3UVN JN 13 10 IW JO ABVBail IVNOIIVN 3 N I 3 I O 3 w J O A B V B a II 1 V N O 11 V N 3NI3I03WJC ICINE NATIONAL LIBRARY OF MEDICINE N A T I O N A L L I B R A R Y O F M E 0 I C I N E NATIONAL II MED.ONI NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MED. ONE NATIONA „„„., ,„,,,.,» ,0 »■»...! "»OI... IHIJI01»iO»l».llll».OIl». 1N,3.0.» »U,*\/ s > S NE NATIONAL LIBRARY OF MEDICINE NATIONA IV\ I /Vi ^ 'NOUVN 3NI3I03W JO ABVBBI1 IV NOUVN 3N 13 10 3W JO ABVB8I1 IVNOIIVN 3NI3I03 ?5i \\ffl v r F MEDICINE NATIONAL LIBRARY OF MEDICINE N A T I O N A I L I B R A R Y O F M E D I C I N E NATION * / i \ 4 j -^ s. ■'■ * IVNOUVN 3NI3.03W JO ABVBBI1 TVNOI1VN 3 N I 3 I 0 3 W J O A B V B a IT 1 V N O U V N 3NI3.Q; 5 'n = MEDICINE NATIONAL LIBRARY OF MEDICINE N A T I O N A I I I B R A R Y O F M E D I C I N E NATIO* 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. OP PHILADELPHIA. riilBRAHY 1 —T MAY SO .300 i^MilL'fii.j IN FIVE V VOL. ] FIFTH AMERICAN EDITION. REPRINTED FROM THE LAST LONDON EDITION, GREATLY IMPROVED AND ENLARGED. Neto*¥ot1t: PRINTED BY J. * J. HARPER, FOR COLLINS AND HANNAT, COLLINS AND CO., AND 0. A. ROORBACH, —PHILADELPHIA, JOHN GRIGG, TOWER AND HOGAN,—BOSTON, RICHARDSON & LORD, AND HILLIARD, GRAY, LITTLE, & WILKINS. 1827. GU3 CLASS III. CLASS in. ELEMATICA. DISEASES OF THE SANGUINEOUS FUNCTION. ORDER I. PYRECTICA. FEVEES. II. PHLOGOTICA. INFLAMMATIONS. III. EXANTHEMATICA. ERUPTIVE FEVER 3. IV. DYSTHETICA. CACHEXIES. CLASS III. HjEMATICA. ORDER III EXANTHEMATICA. ERUPTIVE FEVERS. CUTANEOUS ERUPTIONS ESSENTIALLY ACCOMPANIED WITH FEVER. The term Exanthemata among the Greeks, from eg«vfc&>, " efflo- Class in. resco" " per summa erumpo," " to effloresce, or break forth on the o")*?*"1, surface" imported cutaneous efflorescences or eruptions generally, the ordinal It has since been limited to express cutaneous eruptions accompanied ordinary ivitk fever, a boundary assigned to it by Sauvages, Linneus, Vogel, limitation Sagar, Macbride, Cullen, and various others, and this, in effect, is its general meaning in the prespnt day. Dr. Cullen, however, in in.what his note on Exanthemata, minks it worth considering whether the pe0nseedPb_" word should not be restrained to eruptions (he does not any febrile Cu'ien = eruptions) produced alone by specific contagion: " eruptiones a contagione specified ortae;" while Dr. Willan has still more lately how used narrowed it so as to include those eruptions only which fall within bj Will»" the meaning of the English term bash, whether febrile or not febrile. The two last senses of exanthemata, or exanthematica, are new and singular. Dr. Cullen, however, has not followed up his own suggestion into his own classification ; while Dr. Willan has not always continued strictly true to his own views and definition, as I have observed in the running comment introductory to the pre- sent order in the volume of Nosology to which the reader may turn, for a fuller examination of this subject, at his leisure. The term, therefore, in the present work, is employed in its com- in the pre- mon and current sense, so as to include all cutaneous eruptions in employed which fever exists as an essential symptom ; whether accompanied*1 itsC0II» with or destitute of contagion ; which last is a doubtful, arul per* mon seflse' baps an inappropriate ordinal character. Doubtful, because we cannot very precisely tell where to draw the line : and inappropri- ate, because it is a character that applies to diseases of very differ- ent kinds, and that are scattered over the entire classification, as 6 ct. m.j HiEMATICA. [orp. m. Ord. Ill Exanthe- matica. Eruptive fevers. Cmss m. dysentery and influenza in which there is fever without cutaneou* eruption; itch, and many varieties of tetter, in which there is cuta neous eruption without fever, and blennorrhcea or clap, in which there is neither fever nor cutaneous eruption. The genera included in the order are distinguished by the nature of the eruption as con- sisting of red, level or nearly level patches of pimples filled with a thin ichorous fluid ; of pimples filled with a purulent fluid ; and of foul imperfectly sloughing tumours ; and hence consist of the four following:— I. ENANTHESIS. II. EMPHLYSIS. III. EMPYESIS. IV. ANTHRACIA. RASH EXANTHEM. ICHOROUS EXANTHEM. PUSTULOUS EXANTHEM. rs a constant effort exhibited in the part or in the system generally, to lead it to the sur- face where it can do least mischief,* rather than let it spread itself on the deep-seated or vital organs, where its effects might be fatal. Mr. John Hunter was peculiarly fond of dwelling on this admirable economy of nature, and of illustrating it from the course pursued in inflammations of every kind ;t which, to obtain this beneficial end, often wind their way outwardly through a multiplicity of superin- cumbent organization, instead of opening into some momentous cavity in the interior, from which it is perhaps only separated by a thin membrane. But there is no part of pathology in which this dis- play of a final cause, of an operative intention admirably adapted to the end, is more striking than in the order of eruptive fevers. It is by means of the fever that the disease works its own cure ; for it is hereby that a general determination is made to the surface, and the morbid poison is thrown off from the system. But the fever may be too violent; and, from accidental circum- stances, it may also be of the wrong kind : both which facts occa- * Ste especial!j Class 11. Ord. u. On Inflammation, Vol. h. p. 189, t On Blood, Inflammation, &c. p. 236. 450. 467, cl. in.] SANGUINEOUS FUNCTION. [ord. hi. sionally occur in inflammations, and require the art of medicine for CL* »,» 4.1 • ' ^ Ord. III. their correction. Exanthe- When a febrile poison, producing a cutaneous eruption is gene- ^"^ rated, or has been conveyed into the blood, a small degree of fever fevers. is sufficient to throw it upon the skin ; and if it exceed the proper fmln&t extent, the specific virus will be multiplied, and the fever itself may p«e °f become a source of real danger. It was formerly the practice to necessary. encourage the fever by cardiacs, a heated atmosphere, and a load of fa",°erof bed-clothes, from an idea that we hereby solicit a larger flow of practuion- morbific matter from the interior to the surface. The fact is un- couragUg questionable ; for be theexanthem what it may, the skin will hence, feveir- in almost every instance, be covered with eruption. But it did not occur to the pathologists of those times, that the morbid virus was an animal ferment, capable of multiplying itself by accessories ; and that heat and febrile action, beyond a very low medium, are among the most powerful accessories we can communicate. And hence Example* the advantage of the modern practice of applying cold water in tion in mo- scarlet-fever, and cold air in small-pox, with a view of mitigating demtimes. the fever that often accompanies these diseases : for, by diminishing the febrile violence, we do not, as was formerly imagined, lock up the contagion in the interior of the system, but prevent it from form- ing afresh and augmenting there. But the fever, though the natural mode of cure, may not only be Feve/tmay too violent, but it may also be of the wrong kind. And here, again, wrong kind, the whole scope of professional skill is often demanded. fn eicess? Some of the morbid poisons we are now adverting to have a na- Different tural tendency to excite a fever of one description, and others of are^com- another. Thus the fever of small-pox and measles is ordinarily in- P?"ied ™th _ , _ , _ * ■.. . n diflerent flammatory ; that of scarlpt fever may commence with an inflam- fevers. matory type, but it has a strong tendency to run into a typhous form: while that of pemphigus and plague is typhous from the beginning. Much also, in this respect, will depend upon accidental circum- Constitu- stances, as the constitution of the year, and the prevailing epidemic ; yew often6 the constitution of the patient, his habit of life, or hereditary predis- i,roduccs position. For under the control of these we sometimes see an ence.'" l eruptive fever, having naturally a typhous turn, restrained in its ten- dency ; and, on the contrary, a fever with an inflammatory turn, as in small-pox or measles, converted into a malignant or a typhous. Yet the general intention pursued by the instinctive or remedial power of nature is one and the same: and it is the duty of the me- dical practitioner to watch over that intention, and co-operate with it; to moderate the natural means when in excess ; to quicken them when deficient; and to correct them when deflected by acci- dental circumstances. ci. in.] ILEMATICA. [<*»•ur GENUS 1. ENANTHESIS. RASH EXANTHEM, ERUPTION OF RE», LEVEL,'OR NEARLY LEVEL PATCHES J VARIOUSLY FIGURED ; IRREGULARLY DIFFUSED ; OFTEN CONFLUENT J TERMI- NATING IN CUTICULAR EXFOLIATIONS. The term enanthesis is derived from the Greek t* " in, intra," and m6w " floreo"—" efflorescence from within or from internal affection." Whence the term stands opposed to exanthesis, which, in the present system, constitutes a genus under the sixth class, and comprises such efflorescences as are merely superficial or cutaneous, and not necessarily connected with internal or constitutional affec- tion. Enanthesis is here, therefore, used to express fever accom- panied with rash, the latter word being employed in the broader of the two senses assigned it by Dr. Willan, as importing red, irregu- lar, confluent patches; whether simple, as in the case of scarlet- fever ; compounded of papulae, small acuminating elevations of the cuticle, not containing a fluid, as in the case of measles; or existing in the form of wheales, as in that of nettle-rash. And hence enanthesis, as a genus, furnishes U3 with three spe- cies :— 1. ENANTHESIS ROSALIA. 2.-----------RUBEOLA. 3. .-----------URTICARIA. SPECIES I. ENANTHESIS ROSALIA. SCARLET-FEVER. RASH, A SCARLET FLUSH, APPEARING ABOUT THE SECOND DAY ON THE FACE, NECK, OR FAUCES ; SPREADING PROGRESSIVELY OVER THE BODY ; AND TERMINATING ABOUT THE SEVENTH DAY ; FEVER A TYPHUS. viEN.I. This is the scarlatina of most modern writers; a barbarous The'acar-' and unclassical term that has unaccountably crept into the nomen- tatinaof clature of medicine upon the proscription of the original, and more ternwi*-' classical name of rosalia. which it is the author's endeavor fo •«•,. restore - Gen. I. Origin of the generic name. In what sense em- ployed. SCARLET-FIVER. MEASLES. NETTLE-RASH. cl. m.j SANGUINEOUS FUNCTION. [ord. m. 9 Upon this subject I must refer-the reader to the running comment Gen. i- in the volume of Nosology, where he will find it explained at full Enanthewl length. At present it is sufficient to observe that although, since jj^jj"; the introduction of scarlatina, its use has been generally tolerated, fever. no classical scholar has been satisfied with the term ; while several J^*™ have peremptorily refused to adopt it. disapproved Dr. Morton had so mortal an aversion to the term, that he pre- By aiorton: ferred the error of blending scarlet-fever with measles, and of arranging the varieties of the two diseases under the common generic name of morbilli to employing scarlatina. De Haen appears to by Do have had nearly as great a dislike to it.* Dr. Huxham, for a long Evaded by time, eluded the term by using febris miliaris rubra, or maligna, ,lujtl,aH,> for some of the varieties of scarlatina, and febris anginosa miliaris for others : Dr. Heberden has still more lately exchanged it for »"jj Hebe'- febris rubra ; and Thiery, in direct allusion to the original name, Exchanged calls it expressly mal de la rosa ;t Ploucquet employs porfhy- [a'j™^8 risma, as Borsiero, or Burserius had made use of purpura before T1heJ,°J- him ; Dr. Willan continues scarlatina, but thinks it necessary to SfypJ0uc- apologize for its continuance. " The denomination scarlatina," $J^rft of says he, " was first applied to this disease by British writers : how- Bunseriua. ever offensive the term may be to a classical ear it cannot well be ^y8>zed displaced, having found admission into all the systems of nosology. Wiiiao. Another age will correct and refine the ,language now used in sub- jects untouched by the masters of Physic."J It is singular that Swediaur. Swediaur with all his love for Greek terms, and the determination with which he sat out to give every genus a Greek name, should, while ranking this disease as a genus, still retain the objectionable term.§ It will not be the present author's fault if the correction, so ge- nerally called for in the case before us, should be postponed to another age ; or the error complained of be chargeable on future nosologists. In saying that " the denomination scarlatina was first applied to this disease by British writers," Dr. Willan can only mean that it was by British writers first applied technically and introduced, as a professional term, into the Medical Vocabulary : for the term itself The term is Italian, and was long as a vernacular name, in use on the shores derived of the Levant before it was imported into our own country. u>Tmu Scarlet-fever, measles, and small-pox seem, indeed, equally to Scariet- have reached us from the East, and to be diseases of comparatively measles, modern origin. Some writers fancy that they can distinguish a few »jj£ «™"- traces of one or two of these in the works of Paulus ^Egina, and duced from other Greek physicians ; but the passages referred to are too general J^mpa™- and imprecise to establish any such conclusion. No such diseases twe'y of are described ; and had they existed at the time, a few determinate "\ate. and scattered hints, which may apply to other diseases as well, could ^^the not have been the whole to which they would have given rise. The Greek wri- names, indeed, by which they were at first known, as variola, vem'acuiai rubeola, or rather rcbiola, rosalia, and even morbilli, evidently ™^fi™ * Med. Oontin. Tom. i. Cap. vn, 1 Cutaiicous Diseases, p. 253. t Recueil Periodirjue, 11. 337. ■■» Nov. Nosol. M<".h. Syst. 1.164, V'OL. in.—': Itf cl. m.J HEMATIC A Lord. hi. Gen. I. Spec. I. Enanthesis Rosalia. Scarlet- fever. At Grit used indiscrimi- nately or with confu- sion. Rosalia sometimes eonsidered under un- necessary subdivi- sions. point to the school of Cordova, and lead us to the Arabian or Sara- cenic physicians for our first account of them. And it is not to be wondered at that in such accounts we should meet with some de- gree of confusion and many inaccuracies ; and should perceive that as measles were for a long time confounded with small-pox, so scarlet-fever was with measles; whence it is difficult, in one or two instances, to determine what is the precise species of disease re- ferred to by Avicenna, Ali Abbas and Rhazes : for while they seem to allude to the scarlet-fever, we are not sure that they mean it. On this account it is that rosalia, rossalia, and rubeola, alike derived from the colour of the efflorescence, are, among the earliest writers who used these terms, applied equally to scarlet-fever and measles ; and when some distinction was at length attempted by the introduction of the word morbillo, or morbilli, in like manner a Spanish or Cordovan diminutive, the line of distinction not being ac- curately drawn or adhered to, this term was also erroneously applied to both ; and the confusion became more intricate. So rougeole, which among the French writers is the common name for measles, imported also, at one time, scarlet-fever : and this so generally that, when in process of time physicians became sensible of the difference between the two maladies, and it was necessary to establish distinct terms, we learn from Chevenau that, among the Marsellois, rougeole was at first appropriated to the scarlet-fever, while the measles were denominated senapion.* And in this manner both diseases con- tinued in every country, till within the last half century, to be re- garded and even treated of with but little discrimination ; sometimes as different species, sometimes as a common species, and some- times as varieties of a common species. And hence, even in our own country, we find them united in several of their varieties, not only in the writings of Dr. Morton, but still more lately in those of Sir William Watson. Since, however, they have been considered, and most correctly, as different diseases, another extreme has been run into ; for. rosalia itself has been broken into subdivisions that are in no respect worth contemplating separately ; one or two of which, as we shall per- ceive presently, have themselves been elevated by some pathologists into the rank of distinct maladies. For all the purposes of per- spicuity it will be sufficient to study it under the two following va- rieties :— Simplex. Simple scarlet-fever. Paristhmitica. Scarlet-fever with sore throat. Fever moderate, and terminating with the rash ; little prostration of strength: slightly contagious. Fever severe ; throat ulcerated ; rash later in its appearance, and less extensive ; often changing to a livid hue : highly conta- gious. • E. Rosa- lia simplex. Simple jcarle? Children are by far the most frequent subjects of both these v«- * Ohserr. AW. p. 454 gl. in.] SANGUINEOUS FUNCTION. [ord. m. 11 rieties, and communicate it readily to each other. They are both Gen. '• occasionally epidemic, and in this form occur most usually at the a ipRosa- close of the summer. " The scarlet-fever," observes Sir Gilbert g? »impiex. Blane, " very rarely affects adults. The great majority are under scaXt puberty ; some between twenty and thirty ; a few between thirty De7crijr- and forty. Only one case above forty has occurred to my own ob- tion. servalion."* Public schools may be one cause of the greater fre- quency of the disease in our own day. The anticipating symptoms are those of fever ; about the second day from which, in the first variety, numerous specks or minute patches of a vivid red colour appear about the face and neck ; and within twenty-four hours a like efflorescence is diffused over the surface of the body, and occa- sionally even tinges the inside of the lips, cheeks, palate and fauces. Sometimes the efflorescence is continuous and universal; but more generally on the trunk of the body there are intervals of a natural hue between the patches, with papulous dots scattered over them. There is an exacerbation in the evening, at which time the rash is most florid, as it is least so in the morning. In some cases that have occurred to me it has only shown itself in the day-time in the form of scattered patches, or even specks, though the skin has been very generally roughened and rendered anserine from a more than usual determination of blood to the cutaneous papilla?. Yet even in these cases the pathognomic efflorescence has appeared in a later or less degree in the evening. On the fifth day the eruption begins to decline ; the interstices widen, and the florid hue fades. On the sixth the rash is very indistinct, and is wholly gone on the seventh. The pulse, during the eruptive stage, is usually very quick and feeble : the tongue is covered with a whitish fur in the middle, often interspersed with scarlet points from an elongation of the turgid papillae ; while the sides of the tongue are of a dark red. The face is considerably tumefied ; and there is great anxiety and restless- ness, with a sense of tingling or itching in the skin, and sometimes at night a slight delirium. Though the fever is in most cases mo- Symptoms derate,-it sometimes runs high, but in the present variety is rarely a*arrnhie; alarming. In many cases, indeed, the eruption appears and passes int lhi* Tari" through its course with little inconvenience of any kind from fever, itching, or restlessness. Sauvages, and Cullen, who has copied Sauvages's definition, re- Period of present the efflorescence as not taking place till the fourth day after cence vV the attack. Dr. Heberden, on the contrary, fixes it on the first or j?°™|]* second day :f Dr. Willan, "usually on the second day." This last is the ordinary period, and as such I have entered it in the defi- nition. It is obvious, however, that the interval observes some variety: though not a little of the apparent difference may be as- cribed to the different stages of the disease in which a physician is first consulted; and his inability of fixing very accurately the com- mencement of the febrile incursion. Dr. Plenciz, on this account, pursues a middle course, and avails himself of an allowable latitude j " About the second or third day," says he, " and sometimes later, * Select Dissertations, &c. p. 213. 8vo. Load. 182C. t Med. Trans. Vol. Hi. ]». 397. «-l. m.J ILEM.NTICA. [ord. n/. ceuPH Gkn. I. tj,c rC(]i unequal eruption, makes its appearance."* Generally a EEKosa'- speaking, the more violent the attack the sooner the efflorescence J|*mp["p,c;t'iS thrown forth : and hence, during a severe and extensive range in s.ariot Newcastle-upon-Tyne in 1770, Dr. Clark tells us that, where it T'iemore began with great vehemence, the eruption was often observed on v,0,e"t »he the first day: but commonly it did not make its appearance till the oariierthe second or third, and sometimes not till the fourth. n?,0™' We have seen that rosalia has been often confounded with measles, to which, indeed, it bears, in many cases, no small degree of re- semblance. The following distinctive characters, therefore, may be of use to prevent a mistake. character The efflorescence of the measles does not appear till two days fever com- later than that of scarlet-fever ; and though it consists at first of that ofVlth broad patches amidst the general suffusion of red, stigmatized with measles, interspersed dots, the dots are of a deeper colour, and are never lost in the efflorescence. It commences, moreover, with symptoms of a severe catarrh, which do not belong to scarlet-fever ; and is with- out that restlessness, anxiety, and depression of spirits by which the latter is peculiarly distinguished. a0comT-s From the great determination of blood to the cutaneous vessels, nied with a an effusion of coagulable lymph sometimes takes place in the pa- Jrop'tio" pulous elevations, which is not entirely absorbed by the time the efflorescence subsides ; and hence there is occasionally, though not often, an appearance of vesicles, sometimes nearly empty, and some- times nearly filled with a pellucid fluid, according as the effused Expiana- serum has been more or less carried off. I have seen them exhibit the semblance of minute chicken pox ; and they have been thus no- ticed by many writers, particularly by Dr. Rush,| Dr. Withering, and Dr. Plenciz : the last of whom compares them to white miliarv spots ; and expressly states that he observed them on the sixth or seventh day from the commencement of the eruption, chiefly in the hands and feet: in other words, at the time when the turgid cuticu- lar vessels had contracted and the efflorescence was on the decline. On examination, he further tells us that they appeared to be nothing more than cuticular elevations filled with minute bubbles of air. More correctly, perhaps, they were quite empty, the effused serum salves, beinff carried off ^ absorPtion4 M. de Sauvages has made this but incor- ' form of the disease a distinct species, as scarlet-fever, with him, con- ,e«HHin. stitutes a distinct genus ?§ ™d *s the effused fluid, when its finer varioiories. parts are first absorbed, occasionally appears thick and opake, and has some resemblance to minute pustules of small-pox, he has dis- tinguished it by the name of scarlatina variolodes. There is another peculiarity which the disease sometimes exhibits, and to which the attention of the profession has of late been par- ticularly called by Dr. Maton.H The disorder, in the case alluded to, showed itself in a large family and evinced all the common symptoms of a rmld rosalia ; and, like rosalia, it proved itself con- ! £J- £• flenciz. Mefl- Vindor*. Tractatus de Scarlatina. 1776 T Medical Inquiries and Observations, p. 12S. t Class in. Ord. Exantb. Gen. vm. s Traelaf do «<.avi.»:_- •I Med. Trarl*. Vol. r. Art. xt. * rte Sc*™>»»- cl. in.] SANGUINEOUS FUNCTION. [ord. ra. 13 tagious, for every member of the family, elder or younger, to the Gen. I. number of eight, received it in succession. But its singularity was ff e.KRos1- t.he great length of interval between the time of exposure to the at- {j? simple*. tack in those who sickened nearest to each other in the order of its sc'aXt descent, and any sensible effect on the svstem ; which, instead of f«vor' ... n f " • t Anoma- bemg, as in ordinary cases, four, five, or six days, was, upon an ioua pro- average, not less than twenty-one days; varying in different indi- in*erl°a"in viduals, from seventeen to twenty-six days. And on this account, *ome ca8eB in conjunction with one or two other signs of minor importance, Dr. exposure Maton, though he at first regarded the disease as a modification of nnd"ppear- rosalia, was afterwards inclined to believe it a new complaint re- a»ce of quiring a distinct designation. Yet if we reflect how often a simi- And nenco lar, or nearly similar retardation takes place in particular families '"f,™!68 after inoculation from either the small-pox or cow-pox, in which we posed by have a much more definite period to calculate from, we shall rather genuine ro- perhaps be justified in adopting Dr. Maton's first view of the dis- «aIi»- order, and contemplating it as a rosalia modified by a peculiar taxation family temperament, or some other accidental control. In the ^S"ntg, paristhmitic variety or that accompanied with sore throat the erup- tion is always later in its appearance than in the simple form ; in a case I shall have to quote from Dr. Perceval, not less than eight days later ; though I have never known it protracted to so late a period as in the modification noticed by Dr. Maton, where the fe- brile symptoms have taken place as early as usual from the time of exposure. The efflorescence in the measles, however, sometimes evinces a like procrastination, and has appeared as late as the twenty-first day.* In the second or paristhmitic variety the morbid virus is chiefly & E- Row- directed to the fauces, instead of to the surface of the skin generally. muFc".""'" It is the scarlatina Septorrhepes of Swediaur. And hence, in some fe™rr,ew""ilh cases, the cutaneous efflorescence is very slight, and consists of a sore throat. few scattered patches of flush instead of a diffused sheet. The rfJepM^of rash, moreover, appears later by a day or two, sometimes even a Swediaur. week; probably delayed by the same cause that interferes with its tion?np general spread over the skin, being the local irritation about the throat. This last symptom will be found to commence very early if the throat be minutely inspected ; for though no complaint is usually made of uneasiness in the throat previous to the febrile symptoms, yet, if it be closely examined, the velum pendulum palati will be found redder than natural, and sometimes the uvula will ap- pear to be a little inflamed, the pulse being at this time not more than slightly disturbed, or flurried rather than feverish.! Dr. Willan asserts that this takes place as one of the first effects of the conta- gion, and describes it, as " a dark-red line extending along the velum pendulum palati and lower part of the uvula."J Gradually, how- ever, the tonsils become enlarged, and exhibit a florid paleness on their surface, which extends over the whole range of the palate, its velum pendulum, the uvula, and tlte posterior part of the fauces ■. * Buchholz Tode Med. Chir. Bibl. Band. i. p. 86. t Dr. Sims, Memoirs of the Med. Soc. of Lond. Vol. i. p. S»4. T CutaneoTts Diseases, Io<\ cit. p. 2fi9. 14 cl. irr.'J rLEMATICA. [ORD. III. Gen. I. the tongue assumes a high red colour, the papillae over its entire dtR Ros'a- surface are greatly elongated, and very tender to the touch ; there Haparisth- is often a considerable stiffness in the muscles of the neck and lower Scarlet- jaw ; the throat is rough and straightened from the second day of sore'throat. the eruption ; and deglutition is performed with difficulty. Ail the All the common symptoms are more violent; the fever is se- Violeflun, verer, accompanied with nausea, vomiting of bile, great heat, and languor; considerable inquietude and anxiety, head-ache, and de- lirium ; evidently proving a copious determination to the head as well as to the fauces. The pulse is feeble, the respiration quick ; the throat becomes excoriated and throws off a large quantity of minute superficial whitish sloughs, which intermix with the increased flow of viscid mucus, and augment the difficulty of swallowing. The sloughs generally separate about the fifth or sixth day, or at the decline of the efflorescence ; but sometimes they remain a day or two longer. Aadsome- This is the ordinary course; but, in many cases, the symptoms lyTanger-" run still higher; and the disease is alarmingly dangerous from its Oe first1 eruPti°n- The pulse is small, indistinct, and irregular from the first; there is a stupid, heavy coma, or violent delirium with deaf- ness ; the ulcerations in the throat are deeper and broader, and co- vered with dark instead of with whitish sloughs ; the tongue is lined with a black, chappy crust, and is exquisitely tender ; the breath is fetid ; the rash, extensive from the commencement, assumes a livid hue with intermixed patches of ghastly paleness ; and death ensues shortly after the seventh day, sometimes on the sixth. Resem- The affection of the throat, in this last and most virulent attack, maHgnant bears so near an approach to the malignant paristhmitis, and its pe- Ssrortc,m-i cunar symptoms commence so early, that, some pathologists of great naiiche? authority, and particularly Dr. Cullen and Dr. Withering, have re- garded it rather as a variety of paristhmitis or cynanche than of and is the rosalia, whence in Dr. Cullen's Synopsis it occurs under the desig- snTiisnaof nation of cynanche maligna. But as the scarlet or crimson eruption Cullen: must De contemplated as a pathognomic symptom, this is to give us two distinct diseases, with the same essential signs ; and Dr. Cullen Sfa^ar- has done this ; for while he places this most virulent form of rosalia latina cy under his genus cynanche, he continues it, in the less virulent form whence una"er which we have just described it, as a subdivision of his genus disease"* scarlatina- Tne distinction, however, is altogether unnecessary, twice over and leads to no advantage either pathological or practical in the «iy in0™8 writings of those who have adopted it. With the exception of a degree. higher degree of danger in the one than the other, from the fever assuming the character of a more malignant typhus, both forms of the disease are the same; they are equally produced by a specific virus; equally contagious and at times epidemic ; accompanied with a similar rash ; demand a like mode of treatment; and even, according to Dr. Cullen's own admission, so frequently run into each other as to be extremely difficult of discrimination. In con- sequence of which few later writers have allowed any such distinc- tion whatever. De Haen, therefore, had reason to say, as he does, apparently in reference to Dr. Cullen's arrangement, that different ol. iii.] SANGUINEOUS FUNCTION. [ord. hi. Id and improper names have been affixed to scarlet-fever by different Gek- '« writers : but that varieties in climate or constitution produce the ^^Ron- distinctions under which it has been described. Ha paristh- Dr. Withering, however, who was contemporary with Dr. Cullen, sc'ariet- embraced and strenuously supported his view ; Contending that in gore\hrot!\. scarlet-fever with sore throat the fever is inflammatory, and in sore cuiien's throat with scarlet-fever it is putrid. Yet, in describing the treat- ^pp'oned ment of this inflammatory fever, he seems to have lost sight of his byWith- critical characteristic, for he tells us that its nature is debilitating or sedative rather than entonic ; and condemn both purging and bleeding as the pulse will not allow of these evacuations. In endeavouring still further to lay down the distinctive characters His distinc of the two, he observes, after Dr. Fothergill, that the angina gan- rasters*" grtznosa (sore thrOat with scarlet-rash) usually commences in the winter or the spring, and chiefly attacks persons of delicate habits, as women and children ; while the scarlatina anginosa (scarlet-rash with sore throat,) on the contrary, usually commences in the sum- mer or autumn, and commonly fastens i p »n the vigorous and ro- bust. The scarlet-rash, however, of Newcastle-upon-Tyne in 1778, seems to have reversed this rule in its most essential point; for Dr. opposed Clark to whom I have just referred, and who has given a very mi- marks of" nute and interesting history of this epidemy, tells us that it made its others; first appearance in June, extending from Newcastle over many towns and villages in the neighbourhood ; that it was most frequent in August, September, and October, declining about December ; and that it raged chiefly among children and young persons, although a few adults exposed to the contagion did not escape.* Dr. Clark especially therefore concludes that both these diseases proceed from the same ciarL° specific contagion, and ought rather to be considered as distinct forms of the same exanthem, than as distinct affections. It is ac- curately, also, observed by the same writer, that the epidemy of 1748, which Dr. Fothergill has so ably described under the name of Putrid Sore Throat, is essentially the same as that remarked upon by Dr. Cotton in his letter to Dr. Mead, and which he then denomi- nated Scarlet-Fever, from an objection to any alteration of the name in common use. The subject ought not to be closed without adding the following and Peree- note from Dr. Perceval's manuscript comment on the author's vo- m.° lume of Nosology, already noticed on many occasions. It adds a high authority to the present arrangement of this form of the dis- ease : and contains one or two remarks which very agreeably display the observant tenor of the writer's mind. " Cynanche tonsilaris and maligna, I consider with you as a spe- cies of rosalia. All have been produced by the same specific con- tagion, which in one instance was imported here (Dublin) from England in a Pandora's box, containing plumed soldiers which had served to beguile the convalescent hours of a young family, and were sent by them as a present to their quondam-playmates in this capital. We have had no severe visitation of rosalia in this place for upwards * Observations on Fevers, especially those of the continued type, and on the Scar- let F«rer attended with ulcerated sore throat, &c. 8to. 1779. 16 vl. w.} ILEMATICA. [obi*. iu* Gen. I. Spec. I. H E. Rosa- lia paristb- matica. Scarlet- fever with Bore throat. The conta- gion lias pasted into Ireland from Eng. land. "Three ways in which a disease may be- come epi deinic: from speci- fic miasm generated in the at- mosphere ; or commu- nicated to the at- mosphere from the ■liseased; or from a tempera- ment of the atmos- phere pre- disposing to a gene- ral produc- tion of the disease. Both the last per- haps ope- rate in scarlet- fever. Hence but .lightly in- fectious in n sound at- mosphere. Reiuiirk .inplicable of ten years. In some instances, besides, I have traced the progress of contagion from England, and believe it loses something of its fe- rocity by the* way. Do you think it comes from the continent ? A remarkable case occurred to me of rosalia paristhmitica character- ized most distinctly with symptoms of what is called cynanche maligna. This, with sunk pulse, great prostration of strength, and haggard countenance, ran a course of seven days without eruption ; during which time it was treated with wine and bark which removed the affection of the throat. On the eighth day, after a rigor, a fever supervened of rather an inflammatory type with a rosalia eruption. After proper evacuations the patient recovered." That rosalia, under every form, is contagious, and sometimes epi- demic, is now admitted without a question : and for the later ap- pearance of the efflorescence in the paristhmitic than in the simple variety I have endeavoured to account. But whether some coun- tries are more disposed to favour its appearance in the form of an epidemy than others, and particularly whether under this form it be more common to England than to Ireland, as hinted at by Dr. Per- ceval, I have no data to determine. There are three modes by which this, or indeed, any other dis- order may become epidemic, using the epithet in its geperal sense, as importing a disease of whatever sort that contaminates the atmos- phere of a district or a neighbourhood. It may proceed from a specific miasm generated from local or accidental circumstances in the atmosphere itself, as in the miasm of intermittent, and often of remittent fevers ; from a like miasm generated in the body of a sick individual, and communicated to the atmosphere, as in typhus ; or from a peculiar temperament in the atmosphere predisposing the entire population that inhale it to a common morbid affection. Of any specific miasm originating in the atmosphere, and producing rosalia, we have no proof whatever : but we have abundant proof of its issuing from the bodies of those who are sufferers under it ; and, if I mistake not, of a peculiar temperament or constitution of the atmosphere in a particular district or season, that predisposes to its general production; for it often becomes common to many fa- milies so simultaneously, that they have had no power of communi- cating it directly or indirectly to each other. And hence, however it may be favoured by external concurrent circumstances, we have good reason for believing that the miasm is always ingenerated; and that the disease, when communicated, is always by specific con- tagion. We may hence account for its being in a pure and healthy, or unpredisposing atmosphere but slightly infectious : for, in treat- ing of the laws of febrile miasm which, under different circum- stances, originates both within and without the living body, we had occasion to observe that, when generated in the* former manner, it appears to be less volatile than when in the latter, and less readily impregnates a periphery of pure air : whence the infec- tion of typhus, which is commonly derived from this source, may be more easily avoided than that of intermittent or even remittents. The miasms of all the exanthems seem subject to the same law. as <5L. in.] SANGUINEOUS FUNCTION. joiu*. ui. 17 they all probably issue from a specific affection of the living body; Gek. I. and hence all of them are comparatively confined in the range of/? Efkosa- their actions, though some radiate their influence to a much greater H» pwisth- , distance than others, and are not so soon dissolved orxlecomposed. Seariot- We may hence, also, see why the contagion of rosalia is received ,0*^1,*. much more readily at some periods than at others. Nothing is more to a» the common than for a sporadic case of rosalia to occur in a family Hence the* without communicating itself to the surroiuiding children, although Jc"£t-wh7 no pains may have been taken to keep them separate ; while a few fever is months afterwards it may possibly be received from a neighbour's mon8in°m house, merely by an accidental visit for a few minutes. In the one 8ome p,c- .1 ■• •••.