the pressure of the child's head against the brim of the affection pelvis during a severe labour-pain, the extravasated fluid not being differenUy July absorbed : Professor Caspar, to a mixt inflammation of the local absorbents, and cellular membrane.* Mr. Trye refers it to inflammation of the lymphatic glands ; Dr. Ferriar to inflammation of the side affected generally ; and Dr. Hull to a joint inflammation of the muscles, cellular membrane, and inferior surface of the cutis * Commentiures de Phlegmasia dolente, 8yo. Hullo, 1819. cl. m.J SANGUINEOUS FUNCTION. [ord. b. 381 seated in the affected part, and an effusion of coagulable lymph, Gen. XI. instead of an effusion of the proper fluid of the lymphatics, by a rfucnemia rupture of their coats, the large blood-vessels, nerves, lymphatic sparganosis. glands, and glands imbedded in them, at times, participating in the tu^dj'eg. inflammatory action. The last, if not the real cause, would be suffi- ciently plausible if the inflammation be supposed to commence in the lymphatics instead of being merely extended to them. As it is, Hut"gBoigy" Dr. Hull's hypothesis has been adopted and enlarged by Dr. Hosack, adopted by who regards the complaint as an inflammatory disease, " not merely ""dco'nsi- affecting the limb, but the whole system," commencing, not in the der»n'y ex* groin or pelvis, but about the calf of the leg ; not limited to the lymphatics, or even to females, but common to both sexes, and to every part of the affected limb ; sometimes appearing in both limbs at the same time ; and where depletion is not actively employed, occasionally, like gout and rheumatism, transferred from one limb to another : produced, usually, by a suppression of the natural ex- cretions, exposure to cold, stimulating drinks, and other means of excitement. To the disease thus described, Dr. Iiosack has given the name of cruritis ;* not quite classically formed ; as partaking of two distinct tongues, and not quite applicable to an affection so variable as to seats and so migratory even when it once shows itself. The disease is ably described, and followed up with the hand of a *££j»*p master, but it is not, as it appears to me, the disease before us, and described, 11.1 ^ but not belongs rather to our next genus. sparganosis. It seems probable that a later writer on the subject, Dr. Davis, *f%£™ has thought the same, for he has entirely stripped the tumid leg of the unrestrained license of attack allowed it by Dr. Hosack, and of its migratory spirit afterwards t has restrained it to the female sex, and to the immediate neighbourhood of the pelvis. " The proxi- mate cause, (says he,) of the disease called phelgmasia dolens, is a violent inflammation of one or more of the principal veins within, and in the neighbourhood of the pelvis, producing an increased thickness of their coats, the formation of false membranes in their internal surface, a gradual coagulation of their contents ; and occa- sionally a destructive suppuration of their whole texture: in conse- quence of which the diameters of the cavities of these important vessels become so gradually diminished, sometimes so totally obstruct- ed, as to be rendered mechanically incompetent to carry forward into their corresponding trunks the venous blood brought to them by their inferior contributing branches."! Here again we have a very accurate description of a disease by Acutely no means uncommon, which moreover is supported by a variety of cases, most of which have unfortunately a history of their dissections appended to them, containing a clear manifestation ofthe nature of this very fatal inflammation, and for the most part of the formation of a false membrane within the affected vessel But if the present b^not^ author have succeeded in truly delineating the disease before us, either in his specific definition or his diagnostic description, it must be obvious to every reader who will compare them with the appear- 382 cl. in.J HiEMATICA. [ord. 11. Gen. XI. ances laid down by Dr. Davis, that two different inflammations are BwMmia referred toi m tne respective statements, the symptoms of which spwgMorfs. cannot possibly co-exist; that the very fatality of that described by fumicweg. Dr. Davis is of itself a sufficient proof of a clear and very striking distinction : and that though both occasionally take place soon after child-birth, the enlargement he has treated of is far less a phlegmasia dolens than a particular variety of venous inflammation, the phle- bitis of several authors : for a striking example of which, proceed- ing from an obscure cause, and extending over the arm instead of over the leg, I may refer to Dr. Duncan's interesting case, in the Transactions of the Edinburgh Medico-Chirurgical Society.* It gives us the same general swelling over the entire limb ; rather phlegmonous than erythematous ; but, to adopt the author's own simile, still more resembling an anasarcous affection, yet without pitting. It gives, moreover, the same fatal result; and, on examina- tion after death, developes the same thickening of the coats of the vein, and the same obstruction from morbid secretions. And to show still further how little foundation there is for this doctrine, we have in the very next article in the same volume, composed by the same indefatigable author, various cases of diffuse inflammation of the cellular membrane, without any affection of the neighbouring veins, so closely approaching the general character of the sparga- nosis before us, that he finds a difficulty in calling them by any other name, and appears greatly inclined to adopt Dr. Hull's hypothesis of the disease.t Another Explanation therefore is still demanded ; and there is yet another accounting way °f accounting for this inflammatory affection of the lymphatics for it. ofthe lower limb, and which, upon the whole, I cannot but think is The lym- its real source. It is that of supposing an habitual debility in the affected lymphatics affected, and inflammation produced in them, from what probably Mr. Hunter calls, though with some looseness of expression, the sti- wea'k'and mulus of relaxation : in other words, from the weakly lymphatics, nnd^ence now destitute of the surrounding pressure and stimulus which they inflamma- possessed during pregnancy, yielding too easily to the flow of the UiTstjmuius fluid they have to convey, and on this account becoming morbidly of reiaxa- distended, and inflamed in consequence of such distention. And we may hence see why sparganosis puerperarum seems to occur in no other limb or part of the body than the lower extremities. illustrated Inflammation from debility or relaxation is by no means uncom- organs. uion in other organs. The hepatitis and splenitis of tropical cli- Liver mates are far more frequently owing to this, as a predisposing cause, than to any other. For where the vessels of these viscera are habi- tually weak, they soon become congested from accidental irritants ; have less power than in health of freeing themselves from the morbid accumulation, and must necessarily form a seat of inflammatory tj.Mr.. action. And we shall hereafter have occasion to make the same remark under entonic, or what has been called sanguineous apo- plexy ; and to point out the necessity of copious venesection in * Case of Inflammation of the Cephalic Vein which terminated fatally. Vol. i p. 439. t Trans. Med. Chir. Soc. Edin. Vol. i. p. 585. »L. m.j SANGUINEOUS 1 UNCTION. [ori>. n. 6bo many cases of advanced age and constitutional debility, where we Gen. XI. should wish to withhold depletion if it were justifiable. £nEecm£ It is not to be wondered at that the effused fluid should exhibit a ■pargano- tlnck, glutinous, and even milky appearance : for we have had fre- puerperal quent occasions of noticing a somewhat similar secretion in the case Vvhencefho of inflamed membranes, and even in inflammation ofthe heart itself; milky alid and, at the time we are contemplating, there is a general tendency Ippewance in the constitution to produce genuine milk, and often in great otlh? abundance. Nothing can be more unlike than this complaint and e us'°n'' dropsy, or than the effused fluid and serum : and hence Dr. Cullen seems not less improperly to reckon sparganosis puerperarum, a modification of anasarca (anasarca serosa,) than those who have regarded it as a variety of milk-affection. Serous dropsy of the lower extremities occurs unquestionably at times after labour, but its symptoms and appearance are altogether different. There is apparently as little reason for the hypothesis of Dr. Den- "/penman. man, who, while regarding it as an inflammation ofthe lymphatics, refers the inflammation to an absorption of some acrimonious matter secreted by the uterus: for the disease has occurred where there has been no more morbid action of the uterus than of the mammae ; and all the secretions have proceeded healthily and in their proper quantity. The cure is to be attempted first by a free application of leeches Curative following down the course ofthe limb, poppy-head fomentations, or, swathe of what is better, a swathe of flannel wrung out in hot water applied £*„"*$. over the whole extent of the limb, surrounded by a loose bandage of sheeting. To this plan should be added purgatives of considerable Purgatives. activity, and, where the irritation is considerable, free doses of Sedative? Dover's powder. General bleeding is rarely, though sometimes necessary. As soon as the inflammatory symptoms have a little sub- sided, local stimulants may be had recourse to, so as to excite the torpid absorbents to increased action : of which, the most useful ^J^ in the author's hands, has been the volatile liniment with laudanum, with iau* The laudanum, on a cursory view, may seem to add to the vas- danuu1, cular torpor : but it tends to take off the pain and soreness that still remain, and thus enables the tranquillized vessels the more easily to recover their tone. Yet whatever application of this kind is em- ^ntte ployed, it should be accompanied with gentle friction, continued for half an hour or more, as the limb is able to bear it: for the friction itself is of essential service, and tends, perhaps, even more than any other local stimulant, to restore the limb to a healthy action. Mr. Trye advises, for the same purpose, the use of mercurial oint- Mercurr ment; and others, that of small doses of calomel. But neither have proved decidedly useful; while, in some instances of great debility, ihey have evidently produced mischief. The chronic weakness is to ^«gf«M be removed by a continuance of the friction, bathing with sea-water, i10W to bo or, which is much better, bathing in the sea itself, an elastic flannelremove(1- bandage, horse exercise, pure air, and, if necessary, general tonic* :,nd astringent?. 384 cl. in. J I LE MATIC A [ok»- "■ SPECIES II. BUCNEMIA TROPICA. TUMID-LEG OF HOT CLIMATES. THE tumid limb hard, livid, and enormously misshapen : SKIN at first glabrous, afterwards thick, scat.v, ami wart ed : successive!.v KTTEGING AND INDENTED: OCCURRING CHIEFLY IK TROPICAL climates. Gen. XI. Thls species is intended to comprise that singular disease, known Barbadoe'' m tne West Indies, and generally over Europe, by the name of leg here in- Barbadoes-leg, from its being indigenous to the island of Barbadoes. tended. yet it is not in Barbadoes alone that it makes its appearance : for it is of high antiquity, as well as of very wide range in hot, and espe- cially in tropical climates ; and constitutes the genuine dal-fil or elephant-leg of the Arabians, being so denominated from its livid, Often con- tumefied, scaly, mis-shapen appearance. As the Arabic dal ordaul- with ele- Al *s bterally elephantiasis or elephant-leg, and as the Greeks distin- phantiasis. guish another and very different disease by the name of elephantiasis, whence, the Greek translators of the Arabian writers were very generally betrayed, from the unity of the name, into a confusion of the two disorders, as we shall have occasion still further to observe when treating of proper elephantiasis under the fourth order of the pre- sent class: and the confusion has, in a considerable degree, descended to our own times, insomuch that many writers of the present day continue to jumble the elephantiasis, or elephant-feg, of the Ara- bians, with the elephantiasis, or elephant-sfa'n, of the Greeks, and to describe them as a common affection, though no two complaints can be more unlike : the former being a mere local malady, produced accidentally, and confined to the individ&al who labours under it; and the latter a constitutional disease, in every quarter hereditary, and in most quarters contagious. The Arabians, however, had the disease called elephant-skin, the elephantiasis of the Greeks, by themselves called juzam as well as bometimcs the dal-fil or elephant-leg, the disease before us. And, as the malady with lepro- called leprosy, and by the Arabians beras, was supposed by many whence1 physicians, as well Arabian as Greek, to terminate frequently in juzam, or proper elephantiasis, the disease before us has occasionally also been confounded with leprosy as well as with elephant-skin, and all the three affections have been huddled together by many illustrated, writers into one common disease. Even Dr. Schilling, a late prac- titioner of considerable merit at Surinam, has not escaped this last error ; for he describes the tumid-leg under the name of leprosy ; confuses its earliest symptoms and appearance with those of the leprosy of the Greeks, and especially with those of the lepra or lepri- <*• i«-J SANGUINEOUS FUNCTION. [ord. ii. 385 asis Candida, and then distinguishes elephantiasis, the disorder he Gem. XI. professes to be the immediate subject of his pen, as a peculiar g^,"' branch of leprosy, merely varied by its commencing in the feet, t">Piea. instead of m any other part of the body : and, carrying on the con- o^cii? fusion, he next interprets the tumid-leg, or disease before us, as a mates- mere variety of elephantiasis.* A summary of Dr. Schilling's publication is given in the Edin- Suram?1t* burgh Medical Commentaries, and even the learned editors them- ud|w selves seem to have adopted his views : for the following is their scriPtion- explanation of the general subject before us : " In some instances of this disorder (leprosy,) the feet are the parts chiefly affected, and then the complaint has been termed elephantiasis, not only from the resemblance of the diseased feet to those of the elephant, but from the walk of such patients resembling exactly the step of that animal. In this species ofthe complaint the skin and other soft parts become wonderfully expanded, at the same time that the different small bones swell considerably. The toes become thick, and at last melt down, and run together as if made of wax. The slightest affection ofthe diseased parts occasions a discharge of blood, which, however, is commonly easily put a stop to. The disorder by degrees spreads from the toes over the whole foot, and thence proceeds to the femur, rendering the different articulations in its course stiff and immove- able : at the same time that, in many instances, the muscles and tendons concrete so firmly together that the most skilful anatomist can neither separate nor distinguish them without great difficulty."! Dr. Schilling adds, that notwithstanding the frequency of this dis- order in some of the West India islands, and in some parts of the continent of America, he is clearly of opinion it is not a disease of those climates, but was introduced, and continues to be supported there by an importation of negro slaves from the coast of Africa. For a distinct and more correct account of this species we must More ?