«. i • • .i nods than case there was no predisposition in the habit to receive the com- in others. plaint; in the other, the altered state of the atmosphere has, perhaps, produced such a predisposition in a very high degree, and prepared the way for the disease to become a very general epidemy. What this peculiar state of the atmosphere is, has not yet been The na- very accurately ascertained. It does not seem to depend altogether p"edi°spo-e upon the season ; though, commonly speaking, rosalia is more fre- Jnn/;£atoof quent towards the close of the summer, the common harvest-time mosphere of all debilitating diseases ; and we also perceive that it is usually u,,knowB, checked, at all periods, by a cold, dry, and bracing air, and hence is less frequent in the winter. But, with these exceptions, it has been found to range as an epidemy nearly equally from February to November ; and sometimes through the whole of this term without ceasing ; or only slackening its career when a keen dry breeze has sprung up from the north or the east. We see, also, another peculiarity in this disease, and that is in its Peculiar- ordinary limitation to children ; and we see this character accom- {"* ^j pany it equally, whether the disease be sporadic or epidemic. Or,»«»t. in other words, we behold the predisposing state of the atmosphere observing the same restriction as the disease itself when it operates independently of any such predisposition. Adults, indeed, do not entirely escape, but their attacks are rare, and for the most part less violent. The remote cause of rosalia, then, is a specific virus, or a specific Geoerai miasm generated in the living body. Of its occasional or excitingin causes, separate from the predisponents just adverted to, we know nothing. It has sometimes seemed to follow upon catching cold, and at others upon a surfeit of the stomach ; but as these are per- petually taking place without producing such effect; and as rosalia has often occurred where nothing of the kind could be traced, we can lay very little stress upon such casualties. All exanthems and nearly all fevers produce an influence on the influence system that renders it less susceptive of the same complaint for a thems on certain period of time afterwards : yet the period varies from the {y^e to'1 plague, which exempts but for a few weeks, to the small-pox and rendering it measles, which usually extend the exemption to a term equal to that tfv'e 'f^f of a man's Y.?; • in consequence of which these disorders, except in "^"j a few anomalous cases, never appear but once in the same indivi- of ufluonc* dual. Scarlet-fever seems to hold a middle range. It renders the 4$™$ ostein far less susceptible, and perhaps for several years ; but the diseases. Vol. ITT.—3 IS ci. ui.J IMSAIAT1CA. [«»»■ MJl Gen. I. Spec. I. 0 E. Rosa- lia paristh- raitica. Scarlet- fever with sore Its power in scarlet- fever. Debilita- ting effects of scarlet- fever. Fartieular tendency to dropsy. influence, in many individuals, wears off by degrees, and does not protect the whole of a man's subsequent life. Yet, as rosalia is a disease of infancy rather than of adult age, it is not often that persons suffer from it a second time, though examples of such a recurrence throat are occasionally to be met with. Rosalia is at" all times a disease of debility ; it prostrates both the body and the mind : but it has, in many cases, a peculiar tendency to weaken the absorbent system, and incapacitate it for carrying off the fluids that are exhaled into the internal cavities of the body; and hence to produce dropsy. This calamitous sequel usually creeps on insidiously and without suspicion, and does not distinctly ProgresVof show itself till the twelfth or fourteenth day, and often considerably jScsequeT 'ateri when the patient and his friends are flattering themselves that all danger is over. It commences with a peevishness, and a feeling of increased weakness and languor : the face is found to swell, and the urine to decrease in quantity, and to assume a somewhat bloody appearance, like the washings of flesh. The leuco-phlegmacy of the face extends gradually to the hands, feet, abdomen, and scrotum, till the whole body becomes puffed up. " I have known these swellings," says Dr. Perceval, " to attack all the cavities, the ven- tricles of the brain not excepted, and in one instance fatally, upon an eruptive affection so slight as hardly to be noticed. The child was not confined, but went out and was exposed to air." This last hint should not be dropped in vain; for the torpitude produced on the mouths of the absorbents by a sudden or injudicious exposure to cold air on recovering from rosalia, is one of the most common causes of this lamentable result: and hence we see, also, why it should be more common in winter than in summer ; and in children than in adults, from the greater delicacy of their age. Dr. Withering confirms the instance just offered by Dr. Perceval, that it is occasionally to be found after the mildest form of the disease ; but adds that it succeeds chiefly to its malignant or worst species. The curative treatment needs not long detain us. In slight cases of the simple variety, we may say, with Dr. Sydenham, that the dis- ease hardly calls for medical assistance of any kind. When the fever is mild, it forms, as we have already observed in respect to ex- anthems of all kinds, the natural means of cure by determining the specific poison to the surface. An emetic may assist this determi- nation, and has hence been almost always found serviceable ; and if the bowels be confined, an aperient may follow ; but violent purging will add to the irritation, and distract the remedial course that is taking place. In the paristhmitic variety, the determination, instead of being to the skin generally, is powerfully deflected to the throat and head, and the fever is alarming from its violence. The therapeutic inten- tion is here to counteract this morbid flow and regress of the febrile action, always having regard to the nature of the fever as well as to its severity. Bleeding is the most direct and obvious means of reduction • but it is open to the same objection as in typhus ; with the additional fact, that we have here to deal chiefly with 'hildren who have at • l| Medical treatment. Little ne- cessary in its mildest form. Principle. BJeedio* ijeefion- h|V; X < r,. hi.] SANGUINEOUS FUNCTION. [ord. hi. ID times less surplus of strength to spare than adults. Dr. Plenciz is, Gem« *"• however, a strenuous advocate for the use of the lancet, and Dr. EniatWsii Armstrong has recommended it still more lately. Where the head R°«ju»- is manifestly oppressed from congestion, it may be risked as a mode fe"r.e of local relief, and may be so far of service; but it is a risk at all Treatment. 111 f i. i • though re- times, and ought by no means to form a part of the general curative commend- plan. With the exception of typhus miasm, there is nothing that so write'*0"18 much exhausts, or rather, perhaps, suppresses the secretion of sen- sorial power as the miasm of rosalia; nor is there any evacuation that adds so immediately to the direct debility of the system as vene- section : and consequently none that ought to be so studiously avoided as a general rule. And hence, often as the practice has been introduced by different individuals, it has never been common or established. Even Dr. Withering, who denominated the fever inflammatory, rigidly abstained both from bleeding and purgatives ; and confined himself, in the onset of the disease, to emetics.* Vomiting, which has just been recommended in the first species, f^u is still more necessary in the present; for it not only tends to take fuf. off the dry burning heat of the skin by relaxing it, but unloads the fauces of the mucus and serous fluids that gorge and distend them. Whether, also, as conjectured by Dr. Withering, it arrest the matter Keasoning of contagion received from the breath of the sick, in its threshold, jngupon^ and prevent it from assimilating the confined and viscid mucus to its emetics. own nature, is a question which it is not necessary to examine into. Its practical advantage is sufficiently obvious, without leaning upon any hypothetical good; and it will often be proper, as recommended by Dr. Withering, to repeat it occasionally, as the foul and infarcted state of the fauces may require. We have just observed that this distinguished physician prohibited purgatives as well as bleeding. But in doing this he discovered still *uwS*tivfls further the trammels of hypothesis ; for while he conceived that usefii" emetics tend directly to throw off the matter of contagion from the organ in which he supposed it to be chiefly concentrated, he con- ceived at the same time that purgatives, on the contrary, only pro- mote its diffusion along the course of the intestinal canal. This reasoning, however, cannot be allowed : the system should not be weakened by their violence, but their use can rarely be dispensed with. As aperients they remove whatever acrimonious material may be lodged in the intestines, and as revellents they powerfully recall all morbid determination from the head. Calomel, as ope- rating upon all the excretories, is commonly to be preferred to any other cathartic, or may be conveniently combined with rhubarb. The great inquietude that characterizes this disease has induced Opium in-, many practitioners to try opium, but it rarely affords relief in anyJunou* form or combination ; and generally renders the head worse. Am- monia is in every respect a far more useful medicine ; it takes off the languor, and stimulates the secernents, especially those of the skin, without quickening the pulse. In the form of sub-carbonate it should be given in doses of half a scruple dissolved in a large * Account of the Scarlet Fever in 1788, 8vo. 20 cl. m.] H.-EMATICA. [onv. in. Gek. I. Spec. I. Enanthesis Rosalia. Scarlet- fever. Treatment. Affusion of cold water: water pro- bably de composed on its ap- plication. Gargar- isms. Blisters. Aurum ful- uiinans. spoonful, or half an ounce, of water every three or four hours :* and in this way administered it has a .highly beneficial and powerful effect upon the local inflammation of the throat. Occasionally also, and in the intervals, we should employ some of the acids, whether vegetable or mineral, which are always grateful to the patient, and seem more than any other internal mean to diminish the burning heat of the skin. But our chief dependence for this purpose must be upon Dr. Currie's bold and happy plan of employing cold water freely. Sponging will rarely be found sufficient, or rather will rarely be found of equal advantage with affusion ; the fluid may, indeed, in this case be dashed against the patient till the heat is subdued, and the process be repeated as fast as it returns. The refreshment is often instantaneous, and operates like a charm; and seems to show, as I had occasion to observe formerly, not merely a refrige- rant, but an exhilarating power, as though the water were decom- posed and a part of its oxygen were swallowed greedily by the thirsty absorbents of the skin, which immediately becomes softer and moister as well as cooler. The throat must in the mean while be deterged with antiseptic gargles of oxymel and port-wine, port-wine-negus, or any of those already noticed under malignant paristhmitis; or fumigated with the vapour of mineral acids. Blisters may also be applied with good effect. Dr. Withering objects to them ; but the general prac- tice is very much in their favour. In severe cases Dr. Plencizt had recourse to the aurum fulmi- nans, as recommended by De Haen,J and speaks warmly of its suc- cess. Its design was to operate on the bowels and bladder, and it was given in composition with calomel, rhubarb, and squills. I have never tried it, nor can I very clearly trace out the path by which any benefit may be hence exp«r.ted. Wine and nutritious food may be allowed, but somewhat less freely than in malignant quinsy. The convalescent state requires great care ; and a damp cold atmosphere should be especially avoided from the tendency to dropsical swellings. * Pearl, Practical Information on the Malignant Scarlet Fever and Sore Throat. t Tractat. de Scarlatina. J Rat. Med. Contintiata. Tom. i. Part i. 8vo. Vienna, .:l. m.l SANGUINEOUS FUNCTION. [ord. hi. Z\ SPECIES II. ENANTHESIS RUBEOLA. MEASLES. RASH IN CRIMSON, STTOMATTZF.Tl DOTS, OBOT7PF.TV TN TTtBF.rSITTjAR CIR' CLES OR CRESCENTS ; APPEARING ABOUT THE FOURTH OAY, AND TERMINATING ABOUT THE SEVENTH ; PRECEDED BY CATARRH ; FEVER A CAUMA. Of the earliest accounts we possess of measles, by the Arabian Gfk. l writers called al-hasbet, the origin of the name of rubeola, and the Disease frequency with which it was at first mistaken for rosalia, some no- when per- tice has been taken under the last species. Tn its perfect form it is giOUs from unquestionably contagious from a specific miasm, though we shall jj,'^'60 presently have to notice one variety that is inactive in this respect. Like rosalia, also, it is at times epidemic, and probably from the at times same cause,—a general predisposition in the population of the af- ePldemic' fected district or country to receive its contagion, perhaps to origi- nate it, from some peculiar but unknown temperament or constitu- tion of the atmosphere. It occurs under the three following varieties: a, Vulgaris. Rash slightly prominent extending over Common Measles. the mouth and fauces ; harsh, dry cough ; inflamed, watery eye. /3 Incocta. Rash running its regular course, with Imperfect Measles. little fever or catarrhal affection ; af- fording no certain security against the common or regular disease. y Nigra. Rash about the seventh or eighth day as- Black Measles, suming a black or livid hue inter- terspersed with yellow ; prolonged in its stay ; and accompanied with ex- treme languor and quickness of pulse. The only predisposition or exciting cause of rubeola that we are a E- Rube- acquainted with, is the peculiar constitution of the atmosphere just is. * referred to. And under the influence of this cause the first variety ^aXs? usually shows itself as an epidemic ; generally commencing in the Ordinary month of January, and ceasing soon after the summer solstice, cause"! pe There seem, however, to be some other exciting causes than a pe- ^l„,i0cnon" culiar state of the atmosphere or of the season ; for we meet with of the at- a few scattered cases of it in almost every month of the year, evi- oakm? dently proving an ingenerate origin, and that the atmosphere is not ci,u,s auxiliary to its diffusion, from its continuing to be merely scattered: nnknovvn ci. in.] ILEMATICA. [ob»- m' Srec'ri yet Possessing ^ ordinary principle of contagion, which only ap- a e. RubJ- pears to be less generally active because there is a less general Ojja vul*a" predisposition, in those who have never undergone it, to be acted Common Upon. FuVptoved Dr. Frank divides this disease like variola into the four stages of from its invasion, eruptive fever, efflorescence, and desquammation ;* but the time! fpo- distinctive boundaries are less visible, and the division is of little im- radic- port&nce. Found it occurs most usually in children, though no age is altogether SoniyT exempt from it. As rosalia is accompanied with a typhoid fever, DeS rubeola is accompanied with a catarrhal; and hence, the opening tion. symptoms consist of some degree of hoarseness, with a harsh dry cough, and frequently uneasy respiration ; the eye-lids are tumefied, the vessels of the conjunctiva turgid and inflamed, the cheeks are wet with a flow of acrid tears, and the nostrils loaded with acrid serum, that irritates them and excites an almost perpetual sneezing; the head aches or is drowsy ; and the stomach, from sympathy, re- jects its contents. On the fourth day the rash makes its appearance and assumes the character described in the specific definition. The stigmatised and pathognomic dots are sometimes at first attended by so general a flush as to be lost in them, and to give the appear- ance of scarlet-fever. I have already noticed several signs by which the two diseases may be distinguished, and the following may be Distinctive added to the number. In scarlet-fever there is no cough, the eyes of measles do not water, and the eye-lids ar$ not red and swelled. In measles fever?"101" the papulae are more acuminated, of a crimson instead of a scarlet hue, and do not appear till two days later than in scarlet-fever. In small-pox the fever abates as soon as the eruption makes its appearance. In scarlet-fever this is by no means the case, and as little so in measles ; the vomiting, indeed, subsides ; but the cough, fever, and head-ache grow more violent-, and the difficulty of breathing, weakness of the eyes, and indeed all the catarrhal symp- toms, remain without any abatement till the eruption has completed its course. The earner In rosalia we have also seen that the sooner the efflorescence escence°r breaks forth after the febrile attack, the slighter and more favourable !he attack.' the disease- The same occurs in rubeola. The ordinary period we have already stated to be the fourth day, but it occasionally ap- pears on the third, when the patient commonly escapes with but little 5erildIaof jnconvenience.t A few rare examples may be found of its exceed- appearance. ing, instead of anticipating, its proper term ; and this so consider- ably, that Buchholz gives us an instance of its not appearing till the twenty-first day: thus precisely rivalling the singular anomaly of scarlet-fever already quoted from Dr. Maton.f mET" °* the.th.ird or fourth da7 after the eruption first appears, the Residuary redness diminishes, the spots fall off in branny scales, which some- Kqueis.time?' ho*ever' are scarcely perceptible from their minuteness and tenuity ; leaving a slight discoloration on the skin, with considerable itching. On the ninth day from the beginning, where the progress * De Cur. Horn. Morb. Epit. Tom. m. p. 234. <■ Van der Haar. Waarneeminfren. I Tode Med. Ckir. Bibl. ». j. p. 86. ci. iu.j SANGUINEOUS FUNCTION. jokd. m. gy has been speedy, and on the eleventh where it has been slow, no Geh. I. trace of measles remains. The eyes, however, in many cases con- „ "rU|,£ tinue still inflamed, and the cough is followed with severe peripneu- oia vui- monic symptoms which terminate in phthisis. Yet these sequela? Common rarely occur except where the treatment has been improper, or there meM,ea' is a predisposition to consumption from a strumous state of the lungs or some other phthisical diathesis. If, on inoculation for small-pox, rubeolous contagion should have Power of been previously received into the system, the variolous action will tanoiouii8 generally be, though not always, suspended till the measles have action. run through their proper course, when the inserted virus will resume its power and the variolous eruption follow in its due order. This Similar quality of suspension, however, is not peculiar to the measles. " i oTherVis- have known," says Dr. Perceval in his manuscript comment on the 0Me* present species, " bex. convulsiva yield the pas to variola, and then resume its station." In like manner consumption is generally sus- pended during the entire course of pregnancy, and recommences its inroad on child-birth. Measles in their more perfect form, which is that we are now Ordinarily contemplating, may be said, as a general rule, to occur but once in once'in a the course of a man's life ; for though, as Dr. Baillie observes,* a ™an'lLI,r"i. P ' . . /. . . 'in a few in- few instances of a second attack are to be found, exceptio probat stances a regulam; they are so rare as rather to maintain than disturb the £„" law.t Dr. Willan asserts that he never met with an instance. The anomaly is unquestionably less frequent than in scarlet-fever, and shows that the influence produced by the rubeolous action on the habit is more rooted than effective. In its ordinary course measles is a disease unaccompanied with Commonly danger. It is in fact a catarrhal fever with a specific eruption. panfedm The fever, as we have observed already respecting exanthems in witadM- getteral, is necessary to a certain extent for the purpose of throwing ser' the virus upon the surface : as inflammation in a certain extent is necessary to produce healthy suppuration. But a small degree of py- rectic action is in both cases sufficient; for if this be exceeded, the natural mean of cure itself becomes the disease, rather than the morbid condition it is intended to remove. In all instances the extent of the eruption will depend upon the Extent of fever whenever the latter is in excess. And hence our attention is J^,6^" to be mainly directed to the fever itself; for by diminishing the fever pendent we necessarily diminish the eruption also. In measles, therefore, degree of the remedies we have already enumerated for a catarrh are those we Treatment. are to have recourse to. An emetic is always useful on the incur- sion of the disease; and should be succeeded by cooling aperients and demulcents, the skin being kept moist, and its heat subdued by mild diaphoretics. Dr. Cullen recommends blood-letting during every period of the Veneaec- disease ; and it has hence often been practised at its commence- far'expedi- ment. It is rarely, however, that this can be called for except in £"{;.„„,. spectioo * Trans, of a Society for the Improvement of Medical and Cbirurgical Knowledge, required. Vol. hi. 8vo. Lond. 1812. i Roberdiere, Recherches sur la Rongeole. Paris, 177R 24 cl. in. J HjEMATICA. [OBD. 1II« Gen. I. the case of pneumonic inflammation; and as such an affection does * E.KRnbe- not commonly appear till the close of the measles, we should, gene- "aris11'" ra^y sPeaking, as recommended by Sydenham, reserve blood-letting Common till this period, and not exhaust the patient's strength before hand ; Treatment. and tne more so' as even here the fever has sometimes proved a Fever synochus, and terminated in a typhus form, as particularly noticed Sh7nge,u*o b}' Sir William Watson in the children of the Foundling Hospital in «brnTh°n* 1763 Snd 1768, Wn° ^VeS t0 tmS m<>d'fication tne name Of Putrid measles :* if, indeed, this were an example of the genuine disease, of which there is some doubt, though there is little doubt that in a few constitutions the disease has taken this turn. " In a charity school, where measles prevailed," says Dr. Perceval, in commenting on this species as given in the Nosology, " typhus infection was in- troduced ; hence the variety * changed to y." It is highly j roba- ble that some such accidental cause occurred in producing Sir William Watson's modification. Exposure Exposure to cold, so peculiarly serviceable in small-pox, has, cHevou™1*" fr0111 a supposed analogy, been recommended also in measles by and why. some rash practitioners, and adopted by others. All fair analogy, however, is against the practice : the fever in measles is directly catarrhal, and the analogy should be drawn, not from small-pox, but from catarrh, in which exposure to cold would, in the opinion of every one, be absurd and mischievous ; nor can any thing be so likely to produce pneumonic inflammation, which, in truth, is most Room spa- commonly the result of carelessness upon this very point. The airy. room should be large and airy, free from currents of cold, but not Food. hot; the drink warm, the food light, diluent, and in a liquid form. inhalation If the cough be troublesome, it will be useful to breathe the steam of vapour. Qf warm .wateri not through an inhaler, but over a large basin, with the head covered with a flannel large enough to hang over its edges ; and by this mean the inflamed eyes will also have the benefit of the relaxing vapour. If the oppression of the chest, pain, and coughing should return, as they are apt to do on the disappearance of the eruption, venesection or cupping must again be had recourse to, Opium however they may have been employed antecedently. Opium does uBefu3!. not, in this case, afford the relief we might expect: it increases the heat and restlessness, but rarely conciliates sleep. A supervening diarrhoea proves the most favourable crisis, and should be very cau- tiously corrected. And where it does not take place naturally, it may be wise to imitate it by gentle laxatives. (3 e. Rube- From a peculiarity of constitution, or some accidental influence imperfect8' exercised over it at the time, the rubeolous rash is sometimes found measles, to run through its regular course with little fever or catarrhal affec- tion, as though it were a simple cutaneous eruption, and without appearing to afford an immunity to the individual against a future somotimes attack ; constituting our second species.t This has usually been Sous called, and especially by the German writers, spurious measles; but measles: as ft occurs most frequently when the genuine measles are epidemic," and is doubtless a result of their contagion, it is less properly a spu- * Medical Observations, Vol. iv—Hoffman. Opp. Tom. II. p. 67 * New-York Medical Repository, Vol. v. Art. in. ol. m.] SANGUINEOUS FUNCTION. [ord. ur. 25 rious than an imperfect or immatured rubeola ; and I have hence ex- Gbm. I. changed the term spuria for incocta. Dr. Willan denominates it $ "ruIm- rubeoia sine catarrho; but as the genuine measles themselves, ca- "l!t incocta. pable of affording emancipation, have sometimes appeared with Katies? very slight catarrhal symptoms, incocta seems preferable. " Some," fu,lj^1'a'*n says Dr. Heberden, " have been so fortunate as to have the measles «n« appear after suffering so very little from fever, or any of the prepa- nutim*' ratory symptoms, that they could hardly say they had been ill." In ^J^w^Y this case the constitution is protected by a natural insusceptibility genuine of the disease ; which is the best protection we can possess. In mea,lM- the case of imperfect measles, it is only operated upon by some temporary influence : and hence as soon as this influence ceases, the common susceptibility returns. The third variety, or black measles, seems to consist in an Y e. Rubs- intermixture of dark, discoloured, or petecchial spots from effused Black6'*' blood, with the proper rubeolous fash. It is found chiefly in per- mMBlet- sons of debilitated and relaxed fibres : and the dark patches will sometimes remain for ten or twelve days after the commencement of the eruption, with no other symptoms of fever than a quicker pulse and an increased degree of languor. It is rarely of serious Rarely of consequence unless a typhous infection be accidentally communi- "onse- cated, as mentioned by Dr. Perceval, and usually yields with ease J"8™8' to an infusion of bark with sulphuric acid. 4 typhus as- Inoculation has been tried for the measles by employing the Rubeolous acrid serum from the eyes, or from minute vesicles that sometimes >p°cuia- appear between the patches of the rash. Dr. Home, not being able as perform- to obtain a contagious ichor from either of these quarters, drew Home?'" blood from a turgid cutaneous vein where the eruption was most confluent; and impregnating a dossil of cotton with it, he applied the cotton to a wound made in the arm. It has occasionally sue- of uncer- ceeded, but more frequently failed ; nor does it seem to operate Uun re8ult' with any certainty in producing a mild modification ; for many of the cases of inoculated measles have been quite as severe as we might reasonably have expected from a natural attack. It is in truth and an un- a very unnecessary caution in a disease that in its ordinary range precaution. excites so little alarm ; and which leaves no blemish, like the small- pox, on the skin. Vol. III.—i M cl. Hi.j H-EMAT1CA. (ori». 112 SPECIES 111. ENANTHESIS URTICARIA. NETTLE-RASH. RASH IN FLORID, ITCHING, NETTLE-STING WHEALS ; APPEARING ABOUT THE SECOND DAY ; IRREGULARLY FADING AND REVIVING, OR WANDERING FROM PART TO PART : FEVER A MILD INTER- MITTENT. Gem. I. This, like the last species, is rather a troublesome than a dan- l^v1"* gerous complaint; though it is always attended with some slight symptoms, disorder of the constitution, as head-ache, drowsiness, coldness, and shivering, succeeded by great heat and a white fur on the tongue. But the stomach seems chiefly to suffer : and hence there is not un- frequently pain and sickness in this organ, with great languor, faint- ness, and anxiety. And, as a sympathetic affection, the eruption has often followed on any violent disturbance of the stomach alone, as surfeit, cold cucurbitaceous or other indigestible vegetables, mushrooms, crab-fishes, muscles, cupreous or other mineral poisons, introduced into the stomach by mistake. Kxciting The exciting cause, however, of genuine idiopathic nettle-rash, is unknown, usually concealed from us ; for it often makes its appearance with- out any of these irritants, or indeed any other that we are acquainted with ; and hence Dr. Heberden inclined to believe that the skin itself is often the chief seat of the disorder, and that the stomach How far and the system only suffer secondarily.* He has hence contem- lichcnous plated it as a modification of lichen, closely connected with the eruptions, prickly heat of the West Indies, the essera or rather eshera of the Arabian writers. The resemblance is close ; but there are cha- racters by which the two diseases may be distinguished with tolera- ?",hdbilin ^k ease" *n nettle_rasn the efflorescence is in scattered wheals gnu. a e. wjt^ ^w papUjgg . m iicnen< m scattered papulae with few wheals. In the latter the itching is more mordicant and aculeate ; the erup- tion instead of terminating in a few days runs on to an indeterminate period ; and, however irritating, produces little or no fever, and but a slight constitutional affection of any kind. By Sau- In Sauvages, on the contrary, nettle-rash is treated of as a scarlet- JafdeVas a fever under the name of scarlatina urticata. But its character, as le^ll°r £iven in the sPecific definition,is sufficient to distinguish it from anv Hver'distin fofm ofrosaua, which has no wheals or elevated beds with a defined guished!Un" outline, and no sensation of stinging. Found The nettle-rash occurs chiefly in summer, and more frequently ttJ." among persons of the plethoric or sanguine habit, especially those mer. * Med. Trans. Vol. n. p. 173. r l. in.] SANGUINEOUS FUNCTION. [0BD. hi. 2t7 who indulge too freely in eating and drinking. In children it seems sGEM,,l'r sometimes to be connected with teething or irritation of the bowels. EnTntfiesis The eruption commonly takes place at night after the febrile symp- ^t^ia' toms just noticed have prevailed for about thirty or six-and-thirty rash. hours ; and on this account the Arabians elegantly and correctly ^"fly6"^ denominated the coloured wheals (benat-allil,) " offspring or daugh- "jght. l e .l • u* » How deB°- ters Of the night. minated by By the length of the precursive symptoms the idiopathic disease ^hn* Arftbi" is distinguished from the sympathetic affection, so closely resembling idiopathic it, which is occasioned, as already observed, by crapulence, or sub- duttoguiTh- stances introduced into the stomach that disagree with it. In this Jdn^ro™ last case the general swelling and eruption take place immediately, thetic. and subside as soon as ever the occasional cause is removed. Wheals of a similar appearance are sometimes found with other peculiarities, as of a whiter hue, or interspersed with small tubercles, or of a very small diameter, except when they unite in clusters : some of these sorts trouble the skin permanently : others vanish and re-appear fP£™{"08u°T several times in the course of a day ; others subside for a week or forms. two, and then rally and re-occupy their stations. But all of them are of chronic duration, are little accompanied with fever ; and can- not be considered correctly as varieties of the idiopathic disease. They occur, however, as such in Dr. Willan's treatise. A cooling regimen, and subacid diluents, with a free exposure to Jjf^,1,^ pure air, generally succeed in effecting a cure of nettle-rash without any other medical treatment. A gentle laxative or two, however, should be added to the domestic means : and if the itching be very troublesome it may be often allayed by the use of camphorated vinegar. The juice of fresh parsley has the reputation of producing an equally good effect; but evaporation by means of any other fluid applied to the itching parts would probably be found as bene- ficial. Dr. Willan describes a single case in which urticaria proved h*» »reveii fatal.* The patient was a man of about fifty years of age, who had impaired his constitution by hard labour and intemperance. The precursive symptoms were all violent, and the sickness and ■»«» »p?»- languor were followed by fainting fits; and he had great pain in the whin com- stomach which was increased by pressure. The fever was con- SjJSf^,,, siderable, and soon attended with delirium. While the rash was other affee- most vivid his internal complaints abated ; but he gradually gottlon worse, and died on the seventh day. Here, again, however, the urticaria seems to have been only symptomatic. It afforded him relief, and offered the only chance of recovery. * Cutaneous Diseases, p. 401. 28 ci. in.] HyEMATICA. [ORD. TTI GENUS II. EMPHLYSIS. ICHOROUS EXANTHEM. ERUPTION OF VESICULAR PIMPLES FILLED PROGRESSIVELY WITH AN ACRID OR COLOURLESS, OR NEARLY COLOURLESS FLUID ; TERMI- NATING IN SCURF, OR LAMINATED SCABS. Gek.II. The term emphlysis is derived from the Greek tp. or «», "in, thegcnafic mira >" an(l 0At>««, " a vesicular tumour or eruption." 'E*^w is to™. usually employed among Greek writers nearly in the same sense as ?u°i9hedrtil>" Q*""* *n tne Present system it will be found employed somewhat from ec- more strictly, and in opposition to t/*pxvet; so that while emphlysis, phiysis. from tne jatteri imp0rts an eruption of vesicles, whether large or small, produced by or accompanied with internal and febrile affec- tion essentially connected with it; ecphlysis, from the former, im- ports an eruption of vesicles simply cutaneous or superficial; or, if, in a few varieties, combined with internal affection, not neces- sarily or essentially associated. Of the last, therefore, we shall have to treat in the third order of our sixtli class, entitled eccritica. The genus emphlysis includes the following species : 1. EMPHLYSIS MILIARIA. MILIARY FEVER. 2.---------APHTHA. THRUSH. 3. ■ VACCINL1. COW-POX. 4. --------- VARICELLA. WATER-POX. 5.---------PEMPHIGUS. VESICULAR OR BLADDERY FEVEK. 6. ———-— ERYSIPELAS. ST. ANTHONY'S FIRE. ci. ra.] SANGUINEOUS FUNCTION. [ord, m. 29 SPECIES I. EMPHLYSIS MILIARIA. MILIARY FEVER. VESICLES SCATTERED OVER THE BODY, OF THE SIZE OF MILLET- SEEDS ; TRANSPARENT-RED, AFTERWARDS MILKY : PRECEDED BY A PRICKING SENSATION ^ SIGHIiNG, ANXIETY, AND SOUR SWEAT. The disease takes its name from milia, " millet-grains," in con- Gen. H. sequence of the resemblance of its vesicles to the seeds of this plant 0rfg*n *of* in size, and, when matured, in colour. There is a doubt when it t"e specific first made its appearance, and another doubt among some patholo- gists whether it be ever any thing more than a symptom of some other complaint. It has been treated of at least, for a century and a half, and that, too, as an idiopathic malady. It is said to have appeared first of all in Saxony : and the oldest writers assign two varieties of this Possesses disease distinguished in Germany by the names of Rothen Friesel forTHer!!6" and Weisse Friesel, or red and white miliaria,* but perhaps unne- "[j^-^0 cessarily, as both varieties seem in most if not in all instances to be Red and' only different stages of the same affection. The vesicles are at first JjJjJ6 miU' red from the colour of their under surface, or inflamed base, being i«fferenc« transmitted through the transparent pellicle; they are afterwards explained. opake and milky from absorption of the more attenuate part of the fluid, or some other change. In a few cases, however, the red hue seems to have continued throughout; and in others the white hue to have appeared from the commencement: a variation in the na- ture of the secretion and in the mode of its absorption producing this difference of effect. From the redness of the vesicles on their first eruption, this dis- oftan call- ease has also been denominated by many writers on the continent n?»a&' purpura ; and has hence been confounded with the petecchial or "jnfi"J°d" flea-bite-like spots that appear in scurvy and putrescent fevers: putrescent and the rather as miliaria is also a disease of debility. PloucquetBpois' seems to have intermixed all these as well as pemphigus, and de- scribed them under the common name of miliaria.! In like manner Gerike's dissertation on this disease is entitled De Morbo Miliari, alias Purpura dicto ;\ and Juck's De Febre Miliari, vulgo Pur- pura rubra et alba, seu chronica.§ From the minuteness of its vesicles, whose elevation can often Sometimes only be ascertained by the finger, this species treads close upon the asSa rasb. general complexion of the genus enanthesis, or rash exanthem, and during its red appearance is often called a rash ; and hence another * Sindner, Betrachtungen des Rothen and Weissen Friesels. Schweidniz, 1736. t Initia Biblioth. r. p. 564, S65. ? Hal. 17SS. *. Erfort. 1716. 30 cl. in.] H^MATICA. [o»»- "*' Gen. II. Spec. I. Emphlysis miliaria. Miliary fever. and relat- ed to measles. Occasion- ally a con cause of confusion and intricacy. By Linn6us and Parr it is on this account defined nearly in the same terms as rubeola, so far as re- lates to the eruption ; and at Leipsic in 1650, where it is said to have been contagious or epidemic, was unquestionably mistaken for rosalia or scarlet-fever. As a symptom it sometimes accompanies inflammatory fevers, but more generally those of atony. It is cer- tainly at times attended with flea-bite spots, or petecchia?, and Hux- bmhkm °f nam sPeaks of it as sometimes giving rise to them :* an observa- flamma- tion confirmed by a like statement of Boncerf :t and hence another «oniend reason why it has occasionally been treated of under the term tevcrs. purpura. Descrip- The eruption makes its appearance at an uncertain period after the commencement of the introductory fever; usually, however, on the third or fourth day. It seldom shows itself upon the face ; but is first visible upon the neck and breast, and thence spreads pro- gressively over the entire body. The febrile attack is usually some- what severe in all its stages, the pricking sensation occurs during the hot-fit, and is like that of pin-points struck into the skin ; the sweat is copious, but proves by its sour and olid smell that it is a morbid secretion, and hence affords no relief. The disease runs on with variable remissions or exacerbations for seven or even fourteen days, and has sometimes extended to twenty-one days, commonly terminating in a critical and natural sweat; the red transparent ve- sicles, as already observed, gradually assuming a whiter hue, and losing their transparency ; and about the fifth day drying in minute crusts or scales ; which, in some instances are succeeded, as in the case of aphthae, by a new crop of vesicles that pass through a like course. Notwithstanding the anxiety and depression of animal spi- rits which so peculiarly mark this exanthem, it commonly maintains, through its entire range, a mild character, undisturbed by any alarm- ing symptoms. In some instances, however, either from the con- stitution or peculiar circumstances of the patient, or the peculiar temperament of the atmosphere, it puts on a malignant character, and proves fatal in a few days. Such a character it seems to have exhibited in the departments of the Seine and Oise in France in the autumn of 1821, where also it committed a very extensive havoc as an epidemic. M. Rayer, who has given a valuable history of its range in this quarter, tells us that it usually commenced with symptoms of general restlessness, which were soon succeeded by a copious perspiration, that continued through its entire progress, whether it terminated in recovery or death. The eruption, which, as usual, appeared on the third or fourth day was general or partial, discrete or confluent. And as the transparency of the vesicle was, in some instances, without a red basis, and continued till desquammation, he adds to the two va- rities of red and white miliaria a third, which he distinguishes by the name of phlyctenous. He tells us also that, on dissection, the mu- cous surface of th« stomach and intestines generally showed some proof of inflammation ; an appearance which was likewise traced in Seldom alarming in its pro- gress: but occa- sionally so from acci- dental cir- cumstan- ces. As in France in 1831, where it became epidemic. Phlycte- nous va- riety. * Vol. I. passim. t Hantesierk, Recwil, n. p. 217. ll. iu.J SANGUINEOUS FUNCTION. [ord, m. 31 various instances in the lungs, and even the brain or its membranes. Q*v- ^^ The cause of the epidemy seems obscure ; the air, however, was EmpWysia' humid, and the face of the country is considerably mapped with ^j[|ari"* marsh-land. fever. We have no clear proof of its being contagious ; and Stoll,* and Probably most pathologists with him, deny that it is so at all. It is found in- «0Us. deed more frequently as a secondary or symptomatic, than as an ^ndary original affection of any kind. Cullen denies that it is ever other- affection. wise than symptomatic. But this is to speak as we have already to'cniien seen in two proscriptive a tone. The author himself, indeed, has always so. lately had a clear and well marked example of its idiopathic appear- trary evin- ance in a young gentleman of a bilious habit, thirteen years of age, cod* in which the vesicles were very numerous, but distinct. They passed through the two stages of a red and milky hue, and termi- nated on the seventh day in branny scales, unconnected with any other ascertainable disease : and M. Planchon has given abundant instances of the same kind.f Professor Frank affirms that it is often epidemic, and in some parts endemic ;| but his description seems to combine the symptoms of other diseases along with those of ge- nuine miliaria, so as to make it a mere satellite upon a more im- posing potentate. Dr. Cullen, however, conceives it to be nothing more than an Supposed eruption occasioned by a stage of sweating, protracted till it has tJbeVc^ produced debility, in any fever whatever. But in this case we duced by should expect it most frequently in the clammy saburral sweats of perspua- typhous fevers, in which it is only occasionally to be met with, and non" certainly less frequently than in other fevers. M. Planchon regards B7plahn" it as proceeding most frequently from obstructed perspiration, which guppressed he lays down as its common cause : and M. Triller instead of being jjj0"pira" a result of weakness, when in a symptomatic form, asserts that in various instances it proves critical.§ In few words, miliaria when idiopathic is an eruption accompanied Pathology. with a mild typhus for the most part, though not always, and a pecu- liar irritability of the skin. And where the same eruption appears as a symptom of some other disease, it is probable that a like irrita- bility of the skin has been produced by a course of saburral or acri- monious sweating. Of its remote or even exciting causes we are utterly ignorant. Remote The stomach seems sometimes to be overcharged ; cold in the feet citing1 has been suspected; and, as observed by M. Planchon, we have cau»es often obvious proofs of obstructed perspiration. But all these facts unknown. occur in thousands of instances without producing any such result. It is, however, unquestionably a disease of debility, and has some- Modicai times, like rosalia, been followed by cellular or abdominal dropsy. ea men And to this character of weakness our eye should be directed in attending to its cure. Every thing that heats and stimulates should * Rat. Med. n. p. 58. 169. t Dissertation sur la Fievre Miliare, &c. Tburnay. 8vo. | De Cur. Horn. Morb. Epit. Tom. m. § 322. p. 131. 8vo. Mannh. 1792. § TriUerr et Molinarii Epistolx mutun; de vera Exanthematum Miliariuiu difle renti*. U cl. iu.] HjEMATICA. [ord. ru. Gen. II. be avoided. The bowels should be cleared of all irritating materials ifmpi?y«S by mild laxatives; and, if offensive breath or any other symptom Miliar'*" snoul(1 indicate defedation of the stomach, an emetic should be fever'' given at the first. Cooling drinks, light bed-clothes and a cool Treatment. atmoSphere will, in every case, be of essential service; and the pa- tient may be allowed to lay with his hands and arms out of bed. By these means alone, Dr. Cullen thinks he has frequently pre- vented miliary eruptions in lying-in women and others, where it might have been expected as a concomitant. But where it has actually appeared, he adds to this regimen the use of tonic and antiseptic remedies, particularly Peruvian bark, cold drink, and cold air. Purgatives, however gentle, have been objected to by many pathologists : but when not carried beyond the strength of the pa- tient, they rarely fail to be of service. u 1 am convinced by expe- rience," says Sir George Baker, "* that the prudent application of this practice to the miliary fever has been of singular advantage : and it is worthy of observation in this place, that the symptoms of the measles are often rendered less formidable, when, during this disease, the patient has every day two or three evacuations by stool."* Something, however, more specific than this general plan will, in Perspira- many instances, be found necessary. In his own practice, the only to be author has endeavoured not merely to check but to change the butchang- perspiration : and hence, while from an early period of the disease ediniu he has employed tepid ablution or sponging, which is always highly Te'pWab- refreshing, he has given small doses of antimonial powder with infu- totwn- sion of roses containing a surplus of sulphuric acid : and has rarely alterants continued this course for four and twenty hours without finding the raUcids.6 sweat less copious and of a more natural quality. And where the Camphor, languor has been distressing, he has added camphor in the form of pills, giving a scruple or half a drachm in the course of the twenty- four hours. Alikearup- That the skin is in a state of peculiar irritation is highly probable duced'by from our being sometimes able to excite a like eruption by wearing t"?e'ytheri a smrt °^ coarse flannel or horse-hair. And hence Dr. Darwin gives skin; one example of miliaria, as he calls it, " produced by the warmth, constiuf "° and more particularly by the stimulus of the points of the wool in tionaiaffec- flannel or blankets applied to the skin, which by cool dress, and bed- clothes without flannel, soon ceased." He has distinguished this affection by the name of miliaria sudatoria. but it ought rather to be regarded as a variety of intertrigo, or fret. * Med. Trans. V«). n. Art. xix. p. 300. kl. in.] SANGUINEOUS FUNCTION, [ord. hi. 33 SPECIES H: EMPHLYSIS APHTHA. THRUSH. VESICLES GRANULAR, ROUNDISH, PEARL-COLOURED ; CONFINED TO THE LIPS, MOUTH, AND INTESTINAL CANAL ; TERMINATING IN CURD-LIKE SLOUGHS ; OCCASIONALLY WITH SUCCESSIVE CROPS. Aphtha is derived from the Greek «tt« " accendo," " to burn, Gew« Ir- or inflame." Like the preceding species this eruption, though at orfgfn"o?" one time supposed to be papulous, is now generally admitted to the specific consist of minute vesicles containing a whitish or milky fluid, when matured : and hence, in a nosological arrangement, it naturally fol- lows upon miliaria. This disease is found under three varieties, a white, a black, and* a chronic : 0 Infantum. Appearing in infants soon after White thrush. birth ; and often extending from the mouth to the intestinal canal; mostly with slight febrile symp- toms, and white sloughs, £ Maligna. Accompanied with great debility of Black thrush. vascular action ; usually ascend- ing from the larynx into the mouth ; sloughs black ; fever a typhus. y Chronica. Protracted and exacerbating; with Chronic thrush. great emaciation and hectic fever; extending through the whole range of the intestinal canal. The disease consists in a peculiar acrimony that irritates the Pathology. whole mucous membrane, and particularly the mucous glands of the mouth' and fauces, producing minute vesicles and sloughs. In the second and third species some of the smaller blood-vessels are also eroded at the mouth, and hence the sloughs become livid or ulce- rated. All the varieties, therefore, occur only under circumstances of considerable debility ; and hence while the first is usually found in infancy, the two last are mostly an accompaniment of low-fevers, old age, or cachexies. aE.Aphtha The white thrush, or that of infancy, commences in the mouth. wf^"m* The angles of the lips are usually first beset with the eruption, pro- thrush. bably from their exertion and fatigue in the act of sucking. From uou?np" Vol. III.—5 34 cl. in.] ILEMAT1CA. jOlily. III. Gen. II. Spec. II. «E. Aphtha infantum. White- thrush. Travels from the mouth down- wards to the intes- tines. Sometimes terminates in the mouth with a single crop of eruption. But usually migrates and ap- pears in a second or third crop. Has some- times prov- ed fatal. Fluid highly acrimo- nious and erosive. Probably specific and contagious. Hence pro- pagable by kissing. Sometimes epidemic. Curative intention. Health of the nurse to be in- quired into. Nature and preparation of the food. these it spreads in scattered papulae over the tongue and cheeks, till at length many of the papulae coalesce, and the eruption appears in patches, or strata, The fauces become next affected, and it descends thence through the esophagus into the stomach, and travels in a continuous line through the entire course of the intestines to the rectum, the feces being often loaded with aphthous sloughs. In very mild cases the disease restrains itself, or by judicious management is restrained, to the mouth, and terminates upon a single separation of the curd-like crusts. But it usually proceeds farther ; and a second, and even a third crop, takes the place of that which disappears. The general health is, in the mean time, but little disturbed, though the stomach evinces acrimony, the pulse is often a little quickened, and the infant is rendered fractious. But in an unhealthy habit, when the food is innutrient, and the frame weak and atrophous, the under-surface of the vessels ulcerate, the ulceration spreads wider and deeper, a low fever ensues, and the little patient sinks beneath its malignancy. In the mildest form this eruption seems to be highly acrimonious; for the nipple of the nurse is sure to be affected. There is little doubt, moreover, that the acrimony is specific and contagious : though, in order to multiply itself and preserve its peculiar powers, it seems necessary that it should come into close union with the same membrane, or a membrane of the same structure as that which originates it. Sine proximo contactu, says professor Frank, com- municari hunc morbum, non facile concedimus.* Hence the nipple, though corroded by the sharpness of the humour, does not produce aphthae, nor does the ulceration spread beyond the reach of the acrid ichor : but it has been received by kissing the infected lips of an infant; and has in this manner propagated itself to adults as well as to children. But, beyond this, we have good authorities for believing it at times to be epidemic. For not only all the children of the same family, how cautiously soever separated from one another, but many of those of the same neighbourhood, have been known at times to suffer from it simultaneously. Yet whether in this case the epidemy be the result of the specific matter of the exanthem, floating as an undis- solved miasm in the atmosphere, or whether any particular intem- perament of the atmosphere itself predispose the body to the gene- ration of aphtha, is unknown. In the cure of this species our first object should be to remove all acrimonious materials from the primae viae by a laxative or emetic, or both, and thus, as far as we can conjecture concerning it, root out the primary source of disease. We must at the same time carefully examine the health of the nurse of the infant, if the infant be at the breast, and particularly as to the nature of the milk, and the freedom of the nipple itself from all primary disease, so that the child may not have a foundation laid for it in this quarter. If the child be weaned, we must be particularly attentive to the nature of the food, and the mode of its preparation, concerning which nurses, when left to * £>e Cur. Horn. Morb. Tom. m. S 3** ex,, in.J SANGUINEOUS FUNCTION. [ord. in. 3j themselves, are often too careless. And we have next to prevent Gen« "• the multiplication of the papulae by syringing off the acrimonious aE^pbun fluid as well as we are able with diluting or detergent gargles, and i«f»ntmu. expediting the separation of the sloughs by inviscating astringents, tiimsi?. as bole armenic, alum, borax or catechu, intermixed with mucilage fn"*[Jo* or honey. These astringents, however, must not be made very Detergent sharp ; for in this case we shall hurry off the little sloughy curds too fnifscating rapidly, irritate the tender surface of the new skin, and produce a new astringent.: f ■ i • i • -i /» . but not too crop of eruption ; which is perhaps excited more frequently by irrimnt. being thus too busy and precipitate than by any other means what- ever. If the disease have descended into the stomach and intes- tines, a mixture of rhubarb and magnesia given occasionally will be the best medicine with which we can follow it up. The second variety,or black thrush is sometimes found idio-0 EAphtiia pathically in old age when all the vital resources are failing, and birc!"*' the constitution is sinking apace ; but it is more commonly a con- thrush. comitant on acute debilitating diseases ; as in typhous or malignant duced!! remittents. Stoll affirms that in all these cases the disorder com- Works up- mences not in the mouth as in infants, but in the stomach,and works uiesto-™1" its way both upwards and downwards ;* and, from the pain and car- n^11* dialgia that are often complained of antecedently, there seems ground for this opinion. Birnstiel makes the same remark, and com- pares the feeling to that of a tense cord extending from the cardia to the navel.| This variety is also said to be at times epidemic and, Said to be by some, contagious. But it should be observed that in most of epidemfc these cases aphtha has appeared as a concomitant of other diseases, "{"• ™nJ*~ and probably as the result of them. Thus when it is affirmed by perhaps Muguet to have been decidedly contagious at Paris on a particular competed occasion,! an alarming typhus seems to have been present also. witn ot.her Stoll gives the same account of it, but it was then united with mili-1°"pid'a-"' ary fever ;§ and on another occasion, when it appears to have had mics- pretensions to an epidemic range, it was combined with a prevailing intermittent.il In all these cases the mode of treatment must depend upon the Treatment nature of the particular case. In the drooping of old age we can only palliate ; and our best palliatives will be'cordials, as port-wine negus, or wine itself, and stimulating nutritive food : where the aphtha is dependent upon some other affection it can only be reme- died by remedying the parent disorder. In very cold northern, and especially in cold marshy climates, aphtha in one of its varieties is said to occur frequently in all ages, and often without fever. As we have already seen that it is very generally the result of a reduced state of health and vigour, this is by no means improbable; and the best means of opposing it is warmth, a pure and unstagnant air, exercise, and a generous diet. The third variety, or chronic thrush seems chiefly also to y E.Aphtha have its first seat in the stomach, or some adjoining viscus. clonic" It has been described by Hillary under the name of aphthoides th™»h- * Rat. Med. 167. 5 Loco citato. t Sterblichkeil im Krankenhaus zu Bruchsal. ![ Fontanus. Annal. p. 59. X Faolin, Von Erhaltunj der Kinder. 36 GL. HI.] ILEMATICA. [ord. ni. Gen. II. Spec. 11. y E. Aphtha chronica. Chronic thrush. Descrip- tion by Latham. Exciting causes. Treatment: chronica, and more lately by Dr. Latham under that of cachexia aphthosa. It is more frequently found in hot than in temperate climates, from the inroad which is so often made upon the strength of the constitution by the permanent excitement of the climate. "A slow hectic fever," says Dr. Latham, "with a pulse weak, and a little quicker than natural, marks the commencement of this disease. Pimples on the edges of the tongue, with superficial blis- ters within the mouth and fauces, next succeed, and a corresponding heat and soreness of the stomach more or less accompany this and every stage of the disease."* The whole intestinal canal soon afterwards becomes affected, and diarrhoea, and not unfrequently dysentery, are the consequence. The irritation then subsides, as though the disease had worn itself out, but there is not vigour enough in the constitution to heal the exulcerations ; and, the original cause continuing, fresh exacerbations take place, and every symptom is more aggravated, usually accompanied moreover with a fearful de- spondency. These repeated recurrences gradually exhaust the system, and the patient at length sinks beneath their persevering assaults. Dr. Thomas has given a good account of this affection as it has occurred from time to time in the West Indies : and ascribes it to general relaxation, exposure to cold combined with great moisture, obstructed perspiration, and an acrimony of the humours.t And hence many of its causes, as well as most of its symptoms, are those of the preceding variety. During the exacerbations opium seems to afford the best relief; while in the intermissions light bitters and other tonics should be had recourse to. For the distressing irritation that often exists in the throat and rectum, Dr. Latham is bold enough to recommend gargles and injections of diluted litharge-water ; the latter in com-? bination with laudanum. Gek. II. Spec. III. History. First dis- tinctly no- ticed half a century ago as a prophy- lactic against imall-po*. SPECIES III. EMPHLYSIS VACCINIA. COW-POX. VESICLES FEW OR A SINGLE ONE ; CONFINED TO THE PART AFFECTED ' CIRCULAR, SEMITRANSPARENT, PEARL COLOURED ; DEPRESSED IN THE MIDDLE ; SURROUNDED WITH A RED AREOLA. This disease attracted attention in the county of Dorset about forty or fifty years since, as a pustular eruption derived from infec- tion, chiefly showing itself on the hands of milkers who had milked cows similarly disordered. It had been found to secure persons from the small-pox ; and so extensive was the general opinion upon this subject even at the time before us, that an inoculator, who * Med. Traw. Vol. v. Art. ti. t Modern Practice of Physic, p. 628. jut. in.] SANGUINEOUS FUNCTION. [ord. hi. 37 attempted to convey the small-pox to one who had been previously Gen. H. infected with the cow-pox, was treated with ridicule. A formal R^hiysls' trial was made, however, and it was found that no small-pox ensued. Vaccina. About the same time a farmer of sagacity of the name of Nash, ow"po*" duly attending to these facts, had the courage to attempt artificial inoculation on himself; and the attempt is said to have succeeded completely. Similar facts and numerous examples of them were Factscom- accordingly communicated to Sir George Baker, who, having en- loU-5jrCRtod gaged not long before in a most benevolent though highly trouble- ?''?tge. some controversy respecting the cause of the endemial cholic of Devonshire, was unwilling, notwithstanding his triumph, to tread again the thorny paths of provincial etiology. Gloucestershire, however, another dairy county, had witnessed the same disease with similar consequences ; and the same opinion generally pre- vailing in distant districts of both counties, afforded proof that the power thus ascribed to cow-pox was not wholly visionary.* Dr. Jenner, then resident at Berkley in Gloucestershire, pursued Subject this hint with great judgment and unabated ardour. He was at by Jeuner. first foiled by not distinguishing between the genuine cow-pox and J^^'Jif" an ineffective modification of it, or a spurious disease of nearly a encounter. similar appearance, to which the same animal is subject, but which is no preservative against the small-pox ; and found another dif- ficulty in determining the period of time within which the vaccine virus maintains its prophylactic power. Having at length, however, Publishes made himself master of the distinctive characters of the genuine very'ill0" vesicle, he ventured to publish the discovery in 1798, and to recom-1798- mend inoculation with the virus of vaccinia as a substitute for vari- ola. The result is known to every one : the discoverer has been Rewarded justly and liberally remunerated by parliament, and vaccine inocula- men?''1* tion has passed with rapid progress over every quarter of the world, ,aPid ?r"1 from the arctic circles to the extremes of Asia and Africa ; and progress of been adopted by civilized and uncivilized nations, by blacks as well ocutotionT as by whites, by the Fin, the Hottentot, and the Hindoo. The disease in its present state may be said to embrace the four following varieties : x Nativa. Genuine cow-pox as it ordinarily appears Natural cow-pox. on those who accidentally receive it from the affected cow. £ Spuria. An ineffective modification of cow-pox, Spurious cow-pox. or a different but resembling disease incapable of preserving against small- pox. y Inserta. The genuine cow-pox as it appears on Innoculated cow-pox. inoculation. } Degener. Cow-pox degenerated in its specific power Degenerate cow-pox. of preservation from unknown causes. In the natural form of cow-pox, or as immediately received « e. Vacci- nia nativa. Natural * Evidence delivered before the Committee of the House of Commons, 1821. cow-pox. . 38 ci.. in.] 1LEMATICA. [ord. nr^ Gen. II. by mi]king or otherwise handling a diseased animal, the vesicles arc Sppc III ^ i i_ *■ o e. v'dcci- more or less numerous, and appear on the hands or such parts as NatHrai™* ^ave been in contact vvitn the affected udder ; of a blueish tint: c..wUpox. the fluid at first limpid ; afterwards opake and purulent; often Saracters6 with enlargement of the axillary glands, and considerable fever. DescirpUon Most frequently the vesicles make their appearance about the rr^ntubT joints, or extremities of the fingers ; their figure is circular, and Ject: there is a slight dip from the circumference to the centre. The fever opens with its usual symptoms of lassitude, pain in the head, limbs, and loins, rigor, vomiting, and a quickened pulse ; the head sometimes continues affected after these preparatory signs have gone off, and is even accompanied with delirium. The inflamed and ichorous tubercles having suppurated, burst in three or four days from distention, and become troublesome sores,'healing slowly, and occasionally assuming a phagedenic appearance. The fever in the mean while abates and ceases altogether about the seventh day. The fluid discharged from the ulcers is highly contagious; and the eye-lids, lips, nostrils, or any other part of the body, is sure to become inoculated with it if scratched or rubbed with the fingers accidentally charged with the matter. >n the cow. In the affected cow itself the tubercles are still larger, or rather consist of vesicles surrounded by a broad and circular erythema: the animal droops considerably and yields hut little milk. The ul- cers are foul and often obstinate. £E.Vaeci- In the spurious cow-pox, or the disease to which cows are sub- S|mrfoUusa' ject, that bears a near resemblance to the genuine, and is often cow-pox^ confounded with it though destitute of its propyhlactic power, the characters, vesicles are less uniformly circular ; purulent from the first; with- out the blueish tint: with little or no central depression. Whether this, in the animal itself, be strictly a variety of a common species, or a distinct species of a common genus, has not been accurately de- Produces termined. But it is now fully ascertained that this affection of the agaiinBt"ty cow produces no security by inoculation, and was the cause of small-pox. much confusion and many failures at first, and possibly may be of some in the present day. y e. Vacci- \n the inoculated cow-pox from genuine virus, the pathognomic inoculated' signs are the following ; vesicle single, confined to the puncture; Delcrlpave cellulose; blueish-brown in the middle; fluid clear and colourless characters, to the last; concreting into a hard, dark-coloured scab after the twelfth day. Time In propagating the disease from the inoculated vesicle the fluid taking the should be taken before the ninth day, and from as early a period as fluid. it can be obtained. After the ninth day it is usually so inactive as not to be depended upon. Teenuineness If .tn.e uuid. be not transparent, it forms a decisive proof either from'trans- that it is spurious or imperfect. The puncture should be made as PuncSr'e superficially as possible ; for if much blood be drawn the fluid may should be become so diluted as to be rendered ineffective, or may be entirely superficial. wasjje(J away# cow-pwed As small-pox by inoculation is uniformly a far milder disease, and milder than accompanied with a smaller crop of pustules than when received a,, m.] SANGUINEOUS FUNCTION. [ord. m. 39 naturally, cow-pox by inoculation undergoes a like change. There Gen. II. is sometimes a little increased quickness of pulse and constitutional y^\ Vocci- indisposition ; and in very rare instances, a few pustules have been nia insert*. thrown forth around the areola or even on the limbs ; but with cow-pox. these occasional exceptions, the eruption, as already noticed, is ^l'state!" confined to the single, vesicle produced by the puncture, and there is scarcely any perceptible fever. The general progress is as follows. The puncture disappears phro^s °£ soon after the insertion of the lancet: but on the third day a Advance of minute inflamed spot becomes visible. This gradually increases in the vesicle- size, hardens, and produces a small circular tumour slightly ele- vated above the level of the skin. About the sixth day, the centre of the tumour shows a discoloured speck formed by the secretion of a minute quantity of fluid ; the speck augments in size and becomes a manifest vesicle, which continues to fill and to be distended till the tenth day : at which times it displays in perfection the peculiar features that distinguish it from the inoculated variolous pustule. Its shape is circular, sometimes a little oval; but the margin is al- ways well defined, and never rough or jagged ; the centre dips instead of being polarised, and is less elevated than the circumfe- rence. « About the eighth day, when the vesicle is completely formed, the Constitu- disease exhibits something of a constitutional influence ; the arm- {Son?1" "" pit is painful, and there is perhaps a slight head-ache, shivering, lassitude, loss of appetite, and increase of pulse. These may con- tinue in a greater or less degree for one or two days, but always subside spontaneously, without leaving any unpleasant consequence. During the general indisposition the vesicle in the arm becomes surrounded with a circular inflamed halo or areola, about an inch or an inch and a half in diameter, which is the pathognomic proof of constitutional affection, how slightly soever the internal symp- toms may show themselves. After this period the fluid in the vesi- cle gradually dries up ; the surrounding blush becomes fainter, and in a day or two dies away imperceptibly ; so that it is seldom to be distinguished beyond the thirteenth day from inoculation. At this time the vesicle hardens into a thick scab of a brown or mahogany colour ; and if not separated antecedently by violence or accident, falls off spontaneously in about a fortnight, leaving the skin beneath perfectly sound and uninjured. The entire progress of the inocula- Therapia. tion scarcely opens a door to any medical treatment whatever. No preparatory steps are called for, as in small-pox ; and all that can be necessary is a dose or two of some aperient medicine if the constitutional indisposition should be severe or troublesome. There is a variety of vaccinia, denominated degenerate cow- c*e. Vacci- pox by Dr. (now Sir Gilbert) Blane in his evidence upon this sub- Degenerate ject before the Committee of the House of Commons, of which cow-p°*- the following mav be regarded as the character. Produced by Distinctive . . ° ? , . ,• a • i a * characters. inoculation; vesicle amorphous or uncertain ; fluid often straw- coloured, or purulent; areola absent, indistinct or confused with the vesicle ; scab formed prematurely. The cause of this degene- cause or racy has not yet been sufficiently pointed out; but it is now well nofkno"^. 40 cl. in.] 1LEMATICA. [ord. m.^ Gen. II. ascertained that inoculation from this species will not prevent the 1 ffvac": small-pox ; and hence a variety of mistakes in the early practice niadegener. before the fact was discovered. ^v!p0?te Vaccine virus seems to undergo a spontaneous alteration in a Possesses certain peri0d cf time, whatever be the caution with wnicn it is Z&°P7' preserved ; but there are some circumstances that seem to favour v^cine this alteration more than others, although we know but little ot the virus urr nature of these circumstances. Even in passing through the human Sunetus subject in the form of inoculation it appears to be modified and to r « "■ be rendered milder : for a person immediately inoculated from the riouVa affected cow uniformly suffers more than one person inocu ated cause8, from another. It has been proved however that the fluid loses nothing of its specific power after a certain number, and even a long series of transmissions from individual to individual; for cows have been inoculated with it in this state of repeated descent, and have exhibited the disease in all its natural violence. Yet if the seconJ variety be a modification of this disease, and not a distinct eruption, it bears witness to a change in the qualities of the virus taking place in the animal itself from some undiscovered cause. Genuine It ought also to be stated that the genuine cow-pox itself has hasVsome not proved a permanent prophylactic in particular habits or idi- times failed OSynqrasies, of the nature of which however we know nothing. fag sS" But the cases in which it has failed are very few ; and in almost C still in- every instance the small-pox occurring afterwards seems to have fluencesits been changed from its natural course, and rendered milder and of wS'reTders shorter duration ; the pustule rarely exceeding the fifth day before it milder. ^t j)as begun to turn ; and the fluid generally passing at once from an ichorous or limpid into a concrete or indurated state without the intervention of pus. While, therefore, the absolute infallibility of the prophylactic power of cow-pox inoculation is no longer to be maintained, enough still remains in support of its pretensions of being one of the most important discoveries in medicine, and one of the greatest blessings that has ever been conferred on mankind ; as has been sufficiently proved in an admirable article published by the French Imperial Institute, and drawn up by three of its brightest ornaments, M. M. Berthollet, Percy, and Halle, of the date of August 17, 1812. Many cases For the failure of success in many hundreds of instances that roay'be"' nave been triumphantly brought forward by its enemies, there is no accounted difficulty in accounting ; but there are others which arc not to be but'i>y no disposed of in the same manner, and which irrefragably establish means ail. jjg inefficacy from causes that elude all explanation. It was atone time conjectured by our own National Vaccine Establishment that many of these cases of failure were to be ascribed to the use of a single puncture alone, in consequence of which two or more punc- a plurality tures were recommended on each arm. This hypothesis, however, turesUno"t seems now to be abandoned ; and indeed, after the numerous and uucessary. cautious experiments upon the subject of inoculation for the small- pox by M. Camper, which have abundantly shown that a single effective puncture proves as secure, and produces as large a crop of pustules as any number up to seven, which was the highest he ex. m.J SANGUINEOUS FUNCTION. [okjj. in. 41 thought it worth while to try,* it is not a little singular that it Gen- *'. should ever have been adopted : and the observation of Professor l^phf,"1, Thomson is far more worthy of attention. " I have not been able," Vaccinia. says he, " to discover, after the most minute attention, that any Cow"pox- difference of effect whatever in the modifying power of vaccination has depended upon the skill of the operator, or upon his peculiar mode of performing the operation."! The real merits of the case, General however, are summed up with great candour and judgment in the thTcnse as following passage of a subsequent report of the public establishment ^"i^ just alluded to. " After every reasonable deduction, we are com- of thena- pelled to allow, that too many cases still remain on undeniable CfaeEs^bC proof to leave any doubt that the pretensions of vaccination to the lislimen<- merit of a perfect and exclusive security in all cases against small- pox were admitted at first rather too unreservedly. Yet the value of this important resource is not disparaged in our judgment: for after all, these cases bear a very small proportion to the number of those who are effectually protected by it."—Eight only are stated by the metropolitan stations out of nearly 67,000 vaccinated since the establishment of the board : and " we have undoubted proofs from experience, that where vaccination has been performed per- fectly, small-pox occurring after it is almost universally a safe dis- ease ; and though ushered in by severe symptoms, has hardly ever failed to be cut short before it had reached that period at which it becomes dangerous to life."{ There is some cause for alarm, however, in the information lately eases ot communicated by Dr. Gregory, physician to the Vaccine Hospital, seem6 that the table kept at this establishment manifests, that the prevalence "e®g p1^.0' of small-pox after vaccination is on the increase. " From this gressivciy table it appears," says he, " that in the year 1810, the proportion t0 ,ncrease of cases of small-pox succeeding vaccination to the whole number of admissions was as one in thirty ; in 1815 as one in seventeen ; in 1819 as one in six ; in 1821 as one in four ; and during the year 1822 as one in three and a half."§ This is, indeed, a fearful diminution of protective power. But as we have already noticed Attempted the wonderful loss of energy which the genuine virus of the cow counted undergoes in passing through the human subject in the form of in- femeX*a oculation even for the first time, it is possible that its increasing proposed. inertness may depend upon the innumerable transmigrations from individual to individual, that it has now sustained; and that we ought, at given periods, or after a given number of successive in- oculations to return to the primary fountain for a recruit. The subject is well worthy of being followed up by a serious train of experiments. The only case that has ever occurred to myself in which vac- singular cination has not seemed to produce any influence whatever upon "hiciTvac- the character of subsequent small-pox, is one I was attending while cj."ju°"d no influ- . ence on * Dissertatio de Emolumentis et optimo methodo Insitionis Variolarum. Groning. subsequent 1774. t Historical Sketch, &c. i>. 398. smallpox. t Report of April 12,1821. § Cursory Remarks on Sinall-pox as it occurs subsequent to Vaccination, &c Medico-Cbir. Trans. Vol. xn. Part u. Vol. HI.—6 42 CL. III. i ILEMATICA. [OKU. III. Gek. II. Spec. HI Emphlysis Vaccinia. Cow-pox. Other ani- mal poi- sons may possibly also pos- sess a like power, as grease in the heels of horses, supposed by Jenner to be the source of cow-pox, but errone- ously. But other prophylac- tics unne cessary. writing the first edition of this work. The patient was Mr. Alfred Phillips of Christ's College, Cambridge, about twenty years of age, who had been vaccinated when an infant by Dr. Jenner. 1 he eruption was of the distinct variety, but, for this variety, as full as possible over the whole of the face, body, and limbs ; the fever had been very considerable, and every part was severely hot, sore, and tumefied, so that the eyes were nearly closed, and always opened with difficulty in the morning: and the spaces between the pustules, which, however, were few and small, were of a fiery red. The pimples made their appearance on the third day from the ac- cession of the fever ; they ripened regularly, and were, on the eighth day of eruption, very large, and a few of them just begin- ning to turn brown on the apex, so that it is not necessary to follow up the description any further. It is possible that there are other animal poisons which may, in like manner, act as a prophylactic against small-pox, and destroy the susceptibility to this disease in the human frame ; for the same effect seems to have followed upon inoculation with the sanious discharge from the heels of horses afflicted with the disease called grease. And Dr. Jenner, who, on his first directing his attention to the na- ture and effects of cow-pox, applied himself also to this subject,* felt persuaded at that period that the two fluids of cow-pox and grease from the heel of a horse, are precisely the same, and capable of affording a like emancipation. He conceived the sanious fluid of the grease to be the original disease, and the cow-pox in the cow itself to be nothing more than a casual inoculation produced by the cow's lying down in a meadow where the affected horse had been previously feeding, and her udder coming in contact with the dis- charge which had dripped on the grass and lodged there : and he endeavoured to show the identity of the fluids by the identity of their effects in respect of the small-pox.