<»• turn to the writings of Dr. HillaryJ and Dr Hendy, who have judi- ofHiiiary ciously separated it from both the leprosy and the elephantiasis ofthe and Hendy- Greek writers, and treated of it as an individual malady: the former under the name of " Barbadoes-leg," and the latter under that of the " Glandular disease of Barbadoes." It is singular, however, that Error of^ Dr. Hendy should have adopted the erroneous idea that the disease limiting the before us is not only endemial to Barbadoes, but that it is to be found Bartadws. nowhere else; and that patients who migrate from this island for a cure, are almost sure to obtain one, unless in a chronic or inveterate stage of the disease, to whatever quarter they direct their course. It f^^m has been known immemorially in India, and is by the oriental writers, weii as in and even by Sir William Jones, justly distinguished from the juzam, Arabia- which he tells us must not be confounded with the dalfil, or swelled legs described by the Arabian physicians, and very common in that country. It is also indigenous to the Polynesian isles, where it takes gg£J£ the name of yava-skin, as being supposed to originate from drinking the heating beverage called yava ; and, like the gout among our- selves, is regarded in a sort of honourable light. * G. G. Schillingii de Lepra Commentationes 8vo. Lugd. Bat. 1"6' t Edin! Med. Coram. Vol! v. p. £64. t Works, Vo!. i. p. 549. 4to. ed.t. 17^ Vol. II.—49 &$b cl. m.j I LE MATIC A [ord. ii Gen. XL The tropical bucnemia, like the puerperal, is occasioned by an Bu'cnomfa1' effusion of coagulable lymph into the cellular membrane under the tropica. skin of the part affected, in consequence of inflammation of the ofUho'tci£ff lymphatics of the lower limb, and especially of the inguinal glands ; Description.tne cause °f which is perhaps different in different cases, but which is most commonly cold, operating upon a set of vessels peculiarly irritable, and especially so when affected with inflammation in tro- pical climates. The blood-vessels, and particularly those of the surface, are here also greatly relaxed ; and hence the skin, instead of maintaining the paleness of the first species, very soon becomes suffused with a deep red or purple hue ; while the saburral fluid that exudes from the cutaneous exhalants, concretes, as its finer parts fly off, into rough and sordid scales, and the skin itself becomes enormously thickened and coriaceous. preceded The effusion is usually preceded by a febrile paroxysm induced by paroxysm1.-* the glandular inflammation just noticed ; and which, from the first, i^uter0 discovers a tendency to recur, though often at irregular periods, so returns. as to resemble an erratic intermittent. Every fresh attack adds considerably to the effusion, and consequently to the morbid size of the limb, and exacerbates every symptom : and hence the greater severity of this species than of the former, and the monstrous disfi- gurement of the leg and foot by which it is distinguished. In many instances, also, the inflammation extends to the surrounding as well as to the descending parts ; and hence the scrotum, like the pubes in puerperal bucnemia, is often peculiarly affected and distended to an enormous magnitude ; while, occasionally, the glands of the axilla participate with those of the groin, and the fore-arm becomes also enlarged. In a few instances the disease is said to have commenced in the axilla ; but such cases are very rare, and not well established. Hence the In this manner the disease at length assumes a chrome character : becomes the monstrous size and bloated wrinkles of the leg are rendered chronic permanent; the pain felt acutely at first subsides gradually, and the brawny skin is altogether insensible. Yet even from the first, except during the recurrence of the febrile paroxysms, the patient's consti- tution and general functions are little disturbed : and he sometimes lives to an advanced ager incommoded only by carrying about such a troublesome load of leg; which, however, as we have noticed already, is regarded in the Polynesian isles as a badge of honour. Sthfr™8* In our own country the disease is rarely met with but in its con- Europe, firmed and inveterate state, after repeated attacks of the fever and effusion have completely altered the organization of the integuments and rendered the limb altogether incurable. In this state the dis- tended skin is hard, firm, and peculiarly thickened, and even horny: while the muscles, tendons, ligaments, and bones are, for the most part, little affected. In this advanced stage, the disease seems to be altogether hope- less : nor in any stage has the practice hitherto pursued been pro- ductive of striking success. This has consisted chiefly in endeavours to alleviate the febrile paroxysms by laxatives and diaphoretics, and subsequently to strengthen the system by the bark. It would be ^"-v perhaps by active and repeated bleedings, as well general a= Modo of treatment. CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 387 local, and powerful purgatives, to endeavour to carry off the whole Gen- xr- of the first effusion as quickly as possible ; and then to direct our BS!" attention to a prevention of the paroxysms to which the constitution J^P'?'- appears to be peculiarly subject, after a single one has taken place ofTot cu? by prohibiting exposure to the damp air of the evening and by the Treatment. use of tonics. An original and chronic affection of this kind, in which the inte- Case oc- guments of the legs were much thickened, the limbs swelled to such England" an extent as to prevent the patient from walking, and incrusted with singularly such a vast quantity of brawny scurf and scales, that handfuls of them might be taken out of his bed every morning, was successfully attacked many years ago by a mistake of one plant for another. The case is related by Dr. Pulteney in a letter to Dr. Watson ; and the patient, who had been recommended to swallow a table spoonful of the juice ofthe water-parsnep, with two spoonfuls of wine every morning fasting, was erroneously supplied with half a pint of what afterwards appeared to be the juice of the roots of the hemlock-dropwort (cenanthe crocata, Lin.) ; the first dose produced such a degree of vertigo, sickness, vomiting, cold sweats, and long continued rigor, that it almost proved fatal. So strong, however, was the patient's desire of relief, that, with the intermission of one day, he repeated the dose with a slight diminution in the quantity. The effects were still violent, though somewhat less alarming ; and he persisted in using half the quantity for several weeks. At the end of a month he was very greatly improved, and shortly after- wards the whole of his symptoms had nearly left him.* Amputation of the affected leg has sometimes been made trial of, Amputation but apparently without any success. Dr. Schilling informs us that ofnoU89- in some a locked jaw takes place about the seventh day from the operation, which is soon followed by tetanus, and ends in death ; that in others, fatal convulsions ensue immediately ; and that those who survive the operation have wounds hereby produced that will not heal; while the disorder, still tainting the constitution, often seizes on the other foott And in this last assertion he is corro- borated by one or two cases related by Dr. Hendy.J + Phil. Trans. Vol. lxii. t G. G. Schillingii de Lepra Commentationes, 8vo. Lugd. batav. 177b. J On the Glandular Disease of Barbadoes. 388 ct, tit.} TLF.MATTO.A. :'"•"'• "■ GENUS XII ARTHROSIA. ARTICULAR INFLAMMATION. INFLAMMATION MOSTLY CONFINED TO THE JOINTS ; SEVERELY PAIN- FUL ; OCCASIONALLY EXTENDING TO THE SURROUNDING MUSCLES. Gem. XII. Arthrosia is a term derived from xe8eou, " to articulate," whence the generic arthrosis, arthritis, and many other medical derivations. The usual term. term for tne preSent genus of diseases, among the Greek physicians, was arthritis, which would have been continued without any change, but that for the sake of simplicity and regularity, the author has been anxious to restrain the termination itis to the different species of the genus empresma that have just passed in review before us; whence arthrosia is employed instead of arthritis, and precisely in its origi- nal extent of meaning. Loosely Arthritis, then, among the Greeks, was used in a generic sense, earlier^ so as to include articular inflammations generally. But as almost writers. every sort of articular inflammation has, in recent times, been advanced to the rank of a distinct genus in itself, it has frequently become a question to which of them the old generic term should be peculiarly restrained. And hence some writers have applied and limited it to gout; others have made it embrace both gout and rheu- matism ; others again have appropriated it to white-swelling : while a fourth class of writers, in order to avoid all obscurity and dispute, have banished the term altogether. what spe- Now gout, rheumatism, whether acute or chronic, and white- should swelling, however they may differ in various points, as well of symp- ombrnce: toms as 0f treatment, have striking characters that seem naturally connexion to unite them into one common group. Gout and rheumatism are rhegu°ma?n so nearly allied, in their more perfect forms, as to be distinguished tism. wjth considerable difficulty ; and, in many instances, rather by the collateral circumstances of temperament, period of life, obvious or unobvious cause, antecedent affection or health of the digestive func- tion, than from the actual symptoms themselves. Stoll maintains that they are only varieties* of the same disease : Bergius, that Wtijte- they are convertible affections. White-swelling, in one of its varie- how con- ties, is now uniformly regarded as a sequel of rheumatism, or the tnhecab*ve.h resu,t of a rheumatic diathesis ; while the other variety cannot be separated from the species. Swediaur, who derives rheumatism from a specific humour produced in the body, ascribes white-swell- ing to an extravasation of this humour, and the ancylosis thut fre- * Rat Med. Part m. p. 122—137, r. p. 420 l. in.] SANGUINEOUS FUNCTION. [ord. ii. 389 quently follows on the entonic variety, to a concretion of the humour 9E?'*^11" thus extravasated.* All these, therefore, naturally and necessarily ArticuTsx' form one common genus, and are correctly so arranged by Dr. ^*™m*' Parr. From the close connexion between gout and rheumatism, Sau- ^Jte*ej[ vages,and various other nosologists, distinguish some of the cases of rheuma- disguised gout by the name of rheumatic gout. Mr. Hunter warmly cl™£eu opposed this compound appellation ; for his doctrine was, that no two distinct diseases, or even diseased diatheses, can co-exist in the same constitution. And, as a common law of nature, the observa- tion is, I believe, strictly correct; one of the most frequent examples of which is the suspension of phthisis during the irritation of preg- nancy. But it is a law subject to many exceptions ; for we shall have occasion, as we proceed, to notice the co-existence of measles and small-pox ; and I had, not long since, under my care a lady in her forty-ninth year, of delicate health and gouty diathesis, who was labouring under a severe and decisive fit of gout in the foot, which was prodigiously tumefied and inflamed, and had been so for several days, brought on by a violent attack of lumbago, to which she was then a victim, and which rendered her nights more especially sleepless and highly painful. The constitutional disease had in this case been roused into action by the superadded irritation of the accidental dis- ease ; and the two were running their course conjointly. It is also a striking fact, that one of the severest illnesses that attacked Mr. Hunter's own person, and which ultimately proved to be disguised gout, podagra larvata, he suspected, in its onset, to be a rheumatic ailment. The case, as given by Sir Everard Home, in his life of Mr. Hunter, is highly interesting and curious, as showing the singu- lar forms which this morbid Proteus sometimes affects, and the various seats it occupies ; as also that a life of abstemiousness and activity is no certain security against its attack: for Mr, Hunter had, at this time, drunk no wine for four or five years, and allowed himself but little sleep at night. . Arthrosia, therefore, as a genus, may, I think, be fairly allowed to embrace the following species :— 1 ARTHROSIA ACUTA. ACUTE RHEUMATISM. 2'_________CHRONICA. CHRONIC RHEUMATISM. 3_________PODAGRA. GOUT. 4' m_________HYDARTHRUS. WHITE-SWELLING. • Nov. Nosol. Meth. Syst, i. 150. 390 cl. m.j 1LEMATICA. |oht>. n. SPECIES I. ARTHROSIA ACUTA. ACUTE RHEUMATISM. PAIN, INFLAMMATION, AND FULNESS USUALLY AHOUT THE LARGER JOINTS AND SURROUNDING MUSCLES ; OFTEN WANDERING ; UKINF DEPOSITING A LATEUITIOUS SEDIMENT ; FEVKR A CAUMA. Gen.XII. The disease varies in respect to violence of the fever, and seat Spec. I. 0f tjje pam> The varieties, determined mostly from the last feature, are as follow: x Artuum. Articular rheumatism. 0 Lumborum. Lumbago. y Coxendicis. Sciatica. } Thoracis. Spurious pleurisy. a A. acuta artuum. Articular rheuma- tism. Remote cause. Ages and constitu- tions chiefly predisposed to rheuma- tism. An inflam- matory dis- ease; most pro- bably of the vessels ofthe muscles. Pain felt chiefly in the joints and muscles of the extremities. Pain felt chiefly in the loins ; and mostly shooting upwards. Pain felt chiefly in the hip-joint, producing emaciation of the nates on the side affected, or an elongation of the limb. Pain felt chiefly in the muscles of the diaphragm, often producing pleurisy of the diaphragm. The common remote cause of articular rheumatism, as of all the other varieties, is cold or damp applied when the body is heated ; though it may possibly be produced by any other cause of inflam- matory fever, where the constitution has a peculiar tendency to a rheu- matic action. This tendency or diathesis seems to exist chiefly in the strong, the young, and the active ; for, though it may attack persons of every age and habit, these are principally its victims. We may hence, as well as from its symptoms, prove rheumatism to be an in- flammatory disease. Even in the weak and emaciated, observes Dr. Parr, the pulse is hard, the blood coriaceous, and bleeding often indispensable. It is an inflammatory disease, also, for the most part, of the muscles, for motion is painful, the muscles are sore to the touch ; and we may assume it as a position that the muscular organs are alone affected.* The chief pain, indeed, is usually felt in the joints ; for the more closely compacted organs, or parts of organs, though insensible in a sound state, are peculiarly alive to pain when diseased ; the same arteries belong to both the muscles and tendons of the affected organ ; and in the latter we have reason to expect the pain to be more violent as they admit of distention with greater * Smyth, Med. Comtnun. it. 19 «^. m.j SANGUINEOUS FUNCTION. [ord. ii. 391 difliculty. How far the observation of Sir C. Wintringham is true, Gen. XII. that those who have suffered amputation are susceptible of this dis- ^A^c'ut'a ease more than others,* the author cannot say from his own practice; artuum. but it is the remark of a physician who was not accustomed to form rheuma"-' a hasty judgment. .sm- We have hinted that in this painful affection of the muscles and tioTsaid to their tendons the arteries seem chiefly to be the seat of inflam- $$£F" mation, and various dissections that have of late years taken place, disease. and particularly in France, seem to have established an immediate the arteries arteritis or inflammation of this organ ; particularly the very curious chi^flTat- case, with the post-obit appearances, furnished by M. Barde of the tacked. Ilaut-Garonne. The patient was descended from a father and arteritis." mother both of whom were afflicted with a consumptive diathesis, f^'g^e and the former of whom fell a sacrifice to it at the age of thirty-two. of Haut- The individual himself escaped from this disease, apparently by the Gaionne- domination of a morbid action of a different kind, resulting from hard service and sudden exchanges of temperature, as an officer in the French army ; which, at the age of twenty-seven, produced so severe and protracted an attack of acute rheumatism as to compel him to retire from public duty. The seat of affection in the first paroxysm was the lower limbs, and the disease was strongly marked, and continued for many weeks, but at length gave way. His inter- vals of recovered health however appear never to have exceeded a few months, and his returns of disease always to have been severer, with a more extensive range over the entire frame ; till at length the loins, the epigastrium, the chest, the heart, the shoulders, and the head were successively or simultaneously affected ; the chest in- deed with such spasms and the heart with such palpitations, as on various occasions to threaten immediate death. There was gene- rally an insatiable desire for food in the midst of every paroxysm, and the arteries in every part of the frame, gave the strongest proof of excitement: in the wrists, the back of the hands, the neck, and the temples the pulsation being visible at a distance of several paces, while that of the heart reached to the epigastrium, and communi- cated to it a regular systole and diastole. He continued in this state of diseased affection and temporary recovery from March 1816, till May 1819, the paroxysms, as already observed, gradually augment- ing in violence, till at length he fell a prey to their severity, the force of the arterial action persevering to the last even in the midst of emaciation, general edema, and at last petecchiai spots. The heart, all the larger arteries, and even the vena? cava? gave Aweary evident proofs of inflammatory action. Their coats were thickened, dissection. hardened, of a dark red colour, in some parts covered with a whitish purulent matter, and in some destroyed in the interior tunic : the heart itself being considerably enlarged as well as inflamed.t It is singular under this diseased condition of the arterial system, Generg that the patient should ever have enjoyed intervals of ease and free- dom from the morbid combat; but it shows us the pertinacity with JSbT1™^ Prati^e de Pari, ParM- Rarde. *«•. 392 tL. in.j 1LEMAT1CA. [ord. ii. Gen. XII. which an alternate series of opposite actions will often adhere to the „SrE»Cr'„!» animal frame, when the circle has once become established. In the artuum. general course of acute rheumatism its peculiar inflammation does rhe'uma" not continue long enough in any one organ to injure the structure tif"n' of the arterial tunics ; admitting these to constitute its immediate seat; often, in effect, as in gout, we witness its disappearance in n moment, and find it migrating to some other part of the body arteriann- *n some cases, however, the arterial system appears to be subject flammation to an inflammation of a slower and far more insidious kind than the and mow" present, if indeed the instances brought forward by MM. Dalbant insidious and Vaidy,* may be fairly ascribed, as they ascribe them, to this affection. For instead of the hard, and bounding, and visible state of the pulse just noticed, in the cases they have brought forward, the pulse was uniformly weak, small and irregular ; and hence M. Laennec has some reason for doubting whether M. Dalbant's ex- amples may be fairly referred to an actual inflammation of the arteries affected. Does not As a general rule it may be asserted that rheumatic inflammation Xpura- ^oes n°t tend to suppuration. In a few rare instances the contrary tion. has been known to take place ;t and in one or two cases I have my- self been a witness to an extensive abscess. But the general rule is not disturbed by such rare exceptions. The inflammation therefore is of a peculiar kind. There will often, indeed, be effusion, and the limb will swell considerably ; but the effused fluid is gradually absorbed; and the swelling not unfrequently, though not always, is accompanied with an alleviation of the pain. Description. Sometimes the pains take the precedency of the fever; but in other cases the fever appears first, and the local affection does not discover itself till a few days afterwards. There is no joint, except perhaps the extreme and minute joint of the fingers and toes, but is susceptible of its attack, although it usually commences in, as already observed, and even confines itself to, the larger. Among these, however, it frequently wanders most capriciously, passing rapidly from the shoulders to the elbows, wrists, loins, hips, knees, or ankles, without observing any order, or enabling us in any way to prognosticate its course ; always enlarging the part on which it alights, and rendering it peculiarly tender to the touch. Sometimes it darts internally upon organs we should little expect, as the dia- phragm and the pleura; and I have occasionally known the stomach as suddenly and severely affected as in gout. It is also said at times to pitch upon the heart and the intestinal canal, and to produce ex- cruciating torture in both these organs. The urine is often at first pale, but soon becomes high-coloured, and deposites a red sediment. It may be distinguished from gout by being little connected with dyspepsy, commencing less suddenly, evincing more regularly marked exacerbations at night; but less clear remissions at any time : to which, as already noticed, we may add its attachment to the larger * Diet, des Sciences Medicates:—Journal Compliment, vi. Aout, 1819. t Morgagni, De Sed, et Caus. Morb. Ep. lth. Art, 20,—Med. comment. Edmb, Vol. iy. p. 198. <-l. m.j SANGUINEOUS FUNCTION. [ord. ii. 393 rather than the smaller joints. It runs on from a fortnight to three Gen. XII. weeks : and the average of the pulse is rarely under a hundred. as^i 1 ne lever is generally accompanied with copious and clammy «*«««". sweats ; but the skin still feels tense and harsh ; nor does the sweat rtfma" issue freely from the immediate seat of pain. It seems to be an^amure(>f luetiectual effort of the instinctive principle or remedial power ofthe accom- nature to carry off the complaint: for it is by this evacuation alone Sf tuat we can at length succeed in effecting a cure. But the perspi- ration will be always found unavailing so long as it continues clammy, and the skin feels harsh, and there is a sense of chilliness creeping over the body or any part of it during the perspirable stage. The exacerbation, which regularly returns in the evening, increases during the night, at which time the pains become most severe ; and are then chiefly disposed to shift from one joint to another. Where fever is violent, and especially where the frame is robust, Ram«l3i&1 our only effectual remedies are copious bleeding and the use of dia- copious phoretics ; by the former, which will often demand repetition, we bleeding' take off the inflammatory diathesis, and by the latter we follow up the indication which nature herself seems to point out, and endea- vour, by still farther relaxing the extremities of the capillaries, to render that effectual, which, without such collateral assistance, is, as already observed, for the most part exerted in vain, and an unpro- fitable expenditure of strength. The most useful diaphoretic we are a"d di.a* acquainted with is Dover's powder; and its benefit will often be P oret,cs' increased if employed in union with the acetated ammonia, and sometimes if combined with camphor. Aperients are useful to a of?!n'Ktt?e certain extent, but they have not been found so serviceable as in serviceable. various other inflammations. Small doses of calomel have occa- sionally, however^ seemed to shorten the term of the disease, though they have not much influence in diminishing the pain. To obtain this, Dr. Hamilton has combined calomel with opium ; and in his hands it appears to have been successful. Opium alone is rather Opium injurious ; nor has any decided benefit resulted from other narcotics, domVsefu!. as hyoscyamus, hemlock, and aconite. They are recommended by several writers, but I have seen them tried both in small and large quantities without effect. We have observed that there is no constitution invulnerable to the attack of rheumatism, although the young and the vigorous fall most frequently a prey to its torture. Hence not unfrequently we Venesec- * - r /. . , - . ■ i , • i >,i Hon some* meet with it in persons of weak and irritable habits, who will not times mju- bear the lancet with that freedom which gives any chance of its d,ci0us; being useful. Local bleeding is here to be preferred ; but it cannot {^J""1 be depended upon: since, though the pain may diminish, or even notiobl totally subside, it is, in many cases, only to make its appearance in dp*°nded some other quarter. Here, also, if in any case, we have reason to expect benefit from uniting stimulants with diaphoretics, as ammo- nia, camphor, and the resinous gums and balsams. In such habits, and particularly if opium should disagree with the %™]odfk system, it may be worth while to try the rhododendron (r. Chrysan- thum, Linn.) This plant is a native of the snowy summits of the Alps and mountains of Siberia: and in Russia, as we learn frorr Vol.. n.~firt 394 cl. m.j ILEAIAT1CA. lord. if. Gen. XII. Spec. I. a A. acuta artuum. Articular rheuma- li.-B"™nt. so largely impregnated. Blisters seem rarely to be of all the advantage we should expect; fa'^erJer but the vesication from sinapisms succeeds better than that from serviceable. cantharides, probably because it operates with a wider continuous sympathy, produces more general excitement, and hence proves a better diaphoretic. The burning of moxa is-a favourite remedy on Mom. the Continent, but has been little tried in our own country. It does not seem to afford so much promise of relief as sinapisms or epithems of scraped horse-radish. The tartar emetic ointment has been also Tattar frequently made use of, and sometimes with success : it gives a per- ointment. inanent irritation, but the exulcerations it produces frequently prove foul and troublesome. Dr. Perceval of Dublin, in a manuscript note to the volume of Nosology, tells me that, in sciatica, he has known the pain removed by a sweating course of James's powder, after a considerable emaciation of the nates. Bark and gentle stimulants, as guaiacum, bardana, and seneka, Tomes. may in every instance be used with advantage, with a liberal regimen and chalybeate waters. Sulphureous fumigation has also of late j^furafea- been very extensively employed on the continent, and partially in tion: our own country, in the cure of both the present and the ensuing species, and according to the testimony of those who have employed it, with great success. M. Gales of Paris, who seems first to have of Gales: tried it, affirms, that of sixty-five patients who were submitted to it, twenty-five were cured, thirty-two much relieved, while only eight received no benefit. Mr. Wallace, who has also tried it at Dublin, of Wallace on a large scale, does not speak so decisively of its benefit in these complaints as in cutaneous eruptions.* SPECIES II. ARTHROSIA CHRONICA. CHRONIC RHEUMATISM. PAIN, WEAKNESS, AND RIGIDITY OF THE LARGER JOINTS AND SUR- ROUNDING MUSCLES ; INCREASED BY MOTION ; RELIEVED BY WARMTH ; LIMBS SPONTANEOUSLY, OR EASILY GROWING COLD ; FEVER AND SWELLING SLIGHT, OFTEN IMPERCEPTIBLE. Concerning the proper position, and, in some sort, the nature of *£*•*§• this disease, Dr. Cullen confesses himself at a great loss. In his Difficulty ' Synopsis, he arranges it as a sequel of acute rheumatism, and so ex- $££%%* felt by * Observations on Sulphitreous Fumigation, as a Remedy in Rheumatism and Dis- c-tiien. pases of the Skin, Dublin, 1820, 398 cl. in.] HiEMATlCA. [ord. w Gen.XII. plains it in* his definition : yet he gives it a distinct name, that of Artifro'ia' Arthrodynia, for the express purpose, as he tells us, of having a chronica, distinct name at hand for any one who may choose to regard it as a rheuma- separate genus; and whoever is so disposed is at full liberty, he tism. adj^ as to any objection of his own. Yet in his First Lines he takes a different view ; and perhaps a more correct one than cither Sometimes of the above. Chronic rheumatism, instead of being a mere sequel acButeUrheu- OI* acute rheumatism, or a distinct genus, is here made a separate matism. species of a common genus. "Of this disease,'' says Dr. Cullen, "there are two species ; the one named the acute, and the other the chronic rheumatism." And in his subsequent description of the latter, instead of the universal assertion in his earlier work, " pro sequela rheumatismi acuti rheumatismum chronicum dictum semper habeo," he modifies it by the word commonly. " The chro- nic," says he, " is commonly a sequel of the acute rheumatism."* Sometimes There can be no doubt, indeed, that it is so ; but as, in many dise'Lef instances, it is a distinct disease, characterized by symptoms of its and hence own, and demanding a very different treatment, there can be as little ed of s'epa- doubt that it ought to be arranged as a distinct species ; and in the rateiy. present system it is thus arranged accordingly. Varieties Chronic rheumatism has as many, and nearly the same varieties acute spe- as the acute. It becomes fixt in the loins, in the hip, in the knee, <;ie8. Dut seldom in the thorax. Its symptoms are in most respects like Symptoms. J r .. . l„ those of acute rheumatism, only that there is little or no fever: so that while the general heat is very considerable, and the pulse usually upwards of a hundred strokes in a minute in the acute species, the skin in the chronic species seldom exceeds its natural temperature, and the pulse is rarely quicker than eighty strokes ; the joints are less swollen, and of a pale instead of being of a reddish hue, cold and stiff, and roused with difficulty to a perspiration; and always comforted by the application of warmth. The disease continues for an indefinite period, and sometimes only terminates with the life. The affected joint is occasionally debilitated to the utmost degree of atony, so as, when the acute pain is not present, to resemble very nearly a stroke of palsy. Cold the " Cold, the common cause of the acute rheumatism, is also a com- excuTng mon cause of chronic, even where the acute species has not pre- cise, ceded : and violent strains and spasms may be enumerated as other causes. But it is probable that in these cases the constitution is peculiarly disposed to rheumatic action. a disease of Every symptom proves most distinctly that the present is a disease The treat- of debility ; and the mode of treatment must be founded upon this founded on *dea. ^ *s 'ience tnat stimulants of almost all kinds are found ser- this view, viceable. Warm active balsams and resins, as those of copaiva and andTe°re- guaiacum, essential oils of all kinds, from resinous substances, as preparnaa-te turPentine and amber ; from aromatic or pungent plants, as camphor tions. and mustard, and especially cajeput, the green distilled oil from the leaves of the melaleuca Leucodendron, are all employed in their turn ; sometimes alone, where they combine a sedative with a stimu- * Aph. cccci. cl. m.j 3A>sOLL\EOUS FUNCTION, [ord. u. 399 lant power, as camphor and cajeput, and sometimes in union with Gen.XII. opium, which often proves a very valuable addition. AXi™' Most of these are, also, powerful diuretics ; and as acute rheu- chronica. matism is best and soonest removed by warm sudorifics, so chronic ,1."°™- rheumatism seems to be chiefly relieved, and, indeed, radically cured, Jjj™, with by diuretics of a like stimulus. Hence, horse-radish and garlic are opium. often found serviceable ; and turpentine still more so ; which in *caiTeUcs! truth forms the basis of the greater number of the medieines just "j^,** enumerated. How far the arum, or dulcamara, may be specifically ofK" entitled to this character I cannot determine from my own practice. Jhe"'^^-'1 They are both introduced into the table of diuretics by Dr. Cullen, c™- and are highly commended by many physicians of great celebrity for nuicamara. their arthritic virtues. But it is possible that whatever virtues of this kind they possess are rather derived from their stimulating the excrctories generally, and rousing the entire system, than from their acting specifically upon the kidneys. The colchicum autumnale, Meadow which has sometimes proved serviceable, has more decided preten- sions to a diuretic character. Local stimulants are, here, of more service than in the preceding )^antsgu*f species. The cautery of moxa has been more generally used on service. the Continent for chronic than for acute rheumatism,and is certainly In"™"80 more entitled to a trial. It is peculiarly recommended by baron Larrey.