—So far as can be judged from the few cases before us, performed indeed in different countries, but still few in respect to the number necessary to establish a positive proof, grease-pox seems to have succeeded as well as cow-pox; and hence blacksmiths and farriers who have been infected by the grease have been for ages considered as generally unsusceptible of variolous contagion ; and it is possible therefore that there may be, as already observed, other animal poisons possessed of a similar power. But it is not necessary to search for them ; none can sur- pass, and none be expected to equnl, the cow-pox process in re- spect to cleanliness, simplicity, and little disturbance to the system'; while on the contrary, the mere idea of using the matter of grease from the horse's heel, excited from the first so deep and extensive a disgust that cow-pox inoculation had nearly fallen a sacrifice, from the supposed union of the two diseases. It was fortunate, there- fore, for Dr. Jenner, and the triumph of his discovery, that a minuter attention to the subject gave sufficient proof that there was no foundation for his opinion ; and that, whatever be the prophylactic power of the matter of the disease called grease, this disease is bv no means the origin of the natural cow-pox, and has no connexion with it. * Inquiry into the Causes and Effects of the Variolae Vaccina*, p, 27. 37 or. m.] SANGUINEOUS FUNCTION. ;„bu. ju. 43 SPECIES IV. EMPHLYSIS VARICELLA. WATER-POX. VESICLES SCATTERED OVER THE BODY; GLABROUS ; TRANSPARENT ; PEA-SIZED : IN SUCCESSIVE CROPS WITH RED MARGINS ; PELLICLE THIN ; ABOUT THE THIRD DAY FROM THEIR APPEARANCE BURSTING AT THE TIP, AND CONCENTRATING INTO SMALL PUCKERED SCABS, RARELY LEAVING A CICATRIX. The water-pox appears under the three following varieties, dis- Gen. II. tinguished chiefly by the shape of the pimple : <* Lentiformis. Vesicles lentile-shaped, or irregu- Chicken-pox. larly circular, flattened at the top ; fluid at first pellucid, then whitish; afterwards straw-co- loured. £ Corniformis. Vesicles acuminated ; fluid pellucid Swine-pox. throughout. y Globularis. Vesicles globular and larger ; fluid Hives. at first whey-coloured, afterwards yellowish. ^ Corymbosa. Vesicles clustering upon a common, Clustering water-pox. but broader base ; redder at the first, and later in appearance ; febrile symptoms outlasting the eruption. Several of the varieties are sometimes intermixed, and the fluid Varietio» about three days after the eruption occasionally becomes thickish as ally inter- well as yellowish in the first and third, and possesses a purulent m,xed: appearance;* whence, in various instances, they have been mis- a.nd ■ome- taken for small-pox. The eruptive fever in chicken-pox is also taken for sometimes considerable ; and hence, another cause of the same HencePoc- mistake, a mistake that has not unfrequently led to serious and even casionaiiy fatal consequences, by putting those who have had the disease off evils. their guard against variolous infection. And where this error has been committed, and the small-pox has afterwards been received, it has led to a second mistake, by inducing the patient to believe that he has had the small-pox a second time. The two diseases, indeed, were long confounded by physicians The two of the highest character : they were regarded as alike by Morton ; formerly often con- founded. * Frank, De Horn Morbis, Tom. n. p. 270. It cL.iii.j JLEMATICA, [ord. in. Gf.n.II. and even in Sauvages, varicella is described under the name of Emphlysis variola lymphatica* This, however, is a subject we shall further watef-'o'x examme int0 under small-pox.I Suffice it for the present to a er pox. ^^^ tnat varjceua js adequately ascertained to originate from a Chicken- peculiar specific contagion ; and the characters by which it is suf- guUheT" ficiently distinguished from small-pox are that its fluid, except in a tro,n small- few an0malous cases, is limpid throughout; and that as early as the third or fourth day from the eruption it concretes into crusts, which are thrown off without indenting the culis : while in small-pox the fluid consists of pus as soon as formed, and does not concrete into crusts till the seventh day, and often much later. Like the small- pox it does not attack the same person a second time, excepting in a few anomalous constitutions, that establish rather than oppose the general rule. " I wetted a thread," says Dr. Heberden, " in the most concreted pus-like liquor of the chicken-pox which I could find, and after making a slight incision, it was confined upon the arm of one who had formerly had it: the little wound healed up Confound- immediately, and showed no signs of any infection."| It is singular Frank with that Professor Frank should have confounded this complaint as well other erup- as the horny small-pox, with pemphigus, and made them modifica- tions of this diseased as we shall have occasion to observe hereafter. Fever often In the ordinary course of the first three varieties the pyrectic s 's l' symptoms are so slight as not to require medical attention : and sometimes there is no fever whatever. The eruption makes its appearance chiefly on the back, and is often confined to it; and the but not ai- general number of vesicles vary from 20 to 200. I have some- times, however, known the eruption preceded by almost as severe febrile signs of shivering, sickness, head-ache, and pain in the limbs, as that of small-pox, but the symptoms have always subsided when the vesicles have appeared. Treatment. Iii this case an active purge should be administered, succeeded by some diluting drink ; and the patient should be confined to a quiet, spacious, and well ventilated room, with a cool dress, till the febrile symptoms have left him. corymbose For the fourth variety I am entirely indebted to the observant and pieTfrom indefatigable eye of Dr. Heberden ; for it has never occurred to me, Heberden. nor js jt to De foun(j m tne taDie 0f the Nosologists. " This disorder," says he, " is preceded for three or four days by all the symptoms which fore-run the chicken-pox, but in a much higher degree. On the fourth or fifth day the eruption appears, with very little abate- ment of the fever ; the pain likewise of the limbs and back still con- tinues, to which are joined pains of the gums. The pocks are red- der than the chicken-pox, and spread wider, and hardly rise so high, at least not in proportion to their size. Instead of the little head°or vesicle of the serous matter, these have from four to ten or twelve. They go off just like the chicken-pox, and are distinguished from * See upon this subject the remarks under Empyesis Variola or Small-nox Gf n in. Spec. I. of the present Class and Order. r ' t See Gen. hi. Spec. I. of the present Order Empyesis Variola. 1 Medical Transactions, Vol. I. Art. xvji. $• Dc Cur. Horn. Morh. F.pit. Tom. pit. p. 264. cl. in.] SANGUINEOUS FUNCTION. [ord. hi. 45 the small-pox by the same marks: besides which the continuance of Gen. H. the pains and fever after the eruption, and the degree of both these, KmpMyaU though there be not above twenty pocks, are, as far as I have seen, Vwcciia. what never happen in the small-pox."* SPECIES V. EMPHLYSIS PEMPHIGUS. VESICULAR, OR BLADDERY FEVER. \ ESICLES SCATTERED OVER THE BODY ; TRANSPARENT ; FILBERT- SIZED ; WITH A RED INFLAMED EDGE, BUT WITHOUT SURROUNDING BLUSH OR TUMEFACTION ; ON BREAKING DISPOSED TO ULCERATE ; FLUID PELLUCID, OR SLIGHTLY COLOURED ; FEVER A TYPHUS. The term pemphigus is derived from.the Greek a-f^g, " flatus, Gen. II. bulla," and hence inflation, bladder, bubble. The idea of flatu- Spec.y- lency, however, is seldom connected with this disease in modern import of medicine, though very generally in ancient. The term, in the sense ||,,remipecifi0 in which it is now commonly understood, was, perhaps, first em- ployed by Sauvages ; and has since passed into common use. It is Whether still doubted by many, whether pemphigus is entitled to be consi- "h"ic a°sp.a" dcred as a distinct and idiopathic disease ; and whether all its va- ea9e; J va- ,./... it 1 • ■ netyofery- neties and modifications may not resolve themselves into certain sipeias, or peculiarities of erysipelas or pompholyx, the latter of which consists Pon,Phy,,x? of similar vesicles, or bullae, without fever ; or into mere symptoms of typhus or plague. Gulbrand appears to have been of the former opinion ; and hence he has denominated the disease erysipelas vesiculare :t Dr. Cullen seems to have been of the latter at the time of drawing up his definition, and still later, at that of drawing up his First Lines, in consequence of which he dismisses it in a single paragraph as an affection concerning which he can say nothing. But the fourth edition of his synopsis contains a subjoined note, which intimates that his opinion was altered in consequence of his having seen a patient shown him by Dr. Home, and who was labouring under this disease, as an idiopathic affection, at the time. And when to this we add the authority, not merely of the earlier writers, Bontius, Seliger, and Langhans, but of Frank, Withers, Clarkson, Christie, Ring, Braune, and Dr. Stewart of Aberdeen, it would be unpardonable not to allow it a distinct place in a general system of nosology. Upon a careful review it appears to offer the three following va- rieties, which run parallel with those of Dr. Willan, though not exactly taken from him :— * "\It>d. Trans, ut supra. t Act. Soo. Mod. Hafn. Tom. t Hi cl. in.J 1LEMATICA. toUU- ,n" Gen. II. x Vulgaris. Spec. V. Emphlysis Pemphigus. Vesicular, or bladdery fever. Common vesicular fever. 3 Glandularis. Glandular vesicular fever. y Infantum. Infantine vesicular fever. Vesicles appearing on the second or third day, occasionally not till the fifth or sixth ; in suc- cessive crops ; often extending over the mouth and intestinal canal; fluid, on bursting, yel- lowish; some of the vesicles livid, with a livid base. Preceded by tumefaction of the neck and throat; vesicles chiefly seated on.the fauces and con- globate glands; occasionally producing abscesses; highly contagious. Vesicles irregularly oblong, with livid edges and commonly flat- tened tops ; appearing succes- sively on different parts of the surface in infants a few days after birth; on breaking, pur- plish. We shall have occasion to observe, under variola, that Frank, who made a different division of pemphigus, undertook to include under it varicella, crystalline, and horn-pox, and many of the forms of disease which have been denominated spurious small-pox. The first variety, or common pemphigus, is the pemphigus ParfsU3 VUl* mad0* of Sauvages, a very marked case of which is given in a com- oommon munication of Dr. David Stewart to Dr. Duncan of Edinburgh.* ftvor"'" It appeared on a young private of the seventy-third regiment, who had for a fortnight or three weeks antecedently been unwell from a sudden retrocession of measles produced by an exposure to cold, and afterwards to a damp unventilated apartment. He was received into the hospital at Aberdeen April 15, at which time he com- plained of head-ache, sickness, oppression about the praecordia, thirst, sore throat, difficulty of swallowing ; his tongue was foul, his skin hot, pulse from 110 to 120, rather depressed. The whole sur- face was interspersed with vesicles of the size of an ordinary wal- nut ; especially the breast and arms. In the interstices the appear- ance of the skin was natural; and the distance from one vesicle to another was from half an inch to an hand's breadth or more. The disease did not seem to be contagious, as the patient was a solitary instance of it, both where he resided before and after his reception Treatment, into the hospital. His chief medical treatment consisted in bark and port-wine, with acidulated drinks: many of the vescicles broke, and discharged a bloody and most offensive ichor ; the cutis, upon a rupture of the vesicles, was for the most part sound, of a deep red hue, and in some places livid. A new cuticle was gradually pro- duced : and on April 27, being twelve days from his reception into the hospital, he was dismissed perfectly cured. * Rdinb. Med. Comment. Vol. vi. p. 79. a E. Pern- Descrip- tion. *' cl. in.] SAXGULNEOUS FUNCTION, [ord. w. 47 In this case the bulhe do not seem to have reached below the Gen- ,i.- throat in an internal direction ; nor lower than this region in the a EEpem- severer case described by Sefiger. In the first instance, the vesicles pi>'g« vui- appeared abruptly, and had bursted and were healed in seven or Common eight days. In Seliger's case they issued more gradually, and in 'f^™11" successive crops, ran through a longer period, and were not healed c-nerai till the twenty-first day.* Dr. Frank gives a case of a like kind jugular' occurring to him at the time of writing his epitome, that continued a,lumiil»es' to migrate over different parts of the body for sixteen days, accom- panied with difficulty of breathing, subsultus and pain at first in the region of the liver, but afterwards in the chest, assuming the guise of peripneumony.t In a case apparently of the same kind, published by Dr. Dickson in the Transactions of the Royal Irish Academy, there is evident proof of their having extended from the fauces throughout a considerable part of the alimentary canal: here also the vesicles appeared in successive crops, especially on the ninth, tenth, and thirteenth day, each crop continuing four or five days before it bursted; the fever was accompanied with delirium, but abated on the fifteenth day on the appearance of the catamenia, and the bulla? healed in succession without any trouble.]; None of these appear to have been contagious. I cannot speak of pemphigus from personal knowledge ; but in all the above instances the fever was of a low or typhous type ; and the disease seems to have approached the nature of erysipelas, and was treated successfully by the means usually employed for the latter. For what little knowledge we possess of the second or glandular & e. rCn,- variety, the contagious pemphigus of Dr. Willan, we are chiefly gjafdu indebted to Dr. Langhans, a Swiss physician, who observed it in the J*"* spring and through the summer of 1752 in the low-lands of his own visicoiar country.§ It commenced with a sense of tension in the fauces, and £*";. a slight pain spreading behind the ears to the anterior part of the Hon. thorax, accompanied with the symptoms that mark the first stage of fever, but not succeeded by a hot fit. A greenish bilious matter was sometimes thrown up from the stomach, and the pulse was feeble. The neck swelled externally and internally about the fauces, bulla) were observed of the size of a filbert, producing little pain, and con- taining a yellow ichor of an offensive smell. Soon afterwards simi- lar vesicles were found scattered sparingly over the body and limbs, which, if not broken or opened, collapsed in the second, third, or fourth day, and dwindled into whitish crusts. During this period the tumour of the neck often suppurated, or other suppurating tumours formed in some of the conglobate or conglomerate glands, as the parotid, axillary, or inguinal ; and the virus of the disease being thus discharged by different outlets on the surface of the body, the patient recovered. But if, before this translation to the surface, there were a sense of weight and anxiety about the thorax. ■i large abscess was formed internally, and on its bursting the * Ephem. Act. Nat. Car. Dec. i. Add. viii. Obs. 56. 1 De Cur. Horn. Morb. Epit. Tom. m. p. 266. Vol. i. 17S7. {> Act. Helvet. Tom. it. p. 2fi0 4b cl. in.] ILEMATICA. [ord. hi. Gem. II. Spec. V. 0 E. Pem- ghigus glandu- laris. Glandular vesicular fever. Has disap- peared like the sweat- ing-sick- ness! Was epi- demic, con' tagious, and very fatal. Treatment. Y E. Pem- phigus in- fantum. Infantile vesicular fever. Descrip- tion. Curative process. patient died from suffocation. Or if the matter, lodged in the ex- ternal vesicles, were by accident repelled before any glandular sup- puration took place, he died almost as suddenly. M. Langhans compares this disease to syphilis, but apparently with little reason ; and Dr. Cullen and Dr. Frank with not much more to rosalia paristhmitica. The cause, like that of the sweating- sickness, is altogether unknown, and like this disease also, after having ravaged with great fatality for a certain but a shorter period of time, happily for Switzerland, and perhaps for all Europe, it va- nished, and has been heard of no more. Sauvages, indeed, quotes a description of pemphigus from Thiery, which, by some writers, has been supposed to be the same ; but the account is so brief, and at the same time so loose and indistinct, that it is impossible either to arrange or reason about it. The glandular pemphigus of Switzerland, according to M. Lang- hans, was both contagious and epidemic ; so contagious, indeed, as to spread through numerous families with great rapidity, and so ma- lignant, that all persons affected by it died. This last assertion, however, compared with what follows, appears to be a little over- charged ; for the author proceeds, as already observed, to point out under what circumstances patients recovered from it; and lays down a remedial process, which, "though at first," says he, "I employed it with anxiety and hesitation, I can now with pleasure recommend to all persons labouring under the complaint with the most sanguine hope that it will effect a speedy cure." This successful practice, as in the sweating-sickness, consisted in exciting a strong determination to the surface by active sudorifics ; and at the same time supporting the strength with camphor, and other cardiacs. He commenced his process, however, by venesec- tion, which was sometimes repeated, and, where there was danger of an abscess in the lungs, unquestionably with great judgment. The infantile pemphigus appears, as already noticed, most commonly a few days after birth; but in one case adverted to by Dr. Willan, as late as ten months after this period. The vesicles show themselves on the neck, upper part of the breast, abdomen, groin, scrotum, and inner parts of the thighs. They arise successively, break, and expose a surface that heals with difficulty; and more generally enlarges its boundary, and wears out the little patient with pain, restlessness, and want of sleep. Warm cordials, as camphor and the aromatic confection, with a little port-wine-negus, form the best means of supporting the strength, and giving success in the struggle: and laudanum must be had recourse to where the want of sleep requires it. ex. m.J SANGUINEOUS FUNCTION. [ord. in. 4fl SPECIES VI. EMPHLYSIS ERYSIPELAS ST. ANTHONY'S FIRE. VESICATION DIFFUSE ; IRREGULARLY CIRCUMSCRIBED ; APPEARING ON A PARTICULAR FART OF THE BODY, CHIEFLY THE FACE, ABOUT THE THIRD DAY ; WITH TUMEFACTION, AND ERYTHEMATIC BLUSH : FEVER USUALLY ACCOMPANIED WITH SLEEPINESS, OFTEN WITH DELIRIUM. . In describing the genus erythema, I endeavoured to point out a **EN**r- distinctive line between that inflammation and erysipelas, which are Distinction so often intermixed and confounded even by good writers ; and ob- ^tw*^ent served that the first bears the same analogy to phlegmon, as the last disease to small-pox. Phlegmon is local inflammation tending to suppura- [nneos- nious lymph,'* observes Dr. Willan, " contained in the phlyctaena) or vesications of a genuine erysipelas, is inoculated or casually ap- plied to any slight wound in a person otherwise healthy, it produces febrile symptoms, with a red and painful but diffuse swelling, analo- gous to that of the disease from which the virus was derived."* And Facts in he has added a. case, in which the mother of a young girl severely fhi^offercd affected with this disease appears to have received it in consequence by Willan: of having nursed her. Dr. Wells has strengthened the doctrine of its contagious property by Weils: by a variety of facts and cases that can scarcely, I should think, be read by any one without conviction.t One of his examples extends to four individuals, who received the disease in succession after direct contact or near approximation with each other; and another gives us a like chain of not less than six in descent, all of whom, indeed, he did not attend personally, but the history of whom, as * On Cutaneous Diseases, p. 514. t Trans, of Soc. for the Improvement of Tiled, and Chir. Knowledge, Vol. II. p. 21S. Vnr. III.—7 *0 ol. ur.J HEMATIC a [obi>. m. Gen.IL communicated to him by one of the affected, was confirmed by Dr. Kfophiysis Pitcairn, who had been consulted by two of the rest, and was privy ^yAnthoS- t0 the Seneral fa-ct. Dr. Pitcairn also communicated to Dr. W ells ny'siire." the following highly important statement in addition: "A lady 'liiUJlT immediately after delivery was attacked with a fever which was ac- companied with an affection of her skin somewhat like erysipelas; her child, about three days after its birth, was seized with that spe- cies of erysipelas the French call la gelure, which first appeared about the pudenda, and afterwards extended itself to other parts of the body, among the rest to the face. Both the lady and her child died after a few days' illness ; and about eight days after the death of the child, the lady's mother and servant maid, both of whom had attended it during its illness, were attacked with erysipelas of the siui »y face, from which both of them recovered." The opinion of Dr. ie' Baillie, as communicated to Dr. Wells on another occasion, is to the same effect; to which Dr. Baillie seems to have been more especially led, by having observed in " a part of the years 1795 and 1796, that the erysipelas of the face was much more frequent in St. George's Hospital than he had eveT before known it to be ; that many persons were attacked after they came into the hospital, and that the number in a particular ward was much greater than in any other." Prut*My This last remark seems to give some countenance to the further e»rricmy.aD opinion, that erysipelas becomes occasionally an epidemy, or ope- rates through the medium of the atmosphere, as well as by direct contact: though whether the atmosphere, in this case, be impreg- nated with the specific miasm of the disease, or merely predisposes the body to a more ready generation of it, has no more been deter- mined than in the case of various other exanthems that evince a like power. Dr. Parr asserts broadly, " we have four times seen if epidemic ; and more than once we have had reason to suspect that it was communicated by infection."* At first sight it might seem easy from these accounts to subdivide erysipelas into the two varieties of contagious and uncontagious ; but as it is most probable that the power of communication depends alone upon the peculiar diathesis of the person who receives it, as being endowed with a susceptibility of the disease not possessed by others, we can make nothing of this discrepancy : and shall hence examine it under the following varieties founded upon other circumstances : - locale. Limited to a particular part; the cu- Local erysipelas. tide raised into numerous aggregate, distinct cells ; or the cells running into one or more blebs or large blis- ters. ;3 Erraticum. Travelling in successive patches from Erratic erysipelas. part to part: the earlier patches de- clining as new ones make their ap- pearance. / " Diet, in verUo. -x. in.] S.ArsGLfiNEOIS FLXCTiON, [ma>. ur. :,l The local erysipelas generally exhibits itself on one side of the Gen. II, fece, or on some one of the limbs. In the former case the disease „ PE.CEry»i'- begins with coldness and shiverings, which alternate with irregular p«ias flushes of heat, and other symptoms of pyrexy. Dull aching pains LocnUr?- are felt in the head, neck, and back. The swelling usually appears d1/®,'™',^ in the course of the second night or the third day ; though I have character* sometimes known it take place within a few hours after the attack ; ^on"'1 the redness disappearing when pressed upon by the finger, but re- turning as soon as the pressure is removed. The eruption fixes itself on one side of the nose, or the cheek, temple, or forehead : is of a dark red colour, smooth and soft, and attended with a sensa- tion of heat and tingling. The redness and swelling extend gradu- ally over the affected side of the face ; and spread, in some cases, to the scalp, and to the side of the neck or the upper part of the breast. Hence the face appears much disfigured ; the mouth is drawn to one side; the eye-lids are turgid, and close up the eye, the fever increases, and is often attended with delirium. On the fourth and fifth day vesications arise on different parts of the diseased surface, especially about the centre; but with an increase rather than a diminution of the fever. The vesicles or bullae are of dif- ferent sizes, and have an irregular base. The fluid contained in them is at first clear and watery : it afterwards becomes straw-co- loured or opake, occasionally slightly vivid, without losing its trans- parency. The cuticle gives way in a few places, and the fluid oozes through the cracks. About the eighth or ninth day, and sometimes sooner, the redness changes to a brown or yellowish hue, the bullae subside, and the cuticle dries and desquamates or scales off. Oc- casionally both sides of the face are affected at the same time : though generally the morbid half is separated from the sound by an exact line drawn across the forehead, down the middle of the nose to the chin. The fever subsides about the eighth or ninth day, but sometimes after its cessation it returns suddenly with as much vio- lence as at first, and continues two or three days longer. A sanious fluid approaching the nature of pus, and which by De Preval* and other writers seems to have been mistaken for pus itself, is some- times found in parts of the vesication: and from this circumstance Erysipelas; Dr. Cullen has distinguished one variety of the disease by the name ^odeaoT of erysipelas phlegmonodcs: and has been copied by Dr. Willan. uuhv. But a genuine phlegmon is never met with in erysipelas. "A cir- cumscribed cavity," says Mr. Pearson, " containing laudable pus is never seen in the legitimate erysipelas. Where a purulent effusion happens in any considerable degree, it affords, when the part is ex- amined, a sensation similar to that excited by a quagmire or morass. In that sort of suppuration, which sometimes supervenes to erysi- pelas, the cellular membrane suffers great injury, and not uncom- monly the part is in a gangrenous condition."! When the head is the seat of disease, it occasionally swells to an rro^ ;.^... enormous magnitude, and, according to Do Roma, the malady has proved fatal.J The disturbance of the constitution is less violet * Journ. de Med. Tom. Li. p. 315.—Eph. Nat. Cur. Dec. n. Ami. iv. p. ol. " Principles of Surgery, J; 2S9. t ^rrriM.-lt. Meii «"Ni!uuR«. m. 5; more he left his bed, and attended a cattle-market, half a mile's dis- Gen. III. tance from the town, without experiencing any bad consequences. Enfpyes^s About a week afterwards one of his master's children was taken ill, Variola. and went through the regular stages of small-pox in a mild manner ; "ina pox' then a second similarly. A third suffered in a very alarming degree from the confluent kind ; a fourth was rather worse than the two first; an|l the youngest, of eight months old, had what, if the other cases had not occurred, I would without hesitation, have called chicken-pox : for there was little or no fever, and the pustules were filled with a watery fluid which was not converted into the purulent appearance of small-pox. None of these children had undergone vaccination."* It is very singular that in the Kandyan epidemic described by Kandyan Mr. Marshall, while several cases made a very near approach to Sfarihau.01" varicella, all of them so far deviated from the ordinary character of the variolous secretion as to be devoid of a creamy and consistent pus, and rarely to exhibit more than a whey-like matter, whether the eruption were distinct or confluent, or the fever mild or severe. In other respects Mr. Marshall observes the disease did not materially differ from the description given of the small-pox by the systematic writers. For some days the eruption was papular ; it then became vesicular, each vessel having a depressed point in the centre. During the early stage of the vesicles they contained pure lymph; subse- quently they became less pellucid and assumed a whitish hue : and when matured they contained the above whey-like fluid. " In no instance," says he, " that came under my observation did the con- tents of the vesicle assume a yellow colour and thick consistence, as is stated to occur in small-pox in Europe." These, it should be observed, were not cases that had been pre- still all ceded by vaccination. Many such occurred, but the eruption was )aXnsbdif. here of a still different and more modified, and even a more miti- fe'ent &»«n gated kind, still showing the controlling power of the vaccine fluid, after vac- This eruption, indeed, was occasionally severe, but uniformly ap- odina?' peared after two or three days' fever. For the most part it was progress of confined to the fore, or the upper part of the body, ranging from demy!1 one or two to thirty papulae, and was remarkably uniform in its pro- gress. It consisted of elevated hard pimples containing a vesicle of pure lymph at their apex. These, by the fourth, fifth, or sixth day reached their full size, and were soon followed by desquam- mation. It not unfrequently happens that in dangerous cases the papulae do not rise kindly, but assume the form of stigmatized dots, while the surface is circumfused, generally, with a brighter or deeper efflorescence, according to the nature of the habit; under which Sometimes circumstances the disease makes a near approach to rubeola, and Approach" has, at times, been mistaken for it. Of this form also, the late Cey- £ measles; lonese epidemic, as described by Mr. Marshall, afforded various erfaUo in instances. " There were a few cases," says he, "where the skin lo^g*^. assumed a measly appearance. Under this description of fhedemic: * Variol. Epidem. p. 333. Vol. 111.—8 58 cl. hj.J 1LEMATICA, [or». ur. Gen. III. Spec. Empyesis Vutiola. Small-pox. the eases uniformly fatal. Where confluent, sometimes mimics the erythema or the ignis saeer ol anthrace or erythe- matous plague: and even evinces bu- bonous or other tu- mours. Exemplifi- ed from Russell: from Hui- ham. Hence small-pos at first often confound- ed with all these dis- eases : especially by Aaron of Alexan- dria. Chief diffi- culty felt in respect to small- pox and chicken- pox. Conflict upon this subject eurly and long con- tinued. Distinctive marks hence of great im- portance. Attempted by Rhazes. His combi- nations and dis- tinctions. disease the surface of the body resembled wet brown or blotting- paper. The fever continued without abatement: and frequently little or no eruption appeared. I am not aware that a single cas« of this kind recovered." And where, in the confluent variety, the secreted ichor, for the inflammation is seldom suppurative, is peculiarly virulent, we fre- quently meet with trials of a vesicular and fiery erythema spreading over different parts of the swollen body, not unlike, in appearance, to the ignis sacer of that variety of plague which the ancients pecu- liarly distinguished by the name of anthrace, and which in the present classification is denominated erythematous plague* And the resemblance is still more close when this form of confluent small-pox is combined with bubonous or other ulcers : of which, examples are frequent in hot climates, as in the epidemic attack ot small-pox at Aleppo as described by Dr. Russell. " If the sick," says he, " survived the eleventh day, few of them escaped corrosive ulcers with carious bones, or hard swellings in the glandular parts.'''\ Even in the colder temperature of our own country, the same mise- rable train of symptoms have sometimes showed themselves, as observed by Dr. Huxham, " variolae epidemicae interdum emtio diffluunt ichore, qui subjectam carnem erodit, imo et nonnunquan ipsa gangraena afficit."| It is not very surprising, therefore, that the small-pox on its first discovery, and, indeed, for long afterwards, should, according to the variety it assumed, have been confounded with all these diseases, and especially with the measles and chicken-pox—from their origi- nating, or at least being first noticed about the same period, and consequently being equally new diseases. Hence we are told by Rhazes that Aaron of Alexandria who wrote on this disease as early as a. d. 620, arranged the small-pox, measles, and anthrace or erythematous plague as products of one common specific conta- gion^ The last was, indeed, soon thrown out of the list, but the two former continued to be contemplated by most writers as one and the same disease for eight centuries after the era of Aaron. With respect to the small-pox and chicken-pox there has been more difficulty. A contest of no ordinary magnitude arose in early times upon the subject, in support of which, every nation in Chris- tendom, as in the Holy Wars, for many ages sent forth its cham- pions ; and the conflict has been of a still longer duration than the Holy Wars themselves. In the midst, therefore, of all thi3 confusion of diseases nothing can have been more called for than a judicious attempt to distin- guish the one from the other, and to lay down their respective land- marks ; and hence those who have engaged in such an undertaking have ever been entitled to the warmest thanks of the profession. Rhazes, in this respect, may be said to have taken the lead. He carried at once the anthrace or erythematous plague of Aaron to a * See Gen. iv. Spec. i. Var. -. of the present Order. t Oct. 1742. ; Julio, 1744. § Rhaz. De Variolis et Morbillis, in Continent. Lib. win. Cap. vm, Jntcrnrete Feraerio Judaso. A.D. I486. ' cl. in.] SANGUINEOUS FUNCTION. [oru. in. 59 distinct genus from al-gridi or the small-pox ; and though he con- Gen« III. tinued this last and measles, [al-hasbet rather than al-hasba as com- Empyesis monly written) under the same g*enus, he arranged them as distinct Va".°'a- species, and consequently regarded them as separate diseases : while " to the small-pox, thus disentangled and simplified, he assigned pretty nearly the same varieties as have been allotted to it by the most dis- criminating writers of the present day ; for he very accurately describes the distinct, the confluent, and the limpid or vesicular, including the crystalline and horny ; and treats of the disease under the opposite characters of benign and malignant.* Unfortunately the limpid or lymphatic small-pox was incautiously His vesicu- denominated chicken-pox by way of distinction from the purulent, unfortu- by many writers of great authority and talents, as Morton,! Gideon "^many Harvey,\ Mead.§ While, which was more common, varicella or chicken- water-pox in all its varieties, was designated by the term variola, vaHceiTa though regarded as havinp; no real claim to such a term, and hence or water~ ,. . ■ i r. • i- ii i- • Pox waa discriminated from the genuine disease by the adjunct spurious or called va- bastard variola, of which Van Svvieten furnishes us with a striking \\°^h alt. example. For after having noticed under his description of variola tinsm9h** the steen-pochen (stone-pox) water-pochen and wind-pochen,\\ all juncAas- which he distinctly characterizes by the name of spurious variola, ^"nVby6" and observed that he has seen them as frequently epidemic as the Van Swic- genuine small-pox, occasionally indeed running a race with the ten' latter and sometimes succeeding it, he dismisses them altogether, and proceeds with the history of the genuine disease in all its modifi- cations : telling us that, like Dr. Mead, he had met with the crys- talline variety, as well in the confluent as in the discrete form, occa- sionally indeed intermixed with the pustular: and that under this variety was reckoned by the best writers the siliquose, or that which consists of soft and empty vescicles, but which are sometimes at last filled with pus.1T In much of this he is followed by Sauvages ; sauvages; who, however, regards varicella by name as a distinct variety of small-pox ; while with Hoffman** he separates it from the crystal- Hoffman. line or lymphatic variety which he makes synonymous with horn or cornoidal-pox (spitzpochen) and water-pox.tt A more pointed discrimination, therefore, became necessary, and Heme a a still stricter attention to the specific characters by which small-pox crimination and chicken-pox are distinguishable. This was successively under- still wanted. taken by Fuller,!! Borsiero (Burserius,)§§ Hosty,H|| HeberdeninT temptaej and Willan ; and has been so far accomplished as to have satisfied bydF0J^errB. the profession generally, although it has not perhaps at any time set to wnian; the question altogether at rest in the mind of every one. "onsTdera-"1 Of late years, however, the learning and acuteness of many ™e success. danger of returning to * Rhaz. De Variol. et Morb. Ferag. Jud.—-See also Mead's Works. Vol. n. p. the same 163. Edit. Ed. 1765. 1 Treatise upon Small-pox. Lond. 1694. conflict: I Treatise on Sinall-pox and Measles. Lond. 1696. I Tie Variol. ct Morb. ex Rhaz. Lond. 1766. || Comment. Aph. 1381. Vol. v. p. 11. edit. Lngd. Bat. 4to. IT Comment, ut supra. Aph. 1398. ** Opp. Sect. i. Cap. iii. p. 293. Ed. Gen. 1740. tt CI. Hi. Ord. H. Gen. n. tt Exanthematologia. p. 167. Lond. 1730. §§ Institut. Med. Tom. n. 1||| Mercurc de France, Janv. 1769. iW Medical Transact, i. 427, bO CL. III.J 1I/EMAT1CA. [ok p. ill. Gen. Ill Spec. Empyesis Variola. Small-pox. and why. Singular attempt of Frank. Anomalous epidemic variola of 1816 at Montpel- lier. Described by Berard and De Lavit. Renovated attempt of Thomson. pathologists seem to have put us in no small danger of going back into all the confusion which existed in former times: not in any respect, from ignorance of the real nature of the eruptive diseases towards which their attention has been turned, but from a scientific desire to generalize and simplify them. About thirty years since, Professor Frank of Milan, dissatisfied with the ground of that general composure of mind which seemed to have taken place on the subject, commenced a new agitation, and undertook to show that chicken-pox (varicella,) crystalline, and horn-pox, and in general all those forms of exanthem, which, since his time have been called, though with no very classical term, vario- loid diseases, belong to 1'kmphigvs as a genus, under which also he places pompholyx. This genus he divides into two species p. am- plior, importing the ordinary form of the disease, and p. variolodes: "eamque," says he, alluding to this variety, " aut vesicularem {va- riola spuria emphysematica,) aut crystallina {aquosa, varicella auc- toruiu) aut solidescentem {variola spuria verrucosa, acuminata, sicca, dura, ovalis auctorum) appellari vellemus."* It is not neces- sary to follow up his argument, since, however well supported, it has for some time been sinking into disrepute, though, amidst the versatilities of opinion and conjecture which have of late distin- guished the medical world, it is not impossible that, lUte many far more obsolete doctrines,-it may yet revive and have its day again. It is necessary, however, to advert to it as forming one of the first and best supported deviations from the general concurrence of opinion that had for some time been entertained upon the subject.. In the variolous epidemic which prevailed during 1£516 at Mont- pellier, the eruption seems to have presented almost all the diver- sified forms under which it is ever to be traced, in respect to shape and number of pustules, the nature of their fluid, the length of tune which they require in order to be exsiccated into scales or scabs, and in the duration and severity of the eruptive, as well as in the absence or presence of the secondary fever. The chicken-pox (whether pemphigus or varicella) as is often the case, appears both to have preceded and to have accompanied the genuine variola; and the two were in many instances so closely intermixed, and alter- nated, as to render it a work of no ordinary difficulty to draw a line of demarcation. " Never perhaps," says Professor Berard, who, in conjunction with Dr. de Lavit, has given an interesting history of this epidemic,! " did the chicken-pox in their symptoms so nearly resemble those of the small-pox, nor these diseases more fully as- sume the characters of each other." The result was that, although at the commencement of the epidemy they contemplated the two diseases as perfectly distinct, but running a common race, they were at length inclined to regard them as identic, for reasons highly plau- sible, and which they advance with great modesty ; and thus again enlisted chicken-pox under the banner of variola. And since this time Professor Thomson of Edinburgh, from an attentive observation * De Cur. Horn. Morb. Epit. Tom. in. p. 264. Mannh. 8vo. 1792. t Essai sur les A.nomalir< de Ja Variola pt de la Varicella. Paris, 18*1 P. vt. m.] SANGUINEOUS FUNCTION. [ori>. in. 61 of like coincidences in the late variolous epidemy in Scotland, to G™*' n'« which we have already adverted, has not only felt inclined to draw Empywis the same conclusion, but has, with great industry and force of argu- yan2,a•., ment, endeavoured to establish an identity of species between these two eruptions by a copious reference to their history, and the pro- gress of the contest to which they have given rise, as developed in all the standard authorities, foreign as well as domestic, from the accredited date of their origin to the present day.* It is not a little singular, and tends in the strongest light to show the discursive powers of human genius when aided by the resources of learning, that at the very moment of this new attempt to com- bine diseases, which have of late years been regarded as distinct, or as claimed in various forms by another genus ; Dr. Willan, who Discrepant had laboured hard to support and rivet such distinction, was en- more8 sin- gaged in the more arduous task of establishing the identity of small- f^"tatj pox and plague in that variety of the latter, which makes the near- wuiun est approach to small-pox, and which we have already referred to jmaif-pox under the name of erythematous. His researches, which have been and p'afi^ published posthumously by his learned relative, Dr. Ashby Smith,! are written with an amenity and antiquarian interest that fully en- title them to a place in every medical library, whatever becomes of the question itself, and have, undoubtedly, brought conviction home to the minds of not a few. So that if the whole of these elaborate lucubrations could maintain their ground, plague, small-pox, chicken- pox, pemphigus, and, perhaps, cow-pox, grease-pox,! measles, and scarlet-fever, would all be resolvable into one common malady, and derivable from one common virus. While, as another learned at-While by tempt has been set on foot by a third body of pathologists of no mean oxistenc/of authority or pretensions,^ to show that plague itself, in this case [^^u°th"can the primary and original source of them all, does not exist in any disease is shape, nor ever has existed, as a specific disease ; and is nothing detnJ&aihOT more than a typhous or malignant fever with an accidental appendage of efflorescences, eruptions, or tumours of various kinds, modified by a host of contingencies (to which indeed, Dr. Frank is also a party in his first volume,||) the whole system of pyretology seems, in the present day, to have some chance of being concentrated into a marvellously small compass, and for the benefit of future students, may, perhaps, be engraven on a silver penny. But where the land- marks of diseases are thus successively broken down one after another, till no guiding-post is left, how is the young student to make his way over the trackless common before him ? This view of the subject might easily be carried still further : for The subject J ° J capable of being pur- * Historical Sketch of the Opinions entertained by Medical Men respecting the *"ei for" Varieties and Secondary Occurrence of Small-pox, &c. in a Letter to Sir James "' McGregor, &c. 8vo. London, 1322. j Miscellaneous Works of the late Robert Willan, M.D. &c. comprising an In- quiry into the Antiquity of the Small-pox, Measles, and Scarlet-fever, &c. 8ro. Lond. 1824. t Thomson, tit supra, p. 146. 387.—Willan, ut supra, p. 69. note 75. § Heberden, Observations on the Increase and Decrease of different Diseases, par- ticularly the Plague. 8vo. 1801.—Hancock, Researches into the Laws and Pheno- mena of Pestilence, &c. 8vo. 1821. »! De Cnr. Horn. Morb. Epit. Tom. i. p. 136. €2 cl. iii.] ILEMATICA. [obd. hi- Gen. hi. after Dr# Willan had persuaded himself that the erythematous plague EmJy'oMs of the ancients was nothing more than the vesicular and confluent variola, variety of small-pox, he persuaded himself still further that the dis- bmai.-pox. tJnct and coherent form of thig digease iSi in many caSes, synony- mous with their phlyzaciae, lichenes, and ecthymata ;* thus melting down a multitude of other eruptive affections into the same crucible. Had he lived longer, indeed, it was his intention to have unfolded in a similar way the history of syphilis, which, like all the preceding complaints, he conceived to be of immemorial origin, and, appa- rently, to have had a close fellowship with them.t conces- It must be conceded to Professor Thomson that it is often pecu- TtomNn. liarly difficult, sometimes perhaps unconquerably so, to distinguish by the superficial appearance, the nature of the fever, or even the mark that remains on the skin afterwards, chicken-pox from small-pox, and especially, which is what he particularly alludes to, that modifica- tion of small-pox, which is so apt to follow upon vaccinia or cow- pox, where the latter has only given the constitution a check and But the not an utter exemption. But these approximations are only to be SfJunetion traced in extreme modes of the two diseases, and where they make not hereby a considerable divergence from their right and proper course; for in a pure or perfect state of small-pox and chicken-pox whether we regard them as distinct diseases, or as mere varieties of one corn- Like ap- mon species, there is no difficulty whatever. And even in their Soiw'be- widest departure from such state, and their closest approximation dnTwea111"'to each other' a3 wel1 in UIutv of time as of character, they do not whose dis- more intimately coincide than in the case of various other diseases noquestion8 of whose distinction there never can be a question. Thus in idio- Exempii- pathic epilepsy and intestinal worms the symptoms are often pre- cisely the same ; and the existence of the second, at first only con- jecturable, is, at last, only ascertainable by the action of anthelmin- tics. But worms may also be accompanied with all the symptoms of a genuine hectic; as may this latter with all those of a quotidian or a tertian ague. So measles have often been confounded with rosalia or scarlet-fever, and miliaria with eczema or heat-eruption ; and it is one of the most important parts of nosology to point out the distinctive marks of such analogous diseases, though a part in which it has not always succeeded. Tbe exem- As there are some disorders that render the constitution less dis- appiied.0" posed to the srnall-pox than others, of which the cow-pox furnishes us with an example ; there are also some that render it more so. In like manner we find the measles generally superinduce catarrh; and very frequently prepare the way for hooping-cough ; insomuch that all these maladies become synchronous. So the chicken-pox not unfrequently lay a foundation for the small-pox, and the small-pox may perhaps, in persons of a particular habit, lay a foundation for the chicken-pox ; or even the atmospheric intemperament of either of these diseases, when epidemic, may call the other into play ; so that both, as we frequently see, co-exist, not only in the same place, but even on the same person. In truth the same constitution of the * Will, ut supra, p. 53. t Miscellaneous Works, p. 87, foot-note by Dr, Ashby Smith. cl. iii.] SANGUINEOUS FUNCTION. [okd. nr. 63 atmosphere often favours the growth and spread of various diseases Gen. III. equally; and hence, rubeola, varicella, rosalia, and catarrhs are not En,™% unfrequently coincident. Variola. But still the two diseases before us have marks, if I mistake not, o?acriucai so strictly essential, as to render it highly incorrect and unscientific d'JJJ,ni,wd to contemplate them as mere modifications of a common exanthem : which moreover in various cases, by throwing the practitioner oft* his guard, might lead to a very erroneous tieatment and a dangerous exposure of the person. If these be not to be found in the ordinary distinctions that have been pointed out by Dr. Heberden, Dr. Wil- lan, and other monographists, as resulting from the form and dura- tion of the pock, the consistency of its fluid, and the integrity or dip of the skin after the eruption is over, we must look beyond the ob- vious symptoms to the intrinsic properties of the respective matters eliminated, and the influence of the two diseases on the constitution in future. And here I think we shall not look in vain. I. The matter of small-pox is capable of re-producing small-pox i. Matter of r .r r r .~ ° , * small-pox by inoculation. It continues true to its own specific character, uniformly and possesses this power to infinity. The matter of chicken-pox is g^"^ not capable of re-producing small-pox by inoculation ; nor is it by inocuia- often capable of re-producing even its own kind. It will sometimes m^;,,,. of excite an irritation around the puncture, but it seldom seems to pro- °0eea8s^t ceed farther. Nor, indeed, does it always irritate locally ; for we produce have already seen that Dr. Heberden, with all his efforts to obtain byfnocufa- this effect, found that the little wound healed up immediately, and ,^n:r^,d1 showed no signs of any infection."* Of the two cases described reduces' by Dr. Willan, the first, indeed, affords an example of regular localitself- specific action ; " for the vesicle on the inoculated part went through its ordinary course; and, twelve days after the incision he observed, further, that two small red eruptions appeared on the shoulder, and soon became vesicular;" but in the second case even the local irritation appears to have been nearly as trifling and unspe- cific, as in the case of Dr. Heberden : on the third day after inocu- lation " the small scratches made by the lancet were discernible, but not inflamed."* On the fourth "they were scarcely visible." On the fifth, " a redness with some degree of hardness and elevation appeared at the places punctured, but subsided again on the fol- lowing day." On the eighth, " no vestige remained of the inocu- lation." It should be observed, however, that twelve days after the use of the lancet two small gnat-bite-like spots appeared on the patient's side, which became vesicular; and, that two days after this, " a considerable number of vesicles with surrounding redness, appeared on his body, but there were not any on his face." On the next day, " he was free from indisposition, and no further eruption look place." The whole of which general eruption, in consequence of the imperfect action exhibited on the arm, was reasonably ascribed to contagion received antecedently to inoculation, the pa- tient, who was a boy of nine years old, having been the constant • Medical Transactions. Vol. i. Art. xvn. 64 cl. in.] HiEMATICA. [0RI>- HI- GspEcm" Play-mate of his brother'from whom thc flmd was taken'and who Empyesis had caught the disease at school.* Variola. From this slightness of irritability in the fluid of the vancellous Smaii-pox. vesicle^ many practitioners have supposed that it is nothing more than an increased secretion of the serum of the blood, like that which takes place in " any blister produced by scalding or cantha- its vims by rides."t This, however, is hardly to be admitted ; but it is unpos- !dm^!tatthen sible to reflect upon the readiness with which most cutaneous erup- Lny vfruf tions' whether merely superficial or constitutional, are capable of whatever, propagating themselves by inoculation, as cow-pox, plague, syphilis, of'imali-1 psoriasis, porrigo, and scabies, in all its forms, as well as small-pox, SfXthemost witnout a conviction that the fluid of the varicellous vesicle is, at active. m°s least, one of the most inert and inacrimonious of the whole ; and consequently something widely different from that of the small-pox. And not The power of propagation possessed by genuine small-pox, HariyPac-u moreover, is not only, in direct opposition to the power of chicken- runs' un- Pox' peculiarly active, but runs through all its varieties: each of changed which, however deflected from the standard of perfection, has a ten- itovamtie's. dency, though not an equal tendency, to reproduce the same dis- ease, arid to model it after such standard: and hence we have a thousand instances of discrete purulent small-pox generated by inocu- lation from the confluent or crystalline varieties.J Not, indeed, that the latter is always as sure in its action, for it often fails from its imperfection ; but wherever it evinces specific power enough to operate, it reproduces the genuine disease, and mostly with a com- pletely matured pustule. In effect it is rarely that the fluid in the confluent small-pox becomes thoroughly matured or purulent, and yet it is seldom that this has been found unavailing, n. An in- n. An incursion of natural small-pox protects the system against ainai'i-pox a recurrence of small-pox, and an incursion of natural chicken-pox protects the against a recurrence of chicken-pox, but neither of these afford the against a slightest security against the other. This protection, indeed, is not ofC8maii^0 universal, and hence we have, in both diseases, a few examples of PfXh'akd- secon"■ Blane, Bart. &c. p. 214. 8vo. Lond. 1823. t Anthracia Pcstis y Erythematica, Gen. iv. Spec. i. of the present Class and Order. J. Miscellaneous Works, ut supra, p. 59. Vol. III.—9 t»tj cl. 111. J 1I/EMATICA. l0Ri>- Gen. HI. Greeks and Romans, like our own derivative pestilence, in two eS's verv different senses, a strict or particular, and a loose or general. yarioia. Under the first it always imported, as plague or pestilence does in Sm.ii-pox. ouf ^^ ^ one and the game specific disease . under the latter it was applied to various sorts of disease possessing any high degree of malignity, whether among mankind or among brutes, as the word pestilence is still used among ourselves. But it is immeasurably difficult to adopt the view of this subject taken by Dr. Willan for the following reasons. i No df- Firpt, we have no description whatever of any such disease as wh.ptev"r small-pox in the writings of any of the Greek or Latin physicians: mx amon and a11 that Df- Willan' 0f a»y °ne e,Se Ca" aCCOmPllsh UP°n thlS Greoakno°rns point, is to glean a few incidental passages which may be supposed wipers": to allude to it in different places or volumes. Now if the small- n°rany pox existed among the Greeks or early Romans at all, they must gieane'd be- have existed as a common and popular disease ; and it is impossible ?oscdihintP"to suppose that among pathologists, so minute in their attention to But'if ' other diseases, and the descriptions they have given of them, as Hip- hnda"exi£cd pocrates, Aretaeus, Galen, and Celsus, they should not have de- mVst'have sc"De(1 small-pox also at large, and assigned some fixed and specific been comC name to this as well as to apoplexy, cardialgia, catarrh, opisthotonus, described instead of leaving us to seek for it at random under the names of at large as loemus, anthrace, eulogia, and various other affections. Secondly, as the small«pox, if they existed among the Greeks at a specific name. it. it must jj mugt h jia(j a frequeilt existence, and their varieties of dis- neve exist- ' . . i- i i i ed with it« crete and confluent, mild and malignant, must have been known to every one, it is impossible that Hippocrates or Galen could have made that separation between such varieties as Dr. Willan is obliged to suppose : and have contemplated them as distinct diseases, of very different origins, and destitute of all generic connexion what- ever. Thirdly. Inoculation for the plague was occasionally tried in ancient times, as it is in our day, and especially for that particular variety of the plague which Dr. Willan especially adverts to, as making the nearest approach to the small-pox, and always with the same result. Instead of producing a milder disease, as in the latter case, it uniformly proved fatal. The last attempt of this kind ap- SlhfchWii- Pcars to nave taken place in the reign of the Emperor Commodus, a.d. 189, and is thus described by Dion Cassius, in his narrative of the plague which overran so large a portion of the Roman territory at this era, and which is admitted by Dr. Willan to have been the modification of plague now alluded to : " Many died in another way, not only at Rome, but over nearly the whole empire through the practice of miscreants, who by means of small, poisoned needles, rccurrenc'cr communicated, on being paid for it, the horrid infection so exten- sively that no computation could be made of the numbers that pe- rished."* Remark of Dr. \\ dlan notices this passage of Dion, and very adroitly endea- thii Jui^^t vours to turn it to his own account. *■• This absurd report," sav? Tarictie and these varieties have been appropria- ted to a common species, in- stead of be- ing regard- ed as dis- eases alto- gether dis- tinct. ni. Inocu- latiu-.i for the ver form cry of Ian sup- poses to have been small-pox was tried, but neither produced a milder sort, nor guard- ed against a ' Hist. Rom. Lib. Lxir, ll. in.J SANGUINEOUS FUNCTION'. [ord. hi. 67 he, " is very analogous to the calumnies against our early inocula- Gen- iu- tors." The inoculators, however, in every other part of the world, Empyesis when employed upon small-pox succeeded in every instance in tri- Voriola- umphing over such calumnies: they were upheld by the force of m p°" truth : they pointed to the favourable result of their practice, a result which it was impossible to deny ; and hence there is no nation in ancient or modern times, barbarous or civilized, Asiatic, African, or European, as we shall have to observe hereafter, wherever vario- lous inoculation was introduced, but became gradually sensible of its benefit, and hailed it as an incalculable blessing. Why was not the same triumph obtained by inoculation for the disease before us in Greece and Rome ? Why but for the reason alleged by the his- torian—that, instead of an incalculable blessing, it proved an exter- minating curse, and thus gave a clear manifestation that this disease was not the small-pox ? Fourthly, that the anthrace referred to by Dr. Willan, was not iv. Tins small-pox, but a variety of the proper loemus or pestis, is clear from C ° its existing in the same quarter of the globe in the present day, and ?til'in ex" being expressly described as such by pathologists of the highest au- and suffi- thority, of whom it may be sufficient to mention Dr. Alexander Rus- "p'rulne'd" sell, whose account of this form of plague, as it appeared before his to be eyes, we shall advert to in its proper place ;* and who was also as Unknot accurate an observer of small-pox, which he has in like manner re- ?maii-pox presented as it occurred to him ; but who never once dreamed of sent day. regarding the two diseases as identic,! or possessing any near con- nexion. Dr. Willan, however, relies mainly upon Rhazes, who seems, Rbazes unquestionably, to have entertained some ideas upon this subject imagining in unison with himself; for, apparently misinterpreting a few loose ^{1™^^ passages of Galen in the same way Dr. Willan has done, and par- wman. ticularly where Galen is treating of phlegmonae, erysipelata, her- petes, and ionthi,f he tells us that the small-pox and measles were known to Galen six hundred years before his own era. In answer Proof of to which, however, it may be sufficient to quote the following ad- nessnnd8 mission on the part of the Greek translator of Rhazes's Treatise on inefficiency the small-pox and measles (al-gridi and al-hasbet), written in the tion as to tenth or beginning of the eleventh century, and dedicated to the e^* jj"" reigning emperor, and which he entitles Tlepi Aoifuwc " on the pesti- ».v<,d, fr°™ lence," for by this name, adopting the vulgar meaning of the term, translator. he denominates these diseases : " It is confessed by all persons con- versant with the writings and laborious researches of Galen, that nothing which pertains to medical science or the cure of diseases, has escaped his penetration. With regard, however, to the pesti- lence (Aoif*.tK»,) he is less explicit than on other subjects : he speaks of it cursorily, or in connexion with analogous complaints, but he does not any where state distinctly the symptoms or appropriate mode of treatment in it:—strange, that he who first organized the * Gen. iv. Spec. i. of the present Class and Order. t On the Diseases at Aleppo. Ch. iv. t Tr. De Compos. Med. sec. loc. De Pro^nos. a Pulsions Lib. H. and De Usu Par- jium. I/ib, ix. oS cl. in.] HiEMATlCA. [okd. w. Gen. in, Spec. Empyesis Variola. Simill-pox. The most powerful oupnnenl of Willan, Willan himself. His own prior com- ment on the above opinion of Rhazes. The first distinct de- scription of small-pox, as admitted by all, is that of Rhazes in bis Almau- sor. IVo notice by him that it is conta- gious : and said to "be renewa- ble in the Bame per- son. Cool treat- ment re- commended by tho Arabians. medical art, and defined what had been left indeterminate, should have but slightly noticed a disease to which every man is born liable." But the most powerful opponent of Dr. Willan upon the whole of this subject, is Dr. Willan himself; who, only a few years before gave us his opinion upon it in the following form ; and it is not a little singular to observe how directly it is controversivc of that we have thus far contemplated, while it does not appear that any new facts or additional evidence of importance had sprung up before him to produce such a change of sentiment. On his referring to this celebrated treatise of Rhazes, " he takes it," says Dr. Willan, " for granted that the small-pox and measles were known to Galen more than six hundred years before his own time, being misled by some incorrect translation of Galen's works into the Arabian language. The passages which he quotes have certainly not the least relation to the diseases above mentioned (small-pox and measles). Indeed no description of them, nor the slightest collateral hint, appears in the writings of the Greek physi- cians which could lead us to suppose they had any knowledge on the subject. Some modern writers have held a contrary opinion, maintaining that Hippocrates and his successors applied to the mea- sles and small-pox the denominations of exanthemata, ecthymata, eczemata, erysipelata, herpetes, axthraces, &c. Now some of these terms have been strictly defined, and in a way which admits of no such application : the rest are left indefinite, and always in- tended to express, generally, eruptions on the skin, yet have they not been appropriated to any particular form of them. A contro- versy, founded on materials so slight and unsatisfactory, was carried on with ardour during a part of the last century, but need not at this time be revived, when it is nearly consigned to oblivion."* In the midst of all this diversity of opinion, there is one point at least clear, and universally admitted, I mean that the earliest distinct description of the disease which has descended to modern times, is that of Rhazes. It is contained in his A'mansor, which was com- posed about the end of the ninth or the beginning of the tenth cen- tury ; and in this he quotes from an Alexandrian physician, of the name of Aaron, who had written on the same subject as early as the year 622. Yet it is very singular, that neither Rhazes nor Aaron, so far as their writings have reached us, make mention of the contagious property of the disease, chiefly accounting for its production by an ebullition of the blood, which they thought particularly incident to the age between childhood and youth. And it is equally singular that it should be asserted by Aaron, as it was also by Avicenna, that the same person is liable to a return of it a second or even a third time, pracipue cam sanguis sit acutus. Has the disease un- dergone any change since this period so as to render those who have not had it more susceptible of its influence, and those who have had it less ? In the descriptive part of the disease little is to be added * On Cutaneous Diseases, p. 251. 4to. Lond. ISfip. i:i. in.] SANGUINEOUS FUNCTION. [obd. hi. 69 to Rhazes's statement, and, what is more singular, he recommends Gem. in. the cool treatment. Unfortunately, however, the doctrine of con- E,n,fv""8 coction and despumation of the humoral pathologists spread after- Variiiu. wards so widely, and was so generally supported, as to put to flight Gene™!0*' this correct and rational view of the subject; and every attempt was PatuoloS7- made, by warm clothing and the warm bath, to mature the peccant matter, and drive it in as large a quantity as possible to the surface ; by which the slightest cases were violently exasperated, and too often rendered fatal. The severer the disease the sooner the pustule? show themselves, The severer thus completely reversing the law of scarlet-fever ; a remark for the sooner which we were first indebted to the sagacious eye of Sydenham. 'ane £aJrs,uIes And hence in the confluent variety the eruption appears on the se- cond or third day, while in the distinct we have seldom any traces of it till the fourth, and often not till the fifth day. If a patient have accidentally become impregnated with the con- Usually re- tagion of the measles before inoculation or being exposed to the £ pr0g"ess contagion of the small-pox, the latter, as we have already observed, bya sudden • i. i, . ■ ■ i i • ■ i i appearance Will, generally speaking, be retarded in its progress, and not make of ti.o its appearance till the measles have run through their course, upon measle«- the common law that the constitution is only affected with one dis- ease at a time. But to this common law we have already pointed But to this , , . . *. l law various out various exceptions ; and as gout and rheumatism sometimes co- exceptions. exist, the measles and small-pox occasionally co-exist also. In the illustrated. year 1769, Mr. King, of the Foundling Hospital, Dublin, inoculated forty-three children of the establishment. On the fourth or fifth day afterwards, sixteen of them sickened with the measles, and went through the disease regularly, yet the progress of the small-pox was not retarded or altered ; for the pustules of the latter disease ap- peared as those of the former died away ; and both complaints were of a mild character : a like coincidence occurred in the ensuing year, and with a like favourable termination.* In this case the common law of retardation seems to have been Retarda- interfered with by some peculiar constitution of the atmosphere ; countedfor; for the effect was general to all who were under the influence of rubeolous contagion. In other cases we have a like interference with the common law of variola, from the idiosyncrasy of indivi- duals or some temporary but equally occult power operating upon the system. There are some persons who seem to possess a natu- Somoper- ral immunity to its influence, and pass through life without ever ^"'J^iy being infected, though they may have purposely exposed themselves jjj™"0^- to the most contaminated atmosphere. There are others, who tune: though incapable of being affected at one time, lose their emancipa- °u^pt\nb",Q tion at another. " I know an old nurse," says Dr. Huxham, " and tempora- one apothecary, who for many years attended persons, and a great " y" number too, in the small-pox, and yet never had them ; nay, many that have industriously endeavoured to catch this infection, by fre- quenting the chambers of the sick, have done it without effect; and * F.din. Med. Comment. Vol. in. p. 443. 70 cl. in.] ILEMAT1CA. [OBD. m. in the son author Gen. III. yet some of these persons, some months or years after, have been Empyesis seized with the small-pox."* Variola. But not only does the susceptibility of the disease vary in degree STty- at different times and in different persons, but the irritability of the t°of■lh°influy body beneath its influence. Thus, among fifty persons who receive enwa" va- it at the same time and undergo the same regimen, we may perhaps "uasrepubia- have as many degrees of violence ; some dying beneath its seventy, lity'forit. some escaping, though with great peril, and indelibly seamed and scarred, and others evincing little fever, and a very slight eruption. illustrated The present author caught it casually in London, when a child " "VSe" about six years old' and Passed through it with scarcely any distur- bance, and not more than twenty scattered pustules. In like manner we find, under inoculation, that while some per- sons throw forth a full crop, and suffer considerably from fever, others have scarcely any febrile symptoms, and no more eruption than the pustule on the puncture ; the disease, in this case, exhibit- ing the same change as occurs in inoculated cow-pox, compared with the exanthem as received casually from the cow. It was at one time doubted, whether this slight appearance afford- ed protection for the future. There is now no longer any doubt upon this subject. But we may go beyond this, and reasonably Perhaps the conjecture that those who have passed through the disease with but best secu- jjtt|e inconVenience, are even less exposed to future attacks than persons who have had it in the conflu tit form, and whose faces are marked with its ravages. For as the degree of violence depends, where there is no error in the treatment, upon the degree of irrita- bility which the constitution manifests under the contagion, and as the irritability and susceptibility march with an equal step, he is most likely to have a renewal of the susceptibility in process of time who bears the most evident marks of a greater susceptibility ante- cedently. It had indeed been conceived by very distinguished pathologists that the small-pox can never be had a second time, notwithstanding various assertions in support of this fact; and the argument is thus ingeniously put by Dr. Heberden, who was himself a disbeliever: " It would be no extravagant assertion to say that here in England not above one among ten thousand patients is pretended to have had it twice; and whenever it is pretended, it will always be as likely that the persons about the patient were mistaken, and supposed that to be small-pox which was an eruption of a different nature, as that there was such an extraordinary exception to what we are sure is so . general a law."t This remark is forcible, but the actual occurrences are in many, iTv*! ro-° PernaPs most °ftbe instances appealed to, still more so. For, from currmce, the cause I have just pointed out, those who have had a repetition rnaJkedby of small-pox have generally, if I mistake not, been able to exhibit the violence proofs of a prior attack in pits or scars on the face or some other attack^3' Part °f ™e body, manifesting the violence with which the disease ran its course, and consequently the strong predisposition of the Hence the slightest eruption sufficient aecunty rity: and why. Small-pox Bupposed formerly never to appear a second time in the samo per- son. Opinion adopted by Heberden. * Treatise on Fevers. Small-pox, &c. + Med. Trans. Vol. i. Art. xvn. V.L. III. J SANGUINEOUS FUNCTION. [obd. ni. 71 constitution towards it, and irritability under its influence. " It is Gen. HI. remarkable," says Sir Gilbert Blane, " that almost all the well- r.mpy'esis authenticated cases of second small-pox have been of those persons Variola. who in the first instance had undergone it in its most severe and mu v**' dangerous forms."* Lewis XV. of France, afforded a clear exem- plification of this in 1774 ; and another^sti'l more striking is given, for the ensuing year, in the memoirs of the Medical Society,! in which though the first attack was peculiarly severe the second was more so, and proved fatal. The mediral repositories are rich in cases of this kind, some of them so striking and so well established as to prohibit all doubt whatever : and in the two or three instances which it has fallen to my lot to witness I have traced the same cha- racter ; for pits from the prior attack have been visible while the genuineness of the existing attack was in one instance substantiated by the test of inoculation. In some instances this strong constitu- The eon- tional predisposition runs through every branch of the family, of "ugcepubi- which Dr. Barnes of Carlisle has given us a striking example in five 'I1*,on,e - ,. ., , , . - D. if. ii times runs individuals, sons or daughters of the same parents, who, having all through an caught the small-pox naturally in the summer of 1818, from which famlfy. most of them suffered smartly, caught it again in February 1822, Kxompii- and had it also smartly, though not quite so severely as on the first attack. In both series of affection the individuals varied in the degree of fever and range of pustules ; but in every instance, whe- ther of the first or second series, the eruption was pustular. This account is given in the seventy-sixth number of the Edinburgh Medi- cal and Surgical Journal;\ and the very next article in the same Further ex- number affords an instance of a family diathesis of the same kind in eInp' e " four individuals, sons or daughters of the same parents, who were attacked nearly simultaneously with small-pox after having under- gone vaccination, which seems to have passed through its course satisfactorily, at different intervals varying from six to two years. A fifth child which had not been vaccinated, received the small-pox at the same time, and passed through it in much the same manner, but rather more mildly than one or two of the other instances. The eruption was in every instance distinct and pustular, though in one or two a few vesicles were interspersed. That erroneous statements upon the subject of a recurrence of small-pox have been very numerously given to the world is unques- tionable ; among which we can find little difficulty in placing that Marvellous of Borelli, containing the history of a woman who recovered from °ms8Vpfox seven distinct attacks of small-pox, and died on the eighth; the recurring to antecedent eruptions having doubtless been those of some other exan- time; them or cutaneous efflorescence : but cases thus clear and incon- ^"uke of trovertible are sufficient to establish an occasional departure from eomo other the general law, and teach us to look without a scoff upon the asser-oxant em' tion of Rhazes and Avicenna, and the far earlier of Aaron, that the disease occasionally occurs a second, and, in some instances where there is a strong predisposition to it, even a third time. * Select Dissertations, &c. p. 209. 8vo. 18-22. ". A'ol. ;\. 1775 * Journ. Vol. xix. p. 376—378. 72 CL. HI. J HiEMATICA [oRl>. HI. Gen. III. Spec. Bmpyesis Variola. Small-pox. Other ex- anthema evince a like ano- maly. A high de- jree of fe- ver not ne- cessary for security in any exan- them. This prin- ciple illus- trated. Every part of the sys- tem affect ed, how- ever small the virus applied. Fetus af- fected from the mother: sometimes when the mother is unaffected Remarka- ble example from Mead. A like deviation from the ordinary path of procedure impresses us in the history of other exanthems. The same general law prevails very strikingly in measles and scat let-fever, but we have also a law of exceptions; and the exceptions in one disease seem to hold a steady proportion to those in another. They are most frequent in scarlet-fever, fewer in measles, and still fewer in small-pox. In plague, the general immunity lasts but for a few weeks; yet some who have recovered seem to be protected for a much longer time, and several for life. In influenza, it extends through the whole duration of the existing epidemy, but the susceptibility recovers itself against the next visitation. In some remittents, as yellow-fever, the patient continues little susceptible for many years, perhaps for the whole of his natural existence : in intermittents, the susceptibility, on the contrary, is very generally increased ; for the man who has once suffered from an ague catches it again more readily than another. A high degree of fever is not necessary to emancipate the system in any exanthem ; and consequently not in small-pox. It is upon this principle that inoculation takes its stand in vaccinia as well as variola. Febrile commotion, as we have observed already, though necessary to throw the morbid poison to the surface, is only neces- sary in a small, and sometimes an almost imperceptible degree ; and if it be urged beyond this, the morbid poison will be increased in quantity, the ferment will acquire a wider assimilation; and hence the fever and the eruption always maintain a balance. Provided the entire system submits to the influence of the contagion, the eman- cipation is always as perfect under a small production as under a large ; and it is wonderful to observe how completely this influence extends through every part of the system, often indeed without any disturbance whatever, upon a deposite of the minutest particle of variolous contagion under the cuticle ; for we are perpetually wit- nessing cases, or rather were when variolous inoculation was more frequent, in which a full change has been operated on the entire frame, though the only pustule has been that excited at the punc- ture ; and the individual, before liable to the disease, is become liable no longer. And that the blood itself, and therefore every particle of the blood, is equally influenced in such circumstances, and even charged with the nature of the virus, is obvious from the frequent communication of the disease from a pregnant woman to the fetus ; and this too at times where the mother is no sufferer from the disease herself. A remarkable example of this last fact is given by Dr. Mead in the following words : " A woman who had formerly had the small- pox, and was near her reckoning, nursed her husband who had caught it. At her full time she was delivered of a dead child, whose body was covered over with pustules; a manifest sign that it died of the small-pox before it was brought into the world."