* In our own country, however, practitioners have far more stimulant generally had recourse to cataplasms of ammonia, cummin, and aapasra- mustard seeds, occasionally intermixed with euphorbium or cantha- rides : or, in their stead, have made use of friction, and, which is far preferable, the vapour-bath, brine, warm-bathing : and have after- wards kept the joint well clothed with flannel; and sent through Electricity the organ small shocks of electricity, or roused it by the stimulus of voitnism. the voltaic trough. Sulphureous fumigations, or the application of Suiphuie- sulphur in a gaseous form, as first employed by Dr. Gales of Paris, Hone?1"'85" are in common use on the Continent, and very generally extolled, and have occasionally been employed with success in our own country. And, when every thing else has failed, the patient is usually advised Bath to try what, perhaps, it would be better that he should try at first, the mysterious agency of the Bath waters. The subject ought not to be dropped without briefly adverting to Train oil; the internal use of the oleum jecoris aselli, common train oil, or that obtained from the liver of the cod-fish, not long also so ex- tensively tried, I had almost said so fashionable a remedy, in consequence of the warm and confident recommendation of Dr. Percival. This offensive material is procured by the process of puti faction, and appears to derive its stimulant power, at least, as much from rancidity as from any natural quality. Dr. Percival tried it upon a £«£&>» large scale in the Manchester Infirmary, and with so much success, favour: that, nauseous as it is to the taste, rheumatic patients, from being eye-witnesses of its benefit, were in the habit of applying to him for a course of it. Dr. Bardsley has since spoken of it in terms of * Recueil.dejVifmpires. de Cbirwgie, &c. 8ro. Paris, 1821 400 cl. m.] 1LEMATIOA. [ORD. II Gen.XII. nearly equal commendation ; and Dr. Parr asserts that " he thinks Arthrosia' he has seen chronic rheumatism yield to a steady constant use of chro"nca tms °^' wmch had resisted every other remedy." Dr. Bardsley'3 rheuma- dose was from one to three table-spoonfuls in the course of the day. tism. Some years ago the author of this work tried the train oil very steadily and perseveringly in several severe cases of chronic rheu- matism, but with very doubtful success in every instance ; and cer- tainly without any advantage whatever in one or two, in which the oil was punctiliously persevered in for a month, in the proportion of to theleie-two ounces a-day. In slight cases, it may sometimes prove salutary, binthinate but its virtues cannot fairly stand in competition with those of the 0lls" terebinthinate oils. Arsenic The arsenic solution I have never tried in this complaint. It is strongly recommended by Dr. Bardsley,* and, in his hands, it seems often to have succeeded. It may be commenced in doses of ten drops, and-gradually increased to double this quantity, and should be united with a few drops of laudanum if it sit uneasy on the sto- Coichicum. mach by itself. The colchicum wine and vinegar have also occa- sionally been used with success. Chinese ln many of the eastern parts of the world, and particularly in nee'die^' China and Japan, a mode of treatment for various acute muscular pricking. an(j nervous pains has been in immemorial use under the name of zin-king, or needle-pricking ; and consists in pushing from two to five or six finely pointed gold or silver needles at a small distance from each other, into the seat of pain, to the depth of from half an Or acu- mch to an inch, or something more. This has of late been tried puncture. , , ' _ fe __ , under the name of acupuncture or acupuncturation, m France by M. Berliozt and other practitioners, and in our own country by Mr. Morss ChurchillJ for various affections of the above character, but particularly in severe chronic rheumatism ; and, according to the accounts published, with considerable and almost instantaneous relief. The puncture produces little or no pain, and should be fol- lowed with no hemorrhage. A single puncture is often found suffi- cient to remove the ache, though it shoots occasionally to some neighbouring part: in which case, the same process is to be fol- lowed up to the seat of metastasis, when it is usually found to vanish altogether. The needle, when introduced, is suffered to remain in each puncture for about five minutes before it is withdrawn ; and, in this part ofthe world, is commonly made of fine steel. The sub- ject is curious and worth pursuing ; but at present it requires addi- tional experiments ; and till the effect is hereby fully confirmed, it would be idle to offer any hypothesis on the principle of action; though it may turn out to be that of a mere counter-irritation. When the disease is limited to the extremities, whether of the arms or legs, flannel bandages have often been found highly service- able ; and they should be applied with as much tightness as the patient can bear without inconvenience.^ * Medical Reports. t Memoire sur lea Maladies Chroniques, les Evacuations Sanguines, et 1'Acu- puncture. Paris, 1816. X A Treatise on Acupunctuation, &c. London, 1823. § Trans, of King's and Queen's College Dublin. Dr. Gratton. Vol, i. p. 169. 181" ^■m.j SANGUINEOUS FUNCTION [obd. ii. 401 SPECIES III. ARTHROSIA PODAGRA. GOUT. PAIS, inflammation, and fulness, chiefly about the smaller joints : returning after intervals ; OFTEN preceded by, or ALTERNATING WITH, UNUSUAL AFFECTIONS OF THE STOMACH, OR OTHER INTERNAL PARTS ; UNSUPPURATIVE. The origin of the term gout, or goute in French, is little known, 9EN,^H' or rather is almost forgotten. Among the ancients most diseases ofiginof * accompanied with tumefaction were ascribed to a flow of some th« V0Jn^ morbid fluid or humour to the part affected, which was called a rheum or defluxion ; and the rheum or defluxion was denominated cold, hot, acrid, saline, or viscid, according to the nature of the symptoms. The Arabian writers ascribed even this cause to various diseases of the eyes, which were hence called gutta serena and gutta obscura, " clear or cloudy drops or defluxions," according to the external appearance. Rheumatism and gout were alike attributed to the same origin : and as the terms rheuma and gutta were used in medicine synonymously, both importing defluxion, the old opinion is still verbally preserved, and has descended to us in the names of rheumatism and gout, though the old pathology has been abandoned. "We have still," says Dr. Parr, "the treatise of Carpinati published at Padua in 1609, De Gutta seu Junctuarum dolore;" but the term may be traced to Valescus de Tarenta, who wrote his Com- mentary early in the fifteenth century ; and Schneider in his Liber Catarrhorum Speciallissimus, published at Wittenberg in 1664, usu- ally denominated the sixth volume, and peculiarly scarce, describes the gout as a catarrh."* The resemblance between gout and rheumatism is so close that %£™«p the one is often mistaken for the other; and both by Bergius were gout and regarded as convertible : yet, while the former chiefly fixes on the "J^"- small joints, the latter attacks the large; and the first is often here- ditary, while the second is rarely or never so. We have also observed already that gout is far more connected with a dyspeptic state ot tne stomach than rheumatism ; that its incursions are, for the most part, more sudden, its nocturnal exacerbations less striking, but its remis- S1°Gom!^orelveT,'i3 a far more complicated complaint than rheu- Divert^ matism ; and hence there is no disease to which the .JjP" °™ „«*?£ is subiect that has led to such a variety of opinions, both m theory tice v and^p^JLtice, many of them directly contradictory to each other, as * Med. Diet. App. Vol. II.— 11 402 cl. m.} 1LEMAT1UA. Lord. ii. Gen.XII. the gout; and I may add, there is no disease concerning the nature aT""1, and treatment of which physicians ate so little agreed; so that to this moment it constitutes perhaps the widest field for empyncism, and the hottest for warfare, of any that lie within the domam of medical science. Is the gout a local or a constitutional affection ? is it a spasm or » is its course beneficial or mischievous ? should its inflam- Podagra Gout. Hence opening a wide field for empyri Subjects of a pOlSOn . .^ .*^~~«.„----------- dispute. nation be encouraged or counteracted ? is it to be concentrated or repelled ? is it to be treated with cordials or evacuants ? with cold or with heat ? with a phlogistic or an antiphlogistic regimen 1 No sets of questions can be more repugnant to each other than these are ; and yet there is not one of them but we may obtain an answer to, either in the negative or in the affirmative, by applying to dif- ferent practitioners for this purpose. Shutting the door to disputation and unfounded theory as far as we are ahfe, let us, in as few words as possible, attend to the clear and established history of this disease, as we would to that of any other, and draw our pathology, and our mode of practice from the. principles which it will be fairly found to inculcate. In the first place, it is admitted on all hands, or at least with exceptions so few as scarcely to disturb the general consent, that gout, in whatever way it shows itself, is a disease ofthe system ; or, in other words, is dependent upon a peculiar diathesis or state of the constitution. And, next, it is as commonly admitted that this diathesis is, in some instances, original, and in others hereditary or derived. There are many persons in whom this complaint makes its appearance, who can trace no such affection in the blood of their ancestors ; and as such persons are specially distinguished by a habit of indolence, luxury, and indulgence, and particularly in the plea- sures of the table, it is from this habit that the gouty diathesis is supposed to originate. There are others, who, though exhibiting a life of great regularity and abstemiousness, afford proofs of the same diathesis in occasional paroxysms to which it gives rise: and such persons are almost always capable of tracing it hereditarily. For the diathesis having once established itself, keeps its hold on the thesis when system, and is propagated from race to race, whatever be the mannev bushed1. " of life of the individual, or the general state of his constitution ; though there can be no question that those descendants are most subject to its paroxysms who indulge in the excesses that laid its first foundation. Diathesis A gouty diathesis thus produced, like a phlogotic diathesis, to may remain 1 • u • • • , . •• quiescent which m many respects it makes a near approach, may remain qui- throu**™ °r escent an(l not discover itself for years, till it meets with some occa- nfe: unless sional cause of excitement, when it shows itself by a sudden and painful disturbance of some part of the system, but a disturbance of a very different kind, as well as affecting very different organs, according to the temperament, constitution, manner of life, or some ■ho ws'itseif incidental circumstance of the individual: where the general health differently is sound, fixing on one or more of the extremities in the form of a organs"1" Pecubar but very acute inflammation that runs through a regular paroxysm and gradually subsides; and, where the health is infirm, General history of ihe disease our best guide to a correct pa- thology. Gout a dis- ease of the system: sometimes original; at othor limes derived. Nature of the consti- tution where the disease is original. Constitu- tion fre- quently different when derived. Durability ofthe dia- excited by some occasional cause: •j SANGUINEOUS FUNCTION. [ord. ii. 403 and the general form debilitated, exciting great derangement in Gen.XIi. some internal organ or set of organs, and particularly those of diges- a?,^?"" tion ; or shifting from one form to another, and thus proving itself Podagra. under every form to be the same disease, and laying a foundation Gout for the three following varieties :— x Regularis. Pain, swelling, and inflammation Regular fit of gout. of the affected joint consider- able and acute ; continuing for several days, often with remis- sions and exacerbations ; then gradually resolving, and leav- ing the constitution in its usual or improved health. /3 Larvata. Disguised and lurking in the con- Disguised ; lurking atonic stitution, and producing de- gout, rangement in the digestive or other functions, with only slight or fugitive affeetion of the joints. y Complicata. The disease fixing on some in- Retrograde ; recedent; ternal organ instead of on the misplaced gout. joints; or suddenly transferred from the joints after having fixed there ; producing in the internal organ affected, debility or inflammation according to the state of the constitution. The predisposing cause of a gouty diathesis, when it first forms ?red,isP0S- itself in an individual, it has already been observed, is plethora with oTorfginai entonic condition of the vessels. And hence in its origin, as well g™^.™ as in the symptoms it evinces under a regular paroxysm, gout makes state of the a near approach to various other inflammations of which we have nencethe already treated ; and is more disposed to show itself, where it has ;?ofln™' oeen transmitted hereditarily in men of robust and large bodies, of regular large heads, of full and corpulent, and especially gluttonous habits, £££?£. or whose skin exhibits a coarser surface in consequence of being lauon u> covered with a thicker rete mucosum. Castration is said to act as flamma. a general preventive ; but on what facts I know not: though admit- tjo^o- ting the truth of the assertion, it is not difficult to explain the rea- entente son from the entonic energy demanded for the first production ol nnd hence ' . possibly the disease. . . , euuuehs Such is a brief history of the origin, hereditary transmission, and not predis- effects of the podagric diathesis ; which must be distinguished from p™^ the paroxysms to which it gives rise, and which constitutes the only m^tadu- manifest indications of its existence. irom ,.ar- The paroxysms of gout are excited by certain occasional causes, jg^ some ofVhich are obvious and some doubtful, or altogether unknown; howe, Tut without the co-operation of these, the gouty diathesis may re- ^rurmoticed or quiescent in the body for years, or penans. 404 cl. in.] HAEMATIC A. [ord. 11. Gek. XII. Spec. III. Arthrosia Podagra. Gout. Occasional eauses, what. Violent and pro- tracted paroxysms confirm the diathesis, and quicken the return of fits. Whether particular climates more dis- posed lo produce gout. through the whole term of a man's life. And hence it is that we often see an individual, whose ancestors have been notorious for this complaint, pass the whole of his days without betraying any marks of it, while it appears in one or more of his children, per- haps in their very boyhood. The occasional causes are very numerous ; for where the diathesis exists strongly, almost any thing that is capable of producing a general disturbance in the system, or of throwing it off' the balance of ordinary health, is sufficient to become a cause ; and this whether the incitement be of an entonic or an atonic character. And hence paroxysms in different individuals are often produced by intoxication, or excess of eating ; violent emotions of the mind, particularly the depressing passions, as grief and terror ; sudden exposure to cold when the skin is in a state of perspiration ; wet applied to the feet; great labour of the body ; severe application of the mind, especially when protracted so as to break in upon a due allowance of sleep: cold, flatulent fruits, and often acidulous liquors ; a sudden change from a spare to a full, or from a full to a spare, diet; excessive eva- cuations of any kind ; and, occasionally, a sudden cessation of such as are habitual, as the suppression of a periodic hemorrhoidal flux, the cessation of the catamenia, or even the closing of an issue that has long been in a state of discharge. It seems, moreover, indisputable that the more violent the attack of a paroxysm, and the longer its continuance, the more the dia- thesis is confirmed, and the oftener the attack is renewed. On which account it is of great importance to alleviate and abridge the pa- roxysms as much as possible, and especially when they are as yet new to the system. Whether particular climates or countries are more disposed to favour the existence of gout than others, separate from the occa- sional causes just adverted to, may be doubted. Such an opinion, however, has prevailed among the vulgar as well as among many of the more learned in most ages. Thus, among the Greeks, it was a popular belief that Attica was the hot-bed of gout, as Achaia was of ophthalmy; whence Lucretius, Atthide tentantur gressns, oculeique in Achseis finibus. Gout clogs the feet in Attica, the sight Fails in Achaia. Proximate cause variously accounted for. And thus, too, in more recent times, we are told that China,! and even some of the German provinces, are exempt from the attack of gout, while in our own country it exercises an almost irresistible sway. The last assertion is true enough, but we are not driven to the variable nature of our climate to account for the fact. Thus far we can proceed safely respecting the general pathology of this Proteus-disease. But the moment we enter upon the field of its proximate cause, we are bewildered in a hopeless labyrinth, without a thread to guide our entangled footsteps amidst the grow- ing darkness. There has, indeed, been no want of attempts to ex- * De Rer. Nat. vi. 1117. t Le Conte. Noavelles Memoires sur l'etat present de la Chine. Paris, 1696. vl. in.] SANGUINEOUS FUNCTION. [okd. 11. 40o plain the subject, but thus far they have been attempts alone—inge- Gen.XII. wZn^trfT rathf *hankenUcIeated facts. Thus some, among SSSi"' wnom was the fearned Boerhaave, resolved the proximate cause of £°daSra. gout into a morbid texture of the nerves and capillaries; and Hypothesis others, into a peculiar acrimony ofthe fluids ; respecting the nature tfj™- ot which, however, those who adopted this view were never able to agree ; several of them, like Hoffman, affirming it to be a tartaric ofiioffman. salt, several, a bilious salt, several again, an acid, and several ajrain, an alkali. This morbid material, in whatever it consists, was supposed to be ^orbiub separated from the system and thrown off* during the continuance thmmf- of the paroxysm, which, consequently, it became the duty of the JJldEbe physician to encourage. And by some pathologists it was held that *«>*"> °ff- the morbid matter thus despumated has, in various instances, proved "aid iX contagious, and this not to man only but to other animals as well: comagiouB; thus M. Pietsch informs us that he has known dogs affected with and even the same disease by licking the ulcers that have followed upon a fit do^" of gout accompanied with chalk-stones. Dr. Cullen has taken great pains in a series of nine consecutive JJost °J. arguments to prove the error or absurdity of most of these opinions: opposed by and then he proceeds to establish his own ; which consists in regard- fn"0u"'o'" ing the proximate cause of a gouty diathesis as dependent upon a his own- certain vigorous and plethoric state of the system ; and the proxi- mate cause of a gouty paroxysm as produced by an occasional loss of tone in the extremities, often communicated to the.whole system, but especially to the stomach, succeeded by ^powerful re-action in the same quarter which constitutes the pain and inflammation, and is an effort of the vis medicatrix naturae to restore the tone thus in- jured.! But by this hypothesis we gain as little as by any of the preceding. It is obviously a mere extension of the Cullenian doc- trine of fever to the disease before us, and is chargeable with the same incongruity: for here, as in fever, the stage of strength or in- creased energy is made to depend upon the stage of weakness ; as the weakness or loss of tone is made dependent upon a peculiar vigour and plethoric state of the system. There is, indeed, no great difficulty in conceiving how loss of tone may follow upon excess of energy ; but by what means recovered energy is to be a result of loss of tone, is a problem of more laborious solution. I have dwelt the longer upon this subject because it involves a very essential point in the remedial process, and one which has rarely been sufficiently attended to : before we enter upon which, however, it may not be inexpedient to take a fuller glance at the symptoms by which the different varieties of the disease are cha- racterized. One of the marks by which a regular paroxysm of gout is said " *;e£°?ft" to be distinguished from that of rheumatism, is the suddenness of its faris. onset. This is true, as Sydenham has correctly observed, with re- ^X'gout. gard to the general course of regular or entonic gout, in which the Described constitution is in other respects perfectly sound. But in other cases course. Sometimes * Schaffer Vers. II. P. 176, who denies it: and Degncr de Dysenteria, who main- precede by tajD9 jt. ♦ Pract. of Phys. Part I. B. li, Ch. XIV. pxxxm. 406 cl. in.J HiEMATICA, (ord. ii. Gen'XIJ. the fit is often preceded by certain prodromi which those who have a AEp'oda- suffered from it before very sufficiently understand, and uniformly gra regu- take as a warning ; such as a coldness or numbness of- the lower Regular fit limbs, alternating with a sense of pricking or formication along their particular11' entire length ; frequent cramps of the muscles ofthe legs ; a eras- signs, sament in the urine ;* slight shiverings over the surface ; languor and flatulency of the stomach ; and sometimes a pain over the eye- lids or in some other organ.f Generally The paroxysm is said by Dr. Sydenham, who has drawn its pic- t8nePspringn ture to the life, to show itself most commonly in January or Feb- butnot ruary ; but I have known it occur so often towS-ds the close of the summer, and in the autumn, and have attended so many patients who have never had it except in the latter seasons, that the rule Description, does not seem to be in any way very well established. The first attack is usually in one of the feet, most commonly about the ball or first joint of the great toe ; it commences at night or during the night, and there is sometimes, though not always, a slight horror, succeeded by a hot stage. The local pain and swelling increase in violence, the joint assumes a fiery redness, and the whole body is in a state of great restlessness. The symptoms remit sometimes to- wards the next morning, yet occasionally not till the morning after ; but they still return during the night, though in a more tolerable degree, for three or four days, or even a week ; when the inflam- mation subsides as by resolution ; the foot almost instantly recovers its vigour, as though nothing had been the matter with it; and if the patient have been antecedently indisposed, he enjoys, as on re- covering from an ague, an alacrity of body and mind beyond what he has experienced for a long time before ; the constitutional indis- position disappearing with the paroxysm. Return of At the commencement of the disease, the return of it may be an- yhsmPat°first nual, or not oftener than once in three or four years; but it is perpetu- annuai or aiiy encroaching on the constitution, so that the intervals gradually be- quent; come shorter, and the attacks more frequent and of longer continu- to^imer-8 ance : whence, as Dr. Cullen has justly observed, " in an advanced vais much state of the disease, the patient is hardly ever tolerably free from it, except perhaps for two or three months in the summer." character Nothing can be more specific, more true to itself, or more distinct flammation ^rom everv other kind of inflammation than that of the disease be- specific. fore us, when thus exhibited in a regular fit; the inflammation of erythema does not differ more from that of phlegmon than both these, and indeed every other from that of gout: it never suppu- rates, never ulcerates when simple and genuine, however violent may be the attack, and though to the eye of inexperience the skin may seem to be on the point of bursting ; while, in the midst of the severest pain, there is a sense of numbness, weight, and want of energy ; insomuch, that if the pain could for a moment be forgot- ten, the limb would feel paralytic ; and though the muscles which move the limb be not affected, they raise it or drag it along like a dead load. If the inflammation run through its course where it first * Butler, Nadere out dekkinge der menschelyke Waters. Harlem. 1fiQ7 t Eph. Nat. Cur. Dec, I. Ann. in. Ob*. 2sf Cl. m.j SANGUINEOUS FUNCTION. [ord. ii. <1U7 fixes, it subsides by a resolution that leaves no external discolora- Gen.XII. tion or internal weakness or disability ; and if it make a transfer Ja^po"1- from one extremity to another, it passes with inconceivable rapidity ; p* «>gu- the limb now affected being loaded with all the vehemence of the Regular fit inflammatory action ; and that lately the seat of pain being all of a of the sy down, as well in mind as in body, and becomes a prey to its [o0x8vhsl!£" tyrannic control. In this case the paroxysms, though much longer and'at and more frequent, are less violent and painful than at first; but kcc"ns'(low"' there is no joint exempt from its incursion, nor perhaps an internal organ that does not suffer from induced weakness : so that, in the language of Sydenham, " the patient exists only to be wretched and miserable, and not at all to taste ofthe happiness of life." It is a remarkable fact, hitherto indeed little dwelt upon and '" ^en| altogether unaccounted for, that as the system advances in years secretion ef and debility, and every other secretion progressively fails, that of ^"Xn calcareous earth seems to increase. Hence the bones of aged per- augmented. sons are more fragile and apt to break upon slight concussions ; and the arteries and various other parts become ossified or loaded with nodules of lime-stone ; and where a powerful sympathy exists be- tween the kidneys and the stomach, and either of these is in an infirm state, we have a larger deposite of the same material in the kidneys or the bladder. A similar increase of calcareous earth takes And hence place in the weakness of chronic gout; every affected joint becomes nnrod0ucedy loaded with its secretion, which collects and hardens into nodules °y e°»t. in its cavities, or in the adjoining cellular membrane, or bursas mu- cosas, and renders motion uneasy or destroys it altogether. The lime-stone, moreover, as it hardens, acts as a foreign irritant to the distended integuments, and produces, what simple inflammation of the gout never does, ulcerations and an offensive discharge. For Hence often the same reason nephritic calculi are often a sequel of gout when cafcuH.' it has assumed a chronic form ; and the children of gouty parents are said to be hereditarily disposed to both complaints, some of them exhibiting a podagric and others a nephritic affection. Sometimes This calcareous secretion is thrown off by the surface °Jgc8aJccr«e- of the skin. I have seen, says Swediaur, an inveterate case in which tion by the the patient labouring under a paroxysm of several months' duration,skin- had the entire surface ofthe body covered every morning with a white powder, as though he had been dusted with flour.* Thus far, we have followed up the progress of a regular attack of ££;,";,,. gout in a constitution otherwise healthy and vigorous. But the ^ same diathesis exists in systems of delicate and infirm health, andoraetonic where there is a want of sufficient energy to work up a fit of inflam- g^ mation and throw it off at its appropriate outlets. And in such Pound in conBtitu- * Nor. Nosol. Meth. Syst. I. p. 218. *«£• and 40s cl. in .J lliliiUATUJA. [ord. u Gen. XII. Spec. III. ft A. Poda- gra larva- tn. Disguised, or atonic gout. Under va- rious cha- racters ; but chiefly affects the digestive organs. Fugitive y A. Poda- gra com* plicata. Recedcnt; misplaced gout. How pro- duced. Symptoms. explained. Sensations when in the stomach; in the bead. Sometimes in the blad- der or rec- tum. Indications of cure to apply to the parox- ysms and to the in- terval*' case, as soon as it becomes roused into action by any of the causes of excitement already enumerated, it constitutes the second vari- ety, assumes the guise of various other diseases, as dyspepsy, hys- teria, hypochondrias, palpitations of the heart, vertigo, hemicrania, with several modifications of palsy or apoplexy. The stomach and bowels, however, form the chief seat of affection; the appetite is fastidious or destroyed ; a spasmodic stricture or painful oppression is felt in the epigastric region, or the stomach is distended almost to bursting with flatulence; nausea, eructations, vomiting, and all the symptoms of indigestion follow, and are alternated with severe colic or costiveness. In the mean while the disease shows itself at times, in one or more of the joints in slight and fugitive pains, as though making an ineffectual effort to kindle up a paroxysm of proper inflammation, but which there is not energy enough in the system to accomplish ; whence the articular pains cease almost as soon as they appear; and the visceral derangement is renewed ; sometimes slowly subsiding after a continuance of several weeks ; and sometimes wearing out the entire frame, and terminating in abdominal or cellular dropsy. It sometimes happens, however, that while the general constitu- tion of a podagric patient is tolerably sound, one or more of the internal organs form an exception to the general rule, and are less healthy than the rest. And as upon an excitement of gouty inflam- mation in a gouty habit, the inflammation seizes ordinarily upon the weakest part of the body, it makes its assault upon such organ rather than upon the hands or the feet; or, if it commence in the latter, is readily transferred to it; constituting the third of the varieties before us, and which has usually been called retrograde or misplaced gout. And if the general system should, at the same time, be below the ordinary tone of health when the paroxysm is thus excited by the force of some occasional cause, the organ affected may evince great langour and painful inertness, as in the second variety, rather than acute inflammation, as in the first. The sensation in the stomach, instead of being that of a fiery coal, is that of a cold lump of lead ; in the head it changes from madden- ing pain to oppressive horror, in which the patient suddenly starts from sleep almost as soon as he began to doze, from the hideous- ness of the ideas that rush across the mind and form the distracting dream. The fit is sometimes transferred to the bladder ; in which case there is acute pain at the neck of the organ, strangury, and a dis- charge of thin acrid mucus from the urethra. The rectum has also been occasionally the seat of metastasis, and has evinced various species of affection, as simple vehement pain, spastic constriction, or hemorrhoidal tumours. When thrown upon the lungs it mimics the symptoms of a peripneumony. In applying the art of medicine to the cure or alleviation of gout, our attention must be directed to the state of the patient during the paroxysms, and during their intervals : and particularly to the state of his constitution or previous habits, which, according to their »-i»m.J SANGUINEOUS FUNOTION. [ord. ii. 401) character, may demand a different and even an opposite mode of Gen.XII. management. Spec. hi. t _f • , , VA- Poda- uex us commence with the paroxysmal treatment : and, first era com- of all, with that of the inflammatory attack, as it shows itself in a fc; regular fit ofthe disease. misplaced' It was formerly the belief, as we have already seen, that a gouty Treatment paroxysm was an effect of nature to throw off from the