* Mauri- ceau has another case or two to the same effect :t and others have occurred since, and are noticed in several journals of later date. * Dc Variolis, Cap. iv. + 8ur la G«ossesse et d'Accouchement des Femmes. Obs. 600, et 576. cl. in.J SANGUINEOUS FUNCTION. [ord. hi. 73 In these cases there is no assimilation or multiplication of morbid Gen> ui« leaven: an influence is indubitably exerciied, and that, too, over the Emp'yeaja entire current of blood ; for it could not otherwise reach the fetus, Ya"°la* yet without any sensible effect on the mother. What is the nature Mysterfous of this influence ? is it by an infinitesimal division of the minute o^intfu- drop of contagion inserted into the skin, or that received by the once. breath ? Whatever be the way, it enables us to be less surprised at the mode by which family taints, as gout, scrophula, and phthisis, are transmitted from generation to generation. Unborn infants do not always receive the small-pox under the ^etu»n01 J , r . always same circumstances, nor in every instance even where the pregnant affected. mother sickens with the disease. Sir George Balfer, who was illustrated indisposed to credit these singularities, refers to two instances in George which the mothers having been inoculated, had passed through the Baker- eruption favourably, and brought forth infants, both of whom three years afterwards were also inoculated with good effect.* From all D1ation- which we collect, and we can do no more, that a h'ke variation occurs before birth, as we have just observed occurs afterwards ; and that different individuals, or even the same individual under par- ticular circumstances, evince a different degree of susceptibility ; so that the contagion, though resisted at one time, is readily received at another. There is another feature in the physiology of small-pox, that is Deep-seat- peculiarly worthy of notice ; and that is the power which all deep- admit0no seated organs possess of opposing a lodgment of the pustulous onTheh-' inflammation on their own surfaces, and driving it altogether exter- surface; rialry where it can do least mischief. Dissections have abundantly ^"towards shown that the viscera and cavities of the interior are never affected ^e skJLn- Proved with the eruption, except such as, like the skin, are exposed to the from nn- approach or ingress of air, as the nose, mouth, trachea and its rami- ".ctions^18 fications, and the entrance of the meatus auditorius. As a general rule, pustules are never found in the rectum, but if there be any pro- lapse and the sphincter be exposed to the contact of air, that part of the rectum, which concurs in the exposure, will share in the com- mon fate of the external parts. To what extent variolous contagion is capable of radiating, as it h°w far ^ issues into the atmosphere from a diseased body, has never been phere of satisfactorily determined. In laying down the general rules of febrile eX'tnctmfg10n miasm, I ventured to state that contagion or miasm generated in the not fully living body, does not appear to be very volatile in any instance, and buTappa- soon dissolves in a pure atmosphere. The contagion of small-pox [£J}jJ*dYC17 seems fully to be governed by this law. When small-pox was more frequent than at present, medical practitioners, though passing casu- ally from house to house, were rarely, if ever, accused of communi- cating the disease ; and Dr. Haygarth has appealed to an evidence of facts in proof that the sphere of variolous contagion does not include a diameter of fifteen hundred feet, and probably not a hun- dredth part of such diameter. As the susceptibility of small-pox varies so considerably in dif- Anpc1ec®'f'' thfi eruption at *"" * ?1<;«J. Trans. Vol. h. Art. xix. voi. m.—k< ?-i cl. in.} ILEMATICA* [obd.hi. Gen. III. Spec. Empyesis Variola. Small-pox. different periods from the time of in- fection. Sometimes six days after- wards: ■sometimes twonty-one. Action quickened l»y inocu>- lation.. c E. Vaiio- la discreta. Distinct small-pox. Diagnos- tics. Symptoms vary ac- cording to the degree of fever and extent of erup- tion. ferent individuals, it is not to bo wondered at that the irritability oi the system to its influence should vary also, and consequently that there should be some difference in the period of time between the supposed communication of the disease and its appearance by any manifest tokens. Upon the^rhole, the interval may be calculated to vary from six to twenty-one days in the natural small-pox ; and in the inoculated, which anticipates the action a day or two, from four days to eighteen. The writers on this disease have subdivided it into an endless multiplicity of forms : but the four following varieties are sufficient to include the whole : tt Discreta. 0 Confluens. y Degener. . m. Va into four stages, an incursive, an eruptive, a maturing, and a de- Gf.n. III. clining or scabbing,* at each of which it discovers an exacerbation a e Vari«- of pyrectic symptoms. And when the patient is an infant, it is atIa. discrota. these times, and especially on the incursion of the disease, occa- ■m'aii-po*. sionally attacked with a convulsion fit, or perhaps several in succes- fi^f™18'0* sion, which it was once the custom to make much lighter of than quern in the occasion justifies. the^Sncur" The grand principle in the treatment of small-pox, As of all the °io.n of the other exanthems that have passed before us, is to moderate and keep General under the fever ; and, however the plans that have been most cele- Sjt^ng11' brated fbr their success may have varied in particular points, they principle. have uniformly made ihis principle their polar-star ; and have con- sisted in different modifications of fresh air, cold water, acid liquors and purgative medicines : heat, cordials, and other stimulants having been abundantly proved to be the most effectual means of exas- perating the disease, and endangering life. Dr. Mead seems to have been almost indifferent as to the kind of Mead purgative employed, and certainly gave no preference to mercurial preference preparations. His idea was, that all were equally beneficial that to one pur- would tend to lower the system : " Indicium," says he, " certe satis Holt manifestum, quamcunque materiae diminutionem, fomitem igni sub- another- trahendo, huic morbo apprime convenire." And in this manner he accounts for the mildness of the malady after any great evacuation, natural or artificial; after acute diseases, immoderate catamenia, child-birth, and salivation. Mercury, however, appears to. have a specific influence upon the Mercury action of variolous matter ; perhaps, as in the case of syphilis, upon Po^!s9g0a the quality of the matter itself; for though, when considerably specific diluted with water, it is still capable of propagating the disease by Proofs of inoculation, yet Von Wensel has shown satisfactorily that when tri-lhl*' turated with calomel it loses its energy, and in inoculation becomes inert and useless. Mercury has hence been denominated in Ger- many, remedium pancreston, and has certainly supported its cha- racter as the best corrector of the small-pox we are acquainted with from a period antecedent to the introduction of inoculation into Europe, to the present day. " Physicians who attend hospitals," says Sir George Baker, " have frequently observed the small-pox to be particularly mild in those patients who have happened to receive the infection soon after a mercurial ptyalism ; and inoculation is said to have been a much more successful practice in some of our Ame- rican colonies since the use of calomel has been there introduced into the preparative regimen." When given merely as a purgative it is usually mixed with the powder or resin of jalap, and in this manner acts much more briskly. Professor Frank seems to attach too little importance to a prophy- Prophyiac- lactic treatment of any kind, whether by cathartics or alterants, byVraBk.8* mercurial or antimonial, unless with a view of removing worms or some other known irritant; his maxim being the very dangerous one for a sudden attack of an acute disease, that the firmest health * J. P. Frank, De Cur. Horn. Morb. Epit. Tom. Hi. p. 159. 76 ex. ni.j HJiMATiCA. [oun- hi. Gen. III. is the best state in which to receive it. " Nemo sanior," says he, * e. vario- " quam sanus esse potest; ac saepe, qui ad morbum se i'K.epakat DisUuc?1*' mturum> mc victas huic manus cedit, ac ineptissimis in abscntem, smaii-pox. nec cognitum satis, hostcm invehitur auxiliis."* Exposure Exposure to fresh and cold air is nearly, if not altogether, of as c0oid1irand much service as calomel; and hence the patient, however inactive and dejected he may be, should be roused from his bed, and urged to use gentle exercise either abroad or in a cool capacious room. CoM water. Cold water is usually prescribed in large draughts for the same pur- Mineral pose, and very generally proves highly refreshing. The acids, and especially the diluted mineral acids, have a peculiar influence in diminishing the extent of the eruption ; insomuch that some inocu- lators have been bold enough to prophesy the number of pustules a patient would produce under a given quantity of the acid. Whether any one of the acids has an intrinsic power beyond the rest has never been sufficiently put to the test of inquiry; nor is it clearly ascer- tained in what way they operate towards the present effect. They are an excellent refrigerant in fevers of all kinds, but in small-pox there seems to be a something beyond this power, and they proba- bly restrain the process of assimilation. Lemonade may conveniently form the common drink during the fever ; or a solution of creme of tartar in water, which, as tending to keep the bowels gently open, will be preferable. When the fever is considerable, the purgative should be repeated at each of its ex- acerbating stages ; and if convulsion-fits arise, the spasmodic irrita- tion is best removed by laudanum. . The pathognomic characters of the confluknt variety are the following: Pustules confluent, flaccid, irregularly circumscribed: the intervening spaces pale : with great debility. In this variety the eruption assumes, at first, the appearance of a general efflorescence without any distinctive points ; innumerable pimples, however, show themselves about the third day, being a day or two sooner than in the discrete variety. They soon coalesce from their thronging number, and become filled, not with pus, but a yellowish serum, for this variety seldom suppurates regularly. The fever is violent and exhibits a synochous or typhous type ; and, instead of subsiding on the appearance of the eruption, as in the distinct variety, very generally increases. The head is oppressed, the eyes inflamed, the brain comatose or delirious. After the eighth day the detached pellicle, covering a large secretion of this virulent fluid, becomes brown, and not yellow as in the distinct sort. Peculiar to the confluent small-pox is salivation in adults, and a looseness in children ; the former always attends; the latter more rarely. The spitting begins as soon as the eruption appears, or within a day or two afterwards : the saliva is at first thin, and easily and plentifully discharged; but, towards the eleventh day, which is the period of the greatest danger, it becomes viscid and is discharged with great difficulty ; the looseness in children, however, continues beyond this period. 0 E. Va- riola con- fluens. Confluent small-pox. Diagnos- tics. De Ctir. Horn. Morb. Epit. Togj. i". p. 190. 8ro. Mannh, 1792. 0L.1U.] SANGUINEOUS FUNCTION. [ord. in. 77 When the disease terminates favourably, the swelling of the face Gen. III. about this time begins to abate, and that of the extremities com- a fj!*™'. mcnces. But, if the constitution be incapable of counteracting the »oia con- weakness under which it is suffering, or the mass of disease with confluent which it is oppressed, and particularly the exacerbating or secondary ™«h-p<«' fever, as it is called, which takes place at ithe stage of maturation, the cuticle suddenly becomes flattened, the features sink, the pus- tules are depressed ; the coma increases, flea-bite spots are sprinkled over the body, succeeded often by hemorrhages from dissolved blood; the pulse flutters, and the patient expires ; usually, as already ob- served, about the eleventh, but sometimes not till the sixteenth day. In the commencement of this variety, the same reducent plan is Remedial to be pursued, as already recommended in the preceding variety; treatment- and the affusion of cold water may be added to a free use of fresh and even cold air. Bleeding is a doubtful remedy, and its propriety Bleeding a must entirely depend upon the constitution or habit of the individual, remedy".' and the nature of the prevailing epidemy. In a state of high en- tonic health, and firm elastic fibre, it may be allowed, and perhaps repeatedly : but we should always bear in mind, first, that the pleni- tude of the disease does not so much depend upon the strength or weakness of the frame, as upon its susceptibility of the contagion, and irritability beneath its action : and next, that in confluent small- pox the process of maturation does not take place kindly or perfectly, and that the fever, often a synochus, has always a tendency to run into a typhus, particularly when the temperament of the atmosphere predisposes to this type. On this account, it will often be found Toneoftha necessary, and particularly towards the stage of maturation, to sup- ^'support- port the tone of the system instead of reducing it. Camphor offers ed. us one of the medicines for this purpose ; and may be given in solu- amp °r" tion or in the form of pills. The latter is generally the most con- Diffusible venient, as it can thus be taken in a larger quantity, and needs notB imu ants* interfere with ammoniacal neutrals, ethereal compounds, the acidu- lated decoction of cinchona, or the same tonic in a powerful form, cinchona. If, indeed, on the accession of the secondary fever, the pulse should suddenly sink, the pustules flatten, and the surface turn pallid or purple, wine must be added to the other remedies, blisters or sina- Wine pisms applied to the feet or legs ; and opium be administered if a n°m0esl,'™yS diarrhoea should supervene: though in the earlier stages of the in th,e «e- disease this last symptom should be very cautiously interfered with. feveV-^and Some part of the secondary fever may probably be set down to the ^™: score of the absorbed virus, now thrown back upon the blood from diarrhoea, every part of the surface : and to disarm this source of exacerbation ^demands it may be convenient to open the pustules as they ripen^ and let s,eu* cau~ them discharge their contents externally. And to save the face as checking it. much as possible from those exulcerations of the true skin that ter- ^"opened" minate in pits and scars, a mask of fine linen or cambric should be a.s thRy worn over it, illined with cetaceous cerate to soften the integument r,1'en' and defend it from the air. Small-pox, then, may well be contemplated as a fearful disease. Often lays It is so at all times from the uncertainty of its prognosis ; but espe- fionfor* Wally when it assumes a severe character. And it is so, moreover, s,"^quent 78 QL. III.] HiEMATICA. ORD. III. Gen. Ill Spec. d E. Va- riola Con- rl iiens. Confluent small-pox. y E. Vario- la degener. Horn-pox. Crystalline pox. Peculiar marks. Explained. With Frank a modifica- tion of pemphigus. S E. Varie la inserta. Inoculated small-pox. Peculiar characters. History. Derived probably from China. Simple mode of communi- cation. not merely on account of its own ravage, but of the tendency it produces to subsequent evils, after its own course has subsided. In many cases the constitution is incapable of recovering from the general disturbance and debility it has introduced, and hence atrophy, dropsy, and hectic are by no means uncommon results. But it more frequently proves mischievous by stirring up some hereditary taint that might otherwise he quiet through life ; and in this way becomes an exciting cause of scrophula, consumption, and gout. The horn or crystalline-pock, it is only necessary to notice, as forming a somewhat singular departure from the usual course of the disease, though not often accompanied with danger, or distinguished by an overloading eruption. Its pathognomic characters are set down in the Nosological Synopsis as follows : Pimples imperfectly suppurating ; ichorous or horny ; and semitransparent. From some unknown cause, the variolous fluid is, in this variety, secreted and thrown upon the surface in the form of lymph, and is never exchanged for that of pus. As the finer part of the fluid is absorbed it loses its pellucidity, and the vesicular pimples appear whitish, and preserve this hue till they dry and peel oft*. This is par- ticularly the case in persons of a fair and delicate skin, but, where the skin is darker or coarser, they become brown, hard and horny: and hence it is always in this way that the present variety terminates amongst negroes. Whenever small-pox occurs a second time, it usually shows a tendency to this modification. It is not a little singular that Professor Frank should have sepa- rated this form of the disease from small-pox, and made it, together with varicella as already observed, a modification of pemphigus.* What land-mark can the student find when the boundaries of diseases are thus disastrously broken up ? The fourth variety under which small-pox is to be found, is the artificial modification known by the name of inoculation : a most important advantage to mankind before they were acquainted with the equal or nearly equal protection afforded by the virus of cow- pox ; when, in the language of Professor Frank, " ad illud tandem se reductos viderunt; ut victas huic pesti manus traderent, et sic, quasi daemoni, quo sibi esset propitior, sacrificarent."t Its peculiar characters are thus described in the volume of No- sology : Orange-coloured areola about the puncture ; pain in the axilla about the seventh day : disease mostly mild ; and the puru- lent discharge sometimes confined to the punctured parts. This mode of communicating the disease, like the natural disease itself, appears to have reached Europe from the east, and especially from China ; where, according to the statements of the Jesuits,$ it has been practised immemorially by perhaps the simplest and best mean of communication that has hitherto been devised, that of a needle charged with the contagious matter of a pustule, and introduced transversely under the cuticle. From China the discovery appears to have travelled into India, and thence to Asia Minor. It is not so easy * De Cur. Horn. Morb. Epit. Tom. in. p. 264. t lb. Toeq. hi. § 3S4, I Lettres Edifiantes et Curieuses, &c. passim. ex. in.] SANGUINEOUS FUNCTION. [ord. hi. 79 to conjecture how it arrived among the ancient native tribes of Africa, Gen. Ill, as we know so little of their arriving there themselves. It shows, iE.Pvario- however, that the disease itself is of very high antiquity, though itla «n«eria. does not seem to have travelled in a very early period of the world Bmaii'-pox. ihto Europe ; unless indeed we ascribe to it various sources of origin, which is accompanied with the difficulty* of our not knowing where to stop the moment we embrace such a doctrine, for if we once indulge in a plural number, there is nothing to prevent our carrying such a number on to infinity. That the disease, however, has from Early an early period existed in Africa, and has also been counteracted by Anfy£" ^na the employment-of a rude kind of inoculation, is now clear from the eoumor- narrative of Mr. Campbell, whose veracity will not lightly be called fnocuiation-. in question : and who tells us that he found both the small-pox and the practice of inoculation in use among the Marootzee, or inhabit- ants of the city of Kurreechane about a degree and a half to the northward of De la Goa Bay, or 24^° south latitude. Here the rivers, which before ran westward, were found to flow towards the east, evidently proving that he had reached the loftiest point of this part of the continent. The natives, it seems, have a tradition that they procured the variolous matter, or rather learnt the art, from a people to the north-east called Mahalatyela, who ride upon elephants. They make the incision between the eye-brows. The Booshuanas, however, inoculate for the small-pox also.* The first employment of inoculation in our own country seems to Practised have been the result of some fortunate observation, made, like that 8geam oury of cow-pox inoculation, in the rudest parts of it; for the practice of °rWI)coun " buying" the small-pox, which was in fact a communication of the in Wales, disease by insertion, was prevalent in Wales at a very early period, provinces'0 and appears to have been also occasionally resorted to in the Highlands »i»° "> the of Scotland, from an antiquity nearly as remote ; of which abundant of^scot- proofs are to be found in various articles in the Philosophical Trans-land actions.! All such practice, however, and even the knowledge of introduc it, seems to have been confined to the remote quarters in which it nerai'no-0 accidentally arose, as late as the year 1721, when Lady Mary .ice,jJ La~ Montague who had witnessed its success in Turkey, and had had a Montague. son successfully inoculated there, submitted an infant daughter to the same process at this time in London. Yet so little acquainted with Tried first its success were the public, and even the medical profession, at this demned period, and so cautious in giving it credit, that an experiment of its criminals: effect was ordered to be made in the same year on six condemned vcred. °° 1 criminals, all of whom were fortunate enough to recover, and who thus redeemed their lives. This gave countenance to further attempts; yet the innovation, Jike that of inoculation from cow-Hut the use pox, was sharply and pertinaciously opposed, and not more than i,0nvio"la seven hundred and sixty-four persons, according to Dr. Jurin's cal- ,ent|y °P" culation, were inoculated all over England from 1722 to 1727. Unfortunately the practice of treating the disease with cordials injured and a hot regimen at this time prevailed, and was too generally ap- muchwx-* ous treat- ment * Travels in South Africa, &c. 2 Vols. 8vo. 1822. adopted": ~ See Vol. xxxii. years 1722-3, and especially Dr. Williams's account. * SO r... m.j 1LEMATICA. [oiu>. in. Gen. HI SrEc. n K. Vario- la inserta. Inoculated ^rnall-pox. which gra- dually gave way to a more rational plan. Wonderful improve - ment upon the natural Yet injuri- ous from the wider diffusion of variolous contagion: and hence producing a greater average of mortality than the natural disease itself. Whence the greater mildness of inoculated than natu- ral small- plied to the inoculated as well as to the natural process, by means of which the former was often rendered a severe and in many cases a fatal disease ; though it was impossible for the dullest intellect to be altogether insensible to its high comparative advantages. By de- grees, however, the refrigerant and reducing plan obtained a triumph, and the triumph of inoculation was a synchronous step. Yet half a century afterwards the exploded plan was still persevered in by some practitioners, and it is instructive to mark the comparative mischief that still accompanied it. " I found," says Sir George Baker, writing in 1771, "that in the counties of Essex, Norfolk, and Suffolk, many thousands of people, of all ages and constitu- tions, and some of them,, of every apparent disadvantage, had been inoculated with general good success : whereas at Blandford, in Dorsetshire, out of three hundred and eighty-four persons, who were inoculated, thirteen actually died, and many others narrowly escaped with their lives from the confluent small-pox."* This gives us a direct mortality of something more than one in thirty; and it is almost needless to add, that in the successful districts here alluded to, the cooling plan was prevalent, and at Blandford that ef hot beds and a warm regimen. Even this result, however, with all its fatality offers a wonderful improvement upon the march of natural small-pox; in which one out of every three or four have been computed to die among adults, and one out of every seven among infants ; while, wherever the cooling and reducent plan has co-operated with inoculation, the casualties are not more than one in five or six hundred. Yet great as is the intrinsic advantage of inoculation even upon its lowest scale, there is one evil which has always accompanied it, and which, in a nation so justly proud of its civil liberties as Great Britain, it is almost impossible to provide against; and that is the wider diffusion of variolous contagion through the atmosphere by the indiscriminate use of inoculation in all places. And hence it has been very forcibly observed in our own day by those who have written most warmly in favour of vaccination, that small-pox "inocu- lation is upon this ground a greater public evil than good ; since the multitude who will not consent to be inoculated, receiving the natural disease more generally than they otherwise would do, the total mortality is greater than before inoculation was had" recourse to. I was at first induced to think that this statement was a little too highly coloured for a particular and present purpose. But on turning to Baron Dimsdale's tables of calculation drawn up nearly fifty years ago, I find him arriving at the very same conclusion ; and we may fairly affirm that the deaths from small-pox, since the introduction of inoculation, have increased in consequence of the more extensive diffusion of variolous contagion in the proportion of fourteen or fifteen upon every hundred. The bills of mortality indeed give us something more than this. By what means variolous contagion received by a puncture be- comes so much milder than when received from the atmosphere is a i *Mf*d,T5an,HV0l,i";Art'«X: £°m*,a,e A1 GaMi's Nonvelle, Reflexion* *i<- la Pratique de t'lnocnlation. Pan*. 1~70 ci. 111.J SANGUINEOUS FUNCTION. |o«u. 1*1. 61 problem that has never been satisfactorily solved. Something is Gen> ui< unquestionably due to the preparatory progress of purgatives and a s I'vario- reducent regimen ; but as the same mildness of character does not i*««»erta. obtain in the natural disease, where the same preparation has been smaii'-pox. submitted to antecedently, some other power must be sought for. Under inoculation, and with the usual precautions, the eruption is commonly distinct and widely scattered ; yet the most striking cha- The inocu. racter in the inoculated form is that when the eruption is full, and w!u?out™e- even confluent, the secondary fever, so alarming in the natural dis- f°°drary case, is here for the most part slight, and sometimes altogether ab- even when sent. This exacerbation is usually ascribed to an absorption of the conflucn' contagion from the pustules ; but the feature before us shows that there must be a something distinct from absorption, though perhaps acting in union with it. Is the virus from the first less irritant, and less capable of exciting much secondary fever, for the very reason that it was less capable of exciting much primary ? It is on this account that variolous inoculation may be submitted inocuia- to, without danger, by feeble infancy, advanced age, and even ca- ufe to in* chectic lfebits in every stage of life ; and that the season of the year ^Jcy *nd does not seem to be a matter of great importance. Pregnant should not women, however, ought never to be exposed to it, nor infants, where formeerd ou there is a choice, till after the irritation of teething. piegnant The operation is perfectly simple ; the needle originally employed nor infants in the East is as good an instrument as any, though the lancet is ZcMag. preferred in general. It is only necessary to deposite a minute Mode ?f drop of uie contagion under the cuticle, or at least to make such a opolutlon wound as may give forth a single drop of blood. It is preferable to fluid should take the fluid before the pustule suppurates ; as afterwards it seems be7oareeisup- to partake of the nature of common pus as well, and produces a larger puration. circle of inflammation, and on this account also it cannot so fully be the?nocu-° relied on. The puncture does not so completely disappear as in J,*1^ dls' that with vaccine fluid, but it is often scarcely visible for three or four days. At this period, a minute papula may be traced, a little itching is felt, and sometimes there is a slight inflammation. On the sixth day, a pain and weight are felt in the axilla, proving that the lymphatics of the arm have become affected, and that the virus is conveyed into the system. On the seventh or eighth day, the precursive symptoms of transient shiverings, head-ache, and pain in the back are perceived, and immediately followed by the eruption itself; though mostly in this mild form of the disease the only eruption, as in the inoculated vaccinia, is the pustule on the puncture or a few which directly surround it. Where the disease spreads itself in this manner the local efflorescence commonly spreads over a larger area than otherwise, and the adjoining lymphatics participating in the irritation, the tenderness and sense of weight are increased in the axilla. Where the symptoms are unfavourable, Unfavour- there is a purplish, instead of a rosy inflammation, or a narrow, deep Soltic™2 red, circle surrounding the puncture, with a dip or depression in the pustule. The treatment is to be the same as that already pointed out for Treatment 'he natural disease : but. it should varv with the habit, constitution. y«j. ni.-.ii SI ex. m.J HiEMATICA. LdKU< Gaw. HI. or age 0f tue individual. Sufficient attention was not always given ,5 RVario- to this remark formerly : for the preparatory regimen was a bed of inoculated Procrustes to which every one was alike compelled to adapt himself. sS-pox. Sir George Baker openly complained of this inconsistency in his Treatment. own daT .* but jt wa9 very generally continued notwithstanding his censure. GENUS IV. ANTHRACIA. CARBTJNCULAR EXANTHEM. ERUPTION OP TUMOURS IMPERFECTLY SUPPURATING WITH INDURATED* EDGES, AND, FOR THE MOST PART, A SORDID AND SANIOUS CORE. (xbh. IV. The present genus, denominated anthracia, from «»^«|, " a burning coal," by its definition embraces two diseases of very dif- ferent specific characters, though closely according in their generic marks. These are, 1. ANTHRACIA PESTIS,- PLAGUE. 2. --------- RUBULA, YAWS. proper sta- There have been, however, and still continue to be, great dispute? these spe- among the nosologists, as to the proper station of both these species; nuted!"" manv contending that plague ought not to be regarded as an exan- them, and most writers having hitherto contemplated yaws as an impetigo, or some other dysthetic affection. Dr. Cullen has ex- pressed a doubt whether the first should not be removed from the order of exanthems into that of fevers ; Vogel has actually intro- duced it into this last order ; Willan has rejected it from the exan- thems. Parr arranges it as an exanthem, in his dNScle Nosology, having previously, like Willan, rejected it from that division in his article Cutanei Morbi. In his remarks subjoined to the article Nosology, he again acknowledges that " on reflexion it appears im- proper" to introduce it into the list of exanthems ; and in his article Pestis, he asserts more roundly that "there is no foundation for arranging plague among the exanthemata ; and that it should be reduced to the asthenic remittents." Sauvages, Linneus, Sagar, and Macbride have entered it in the order in which we have ptaced it in the present system. Swntogto In few words'there appears strong and almost incontrovertible piagDueits reason for thus placing it The fever, as will presently be shown. "MM Trans. Vol. u. p. 28?. cl. iil] SANGUINEOUS FUNCTION. [ord. in. &6 is eruptive, and as specifically so as that of any of the exanthems ; Gen- *v* it is contagious like most of them ; and, although frequently oc- carbunca- curring oftener than once in a man's life, we have the concurrent [j^1"1" testimony of all the writers, who have been eye-witnesses of its effects, that it renders every one less susceptible for a certain period afterwards, and some for the whole term of their existence. With respect to yaws, the diversity of opinion has been quite as Reason* considerable as that respecting plague. Generally speaking, it has ingto'^aws been placed in the loose and indeterminate class which has been it.a Prescnt distinguished by the name of cachexies ; Sauvages and Sagar ar- range it in the ordJlr tubera of this class ; Cullen in that of impe- tigines. These writers take little or no notice of any kind of febrile features that accompany it whether specific or sympathetic. Dr. Young pays as little attention to the febrile symptoms by which it is said to be distinguished, and at the same time transfers it from the division of cachexies (cacochymuie as he denominates them) to the order of paramorphise or structural diseases. Dr. Winterbottom, and Dr. Dancer, on the contrary, contend that a slight fever is its primary symptom ; and Dr. Ludford, to whom we are indebted for, perhaps, the best history which has yet been given of this disease, describes it as a proper eruptive fever, totally unconnected with diet, lues, or any other taint in the blood ; commencing with alter- nations of shivering and heat, lassitude, want of appetite, and pains in the head and loins to so great a degree as to prevent sleep ; the fever and every inconvenience diminishing after the eruption, and the appetite returning. So that, like small-pox, it appears to have a regular accession, height, and decline ; and, as already observed, may be propagated by inoculation ; and is never known to occur a second time. Hence Parr, who seems to have long wavered in his opinion concerning the real nature of this disease, regarding it at one time as a pustulous exanthem, and afterwards as a mere cuticu- lar intumescence, returned, at last, with a decided mind to his first opinion, and again asserts that " the detail of symptoms shows that the disease is truly exanthematous." This .view of the subject will therefore abundantly justify the "^,ce bolh present arrangement of both these diseases; support their pretensions he pestilential eruptions appearing under the form of Aiunhem buboes, carbuncles, or other exanthemata ; among which last he in the A takes particular notice of an erysipelatous redness forming streaks piae|ue of a reddish purple or livid colour, intermixed with vibices and '600-1-2. wheals, or large blue and purple spots, the maculae magnae of authors; while, in some cases, he observes that an extraordinary concurrence of these eruptions took place, which, however, was chiefly remarked among children under ten years of age. In the Barbary plague of 1799 and ltiOO, so fully and excellently Jnhdegfierc8^nd described by Mr. lackson,* who was an eyewitness to its effects,— varieties in the first and secchd of the two varieties here offered, the fructiferous [)£ b!u" and infructiforous, were intermixed, while the erythematic seems to plague of have been absent. It was probably absent abu in the plague of probUiy ' Moscow of the year 1771, as it is npt noticed by Dr. Mertens, who »|»°^ *e gives a full descriesiou of both the other modifications. In the Moscow of London plague of 16.55, all of them seem to have occurred occa- Ail0'cca. sionallv ; the first anJ the second, however, most frequently, ex- sionally v .. occurred 111 amples of which are to be found in Hodges, Sydenham, Sir Gideon -hr London Harvey,t and in ' >ed all the writers; while, in allusion to the last, J'^|"eb°t Sydenham compares the inflammation o1' the plague, as it often ap- mostiythe j * i.1, .. c • 1 1 • ■> u • 1 first and peared, to that of an lgms sacer, by whjvn he means an erysipelas ; sec0nd-. in which, nature, he tells us, expels the matter of the disease from the blood to sligiitly elevated tumours dispersed over the surface in broad red patches: only that this ignis., says he, is more violent, than the ignis sa;er : j.—'' ignis noster isto sucro longe divinior est.'''' They seem also to have co-existed in the Neapolitan plague or rather as also at that of Noya in 1816, for the police i\guIatiorjs,§ as well as the J^Ja m medical descriptions, have a reference to each of these in very dis- tinct terms.': In the p.ague of Athens, on the contrary, as described by Thu- in the cydides and Lucretius, we are not sure of the existence of Al|iftu1f, °le buboes, as not being distinctly noticed, though probably included in third m- the inflammations that are stated to have fallen upon the privities {y fJund? {rot xtfoix), while the last two varieties A'ere perpetually intermixed ; the chief eruption, however, being that of the vesicular erythema, the sacer ignis, or holy fire, as observed by Sydenham. In conse- quence of which Thucydides tells us, that " the surface of the body was neither violently hot nor wan ; but reddish, livid, and covered over with an efflorescence of minute vesicles and ulcers,"— . v'. Obs. xi. xii. Schol. ? Traite de la Peste. p. 1.436. # ss Gen. IV. Spec. I. Anthracia Pestis. Plague. but not by Forcstus and Got- wald: nor quite accurately by P. Rus- sell. Carbuncu- Iar varie- ties of Got- wald. Papula: of Sitorius. Forestus. in.] 1LCMATICA. [ORD. IU. to contemplate them in a similar light, though he speaks v. "The same eruption," says iie, "appears under va- Hodges. A general conclusion. Synony- mous with Sauvuge tf erysipelas pestilent: inclined doubtfully. " The same eruption, rious forms, as it happens to be viewed in its different stages ; and hence, perhaps, the varieties of the carbuncle have sometimes been erroneously multiplied. I will not be confident of not having fallen into the like mistake."* Gotwald makes not less than four varieties of the carbuncle, as he traced it in the plague at Dantzick m 1709. It is the last of these that constitutes the erythematous form before us. u It is," says he, " the most curious, as Purman in his Treatise of the Plague, has well observed, Sitorius calls them pale, livid, ulcerous, papula. : they appear with a high, yellow blister, which seems full of corruption: the circle round it is first red, then of an ash colour: the blister soon falls, and, with the carbuncle, appears scarce so big as a pep- per corn, continually eating deeper and wider."t To the same effect F_ ;estus. " Carbunculus fere autem oritur ex pustula exili, milii seminis magnitudine : interdum vero multi prosiliunt, primo quidem pruritu, deinde rubore, ardore, doloreque vehementi. Hoc vero sensim increscente, pars uritur, crustosumque ulcus quasi candentiferro inducitur,idque vol nigrum, vel cinereum."J To which he adds in another place, " et in ore eorum cernes aliquid pestilentis coloris cum partim erysepelatosum, partim colorem habeht depascentibus serpentibus similem per plures partes diffusam."* And in proof that the same variety of eruption did occur also in the plague of London, to the testimony already offered of Sydenham, it will be sufficient to add the followingof Hodges. " There were occasionally," says he, " vesications of size from a pea to a nutmeg encompassed with a variegated circle, generally reddish. They arose with exquisite and shooting pain, and contained an ichor of a yellowish or straw colour, which was so acrid or caustic that it soon corroded the vesicle and burst out, of a colour yellowish, livid or black. These pustules broke out in many parts of the body ; their station and number being uncertain: sometimes few, sometimes many : in one case the whole body was covered all over with them."\\ It is impossible that these writers could be mistaken in the nature of the complaint, and have regarded that as plague which was really small-pox : and as they describe, in these passages, the very lini- ments of the Athenian plague and other erythematous forms of it among ancient nations, there is no reason whatever for conceiving the physicians of Greece and Rome to have been more deceived than those of recent times. The greater part of these passages precisely correspond with the character of the erysipelas pestilcns of Lorrain, delineated under this name by Sauvages, who has copied freely both from Sydenham and Hoffman ; but w'sich, though lie -..-alls it an erysipelas, had, as he admits the closest affinity with plague m its most malignant form, " cum atrocissimo morbo pestilenti sum mam aflinitatem habet:" * Treatise of the Placrue, Book I. Chap. iv. p. 121. t Historical Account of the Plague, i^. By N. Goodwin, M.D. London 1743. P- 49. . J Lib. vi. Cos. xi. Scho!. o lb. Obs. xii. Schol. I> Lftimolos. p. 110. cl. in.] SANGUINEOUS FUNCTION. |oxd. hi. »9 and was in reality this disease in the form before us. " Each," says Gen- IV"- he, " commences with horror, burning heat, delirium, prostration of Amifracia" strength, vehement pain of the back and head ; in each the burning £08^s- matter of the disease breaks forth on the fourth day on the axillary 3 or inguinal glands, and spreads to the feet in the form of the ignis sacer : in the glands it produces abscesses ; in the extremities, gan- grene." It is the mal des ardens of the French writers ; and, in and the its malignant variety, the erysipelas gangrenosum of Willan. Much JTrSenaof of this difference, however, seems to be dependent upon local or the.tFre>»cii accidental circumstances, and especially upon the state or constitu- Discrepan- tion of the atmosphere. Thus we are told by Sir James M'Gregor, varieties1" that when the plague first broke out in the Indian army in the course accountea of its laborious expedition to Egypt, the cases sent from the crowded hospitals of the 61st and 88th regiments were, from the commence- ment, attended with typhous symptoms : while those from the Ben- gal volunteer battalion and the other corps encamped near the marshes of El-Hamed, evinced uniformly an intermittent or remittent type ; and those that occurred in the cold and rainy months of De- cember and January, an inflammatory character ; after which, as the weather became warmer, the disease at Cairo, Ghiza, Boulac, and the isthmus of Suez, wore the form of a mild continued fever.* The plague of London in 1665 was,in like manner, distinguished Plague tf by a peculiar constitution of the atmosphere, which excited an epi- distinguish- demic synochus of great violence and danger, often accompanied °jj, £* *QP_e" with symptoms of rheumatism or pleurisy, and which seems to have stitution of added considerably to the progress and mortality of the plague, phere!"10* Sydenham expressly calls it a pestilential fever, febris pestilentialis ; and adds that the fever of the plague, after it had broken out, so completely assimilated itself to its character, that, in the second or infructiferous variety, it was extremely difficult to distinguish between the one and the other.t In like manner Thucydides expressly tells us that whatever inci- dental complaint any person was labouring under during the plague at Athens, it was sure to run into this disease, which swallowed up every other. Yet he adds, that at the commencement of the plague, complaints of all kinds were peculiarly uncommon ; insomuch that by the acknowledgment of every one, the year seemed to have en- joyed a general immunity .\ The plague at London first attracted attention about Midsummer, it* <»_»*, and augmented in its destructive ravage till the autumnal equinox, dec-ine*"'1 at which time about eight thousand died within the bills of mor- tality in the space of a week, though two thirds of the inhabitants, at least, had fled into the country to avoid the infection. From this time it suddenly put on a milder character and made fewer attacks, nearly ceased, as is uniformly the case with the cold of the winter, and totally vanished by the spring: the epidemic fever, nevertheless. remained for a twelvemonth longer, though this, also, was both less common and less virulent. u * Medical Sketches of the Expedition, &«-.. t Sect, h, Cap. ' I Hist. Lib. ii. 49. Voi, 111—12 «« «*. iu,j 1LEMATI0A. [tnuj. ul. <*pec ^ It is remarkable though, as Sir Gilbert Blane observes, incoa* Antifracia' testibly established by the experience of ages, that the disease of ^■*p the plague cannot co-exist with a heat of atmosphere above 80°, i'ro|er' nor a little below 60°.* It never fails to disappear in Egypt at the lure of*" summer solstice, the heat being then pretty uniformly at 80° or up- pfaaue. wards. Its chief prevalence therefore, is in Lower Egypt. It is almost unknown in Upper Egypt; totally so in Abyssinia, in Mecca, and the southern parts of Arabia. On the contrary, it appears from the history of all the plagues of which there is any account in England, that they have never begun to appear epidemically but in the end of June or about the beginning of July ; that they proceed increasing till September, when they are at their acme, and then de- cline till they entirely subside in winter, with the exception of a few sporadic cases.* The influence of temperature is, indeed, striking in numerous diseases, and even in many of those that issue from a specific contagion, of which we have already given an impressive example in its effects on syphilis in the. West Indies. .v.kocou- The same controlling circumstances take place all over the world; agemfto and in studying the history and progress of the disease we must 'aUfo_ar-in a^ow ^or tne changes they effect: Dr. Mertens has well described^ ters. this progress in the plague of Moscow of 1771, at which time hejj presided over one of the largest hospitals of the imperial capital, Symptoms and was an eye-witness to its ravages.! Having noticed its liability " thoI in to modifications from the above causes, he tells us that in general, curred the rJague it begins with head-ache, giddiness, horripilation, prostration of strength, fevei, nausea, vomiting, redness of the eyes, a dejected countenance, and a white foul tongue.. A tickling attended with slight pains is perceived in the parts where the buboes and carbuncles afterwards break out. " The former," says he, u are glandular swellings, not acutely painful, and more or less elevated; usually seated in the groins or arm-pits, but occasionally occurring in the neck, cheeks, and other organs of the body." The latter he de- scribes very nearly in the words already employed in the specific definition of the carbuncle or anthrax in the preceding pages of this work, though he observes, that " in the plague this tumour evinces somewhat less prominence, pain, and inflammation, than when it arises as an idiopathic affection." »' Proguos- « Many," he tells us, "died on the first or second day of the attack, before either of these kinds of tumours made their 'appear^ ance." In such cases, an eruption of petecchiae, maculae or vibices, like what occur in putrid fevers, usually took place a few. hours be- fore death ; but sometimes the disease was so sudden as to outstrip the march of these active' precursors of dissolution. Almost all who died were cut off on or before the sixth day: insomuch that those who reached the seventh were pronounced to be out of danger. !3ay * , T,ne d,iseasc was introdueed into Moscow by a communication with the lurkish army : it made little progress during the earlier part of * Select Dissertations, &c. p. 314. 8vo. 1822 vifibSTlSr*McJici de "bus putridiB'd*PestC: nonnulli^ue aliis m°rfcis -j,. in.] SANGUINEOUS FUNCTION. [eno. in. !)1 the year, but became fearfully fatal with the advance of summer, Gen. IV. and gradually died away with the frost. The mortality was tre- Amhracu mendous. Seventy thousand inhabitants were cut off in a few Pestis- months, twenty-two thousand in a single month, and sometimes ague,~- twelve thousand in twenty-four hours. Notwithstanding which, by Advantage cautiously blocking up every avenue, except one, to the large hos- ^D*r8B,t'„1t pita! over which he was appointed physician, and keeping a strict from the and constant guard at the entrance thus left open, although the inkcXcd- building was in the midst of the city, it was maintained perfectly free from infection, while the disease raged around it in every quarter. Mr. Jackson's account of the plague at Morocco is in perfect Plague at consonance with this description, though it contains a feature or two accordant in addition, which probably became more prominent from the higher w'th ,ho temperature of the atmosphere. " The symptoms of this plague," scription. says he, " varied in different patients ; the variety of age and con- ' stitution gave it a like variety of appearance and character. In some it manifested itself by a sudden and violent shivering, in others by a sudden delirium, succeeded by great and unquenchable thirst. Cold water was eagerly resorted to by the unwary and imprudent, and proved fatal to those who indulged in its momentary relief. Some had one, two, or more buboes, which formed and became often as large as a walnut, in the course of a day ; others had a similar number of carbuncles; others had both buboes and carbuncles, which generally appeared in the groin, under the arm, or near the breast. Those who were affected with a shivering, having no bubo, carbuncle,'spots (vibicesor maculae latae), cr any other disfiguration (eruption), were invariably carried off in less than twenty-four hours ; and the body of the deceased became quickly putrefied, so that it Rapid pu- was indispensably necessary to bury it in a few hours after disso- UefacIwnt lution. " The European merchants shut themselves up in their respective houses, as is the practice in the Levant. I did not take this pre- caution, but occasionally rode out to take exercise on horseback. My daily observation convinced me that the epidemy was not caught Miasm by approach, unless that approach was accompanied by an inhaling jnilfyT of the breath, or by touching the infected person." small dis- This last remark is in strict agreement with the observations theCde-roin of the best medicalwriters of modern times who have witnessed the Re"eadrks disease in different countries and climates : and the wholesome coincident practice of drawing a line of demarcation, and thus cutting off all Ja'/obfc"' communication with the sick, is founded upon the same view. M. vation- Assalini traces the progress of the plague among the French army in Egypt with great care, and asserts that even those who associated with the sick were seldom infected unless inmated in their rooms : and instances the small degree of danger there is from casual inter- course, by showing how very rarely the medical attendants suffered. Dr. Frank the younger, who was with the French army at the same time, visited his patients closely and frequently, but never ventured to feel their pulse.* " T)p Perte. Bysenteria, fcf. Svn; Vienn. t'J cl. m.j hj;mat1ca. I0*0, III. Gen. IV. Yet fresh persons are far less safe than the stated inhabitants of Anlifraca' an infected place, who have been gradually inured to the influence Pestis. 0f the morbid miasm. " Families," says Mr. Jackson, " who had FrelrTper- retired to the country to avoid the infection, on returning to town, safethTn when all infection had apparently ceased, were generally attacked those ac- and died. After the mortality had subsided at Mogadore, a corps toThT"1 of troops arrived at the city of Terodant in the province of Suse, miasm. where the plague had been raging, and had subsided : these troops after remaining three days at Mogadore, were attacked with the disease, and it raged exclusively among them for about a month, though they were not confined to any particular quarter, many of them having had apartments in the houses of the inhabitants of the town." Bremen- As in the plague of Athens and of London, " the mortality," taiSty.mor" continues the same author, " was so great that the living not having time to bury the dead, the bodies were deposited or thrown together into large holes, which, when nearly full, were covered over with earth. Young, healthy, and robust persons with strong stamina, were, for the most part, attacked first, then women and children; and, lastly, thin, sickly, emaciated, and old people." The depress- ing passions of fear and grief had also a strong predisposing effect: a few suffered twice. Morocco lost a thousand upon an average daily, when the infection was at its height, being about the max- imum that fell at London ; Old and New Fez, from twelve to fifteen hundred ; Terodant, about eight hundred. The total loss sustained in these three cities, and in Mogadore, was estimated at one hun- dred and twenty-four thousand five hundred souls : not quite equal- ling, however, the mortality that desolated the Coast of Provence from the same disease in 1720-1, and particularly the three towns of Marseilles, Toulon, and Aix, in which the first of these lost half its inhabitants in a short time, and'the second sixteen thousand out of a population of twenty-six thousand : the destruction throughout the entire province amounting to two hundred thousand souls: but this was before the laws of quarantine were perfected and rigidly carried into execution. Dr. L. Frank calculates the average popu- lation of Cairo at three hundred thousand ; and its annual mortality from plague at seven thousand: yet when the disease proves very mild he thinks it may not be more than a fifth part of this.* Order of In the regular progress of the disease, buboes make their appear- buUuPoteB"' ar»ce first, and about the second or third day from the attack ; then _o5UfinreeiS' carDuncles and. ignis sacer, if either of these occur at all; and, lastly, and petec- as the danger increases, petecchiae and vibices. But, as already ob- eh«. served, where the plague shows great malignity from the first, it opens with petecchiae and vibices, and sometimes kills in a few hours, even before these have time to appear. Buboes a^ Buboes, in the opinion of all the practical writers, or nearly with- favourabie out. an exception, are a critical mark of the disease, and the natural "uuothis means of conducting it to a favourable termination : " but in order," end should says Mertens, " to their proving beneficial, they must undergo per- suppu- ra,pfl: * De Peste, &c. nt supra. ui. in.] SANGUINEOUS FUNCTION. [ord. hi. 93 feet suppuration." In many instances they neither inflame nor be- Gen. IV. come painful: and in others they suddenly disappear after having Acacia reached the size of walnuts. In the former case they afford no re- peBt's- lief, and in the latter death is almost sure to foiiovv speedily. The ae"e" earlier they make their appearance the better ; and upon a free sup- and then puration they certainly render the patient less susceptible of the dis- *'^ {„_• ease afterwards. In the opinion of M. Sotira, indeed, and of most demnity of the French medical staff appointed to the Egyptian expedition, fume at- they prove an indemnity for life ; yet the examples of a second at- took- tack are too numerous to allow us to adopt this opinion as a general rule. Mr. George Smith, surgeon of the Russian Imperial Land-Cadet Disease corps of nobles, was twice a sufferer from the plague at Bucharest ^turns?" in the year 1772, as I think, and had the rare privilege to recover from both assaults. But that an exemption for a considerable term of time is hereby very generally obtained, is established by innume- rable examples; of which M. Mathias Degio, one of the surgeons attached to the same establishment, affords us a striking instance in his own person. " Perceiving," says Dr. Guthrie, " the gentlemen buttheex- of his profession condemned, in a manner, to death if punctual in s^e'tunes their duty, he had the resolution to inoculate himself for the plague perfect. in a full confidence of its efficacy ; and ever afterwards found him- self invulnerable, while his companions around him were falling vic- tims to its fury."* And to the same effect we are informed by Dr. P. Russel that in four thousand four hundred cases of infection he only met with twenty-eight of a well ascertained renewal of disease.! Of the efficacy of inoculation from the virus of a buboe there can inocuia- be no question ; and we have hence a sufficient proof of the specific c^ntw^ffi- character of the eruption ; but it is not always a successful efficacy ; cacious; and, even where it is so, as the extent of the immunity is not suffi- be reu"™1 ciently ascertained, inoculation for the plague is by no means to be onf°r a recommended. We are told by Mr. (now Sir John) Webb of a result.y bold experimenter in the person of a young physician and hospital ^?£pu- surgeon attached to the British army at Rosetta in 1802, who, to fieation, determine the question whether bubonous virus of the plague be or be not a specific and propagable poison, inoculated himself at El-Ha- med, on January 3d, twice by friction from the matter of a buboe, and once, on the ensuing day, by incision. He was attacked with rigor and other symptoms of fever on the evening of the 6th of the same month, which proved to be the plague, became delirious on the 8th ; and continued in this state till the evening of the 9th, when he expired. | I gladly avail myself of this authentic narrative of the Director General of the Ordnance Medical Department, published since the first edition of the preceding pages was written, in confirmation of the general statement here offered ; and as containing, if a feeling of high esteem and friendship have not unduly biassed my judgment, one of the most valuable documents we possess on the subject; par- * Guthrie's Observations on the Plague, &c. in Edin. Med. Com. Vol. vm. p. 348. t Treatise, &c. p. 190. t Med. Trans. Vol. ti. Art. vm. 04 Gen. IV Spec. I. Anthracia Pestis Plague. Plague in the British army of Egypt; from Sir J Webu'i narrative CL. III.] 1LEMAT1CA. [ORD. III. Specifical- ly conta- gious. Atmos- phere of. contagion yery limit- ed. Disease exhibits diSct^t ticularly in respect to the best practical means of opposing the in- fluence of thi* desolating scourge upon a large scale. Sir John Webb's narrative embi act s the history and progress of the plague as it appeared in the British army employed in the con- quest of Egypt in the years 1801, 1802, and 1803, during the whole of which time he was present, and actively engaged in arresting its course : and it justifies us in drawing the following conclusions. Firstly, that the disease is specifically contagious. Secondly, that the'atmosphere of contagion is very limited ; and that, hence, it is by no means difficult to avoid being infected. Thirdly, that the disease makes its attacks with very different degrees of malignity, at different seasons of the year, and on different constitutions. And, fourthly, that those who reside in a place in which the plague exists, and have been gradually inured to the influence of the pestilential miasm, are less disposed to be affected by it than those who are fresh to its poison ; and, as in the case of the jail-fever, may carry about them, in their clothes, effluvium enough to infect those who come within its atmosphere, while they tuemselves remain in a state of heaith. The first position is sufficiently proved, not only by the test of inoculation just adverted to, but by numberless other facts ; of which one of the most forcible is the following : A lieutenant of the 10th regiment of foot, residing in Alexandria, was attacked with the disease and conveyed within the boundary of the quarantine. A rent having been made in a musquito curtain, it was taken without his knowledge by John Lee, a private and servant to the lieutenant, who prevailed on the sentinel to let him pass, in direct violation of orders, to another private of the same regiment of the name of Wil- liam Bower, to be repaired ; after which, Lee immediately carried it home, and, at his own request, accompanied his master into the pest-hospital, and attended him till he recovered. On the fourteenth day after this visit of Lee to Bower, the latter was taken ill with very suspicious symptoms, which, on the idea that it was an attack of plague, could be accounted for by no one till the application to repair the musquito curtain was recollected by the patient. The suspicions were confirmed on the next morning, and in the evening he died. So long, however, as the line of separation was faithfully main- tained, and the sound and the diseased were thus kept distinct, there was scarcely an instance in which the disease broke out among the former. I say scarcely an instance, because an anomalous case or two occurred occasionally. But such was the judgment and the vigilance exerted from first to last, that the Board of Health were able to trace almost every instance of fever to the source from which it was derived, notwithstanding the difficulty of maintaining a rigid and permanent prohibition of all communication whatever And hence it is most probable that the few exceptions to the general fact proceeded from a disobedience of orders which the Board were not able to detect. In general, Sir John Webb observes that the course of the dis- ease is nearly the same every year, and equally varies in diflerent cl. ra.] SANGUINEOUS FUNCTION. [ohd. hi. 93 seasons of the year. In Egypt it commences in November, at Gen. IV. which time it rages with its most deadly malignity, " and those who A.iTwia' are affected by it sink into the grave almost without complaint." It £8»t'»- continues its ravages with little abatement through the winter and degrees' of the earlier part of the spring, when, as the weather becomes warmer [^Jl""/^ by the approach of summer, its attacks are less frequent, its symp- seasons of toms much milder, and it subsides into a manageable malady ; still, e year' however, retaining the characteristic test of glandular affection : and on the 24th of June the Turkish government announces to the pub- lic its supposed cessation by a discharge of cannon ; the atmosphe- ric temperature being now acquired in which the matter of plague ceases to operate. Sir John, however, with great judgment entertains doubts of its ^b°'^ entire cessation, even then or at any time ; and brings a proof or be ever two of its existence during the period of official emancipation. In destroyed. few words, he conceives the plague to exist in Egypt as the small- pox exists in England ; only, from a greater regularity in the atmo- spheric changes of the country, evincing a greater regularity of epi- demic flux and reflux, operated upon at the same time by contin- gencies often difficult to be developed ; and hence equally varying in violence and extent. That the miasm of plague, like that of typhus, is sometimes inert ^*r,J on upon those habituated to its influence, is obvious from the following those long fact. " When our Pest establishment at 'he camp was broken up, Action? I discovered that the Arab servants, who had been employed in it had secreted a great part of the clothing of the men who had died of the plague ; some of which they wore with great satisfaction and perfect impunity." I have noticed this effect of habit in the pre- ceding view of the plague at Mogadore : and to the same cause Sir John Webb ascribes it that the Chasseurs Britanniques, on their first arrivd at Alexandria from Trieste, suffered far more severely from the disease than the troops that had been stationed there for some months.* How slightly the disease makes its assault upon some constitu- ^Jf* tions, may be inferred from the case of one of the sailors of the Ma- peculiarly jor transport, who was attacked towards the end of March with an sl,sht- ♦ inguinal buboe, but was otherwise in perfect health. " The man," says the Director General," declared he had had it three daya, and attributed it to cold. I was, however, satisfied, after a careful in- quiry into his state, and an examination of his leg and thigh of the same side, that it was an effect of pestilential contagion, but in its mildest form. He was, therefore, placed in a separate tent, and a gentle aperient was administered, which was all the medicines he re- quired. On the 2d of April I found the swelling had begun to di- minish, which it continued to do until it entirely disappeared." The following description is of a different character. It is writ- interesting ten with a touching simplicity that does credit to the author's heart, mow "fatal and will not be read without feeling by the most torpid. t" As I k»ud. approached the beach to examine them (the sick and suspected of * Compare Dr. Patrick Russcl's Treatise on the Plague, B. i. Ch. iv. (Aleppo) (.. 19. 4to. 1791. 96 Gen. IV. Specv I. Anthnicia Pestis. Plague. CL. III.] HiEMATICA. [ord. m. Average of the loss sustained under the regulations adopted. Hence plague •vincet dis- crepancies in all parts of the world: but still pre- serves an identity of character. the Major transport,) the first object that presented itself was a young woman supported in a chair (Francisca Kennis,) moaning under oppressive disease. She stared wildly about, quite insensible to every object around her, and there was a muddy glistening in her eyes, Which I had seen described, but had never before observed. Her husband stood over her in the deepest distress, and held a lovely infant to her breast, who tranquilly sucked the poison that soon after- wards destroyed him. I feared at first that force would have been necessary to separate the father from his wife and child, but he at length yielded to entreaty, and was removed from the infection though too late to save his life. She was conveyed to the Pest Hos- pital, where she soon expired ; and the child was confided to an Arab, who fed and watched over it with the greatest care. On the 28th of March, the fifteenth day after the separation took place, the infant was attacked with plague, and languished until the 14th of April, when death terminated his sufferings."* Upon an average, from a table of the general return of the loss sustained by the British army from the plague, during the conquest and evacuation of Egypt, from the 8th of March 1801 to the 8th of March 1803, comprising just two years, it appears that the whole number of sick was 660:—of whom 361 died, and 299 were dis- charged cured : making the deaths rather more than half the number attacked. And further, that of the above 660, 612 were seized be- tween March 8th, 1801, and June 30th, 1802, being nearly sixteen months; and only 48 between July 1st, 1802, and March 8th, 1803, including the remainder of the time : a result which reflects a very high degree of credit on the means resorted to on the occa- sion, and on the vigilance and activity with which they were carried into execution : 361 being the entire loss sustained from this fatal scourge operating through a period of two years: whilst in the French army in the same quarter, as we learn from M. Desgenettes, not more than one in three of those that suffered were fortunate enough to recover : and, according to Dr. L. Frank, not more than one in five. Such is the history of plague as it has shown itself in different ages and parts of the world, collected from the writings of unim- peachable eye-witnesses of its progress. In the midst of many dis- crepancies it exhibits a sufficient identity of character ; and I have dwelt upon it the more largely, because, from the time of Dr. Cullen to the present day, its discrepancies have been chiefly attended to. And hence, while some writers of respectability have attempted to divest it of one, and others of another of its peculiar and most striking attributes, as that of contagion,! or that of atmospheric in- fluence,! some, and especially Professor Frank,§ have been equally * Loc. citat. p. 148. | Lsessis, Rechercb.es stir les veritable* Causes des Maladies Epirkmiques, &c. 8vo. Paris, 1819.—Lange, Rudimenta doctrinae de peste.—Magirus, Von der Pest —Maclean, Results of an Investigation respecting epidemic and pestilential diseases, including researches in the Levant concerning; the plague. I Sir Brooke Faulkener.—Tully, Hist, of Plague in the Islands of Malta, Gozo, Corfu, &c. 8vo. 1821. S J. P, Frank, De Cur. Ilom. Morb. Epit. Tom. i. p. 136. 8vo. Mannh. 1792. ct. nt] SANGUINEOUS FUNCTION. [ord. in. 97 inclined to sweep the whole away at once, and to reduce it to a Gen> iv- mere modification of typhus or some other fever of great malignity :* An^ra'cia on which account, in Swediaur's Nosology, it is placed next to ty- £titi8- phus in the class of continued fevers, instead of in that of exanthems; Swediaur's and is distinguished by the name of loimopyra.f men"88" From its history then, let us endeavour to collect its pathology, or General the laws by which it is governed, and which connect it with or sepa- deduci^ rate it from other exanthems. aboveT In the first place, it is obvious that the plague, like many other wives. febrile eruptions, is under the occasional influence of various con- oc^onai comitant circumstances that give a considerable diversity to many influence of its features. Its proper fever is an acute typhus ; but even this, miiants. by the constitution of the individual, or the peculiar state of the at- JJed'"'hJ mosphere, sometimes changes to a remittent, and even to an inflam- nature of matory type. So the measles and small-pox, whose proper fever is 18 a cauma, sometimes change, as we have already seen, into a typhus or synochus. The final end of the fever in plague, as in other ex- anthems, is to restore the body to health by throwing the morbid ferment to the surface in a specific way. And, as in other exan- A ,m*J! dc- thems also, a very small degree of fever is requisite for this purpose, only suffi- And hence we find that wherever the disease runs through its pro- p'eerfect°the gress kindly, the fever is slight in degree and short in continuance ; specific and the specific eruption shows itself in its perfect character. Dr. erup lon" Frank the younger tells us of a patient who even danced, and was merry at the very time when he had a bubo forming in the right axilla, j In the small-pox we sometimes find scarcely any eruption, Exempli- and very little disturbance of the system ; and the same benign dis- position is occasionally found to attend the plague ; for the soldier who is struck while in the ranks with a sudden shock, or m' drop, as the Arabians call it, and is taken to the hospital on one day, has, in a few instances, by proper treatment, passed through the febrile assault in three or four hours and resumed his station the day after :§ the disease in such cases evincing the same rapidity of attack and recovery which we have already noticed in that tremendous and fatal scourge, the spasmodic cholera of India, to which the plague bears a near resemblance in many respects. Next, the proper eruption of plague is that of buboes ; and where '^J19 Pr°p«' these alone arise, and in their proper period, the disease is not ac- taryemp- companied with much danger. They are always a favourable sign, ^abu' and seem to afford the longest indemnity against future attacks. When the fever is more considerable, carbuncles, the jimmerat of Oniyac: the Arabians, are thrown out at the same tune over different parts of hy'cMbun- the body ; and there is in this case always great debility ; which is ^8f™heer"a probably the cause of their appearance, and a considerable degree higher. of danger. And if the fever run still higher the danger will be pro- portionably increased, the proper eruption of buboes may perhaps * Dr. W. Heberden, Observations on fhe increase and decrease of different dis- eases, particularly the plague, 8vo. 1801.—Dr. Hancock. Researches into the laws and phenomena of pestilence, &c. 8vo. 1821.—Dr. L. Frank, De Peste, Dysen- teria, &c. 8vo. Vienn. 1822. t Nov. Nos. Med. Syst. i. 23. X De Peste, Dysenteria, &c. 8ro. Vienn. § Edin. Med. Com. Vol. Hi. p. 35..', Vol. Ill—13 98 cl. ui.J ILEMATICA. [ORD- m- Gen. IV. be supprest, and carbuncles alone be found, highly malignant, and Annfracia' secreting a most acrid and corrosive ichor which burns as it ooze9 Pestis. anti Spreads about, and occasionally forms extensive trails of painful Plague. i i- • and distressing sores. When v()ry But the fever is often still more acute, and especially, for a rea- boe.r.eu-bu" son we shall presently notice, when the disease earliest appears perjeded • among a people; and the danger may be imminent from the first toym7oTP" shock. The typhous symptoms are here of the most malignant na- 5JiS*Bt ture: there is a sudden and almost utter exhaustion of sensorial power without the smallest means of recruit: all the larger viscera are disturbed in their functions, the head, the heart, the lungs, the stomach, and the liver ; some overwhelmed with congestion, others sinking and powerless, as though the morbid virus were translated from the surface to themselves ; the only active principle throughout the entire system being that of fever itself; which increases with the increase of the general mischief, and, like a house on fire, ga- thers fuel from the downfal of the fabric. All the symptoms of pu- trefaction make an early appearance, and appear at the same time under these circumstances ; the animal spirits fail and are despond- ent ; the respiration is anxious and feeble; the stomach faint and sinking, or the brain comatose ; purple stigmata and vibices are scattered over the body; and the patient is destroyed by the incur- sion of the eruptive fever, as often happens in the small-pox, before the specific tokens have time to show themselves. Primary Of the primary source of plague we are in as much uncertainty plague un- as in respect to that of any other exanthem ; it appears, however, buVof'eariy to nave a Just c'auT1 to a higher antiquity than any of them : for we date: have already seen that it was known in an early era to the Greeks, and that histories of it, as it has shown itself in different ages and countries, have descended in a regular stream of Greek, Arabic, and known Roman, and neoteric writers down to our own day. We might, in- ftom^ifeir8 deed, if it were necessary, ascend to a far remoter period, and prove captivity its existence in the earliest ages of the Jewish history, for it is very gyp • freqUentiy referred to in the Pentateuch under the name of deber (13*1*), and is more particularly described in the prophetic writings as DEBERXMISRAIM (D^ifD "\2"\ Or ">3T O'-tfD "]VOt), the PLAGUE OB EGYPT, THE PLAGUE PROCEEDING FROM EGYPT ; thus pointillgly ad- Verting to what was equally regarded as its indigenous soil by the GreeksJ and Barbarians as well as by the Jews : while the carbun- cular variety is also peculiarly distinguished and characterized by the name of Shechin perech (me PIW§) " burning carbuncle," and Shechin Misraim (DnjfO pn^'ii) carbuncle of egypt. That, like other exanthems, it consists in, and is propagable by a specific virus is unquestionable ; for we have already seen that it has often Dependent been put to the test of inoculation ; and, like most other exanthema epidemic also, it appears to be dependent for an extensive spread upon the .u^fnUie same accessories as give rise to febrile miasm o.- -ontagion ; and Mxfflariea w*"cn' as Def°re noticed, are for the most part the common auxilia- of putre- j. _, . _ .... facii.n. * Exod. v. 3. et alibi. J Amos it. 10. t See especially Lucr. vi. 1139, who quotes from Thucrdides * Exod. ix. 9. || Deut. xxviii. 27. cl. hi.J SANGUINEOUS FUNCTION. [ord. hi. 99 ries of putrefaction.* Whether any combination of these be capa- Ge.v. iv ble of originating it of themselves either without or within the A^'hracil human body, or whether it be only propagable by a stream of here- Pe9,i»- ditary descent from piimary matter communicated from place to wlfe'ther place, is a problem to the present hour; though it is probable that j^rate8" the' principle which in this respect governs most of the other exan- doubtful. theins, as measles, small-pox, and scarlet-fever, governs the miasm of plague also : for all of them, while derivable by communication with the affected, seem, at times, to have assumed the form of epi- demics. In deducing the more obvious laws that regulate febrile miasm, I L?w of h- observed at some length that whenever originating from the human appiicator'y body itself, this miasm does not seem to be very volatile and is soon j£ e*"n" dissolved or decomposed in an atmosphere of pure air :| and we have since had occasion to apply the same remark to the specific miasms of all the preceding exanthems. I have now to observe, and parti- that it applies especially to that of plague, whose sphere of infec- pu|ue:l° tion in pure air appears to be more limited than that of any of the on ~,,li,a i ,,j/ Amniacia died at all out of them. * Pestis. Alpinus speaks in the same manner of the sudden decline of mor- Exempli- tality in the plague of Egypt: " in the month of June," says he, fied- " to whatever degree pestilence may be raging in Lgypt, as soon as the sun enters Cancer it ceases entirely." And Dr. Russell con- firms this remark as follows :—" It is agreed on all hands that about the 24th of June, at Cairo, there is a remarkable sudden alteration in the contagious property of the plague, as well as in the malignity of the disease itself, to whatever cause it is to be ascribed; and Alpinus's remark, that at the same time it ceases, the furniture in infected houses suddenly loses all power of communicating the disease to the inhabitants, so that health and tranquillity are at once restored, agrees in some measure with the general experience of other places in Turkey, where it is well known houses or goods undergo little or no purification."! Mr. Bruce speaks to the same effect: " The Turks and Moors, immediately after this day, expose in the market-places the clothes of the many thousands that have died of the plague during its late continuance ; and though these ' consist of fur, cotton, silk, and woollen-cloths, which are stuffs the most retentive of the infection, no accident happens to those who wear them, from their happy confidence." And we are hence able to enter more fully into the meaning of a passage already quoted from Sir John Webb, in which he tells us that on the approach of summer the plague subsides into a manageable malady, and that on the 24th of June the Turkish government announces to the public its supposed cessation by a discharge of cannon. Unless, therefore, we withhold, most unjustly, all belief in this Hence iu- accumulation of unimpeachable evidence, it seems impossible not to f,"r°eced'". admit that the state, or, to speak more definitely, the temperature, g/ress, and of the atmosphere is connected with the decline of the plague, and the'stateb,r consequently with its previous progress ; and that, as already ob- of th? at"_ served, it cannot maintain its energy, nor perhaps exist under an butessen-' atmospheric heat of 60°, nor above that of 80° ; while its depen- jjel^en*e" dence upon a specific miasm seems equally clear from its occasion- ui>«n ."pen- ally commencing in the healthiest, as well as in unhealthy seasons; 1C mia,ra' though most frequently, and most fatally, in the latter. In the plague of London, as we have already seen, the disease followed upon a malignant epidemy ; in that of Athens, the preceding year had been so peculiarly healthy that mankind seemed to have ac- quired an exemption from complaints of every kind. In that of Egypt, it makes a regular return whatever be the constitution of the season. Dr. L. Frank, in one place, ascribes the diminution of the fatal power of the plague to a periodical return of the north wind : but he afterwards observes that winds, at times, or even moisture, seems to have little influence upon it. That the change in its degree of activity is connected with, the change which takes place in the temperature of the atmosphere is unquestionable; and * Journal hy H. F. p. 250. t On (he Plague, B. hi. Ch. v. 104 ct. iri.] H^MATICA. [oitni Hi Gen. IV Spec. I. Al! 