constitution, ^/,,t. and thereby restore it to a state of perfect health, some peccant During the matter forming the proximate cause of the distemper ; and it was Ef'areguiar hence, also, conceived, in addition, to adopt the language offiL Sydenham, that the more vehement the fit the sooner it will be over, and the longer and more perfect the intermission. And in this view of the subject there can be no question that the wisest plan must have been that of leaving the paroxysm to run through its regular course without interruption. Yet, as this hypothesis has Jne^rnil. long fallen into discredit, we are not in the present day prevented, ry means on such ground, from endeavouring to subdue the inflammation of "numi" a sroutv paroxysm by the ordinary means resorted to in inflamma- inflamma- tions ni&v tion of any other kind, as bleeding, purgatives, sudorifics, local apply. astringents, and even refrigerants. But a very general objection Objection has since been taken to this plan on another ground, and that is, posed dan- the great danger of repelling the disease to some internal organ off^J,^' more importance, and thus of converting a regular paroxysm into a case of retrograde or atonic gout. And in consequence of this and hencs apprehension, the practice even in the hands of many of our most pra/tfce'4 celebrated physicians, has, for a long period, been in the highest ™fi"fataini degree vague and vacillating. Sydenham prohibited equally purg- Practice of ing and sweating of every kind, whether gentle or copious, and sydenham; only allowed bleeding where the patient was young and vigorous, and on the first or second paroxysm : while of cold applications he takes no notice whatever. He admits, however, the use of lauda- num where the pain is very acute : trusting chiefly for the cure of the disease to an alterant regimen and apozems to be resorted to in the intervals. Dr. Cullen allows bleeding with the same restriction of Cullen ; as Sydenham, though he recommends the application of leeches to the inflamed part, as at all times a safer practice than the use of the lancet. Of cathartics and sudorifics he takes no notice otherwise than as these may enter into the general course of an antiphlogistic regimen : he is decidedly adverse to the use of cold ; and thinks ^ek^de- that warm-bathing and emollient poultices, blistering, burning with verse to the moxa, camphorate and aromatic oils, induce the inflammation toJJJ^re. shift from one part to another, and consequently tend to repel the ^e(ra"^ inflammation from the extremities to some more important organ : mosti„cai while opium, though it affords relief in the present paroxysms, occa- •p£9£Me sions them to return with greater violence ; and, therefore, he ob- a metas- serves, by way of conclusion, " The common practice of committing objects to the person to patience and flannel alone, is established upon the best opium, and foundation "* chiefly tu Now. as we have already seen that the gout, after it has shown v*«*™nel Why a tnoreacti''t * First Lines of the Practice of Physic, Aph. dijcix. coTiwe Vol. 11.—3? 410 in.] 1LEMAT1CA. [ord. jl Gkn. XII. Spec. III. Arthrosia Podagra. Gout. Treatment of gout during the paroxysms. ought to be pursued. Whether the fear of repulsion ought to extend equally to all the va- lielies, and the ordi- nary re- ducing pro- cess may not some- times be used safely. General character and ten- dency of the disease. In healthy constitu- tions the weakest parts are the extre- mities. In un- healthy habits other parts. Hence sometimes the extre- mities and sometimes other parts the seat of paroxysm. And hence a distinct line of treatment pointed out, often per- fectly op- posite. itself in paroxysms, is never idle ; that one paroxysm, in the opinion of Sydenham, Cullen, and every other physician, hastens on another, renders its intervals shorter, and its durations longer ; and progres- sively saps all the energies both of mind and body, and renders life itself a burden ; it is of serious importance to inquire whether this fear of a repulsion, however well founded in some instances, be not allowed too generally ; whether it be not possible to draw a definite line between the form of the disease in which it ought to operate, and that in which it ought not ? and whether in the latter case we may not derive all the benefit from a full use of a reducing process, which is obtained in other inflammations, accompanied with a like degree of constitutional vigour 1 From the history of this disease, as it has already passed before us, we may draw this general corollary : that the specific inflamma- tion of gout, or whatever other morbid character it may evince, when once excited by some occasional cause into action, has a peculiar tendency to fix and expand itself upon the weakest parts of the system, and where several parts are equally weak, to pass in sudden transitions from one part to another, though transitions are rare where the system is sound. In healthy constitutions the weakest parts are the extremities ; and hence, in such constitutions, these are the parts, as we have already seen, in which the gout uniformly opens its assault. Here it com- mences, and here it runs through its course, seldom migrating, or, when it does migrate, only passing from one extremity to another ; as from foot to foot, or from one of the feet to one of the hands ; and limiting itself to these quarters because they are the weakest. parts of the system: though, as just observed, in a thoroughly sound constitution such migrations are not common. In unhealthy habits, however, the extremities are not the weakest parts of the system, but perhaps, the stomach, or the heart, or the head, or the lungs, or some other organ ; while several of these organs may, moreover, be equally debilitated, according to the idiosyncrasy, or to accidental circumstances. And true to the general rule, we see the gouty principle, when roused into action in habits of this kind, fixing itself from the first on one of those important viscera rather than on the extremities ; or roaming from one to another, on its alternating its course from these organs to the extremities, or from the extremities to these organs. And as metas- tases are rare where the system is sound, they become frequent in proportion as it loses this character, and especially in proportion to its debility in particular parts. These are rules which we cannot too closely study and commit to memory, and they seem to point out to us the line of distinction between that form of the disease in which we ought to entertain a prudent fear of revulsion, and that in which we may safely act with- out any such fear whatever. They directly lead us to two states of constitution that require a very different, and in many instances a very opposite mode of treatment; and seem to settle the important question before us, under what circumstances it may be expedient to employ a palliative plan ; and under what a cooling and reductive. '; ■ »"•! SANGUINEOUS FUNCTION. [oiu>. ii. 411 Let us commence with the first of these two states, forming a Gen.XII. regular but violent fit of gout as it shows itself in a sound constitu- Aft^J?* tion, and inflicts its torture on the hand or the foot. Guiding our- Podagra. selves by the laws just laid down, there seems no reason why, Treatment instead of " committing the person to patience and flannel alone," S^ftj^,,, we should not pursue the evacuating and refrigerant means employed paroxysms. in entonic inflammations of any other kind, and have cause to ex- '" In sound conBlitu- pect a like success : such as bleeding, so strongly recommended by 'ions n" Dr. Heberden, and allowed occasionally by Sydenham, and empty- metastasis, ing the bowels, relaxing the skin generally, and cooling the fiery evacuanu heat of the affected limb by cold water or any other frigorific appli- and refn- cation. With a transfer of morbific matter we have now no longer maybe to contend. Yet, even where such a cause is admitted, as in most iJfJ^Jfp.j exanthems, the plan thus proposed is, in many instances, pursued by the without hesitation. Thus, in measles, cathartics and venesection of e^n-' are not only in general use, but often indispensable ; in the heightthe:ns- of malignant scarlet-fever, we sponge or wash the entire surface of the body with cold water ; and in small-pox, not only purge freely, but expose the patient to the coldest atmosphere of the winter season. In weakly habits, or idiosyncrasies, or incidental debilities of par- J" weakly J ' .-ii • u habits me- ticular organs, we have admitted that a metastasis, as we nave tnstasis is already seen, is a frequent result, and peculiarly marks the character co"irno"; of gouty inflammation ; and here, indeed, refrigerants, violent pur- j1^Bha*n°e gatives, and venesection ought to be most sedulously abstained from ; treatment and not unfrequently, the best practice we can adopt is that of Joyous!3" " committing the person to patience and flannel alone." But what I am anxious to establish is, that, agreeably to the laws which regu- late the progress of gout, a metastasis in sound and vigorous con- stitutions is rarely to be expected, and perhaps never takes place, except from one extremity to another. In order that some internal f^f^. organ may become the seat of transferred gout, it is necessary that plained. it should possess a weaker action than the part from which the inflammation is to be transferred : but the parts of weakest action in a sound and vigorous constitution are the extremities themselves : and it is probably because the living energy is, in all the extremities, upon a balance, that in a sound frame a metastasis, even from one extremity to another, is a rare occurrence. Local infirmity seems to form the only ground for a metastasis ; ^?t'yin- but where health prevails generally, and all the organs are equally the only sound, admitting the inflammatory action, instead of being reduced ^XtasiL* and resolved, to be repelled, there is no one organ to which it seems \fj»»™* capable of being transferred rather than to another ; and in such Iobu.t case it would be most reasonable to suppose that the morbid entony y™$<™; would be thrown back generally and divided among the whole, from thejra,;,0 which division of labour little mischief could happen. As far as I have seen, the inflammation of a regular fit of gout subsides gradually, though rapidly, under the treatment now pro- posed, without any repulsion whatever. \ et, ma tew instances, it Hj.-- has seemed to be replied in part, whilst it has chiefly passed oti by j-^ resolution. For during the use of a cold pediluvium, or shortly lM)rtallt ience in 11:2 CL. 111.] 1LLMATICA, ORD. il. Gen. XII. Spec. III. Arthrosia Podagra. Gout. Treatment of gout during the paroxysms. partially repelled ; but without evil. Advertency to facts proving the proposed plan inju- rious. Vet highly and essen- tially bene- ficial in numerous cases. Hence a call for proper dis- crimination, Benefit ex- emplified in the author's own person. Case described. Reclined position and appli- cation of flannel. afterwards, I have known patients speak of a peculiar kind of. aura creeping over them and through them, and exciting an undefinable sense of glowing which has lasted for a few minutes, without any inconvenience at the time, or even any change in the pulse ; and certainly without any ill effect afterwards. But, it may be replied, there is no resisting facts. The cases arc innumerable in which great mischief has resulted from the depleting and the refrigerant plan ; and, as we cannot always tell that all the internal organs are or are not in a state of sound health, it is most prudent to abstain from a practice which may prove highly injurious in case of a mistake. The answer to this remark is, that here, as well as in every other disease, professional judgment is to be called into exercise, and the practitioner is to draw largely upon that skill and discrimination which it was the object of his education to bestow upon him : and thus bestirring himself, he will rarely fall into an error. That mis- chief has resulted, and frequently from the use of the plan before us, cannot be denied by any one; but that great and essential good, and an easy and rapid cure have been also in hundreds of instances effected, must be admitted as readily. No clear distinctive line, however, has hitherto, so far as I am acquainted with, been acted upon or even laid down: and hence it is rather to be ascribed to a want of discrimination upon this subject that the evils adverted to are chargeable, than to any mischief in the plan itself. Yet it may be doubted whether the injury produced even by an injudicious use of evacuants and refrigerants amounts to a thousandth part of that entailed on the constitution by allowing the gout to make its inroads tacitly and unresisted; till by degrees it triumphs equally over all the powers, as well of the body as of the mind, and, in the forcible language of Sydenham," The miserable wretch is at length so happy as to die." Of the benefit produced by the external use of cold-water, the author can speak from a trial of several years upon his own person, and is only anxious that others sliould participate in what has proved so decisive a comfort to himself. The author, in the enjoyment of undisturbed health, amidst great exercise of body and mind, which, however, acted as a relief to each other, was, for the first time, in his forty-seventh year, attacked with a regular fit of gout in one of his feet, some of his ancestors having been subject to the same complaint. Having long before drawn the distinctive line of treatment just adverted to, and carried it success- fully into practice, he was on the point of trying it on himself, and particularly the affusion of cold water ; but his family were so alarmed at the proposal, that he consented for the term of three days, but no longer, to follow the Cullenian prescription, and to employ nothing but flannel and as much patience as he could com- mand. The foot was in consequence warmly wrapped up, and the sofa received him when he quitted the bed. The inflammation was extensive, and very painful, the pain, however, remitted occasionally in the day, yet returned towards night with a vehemence that entirely deprived him of sleep, and kept him in a profuse perspiration ; but cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 41:3 a perspiration that afforded no relief. The limited time having ex- Gen.XII. pired, and the inflammation having gradually augmented instead of aX,","f' subsiding, early on the third morning he called for a large basin of PodaerB- cold water, stripped off the flannel, and boldly plunged the foot into It gouT" it for four or five times in succession. The application was pecu- ^"1^ liarly refreshing ; the fiery heat and pain, and all the inflammatory Bath of symptoms diminished instantly ; he repeated the cold bathing two Gradual' hours afterwards, and continued to do so through the whole of the dhecl8inra°! day; the complaint gradually diminishing upon every repetition, toms!™1" He slept soundly all night, the pain was trifling, and the inflamma- tion had almost subsided by the morning : he was able to hobble a little in the course of the day ; and in four and twenty hours more the fit completely disappeared, and he was capable of resuming his accustomed exercise of walking. For five or six years afterwards he suffered annually from a like attack, but always had immediate recourse to cold emersion or affusion. No paroxysm continued longer than about three days, nor any one ever confined him totally to his house for a single day. Since this period, the use of a car- riage has prevented the excess of fatigue which he had hitherto often undergone ; but from a love of walking he still frequently indulged in it; and for about the three ensuing years he had neither gout nor any other complaint to interrupt his usual career of good health. During the preceding paroxysm, the appetite being good, the bowels regular, and the pulse not much quickened, he made use of no colla- teral means, nor never found the use of the cold water productive of the least inconvenience ; though he has occasionally been sensi- ble of a gradual creeping through the system of the peculiar aura just adverted to, which may perhaps be called the aura podagrica, but which constituted no unpleasant sensation. To the preceding statement, it becomes the duty of the author to Return of add in this second edition, that apparently owing to too much exer- •mrox-v,"B' tion of mind in the composition of this work, the gout has since appeared, accompanied with a more irritable state of the general frame than had hitherto been manifested. On this occasion, there- fore, he did not venture upon the cold-bath, but confined himself chiefly to the wine of colchicum, with, very frequently, a full dose of magnesia; and, by this simple plan alone, he has again been able to obtain a restoration of health, and the full enjoyment of foot- exercise. Yet the bolder practice before us is by no means of modern inven- The prac tion, however it may have become a subject of warm controversy in modem in- the present day. An active evacuant plan, both by vensection and X'lhef in purging, has never ceased to be in use among many practitioners, respect to and is particularly alluded to by Sydenham, though, with a view ofevacuanU entering his protest against it, as injurious to a free discharge of the peccant matter, which, in his opinion, required to be carried off; while, with respect to the external use of cold-water, not to mention or refrige- that it seems to be alluded to by several of the Greek writers, and tant* especially by Hippocrates,* it has descended in a stream of recom- * Aphor. Sect. v. p. 25. 414 cl. in.] HiEMATlCA. |okd. it. Gen.XII. Spec. III. Arthrosia Podagra. (jouU Treatment of gout during the paroxysms. Has been employed rashly and fatally. Hence the necessity of attending to the line pointed out Treatment of regular fit when a different plan is called for. Local ap- plications. Gentle aperients. Breathing perspira- tion. Opium. mendations from Zacutus Lusitanus* in 1641 to Kolhaas,! and KeckJ in 1788 and 1789. Bartholin speaks of the use of snow as a com- mon application in 1661,§ and Pechlin both of snow and cold sea- water towards the close of the same century.|| But this treatment, I am ready to admit, has often been employed rashly, and sometimes with great and even fatal mischief. It ought never to be ventured upon except, as already stated, where the con- stitution is decidedly sound and vigorous ; for though I subscribe to much of Dr. Kinglake's therapeutic plan, I cannot agree with him that a gouty paroxysm is a merely local affection. The treatment before us should be limited to those who are in full vigour, and per- haps entony of health; and is especially to be avoided where the stomach is dyspeptic, the lungs asthmatic, the heart subject to palpi- tation, the head to nervous pains or drowsiness ; or where there is any known disability in any other important organ. Yet even here we need not, I think, condemn the sufferer to the torture till cured by patience and flannel; for it will often be in our power at least to palliate his pain, and not unfrequently to expedite his cure, without any risk whatever of effecting his general state of health. Leeches may, in many instances, be applied where venesection would be of doubtful expediency; a liniment of oil of almonds impregnated with opium, rubbed on the tumefaction with a protracted and very gentle friction, I have often found highly serviceable in mitigating the pains ; and epithems of tepid water, as recommended by Dr. Scudamore, alone or mixed with a portion of ether or alcohol, formed by cloths wetted with the fluid, and applied to the inflamed part, renewable as they become dry, in many cases prove a grateful substitute for cold water ; and are preferable to poultices, warm water, or even vapour-baths, which too generally relax and weaken the joint, and prevent it from re- covering its elasticity, after the paroxysm is over, so soon as it other- wise would do. At the same time, the body should be cooled with gentle aperi- ents or injections ; and while drenching sweats are avoided, which never fail to be injurious, the breathing moisture or diapnoe should be imitated, which often breaks forth naturally in an early part of the morning, and is sure to afford relief after a night of distraction. Nor should opium be omitted where the pain is very acute ; for, while it affords temporary ease, it diminishes the duration as well as the violence of the paroxysm. Dr. Cullen, in his Practice of Physic, seems disposed to postpone the use of this medicine till the pa- roxysms have abated in their violence, for when given in the be- ginning of gouty paroxysms, he asserts that it occasions the fits to return with additional fury. Yet it should never be forgotten, that it is a law in the history of gout, and one to which we have already adverted, that the frequency and vehemence of the ensuing paroxvsms are measured by the violence of those that have preceded. *De Medicorum Princip. Historia, Lib. in. Amsterd. 1641. t Baldinger, Neuer, Mag. Band. v. p. 521. 1788. I Abhandluugen und Beobachtungen. Berl. 1789. § De Usu Nivis medico, 1661. 8vo. p Observ. Physico-Med. Hamb. 1691. 4to. • iu.J SANGUINEOUS FUNCTION. [ord. ii. 41j In the mean tune, the regimen should be light and inirritant; and Gen.XII. he diet below the standard to which the patient has been accus- Sth^L tomed ; though to guard against a metastasis to the stomach, we Po-iegra. must be cautious that we do not reduce it too much. His beverage Treatment should be cool and unstimulant: Sydenham allows him sound table dufmg'tho beer, and, if he have been accustomed to stronger malt liquors, such paroxysms. a drink may be conceded to him. His chamber should be well Reg,men- ventilated, and his dress light and easy. In the two ensuing varieties, constituting atonic and retrocedent Trea,ment gout, we have a podagric diathesis grafted upon an unsound frame ; coud und the unsoundness being general or local: and, however fearless we I?eltiLv.a" may be of the disease fixing on any internal organ in the preceding variety, we have here a constant apprehension that it may do so, and in many cases see it commence in such organs. In atonic gout, our uniform attempt should be to produce a transfer c"ra'!vo from the part on which it has seized, and fix it in the extremities: in atonic in retrocedent gout, on the contrary, to render the vacillating attack fet"5,cede»t. on the extremities more permanent, and prevent it from shifting to any otlier quarter. To obtain the first intention, we have to strengthen and even sti- Jbht"£™d by mulate the system generally by warm tonics and a generous diet, tonics and u and above all things to take off the severe suffering, in whatever it dTet!'0"8 may consist, from the affected organ ; for the longer the fit continues there, the weaker the organ will become, and the less capable of any instinctive remedial exertion. At the same time we may solicit the vfum" paroxysm to the extremities by putting the feet into warm water, and thus unstringing. the tone of their vessels ; so as to bring the standard of their atony below that of the affected organ. In atonic gout, the sufferings, though widely different according ®UJ"'"^. to the seat of the disease, are almost insupportable. In the head nety often the pain is maddening, or the disorder is accompanied with great lb""ppo,ta" horror, or mimics the stupor of an apoplexy : in the stomach there is a faintness like that of death, with a sense of a cold lump of lead lodged within it; or there is a gnawing or a burning agony, or a spasmodic stricture which cuts the body in two, and renders breathing almost impossible ; often also accompanied with a rapid and sinking palpitation of the heart. It is of importance, before we proceed, to determine accurately ^wri£ne that these anomalous symptoms are really those of gout; of which that the we have chiefly to judge from the general character of the patient's Bymm,aom°s constitution, his hereditary predispositions, habits of life, and the ail- %°Jegfjt ments to which he has been previously subject. In mos. cases, stimulant' during the paroxysm, and especially, where the stomach is affected, cordiaIs' the warmest cordials are necessary, as brandy, the aromatic spirit of ammonia, the tincture of ginger or of capsicum ; or, what is still better, usquebaugh. And it is always advantageous, and especially J£™ "P«- where the bowels are confined, to add to it some warm aperient, as aloes or rhubarb. Most of our family gout-cordials are made upon this principle, and judiciously consist of some active aperient, and the hottest aromatics dissolved in ardent spirits. And the patient s™«»<* who is subject to these attacks should never be without having should be hand. lib ex. m.j HJtiMATiCA. Loiiu. n Gen. XII. Spec. III. Arthrosia Podagra. Goat. Treatment of gout during the paroxysms. Essential oil of tur- pentine. Ethereal prepara- Phosphorus. Musk. External irritants. Opium internally a sheet- anchor : in large doses. Exempli- fied. something of this kind at hand, since the paroxysm often makes itn onset without any warning. Yet he should resolutely forbear having recourse to any such medicine except in the time of necessity; for an habitual indulgence in any of them will still farther debilitate the affected organ, and indeed the entire system; and hence quicken the returns of the paroxysm, and render the stimulant antidote less availing. The best aperient, and at the same time stimulant medi- cine that I know of for this purpose is, the essential oil of turpentine, which, as uniting the powers of an active cathartic and a campho- rate cordial, give us all the qualities we are looking for. I do not know that this valuable medicine has ever yet been brought into general practice in any form of gout; but I may venture to predict, that those who try it in the modification before us will seldom have to repent of their experiment. The dose should be about six drachms swallowed unmixed. Most of the preparations of ether contained in the current Phar- macopoeia of the London College, may be employed with benefit in the variety before us, and particularly in that icy coldness of the sto- mach, accompanied with a numbness of the limbs and a rapid palpi- tation of the heart, under which it occasionally exhibits itself. Phos- phorus itself has sometimes been ventured upon in this case, in the proportion of two or three grains to a dose dissolved in double the proportion of ether ; but I have never employed it, and cannot speak of its good effects. Musk seems in many instances to have been of decided advantage if given in sufficient doses, as well in gouty affec- tions of the head as of the stomach. The case related by Mr. James Pringle is strikingly in its favour,* and seems to have induced Dr. Cullen to make trial of it in similar instances, who found it produce sudden relief by free doses repeated after short intervals ; and this where the lungs as well as the head and stomach were the seat of transferred disease.! External irritants may also be beneficially employed at the same time; and particularly those of rapid action, as the compound cam- phor liniment, sinapisms, and the burning of moxa, or coarse flax as recommended by Hippocrates : at the same time the extremities, as already advised, should be plunged into the warm bath. But our sheet anchor is opium ; and it should be given freely, and in union with some preparation of antimony, so as to act towards the surface generally, and thus restore to the living power its inter- rupted equilibrium. Small doses of opium will here be of no avail; and we may generally repeat or increase the quantity to a large amount with perfect safety. " In a case of the gout in the stomach," says Dr. Cullen, " I have by degrees gone on to the dose of ten grains twice a-day; and when the disease was overcome, the dose of opium was gradually diminished, tdl in the course of two or three weeks it was none at all: and in all this no harm appeared to be done to the system. We frequently find that when a strong irrita- tion is to be overcome, very large doses may be given without pro- curing sleep, or showing any of those deleterious effects that in other * Physical and Literary Essays, Vol. n. Art. xii, t Mat. Med. Part u. Ch. vm. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 417 cases appear from much smaller quantities given. All this appears Gem. XII. from the practice now well known in tetanus, mania, small-pox, S^?"' gout, and syphilis."* ' ! ' &£££■ In retrocedent gout the same plan is to be pursued where the Kment attack has actually shifted from the feet or hands to some internal J&g-ui organ. But where it still lingers in the extremities, though with parT/ysn?.. slight pain and inflammation and frequent cessations, as though it KSSlta were on the point of removal, we should increase the morbid action retrocedenj by local irritants applied to the joint, as camphor, ammonia, blisters, SCocai sinapisms, or the cautery of moxa or coarse flax ; and at the same fmgefin?en time prescribe a light, but generous diet, with rather more wine than in »he .. the patient is in the usual habit of taking : carefully avoiding all vio- ?* %e™tl6a lent cathartics, and keeping the bowels moderately open with rhu- lU8fi™{eA barb, aloes, or the compound colocynth pill. irritants: In gout, however, the intervals of the disease are of as much gfnerou. importance to be attended to as its paroxysms: and here, also, the die': mode of management under the first form should differ essentially aperients. from that under the second : for though the occasional causes may ^""tbe' in many cases be the same, they have in the former to operate upon intervals of a vigorous, perhaps upon an entonic scale of power, and in the 8°ut" latter upon a scale decidedly reduced and atonic. In every variety all known occasional causes must be equally ^^j^,'1 avoided. Where the diet has been too rich it must be lowered, and be avoided. where too spare and abstemious, made more liberal. Indolence and a sedentary life must give way to regular exercise, and over- exertion of body or mind to repose and quiet. In the young, robust, and corpulent, whether the disease result from too great indulgence at the table, or an habitual taint, it may be requisite to abstain from animal food, wines, and fermented liquors altogether; but where the sufferer has passed considerably beyond the zenith of life, and the luxuries of the table have become habitual, his ordinary fare should be reduced or diminished rather than entirely commuted. And in every change it is better to proceed slowly than to rush ^Sh'shed" rapidly from one extreme to another: since nothing has so great a habits to be tendency to prepare the internal organs for gouty paroxysms, as gioW!y. such sudden and violent transitions. The bowels should be kept in regular order, and the hour of rest be early. A due and unswerving attention to these general rules of the hy- General giene will often be sufficient to keep those free from all disturbance regimen ofthe gout for many years, and perhaps for the whole of their sub- £££*[£ sequent life, who have only known it in the form of a few regular pa- B«°*rhal.g roxysms. But where the system, and especially the digestive func- g„od: but tion, is weak, and the patient has had anticipations of atonic or notjo in recedent gout, or has actually suffered from its assaults, it will be h^™*- necessary to superadd a course of invigorating medicines. im last ° There are three classes of remedies that generally pass under £%%* this name, stimulants, bitters, and astringents. The first increase indelicate the action, the two last augment the tone. Stimulants can rarely {*»'»•*- be employed alone, except in cases of emergency, for a lax state of «onjegont. * Mat. Med. Part n. Ch. w. Vor, II.—53 41S cl. m.] ILEMAT1CA. [ord. xr. Gen.XII. fibres will bear little increase of action without, at the same time, Arthroi£L suffering an equal increase of debility. But they may often, and in Podagra, the case of gout perhaps always, be combined with astringents and Treatment bitters with great and decisive benefit. Upon this subject, however, fnUterDv8ai3hof ^ have alreakd. ii. Gen.XII. any fit of inflammatory gout;" and, having completed the course Anhfo's!"' prescribed, " had never a regular fit, nor any inflammation ofthe c.\- rodagra. tremities, for the rest of their life. In no instance, however," con- Treatment tinues Dr. Cullen, " that I have known, was the health of these hitemiUof Persons tolerably entire. Soon after finishing the course of their gout. medicine, they became valetudinary in different shapes, and particu- larly were much affected with dyspeptic, and what are called nervous complaints, with lowness of spirits. In every one of them, before a year had passed, after finishing the course of the powders, some hy- dropic symptoms appeared, which, gradually increasing in the form of an ascites or hydrothorax, especially the latter joined with ana- sarca, in less than two or at most three years, proved fatal. These accidents, happening to persons of some rank, became very generally known in this country, and have prevented all such experiments since."* But such No testimony could be more confirmatory of the hypothesis I movethe nave ventured to lay down respecting the different effects of a tonic contrary plan in different constitutions than the present. For the cases are warned/ taken entirely from persons who, upon this hypothesis, would entail upon themselves the very evils which are here described. And as Dr. Cullen gives us no account of any mischief that has followed the use of bitter tonics in constitutions of an opposite character, or marked by general debility and atonic gout, the evils he has described seem, on his own evidence, to be limited to those whom we have already cautioned against the employment of such a course. No pro- per classification or line of distinction seems to have been drawn or adhered to ; which would probably have presented us with very different results if it had been ; and have superseded the clashing and unsatisfactory explanation of atonic effects uniformly produced by a continuance of tonic medicines. The subject The subject, however, requires to be further examined into by a further ex- more accurate classification of gouty patients who may be put under animation, the influence of medicines of this kind; and I throw out the hint for That bitters this purpose. Yet, that a persevering course in bitter tonics does Sntvereaiiy not uniformly prove in any way injurious to those who engage in it, evidenced *s ' tnm^ demonstrable from the daily use of table-beer in almost from the every family throughout the country, and its appearing to be one of mSeta°bfieh-op8 the wholesomest beverages we can adopt. Dr. Darwin, indeed, fceer. ventures to ascribe part of the mischief produced by highly spirited malt liquors to some noxious quality in the hops they contain ; but the stronger and headier malt liquors are uniformly prepared with a much smaller proportion of hops than the weaker, and especially than those which go under the name of table-beer. For the only point aimed at by the employment of hops is to prevent an acetous fermentation ; which is effectually guarded against by the larger proportion of spirit contained in ale and strong beer ; but which every one knows would soon take place in table-beer if it were not powerfully impregnated with this grateful bitter. And hence the remark of Dr. Darwin seems to have no foundation whatever, since * Mat. Med. Part ii. Ch. n. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 421. the stronger bitter affords a beverage proverbially wholesome ; while Gen. Xlf. the weaker bitter is that which proves injurious. AnhrVsia There have also, in all ages, been offered to the public specifics G°duatsra- for the sudden cure or removal of the paroxysm when present, as specifies well as for preventing its return hereafter. Lucian, in his Tragopo- ^nVu're'of dagra, gives us with great humour, a list that occupies a page of tneparox- such as were chiefly in vogue in his day ; and the catalogue is cer- |unc'h from tainly not diminished in our own. Those that have acquired the Jh'|a'™||f/. highest reputation appear to have been composed of some species and many ' of hellebore or of meadow-saffron ; the first of which is among the "ameetoth2 remedies quoted by Lucian ; though it is probable that the pifav H^®1e1^t0f*T• 'EAAEBOPOT of the Greeks was a different plant from either the Meadow-' white or black hellebore of modern dispensatories. safTron. The favourite specifics of the present day are M. Husson's Eau ^"9^dt meMicinale, and the vinum colchici, or wine of meadow-saffron, in- einaie; troduced into the current pharmacopoeia of the London College, yj,"^. chiefly upon the authority and recommendation of Sir Everard Home. The exact components of the former are kept a secret; though its basis is well known to be either the one or the other of the above plants, most probably the meadow-saffron. The effects ^pct*pro. of the Eau medicinale and of the colchicum-wine do not essentially babiy from differ ; for after taking about sixty drops of either the pulse becomes p'^0™" slower, and at length sinks, in about twelve hours, from ten to twenty strokes in a minute below its natural number, at which time the inflammation subsides. The action of both medicines is accom- panied with great languor and a deadly nausea or sickness, which terminates in vomiting, or a discharge from the bowels, or both. If the dose be in a small degree in excess, the symptoms are syncope, cold sweat, extreme prostration of strength, violent vomiting and purging, a wiry and almost imperceptible pulse, or a state of utter and very alarming insensibdity. And in some constitutions these effects have followed from the use of even a common dose. So that these preparations seem to be rather stronger drugged than the celebrated oxymel colchici of Stoerck. Sir Everard Home made several trials of the colchicum wine on a Jj,^,0/^ dog, both by the stomach and by infusing it into his jugular vein, winVbysfr From thirty drops he recovered in about seven hours ; from sixty gveirard drops in eleven; but a hundred and sixty drops, thrown into the jugular vein, killed him, after having suffered great agony, in five hours. On opening him, the stomach, smaller intestines, and colon were highly inflamed.* And it is hence obvious that this medicine, like many other emetics and cathartics, acts rather upon the stomach, through the medium of the circulation, than on the system through the medium of the stomach. It is possible that the colchicum may wheth^ act by a specific power on the peculiar inflammation of a regular fit; specific yet as other intestinal irritants have occasionally produced a like p°w effect, and particularly the gratiola officinalis (hedge-hyssop) and ranunculus Flammula, the disappearance ofthe paroxysm may also be ascribed to a transfer of action to the stomach and intestmes. * Phil. Trans. 1816. Art. xn. xui 422 cl. in.] ILEMATICA. [oro. ij. Spec. Ill Arthrosia Podagra. Oout. Treatment of gout by reputed specifics. If a specific power over the parox- ysm, such medicines have none over the diathesis; and hence may be of temporary use at a great ex- pense of the Consti- tution. Mote dis- criminate trials te- ouired. But ought gout. Gen. XII. Generally speaking specifics operate by a secret and inexplicable power, as the bark in intermittents, the vaccine virus in shielding the constitution against small-pox, and mercury in syphilis; for though a ptyalism gives proof that the system is impregnated with the last, there tie few practitioners so attached to the Cullcnian doctrine in the present day as to contend that the venereal virus is carried off by the salivation, since we arc perpetually beholding it carried off under the influence of mercury without any salivation whatever. Yet, admitting that the co-chicum has a specific power over a regu- lar inflamaiatory paroxysm of gout, it is clear that it has no such power over the gouty diathesis, since the paroxysm has never been so removed as not to return again. And it hence becomes a se- rious question, whether the mischief produced in the constitution by the employment of so active a medicine in the large doses recom- mended by some practitioners be not greater than the temporary good obtained by the suppression ofthe inflammation ? and I do not. think that either the Eau me.licinale or the colchicum-wine have been noticed with a sufficient degree of discrimination fairly to de- termine this point. From the rapidity and force of the operation, it is clear that they ought never to be tried, or, never without the utmost caution, ex- novor u be cept in the first variety of gout, or where the system is firm and in emonic healthy, and the disorder shows itself in a regular fit. And as it is highly desirable, for reasons already stated, to restrain the violence ofthe paroxysm, shorten its duration, and carry it off as soon as pos- sible, the use of the one or the otlier of these medicines may be judicious so long as the system is able to recover itself with speed from their influence, and provided that the patient limits himself to the smallest dose that will answer the purpose. Yet these medicines, from too little attention to their real effects, and from a mistaken idea that they are equally a specific for gout under every form, have not often been confined to the entonic varietv, nor employed with sufficient discrimination in the second and third varieties of the disorder, in which the system, and particularly the disgestive organs, are in a state of chronic debility ; and the inflam- matory fit, when it shows itself in the hands or feet, is incom- plete and evanescent. In all such cases, such medicines without the superintendence of much practical caution and judgment, cannot fail to do serious injury to the constitution ; they have a tendency to increase the ventricular weakness, and hereby to leave the system more open to all the miseries which gout is so perpetually entailing. And hence the reason of the very general complaint among those who have tried these remedies, that, although they remove the fit at the time, they shorten the intervals, and render their frames more obnoxious to relapses. In my own person I have never exceeded forty drops of the colchicum-wine, prepared after the form of the royal college ; and I have seldom failed to find this serviceable, though I cannot affirm that it has been uniformly so. The remarks of Dr. Lucas upon this subject are well worthy of attention, and as being offered since the first edition of the present Have been often tried improperly: and hence made pro- ductive of serious in- jury. cl. m.j SANGUINEOUS FUNCTION. [ord. n. 423 work may be quoted as confirming the author's views. Having con- Gen. XII. tended for a specific principle in gout which he thinks obvious from Arthrlsfl1' the peculiar acid smell ofthe perspiration, and the deposite o chalk- £> and appears to shoot almost from a point, and the + Patholog. and Surgf. Obserr. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 427 swelling is inconsiderable. The pain, however, though more limited, Gen- *"• is very acute, and increased by the least attempt at motion ; so that, ^ AE°Hy-' in this case also, the muscles being always kept quiet and in a bent ('»rthrU8 *irp /•.!•■ •.-. ■ ? . atonicus. position, a stiffness of the joint is readily superinduced. Atonic The inflammation proceeds more slowly than in the entonic form, TweiiTng. but it produces at length the same effect; the tumour acquires the Progress of same elastic feel; varicose veins appear on the surface, and collec- tions of matter take place in different parts of it. The minute and separate abscesses burst one after another, and discharge an icho- rous or cheesy and purulent fluid, and small exfoliations of the sub- jacent bone are occasionally thrown out at the openings. This variety constitutes the scrophulous white-swelling of Mr. Bell ; and, if not always confined to scrophulous subjects, is most common to those who give proofs of this diathesis, or of an approach to it. " I conceive all such collections of matter," says Mr. Hunter, "to be of a scrophulous nature : they are most common in the young sub- ject, and seldom found in the full grown or old. The suppuration is not proper pus, nor the swelling proper inflammation."* The occasional causes are sometimes those of the preceding occasional variety ; but the disease more generally commences, without our being able to trace any occasional cause whatever : and is far more disposed than the preceding to terminate in a fatal hectic. The practice is most disheartening and the prognostic most melancholy. No course of medicine promises much success; while even a removal of the limb may only lead the way to an appearance of the disease in some other joint. The pain may be Treatment. soothed with opium ; and local stimulants have been found useful in an early stage of the disease, or where the diathesis is not de- cidedly scrophulous. Of the last class of medicines almost every preparation has been tried in its turn, according to the inclination of different practitioners : as solutions of muriated ammonia, some- times commixed with acetic acid ; essential oil of turpentine ; cam- phor ; acetated ammonia; tincture of cantharides ; mezereon in various forms; mercurial or other irritant emplasters ; the actual cautery both by moxa and heated irons; fumigations and the vapour- bath impregnated with essential oils; setons, and electricity.! While internally, have been administered the compound decoction of sarsaparilla, hemlock, pulsatilla nigra, and various preparations of almost all the metals.j; Where these fail, and they fail too often, our only resource against the certain destruction of hectic fever is amputation, however doubtful its issue. Dr. Akenside thought he derived advantage from large blisters, freely kept open, in conjunc- tion with the internal use of calomel: but he candidly admits that nothing can be expected even, from this treatment, or indeed any * On Blood, &c. p. 391. t Heister, Wahrnehmung »m.—De Meza, Anhang zi •rv. i. in. p. 704.—Bromf ^ett^u^t^ - Kopenhagen.-Ba;lie Pract. fIIjs^-ivlSis, in*Ster, ChTr. Bibl. B. v. p. 113._Stoerck, von o'er Schwar- * On Blood, see. p. ovi. ... t Heister Wahrnehmungen B. i.-Wendt, Nachricht von dem Institutum clim- n,,m-De IVIeza Anhang zer Strack Abh. von der Petetschenkrankeit. Plater Ob- ser^T HI p! 704 ITfmfield's Observations.-Kirkland, on the Present State of Surgery.—Percival, Med. Com. Eton.nuf>^ J Proett, Versunhe vein ~ Essays.—Michaelis, in R /.en Kiichenschelle. p. 8'2 42b cl. m.j 1LEMAT1CA. [ord. 1/. Gen.xii. other treatment where the disease has made much progress, or if, pTA.%y- ' "there is any sensible collection of a fluid within the joint." In darthrus two or three of the cases he has described, the tumour, when in an Atonic ' incipient state, seems to have been quite as favourably acted upon swelling, Dy the attack of some unforeseen exanthem, as small-pox or miliary Treatment, eruption, as by any topical plan whatever.* And hence, where the stimulants, structure is not seriously injured, we may possibly derive benefit from local or general counter-stimulants, as the tartar emetic oint- lodine. ment, or the different preparations, and especially the ointment of iodine. There is no class of medicines that acts so directly on the absorbent system ; and we areSnformed by Dr. Gairdner, that M. Manoir of Geneva, has in one case of a very decided character, and in which, even amputation had been advised, after a failure of every other mean, found the use of the ointment, together with the tinc- ture, completely succeed; so as not only to remove the tumour, but to restore as free a motion to the affected as was possessedTby the sound knee. The dose of the tincture contained one-twelfth of a grain of iodine at its utmost. The patient was eight years of age.t * Med. Trans. Vol. I. p. 104. t Essay on the Effects of Iodine, &c. p. 49.64. 8vo. 1824. END OF VOL. II. NLM032779350