'H.iCld Pestis. l'lague. Medical treatment. Venesec- tion whe- ther ad- visable. it is highly probable that it is dependent upon this alone. That below 60J, or in the cold of the winter months, the miasmic cor- puscles lose their volatility, and gradually become decomposed; while above bU°, as in the summer months of Egypt and Arabia, they become almost immediately dissolved, so that clothes and bedding, however loaded with them, are rendered harmless. And hence the reason why it has never been known either in the tropical or arctic regions. * In entering upon the medical treatment of plague, I regret that I am not able to give the judicious plan, in conjunction with its results, that was adopted for the British army in Egypt. The care of the Pest Hospitals did not fall within the range of Sir John Webb's department, but I' availed myself of his friendship to solicit informa- tion upon this subject from his colleague Dr. Buchan, who, I have reason to believe, had made a journal of very valuable notes in rela- tion to it. The public will hear, with regret, that this information is incommunicable from the destruction of a great part of these minutes, which followed the fate of Dr. Buchan's clothes and bed- ding at the time of his quitting the hospitals. Respecting the proper plan to be pursued, there is still some con- troversy. Early, copious, and even repeated venesection was at one time, and by very high authorities, recommended in this disease, and especially by Sydenham at the commencement of the plague of London in 1666 and 1666, before the appearance of any eruption. Like Dr. Rush, in North America, respecting the yellow fever, he was stimulated by the bold determination of quelling this formidable enemy in its very onset, and before it should have made a fatal breach in the constitution. This practice, however, has been far less suc- cessful, and therefore less persevered in, with regard to the plague, than with regard to the yellow remittent. Dr. Mergens says, he would never advise its being resorted to: and even Sydenham hesi- tated as he became more experienced. " But though," says he, " I approve and have often experienced the utility of bleeding, yet for several reasons I prefer the dissipation of the pestilential ferment by sweat, because sweating does not in the same degree prostrate the patient's strength."* Blood-letting and purgatives Dr. L. Frank assures us prove equally hurtful in the plague of Egypt. During the plague at Noya the doctrines of Dr. Brown were in high vogue, and the disease was divided into sthenic and asthenic ; free bleeding and large doses of calomel were prescribed for the former, and acids, opium, ether, and other stimulants for the latter. But in general the medical practice was here as confused and inconsistent as the precautionary means of the police were excellent and effective, so that Romani was right in affirming that, after all, their real alexi- pharmic was to be found in God alone.t Wherever there is great and threatening congestion in a large or vital organ, bleeding, and bleeding freely, should certainly be employed, for this symptom alone would lead to a fatal issue. It is hence, in such cases, wisely * Loco citato. t Rieordi sulla Peste, redatti in un Sisteraa Teorico-practico da F. Romani dot- tore in Filosofia e in Medicina. Napoli 1816. hl. m.] SANGUINEOUS FUNCTION. [oitn. «i. 105 recommended by the elder Frank.* But the practice must form an Gek. IV exception to the general rule, and not the rule itself. A^ufracia The use of external cold by the application of sheets of pounded Pestis. ice to the body generally, has been also tried', but with no satisfac- Treatment. tory result. It has, indeed, been chiefly confined to Russia, under Appiica- the vigilant eye of M. Samoilowitz. How far it might succeed in temai cold. warmer climates is uncertain, but ablution with cold water offers a fairer promise. A brisk emetic, given at the commencement of the Great use attack, has often proved of the utmost advantage. M. Degio, to of eraenc'' whom I have already adverted, affirms that he has seen men, sud- denly cut down by the disease when on duty, as though shot by a musket-ball, so completely recovered by an emetic given instantly, as to be on duty again within twenty-four hours afterwards.! If the nausea and bitter taste in the mouth be not removed by a first emetic, a second, and even a tliird is often prescribed ; and, where the symptoms are urgent, at a distance of not more than four or five hours from each other. And this plan is found to produce far less exhaustion than that of purging which the patient is often unable to support. After evacuating the stomach, and hereby exciting a determina- warm su- tion towards the skin, the cutaneous action is to be maintained by dormc8- active and cordial sudorifics, which, indeed, constitute the ordinary plan of the present day. For cordials, there is the utmost necessity : the debility is, from the first, extreme and threatening, and the vas- cular action must be supported at all adventures. Even Sydenham, who at one time hesitated as to the use of them upon theory, in which he did not often indulge, was obliged to admit their beneficial effects, though he regarded the practice as hazardous. With respect to sudorifics, the concurrent voice of all physicians in all countries is in their favour. Diaphoresis is, indeed, the evacuation that relieves Perspira- most certainly and most effectually; and it should be maintained twai'meani by warm, diluent, and supporting drinks. James's powder em- b>„trelie.f:d ployed without cordials does not appear adviseable. It was very byan'timo- largely administered at Moscow, but, according to Dr. Mergens, eihMBu"6 with no particular advantage. In many cases the warmer opiates, j""* •« rare- as the opiate confection, have been found serviceable, assisted with waTi°nUopi- camphor and ammonia, and blisters repeated in succession. j^ ^*™" As oils of all kinds applied to the surface of the body have been ammonia. found a good preservative against the absorption of the contagious oUmay'be miasm, it has been also had recourse to, and employed in the same regarded manner as an antidote when the disease is present, and particularly dote. in the East where the zeit jaggliy, or olive oil, has been regarded almost as a specific. Mr. Baldwin affirms that he made use of it in this form very extensively at Cairo, and with great success: and it is usually employed in Barbary and at Constantinople. The French physicians, however, do not seem to have relied much upon its virtue. M. Sotira suggests that Mr. Baldwin's benevolence in the distribution of oil for this purpose was occasionally abused, and the * De Cur. Horn. Morb. Epit. Tom. I. p. 136. t Substance of notes taken at the Russian army during the prevalence of the Plague. See Edin. Med. Com. Vol. vm. p. 352. Vol. TIL—14 J Ob cl. in.] H/E.MATICA. [ord. m. gen. iv. curC3 by oil exaggerated and multiplied by those who wished to have Amhraci" oil gratis. M. Assilini, however, inclines to a belief that it may be Pt*ti?. useful: it is most pointedly recommended by father Louis of Padua, Treatment, director of the hospitals at Smyrna: and quite as strongly by Dr. Pauvini of Palermo, who had practised indeed at Malta, but whose work was reprinted during the plague at Noya, and gave a character to the medical practice pursued in that city.* The application should be accompanied with a long-continued friction ; and, when success- ful, is followed in about half an hour by a perspiration profuse and it* proba- general, and which affords immediate relief. It is not difficult to bie action. reagon upon me SUDject: the oil probably obstructs the pores of the skin, and prevents the escape of caloric, which, aided by the friction, accumulates on the surface, and shortens, or altogether prevents the shivering fits, which are otherwise very severe. Sir Brooke Faulk- ner admits its sudorific power, but is by no means friendly to its use; believing that even by this very power it has often proved highly injurious. Yet he does not speak from much personal acquaintance with its effects ; but tells us that " a gentleman who superintended the health of one of the districts of Valetta, assured him that although he had constant opportunities of seeing oil frictions used by those under his immediate orders, he was satisfied that it was not merely useless as a defence, but hurtful to the general health, by the debi- lity which succeeded to the profuse perspirations which it occa- sioned." Sir Brooke, in the passage of his work now referred to, estimates its prophylactic virtue as low as its remedial,t and is thus far in a state of direct antagonism, not only with Mr. Tully, who was afterwards inspector of quarantine on the same station, but with himself at the time of delivering his evidence before the Select Committee of the House of Commons ; an extract from which we have already quoted. Dr. L. Frank employed oil according to his own statement with great and decided success. In his hands it proved a most salutary sudorific ; and to sudorifics he principally trusted. He used it in the form of friction, six ounces at a time, and a single friction a-day. During re- In the remissions of the fever, the bark is used in great abun- ba'rk"^ fiance, commonly intermixed with port or other generous wines. r.ort wine. During the fatal plague which depopulated the whole of western Barbary in 1799, the Emperor Sidi Soliman is said to have had the disease twice, and in both cases to have derived his cure from a free use of the bark : in consequence of which he was never afterwards without a large supply of it. When buboes or carbuncles appear, they are always to be promoted and matured by warm cataplasms. Preven- Camphor, smoking tobacco, fumigation with gum sandrac, and the vinegar of the Four Thieves, are still largely employed as pre- ventives. But the contagion, as we have already observed, is not peculiarly active, and the best prophylactics are cleanliness, pure air, freedom from actual contact, a liberal diet, and cheerful spirits. I may add that vaccination has been repeatedly tried ; but has + Cbiara di Mostrazior.e de veri Preservativi della Peste e de remedj, &c. del -sacerdote P. Pauvini, dottore in Medicina, &c. Palermo. 1813. t Treatise on the Plscriie. &c. p. 231, 232. cl. m.] SANGUINEOUS FUNCTION. [ord. m. 107 answered no good purpose. Sir Brooke Faulkner, indeed, gives a Gf.n. IV'. striking example of its failure, for " in a numerous family," says he, Amhra'cia " who had been recently vaccinated, the whole fell sacrifices to the J^'* prevailing contagion, with the exception of the parents who had Treatment. never undergone the operation."* SPECIES II. ANTHRACIA RUBULA. YAWS. TUMOURS NUMEROUS AND SUCCESSIVE; GRADUALLY IISOREASlXU FROM SPECKS TO THE SIZE OF A RASPBERRY : ONE AT LENGTH GROWING LARGER THAN THE REST ; CORE A FUNGOUS EXCRES- CENCE ; FEVER SLIGHT : OCCURRING ONLY ONCE DURING LIFE : CONTAGIOUS. The term rukula, by which this disease is distinguished in the Gsn. iv. present work, is derived from the Latin rubus, " a black-berry or 0^'o{' rasp-berry," in French framboise, whence the common but bar-^specific barous name of frambozsia, quite as objectionable as that of scar- why called latina; and which the author has thus attempted to exchange for fr""1"*"1- an euphonous and strictly classical, term, in perfect concordance with the ordinary law of diminutives, which seems to prevail through the general nomenclature of exanthematous diseases, as rubeola, variola, varicella. Perhaps morula, from morus, a mulberry, a diminutive used in an approximating sense by Plautus, might have been somewhat more appropriate, since the eruption seems to bear a nearer resemblance to small mulberries than to rasp-berries. But J}*™1* ef as this last plant has laid a foundation for the vernacular name both yuew and" on the African and American coast, on the former of which it is •re- called yaw, and on the latter pian or epian, both importing rasp- berry ; and as the earliest writers have, upon this authority, deno- minated it framboise or frambozsia, I have not felt myself at liberty to deviate from the original idea. Swediaur has denominated it Tfh|™|!0,1), thy miosis, but with less attention to the external character of the diaur eruption. He arranges it, indeed, under the division of cachectic ulcers, and has made it synonymous with the synochus of the Greeks, as described by Celsus ;t to which it has only a few casual resemblances, while in its essential signs it is widely different.^ The disease, as it occurs in Africa and America, exhibits some diversity, and lays a foundation for two varieties as follow : « Guineensis. Attacking infants and young per- African Yaws sons chiefly ; and subsiding as soon as the eruption appears, • Treatise on the Plague, p. 233. t !•»»• *'• Cap. >«- i Nov. Nosol. Meth. Syst. Vol. n. p. 180. 108 m.j H^EMATICA. [ord. hi. Gek. IV. Spec. II. Anthracia Rubula. Yawg. No account of the dis- ease in the early writers. Supposed by some to be a modi- fication of syphilis: but distin- guishable by diacriti- cal marks. a A. Rubu- la Gui- neensis. African yaws. The mildest and proba- bly the ori- ginal form of the disease. Diagnosis. /3 Americana. American Yaws. Depacent; and destroying progres- sively both muscles and bones. In the precursory remarks to the present genus, I have stated the reasons for introducing this species into the list of exanthems, or febrile eruptions ; and the history of the disease will still further show that it could not with propriety have been placed under any other division. It is singular that we have no decided account of this malady among the early writers; nor, indeed, any account what- ever till after the appearance of syphilis ; whence, as several of its symptoms, and especially where the bones become affected, bear a resemblance to those of syphilis, yaws have been supposed by some writers to be a species of lues, and especially of that which in Scot- land is denominated sibbens or sivens, of which we shall treat in the ensuing order : but the eruptive fever and consequent efflorescence, the indemnity from a second attack, as well as other symptoms, draw a sufficient line of distinction. The first variety will often run through its course favourably without any medical assistance whatever ; and is, indeed, often injured by it when incautiously and injudiciously interposed. This seems to be the primitive form, and that under which it chiefly shows itself in Guinea, and some other parts of Africa, where, as just ob- served, it is vernacularly called yaw or morbus rubulus. It commences, like the other exanthems, with the ordinary symp- toms of fever, although they are usually more tardy in their pro- gress. Hence the precursory symptoms are languor, debility, head- ache, loss of appetite, rigor, and pain in the back and loins, which continue for a few days, with evening exacerbations. To these suc- ceeds the specific eruption; consisting of successive crops of papu- lae, at first not larger than a pin's head, but increasing in size with every series till they acquire the magnitude of a raspberry or mul- berry. The smaller papulae become real pustules, and discharge an opake whitish fluid when broken, and concrete into dense scabs or crusts. The larger are fungous excrescences, and, in their granular surface, as well as in their size and colour, bear a near resemblance to the fruit from which they derive their name. These sprouting tumours have but little sensibility, and suppurate very imperfectly; dis- charging rather a sordid ichor than a matured pus. They originate in scattered groups over different parts of the body, but are chiefly found, like the eruption of plague, in the groins, parotid glands, axilla.', and about the arms and pudenda : though they often disfigure the neck and face. The colouring matter of the hair, wherever they are seated, is obstructed in its secretion, and, as in old age, the hairs themselves, from a brown or a black, become a dead white. Dr. Thomas, who has given a very accurate account of this variety, apparently from personal knowledge, observes that, " In general the number and size of the pustules are proportioned to the degree of eruptive fever. When the febrile symptoms are slight, there are few pustules ; but they are mostly of a larger size than when the complaint is more violent and extensive."* Pract. of Phvs. p. 613. Ed. 1819 cl. in.] SANGUINEOUS FUNCTION. [ord. The duration of the eruption is uncertain, and seems to depend Gbh. iv. considerably upon the state of the habit, and its power of promoting 0saEr ?'. their maturity. They sometimes acquire full perfection in four or '» Gui- five weeks, and sometimes demand two or three months. In their aS progress to this state, there is usually some one that appears larger yRW3-. and more prominent than the rest, and is called the master-yaw. It ot the erUp- is, in truth, a broader and more sloughy fungus, and discharges a bie.' mia" larger portion of erosive sanies, which, if not washed off as it Ma"'«- issues, will spread widely, and sometimes work its way to an ad- yaW joining bone, and render it carious. When the tumours point from Tubba, or the soles of the feet, they cannot press through the thickness of the fnthe'lotes skin, and hence acquire form imperfectly, and produce highly ele- of **»feet' vated calluses, which are called tubba or crab-yaws : and often very much impede the power of walking. As soon as the eruption has attained its height, the tumours when the disease proceeds favoura- bly, become covered with crusts or scabs, which fall off daily in whitish scales ; and, in the course of a fortnight, the skin is left smooth and clean; the master-yaw alone remaining and demanding attention. In attempting the cure of this disease, the first step should consist Treatment. in separating the patient from his associates, to whom he will other- wise assuredly communicate it by contagion. He should then take freely of decoction of sarsaparilla or some other warm diluent, for the purpose of attenuating the specific virus in the blood, and quickening its passage towards the surface. And it is highly proba- ble that the warm aperient bolus, composed chiefly of ascruple of sublimed sulphur and five grains of calomel, as recommended by the anonymous writer of a very excellent treatise upon the'subject in the Edinburgh Medical Essays,* may be found serviceable, continued every night. The master-yaw must be attacked with escharotics for it is to be destroyed in no other way. The callous tumours on the soles of the feet, should be softened by warm-water, or cataplasms of some gentle stimulant; and, when on the point of breaking, are best subdued by a slight application of the actual cautery, which proves the most advisable escharotic. The diet should be nutritious and liberal, so as to support the strength during the progress of the disease. And under this mode of treatment it is rarely that a patient fails to do well. Mercury was at one time given in great abundance from the com- Mercury mencement of the complaint, under an idea that it would prove as j$firrg°tus beneficial as in the case of lues. But it is now sufficiently known to be productive of great mischief, and particularly when carried, as it used to be, to a state of salivation. It retards the cure, and gene- rally aggravates the symptoms. It is often given in small doses as though an alterative, when the disease is on the decline, and perhaps with "'^"4". advantage ; but it ought never to be employed in any other form, tiveon the When the excrescences discharge a sordid ichor, they may also the'diseaL. be stimulated with the nitric-oxyde mercurial ointment: but the Practice of natives themselves, who rigidly abstain, also, from the internal use of e nEtlve8, * Vol. ▼. Part h. Art. ixxvi. 110 cl. in.] H.EMATICA. [ord. in. Spec ff" merctn7i employ, instead of this, a liniment of the rust or sub- a a. RubJ- carbonate of iron and lemon-juice, which proves a very useful ap- rfeeG8Uis plication; though probably a solution of sulphate of zinc might answer African better. And during the maturation of the eruption they excite a vaws* profuse sweat by what may be called a warm air bath, which con- sists in putting the patient into a cask with a fire at the bottom in a brazier or small fire-pan ; the top being covered over with a blanket Under this mode of treatment a cure is said to be often effected in three weeks, and the funguses thoroughly healed.* 0 A. Rubu- The second, or American variety, is a far more terrible com- cana. plaint; or rather is the same complaint in an exasperated and chronic yaws"0*11 wrm » anc' hence, though incomparably slower in its progress than Evincing a the plague, is accompanied with a carbuncular eruption quite as plated** mischievous and disgusting, and more certainly fatal in its issue. nuffor™ I* was ^rst distinctly described by M. Virgile of Montpellier, who ProbaWy had practised with great reputation at St. Domingo. There can be from Africa little doubt of its being imported into the West Indies along with biy ""L a the slaves from the African coast; and is here called, as already ob- ■lave trade. ,. ..' •..»#.. served, pian or epian, precisely synonymous with the African term Mama- yaw : the master-fungus being named mama-pian, or mother-yaw, mother' as supposed to be the source or supply of the rest. The fungous yaw, what. Derrjes \n this form precisely correspond to the carbuncle already described under the trivial name of terminthus, which consists of a " core of fungus, spreading in the shape, and assuming the figure, and blackish-green colour of the fruit or berry of the pine-nut, or terminthus of the Greeks."t And it has hence been conjec- tured, but without sufficient foundation, that the disease of yaws is referred to by Galen and Dioscorides under this name. Descrip- The erosive secretion from the carbuncles of this variety gene- rally, but especially from the mother-yaw, spreads widely, and, in its meandering, destroys all the surrounding parts, not excepting the bones. Nothing can exceed the revolting scene of a yaw-house, or hospital for the reception of slaves suffering under this disease in the West Indies. " Here," says Dr. Pinckard, " I saw some of the most striking pictures of human misery that ever met my eyes. Not to commiserate their sufferings is impossible, but their offensive and wretched appearance creates a sense of horror on beholding StopS?*" tnem* ?f a11 tne unsightlv diseases which the human body is heir gress. to this is perhaps the worst. Some of these diseased and truly pitiable objects were crouching upon their haunches round a smoky fire ; some stood trembling on their ulcerated limbs ; others, sup- porting themselves by a large stick, were dragging their wretched bodies from place to place ; while many too feeble to rise, lay shivering with pain and torture upon the bare boards of a wooden platform."J Dr. Pinckard adds that "unhappily this most odious distemper has not hitherto been found within the power of medicine : that it often exists for years, and even where it sooner yields, its re- moval is more the effect of time and regimen, than of medical treatment. * Edin. Med. Com. Vol. n. p. 90. t Cl. in. Ord. n. Vol. 11. p. 221 t Notes on the West Indies. Vo! h. Letter xxn. cl. iu.J SANGUINEOUS FUNCTION. [ord. hi. Ill This view of the case is too generally true: but from the length Gen. IV. of time which, under the best treatment, is required to effect a cure, ^"ituim it seldom happens that these miserable wretches receive all the at-la Ameri- tcntion which their situation deserves; and the) are rarely suffi- American ciently heedful of personal cleanliness, which, even alone, is of the ^*ot in. utmost importance. This, with a generous diet to support the capable of strength, pure air, regular hours of rest, and such exercise as can °r ovcn'°n be used without fatigue, with warm balsamic applications to the cu™ ''* sores, have not unfrequently succeeded where the bones have not tention. become extensively carious. But the latter stages of the disease are horrible when it proves fatal ; for the pains are excruciating, the debility extreme, and the bones are covered over with a quagmire of foul exostoses and corrupt ulcerations. It is happy for the European inhabitants of the West Indies that Whites they are less liable to this miserable malady than their slaves : {Hi'tharf probably from using a better diet and being more attentive to Macks cleanliness. CLASS III. H.EMATICA. ORDER IV. DYSTHETICA. CACHEXIES. MORBID STATE OF THE BLOOD OR BLOOD-VESSELS ; ALONE, OR COH- NEOTED WITH A MORBID STATE OF THE FLUIDS, PRODUCING A DISEASED HABIT. Range and explana- tion of the order. Class III. The words ordinarily used to import the diseases meant to be Ord. IV. comprehended under the present order are cachexia and impetigo, or, as the Greeks expressed it, Aw«, lues, or lyes. None of these, however, exactly answer : and that on two accounts ; first, because the order is limited to those depravities which seem to originate or manifest themselves chiefly in vessels or fluids of the sanguineous function ; and secondly, because no very definite sense has hitherto been assigned to either of these terms ; and they have, in conse- quence, been used in very different meanings by different writers,. from the time of Celsus to our own day. Upon this subject the author has dwelt at large in his volume of Nosology, and it is not necessary to add to the remarks there offered. import of The word dysthetica has hence been adopted for the purpose of tcrem0rdmal avoiding confusion, and is justified by the eusthesia and eusthe- tica (EYS0ESIA and ETS0ETIKA) of Hippocrates and Galen, importing a " well-conditioned habit of body," as their opposite dysthetica, from the same root, imports " an ill-conditioned habit," but a habit, as just observed, originating in or dependent upon the organized parts or fluids of the sanguineous function. Thus ex- plained, it will be found to embrace the following genera : I. plethora. PLETHORA. II. h^emorrhagia. HEMORRHAGE. III. MARASMUS. EMACIATION. IV. MELANOSIS. MELANOSE. V. STRUMA. SCROPHULA. KING'S EVII VI. CARCINUS. CANCER. cl. m.j SANGUINEOUS FUNCTION. [ord. iv. 113 VII. LUES. VENEREAL DISEASE. CtASS III. VIII. ELEPHANTIASIS. ELEPHANT-SKIN. Dysthetica. IX. CATACAUSIS. SPONTANEOUS IGNESCENCE. Cachexies. X. PORPHYRA. SCURVY. XI. EXANGIA. VASCULAR DIVARICATION XII. GANGRJ3NA. GANGRENE. XIII, ULCUS. ULCER. GENUS I. PLETHORA. PLETHORA. COMPLEXION FLORID ; VEINS DISTENDED ; UNDUE SENSE OF HEA! AND FULNESS; OPPRESSION OF THE HEAD, CHEST, OR OTHER INTERNAL ORGANS. Plethora is seldom ranked as a disease, and hence seldom Gen. i. treated of in a course of medical instruction. From what cause this hitherto* omission proceeds I know not, nor is it worth while to inquire, generally That it is an important omission will be obvious to every student by8nosolo- before he "has been six months in practice ; lor there will probably sists- be few affections on which he will be sooner or more frequently consulted. Yet the subject has not always been neglected by noso- logists, for plethora, as a genus, occurs in the classifications both of Linneus and Sagar. In a state of health, the quantity of blood produced from the sub- General stances that constitute our common diet bears an exact proportion Patholoey to the quantity demanded by the vascular system in its ordirfery dia- meter, and the various secretions which are perpetually taking place in every part of the body. But the quantity of blood produced within a given period of time may vary ; and the diameter of the blood-vessels, or the call of the different secernent organs may vary; yet, so long as a due balance is maintained, and the propor- tion of new-formed blood is answerable to the demand, the general health continues perfect or is little interfered with. Thus, a man Example of exhausted and worn down by shipwreck, or by having lost his way t^e'or're? in; a desert, or who is just recovering from a fever, will devour double medial the food^ and elaborate double the quantity of chyle, in the course Eature. of four and twenty hours, to what he would have done in the ordi- nary wear of life ; but the whole system demands this double exer- tion ; the double supply is made use of, and the general harmony of the frame is as accurately maintained, as at any former period; there" is no accumulation or plethora. Vol. TIL—15 114 CL. HI.J HEMATIC A. [0R». I* Gen. I. Plethora. Plethora. Further exempli- fied. Morbid de- viation from the ordinary rule of action : and its con- sequences : operating in the pro- duction of opposite effects: being a Plethora ad niolem: and a Plethora ad spatium. Both causes somotimoj coexistent. How indi- cated. Hence called Sanguine Plethora. Plethora ad virea what. How indi- cated. It should also be observed that in this case the same remedial or instinctive power that stimulates the sanguific organs to the formation of a larger proportion of blood, stimulates also the blood-vessels to a diminution of their ordinary capacity ; and lessens the activity of the secernents ; and hence the difficulty to which the animal machine is reduced, is also met another way ; and a balance between the con- tained fluid and the containing tubes, is often preserved as completely during the utmost degree of exhaustion, as in the fullest flow of healthy plenitude. , • We sometimes, however, meet with cases in which an increased supply of blood is furnished when no such increase is wanted, and the vessels remain of their ordinary capacity. And we also, some- times, meet with cases in which, from a peculiar diathesis, the capa- city of the vessels is unduly contracted, while no change takes place in the ordinary supply of blood. It is evident that in both these contingencies, there must be an equal disturbance of the balance between the substance contained and the substance containing, and that the measure of the former must be too large for the measure of the latter. In other words, there must be In both cases an excess of fluid or a plethora, though from very different, and what are usually regarded as opposite causes; and, hence, it has been distinguished by different names ; that proceeding from an actual surplus of blood being denominated a plethora ad molem, or a plethora in respect to its general mass, or absolute quantity ; and that proceeding from a diminished capacity of the vessels being denominated a plethora ad spatium, or a plethora in respect to the space to be occupied. It is possible, however, for both these causes of plethora to exist at the same time, and for the vessels to evince a contractile habit or diathesis, while the blood is produced in an ordinate proportion. And this, in truth, is by no means an uncommon state of the animal frame ; for where the excess of blood is the result of a highly vigor- ous action or entony of'the organs of sanguification, we often see proof of the same entony or highly vigorous action through the whole range of the vascular system, and indeed of every other part of the machine ; the pulse is full, strong, and rebounding ; the muscu- lar fibred firm and energetic, the complexion florid, the whole figure strongly marked. We have here the sanguine temperament; and this kind of plethora has hence been called the Sanguine Plethora. But we often meet with an inordinate formation of blood in a constitution where the vascular action is peculiarly weak, instead of being peculiarly vigorous, the muscular fibres are relaxed instead of being firm, and the coats of the vessels readilv give way, and become enlarged instead of being diminished in their diameter ; and where, instead of entony or excess of strength, there is considerable irritability or deficiency of strength in the organs of sanguification. Yet, though the cause is different, the result is the same; 'the vessels, notwithstanding their facility of dilatation, at length become distended, and a plethora is produced which has been denominated a plethora ad vires; or a plethora as it respects the actual strength of the system. The pulse is here indeed full, but frequent and feeble; the vital actions are languid ; the skin smooth and soft: th" cl. in.] SANGUINEOUS FUNCTION. [orb. iv. Ho figure plump, but inexpressive ; all which are symptoms of debility Gen. I. of the living power, or rather of that peculiar diathesis which has plethora." been distinguished by the name of the serous, phlegmatic or pitui- tary temperament; and hence this sort of plethora has been com- Hence monly denominated Serous Plethora. Serous. We have, hence, a foundation for the two following very distinct species of this affection, the names for which are derived from their proximate causes. 1. plethora entonica. sanguine plethora. 2. ------- atonica. serous plethora. SPECIES I. PLETHORA ENTONICA SANGUINE PLETHORA. PULSE FULL, STRONG, REBOUNDING : HUSCULAR FIBRES FIRM AND VIGOROUS. Sanguine plethora is more common to men, serous to women. Gkn. I. It is the disease of manhood, of the robust and athletic. Plethora To bedil' of this kind must be distinguished from obesity ; in effect, they are tinguished rarely found in conjunction, for the entony or excess of vigorous Bj°™ °^ action is common to every part of the animal frame, and hence, "idom though it is probable that a larger portion of animal oil is secreted with it. than in many other conditions of the body, yet it is carried off by the activity of the absorbents, and there is no leisure for its accumu- lation in the cellular membrane. And hence persons labouring under sanguine plethora are rather muscular than fat, and their distended veins lie superficially and appear to peep through the skin. In this state of the blood-vessels, slight excitements produce Diagnos congestion in the larger vessels or organs. The head feels heavy tics" and comatose ; the sleep is disturbed by tumultuous dreams ; the lungs labour in respiration, and the muscles feel a want of freedom or elasticity in exercise. If fever arise, it will assume the inflam- matory type; and a slight excess in feasting or conviviality wili endanger an apoplexy. The cure, however, is not in general accompanied with much Medical difficulty ; and far more easily effected in this species than in the teatineD • ensuing: for the entonic power may readily be lowered by venesec- tion and purgatives; and its disposition to return fnay commonly be prevented by the use of refrigerants, as nitre, or other neutral salts, and an adherence to a reducent diet and liberal exercise ; at the same time it should be observed, that where the plethora depends upon a sanguineous temperament, or phlogistic diathesis, venesection, 11G cl. m.] H^MATICA. [«r». iv. though rightly employed at first, should be repeated with great cau- tion, as it will tend to generate in the system a periodical necessity for the same kind of depletion, and consequently promote the disease it is designed to cure. SPECIES II. PLETHORA ATONICA SEROUS PLETHORA. PULSE FULL, FREQUENT, FEEBLE : VITAL ACTIONS LANGUID ; SKIX SMOOTH AND SOFT'; FIGURE PLUMP, BUT INEXPRESSIVE. Gen. I. The general pathology we have already treated of: and the Spec. II. reasons given under the last species for the usual appearance of ' sanguine plethora in persons of a spare and slender make, will explain the plumpness of figure and glossiness of skin which so piagnos- peculiarly mark the species before us. In the first, there is great and universal vigour and rapidity of action ; the secretions are all hurried forward in their elaborations, and carried off as soon as produced. In the second, there is little vigour or activity of any kind, and whatever is eliminated is suffered to accumulate. Hence costiveness is a common symptom ; the ankles are cold and pitui- tous ; and the animal oil, when once separated and deposited in the chambers of the cellular membrane, remains there, becomes aug- mented, and produces corpulency and sleekness. The inertness of the body is communicated to the mind ; every exertion is a fatigue; and the mind thus participating in the inertness of the body, the countenance, though fair and rounded, is without expression, and often vacant. Debility is always a source of irritability: and hence there is great irregularity, and a seeming fickleness in many of the symptoms by which this species of plethora is characterized, and the results to which it leads. The bowels, though usually quiescent and costive, are sometimes all of a sudden attacked with flatulent spasms, or a troublesome looseness. The appetite is languid and capricious; the heart teased with palpitations, the chest with dyspnoea and wheezing ; the head is heavy and somnolent; the urine pale, small in quantity and discharged frequently. Medieai In this species, as in the last, we are compelled to begin with treatment. cupmng or t^e use 0f the lancet. But, though the distended and overflowing vessels demand an abstraction of blood, it should never be forgotten that the relief hereby afforded is only temporary ; and that, as the disease is, in this case, an effect of debility, we are directly adding to the cause as often as we have recourse to the Sdication *ancet* °ur leacnng object should be to give tone to the relaxed 5atVgiv- fibres; and to take off the morbid tendency to the production of a Gen. I. Spec. I. Plethora entonica. Sanguine plethora. Medical treatment. «;l. hi.] SANGUINEOUS FUNCTION. [ord. iv. Ill surplus of blood by counteracting the irritability which gives rise to Oen. I. it. Our attack must be made upon the entire habit, which as far as P^,P,hC'H' possible should undergo a total change. The diet should be nutri- atonica. tious, but perfectly simple, and the meals less frequent or less abun- pieX.™. dant than usual; the sedentary life should give way to exercise at insge«wrai first easy and gentle, but by degrees more active, and of longer ex- tent or duration. Tonics, as bitters, astringents, and sea-bathing, may now be employed v^th advantage ; and the muscular fibres will become firmer as the cellular substance loses its bulk. The whole, however, must be the work of time ; for although in by a gra- morals it is a wholesome principle that bad habits cannot too speedily j!^1 pro' be thrown off, it is a mischievous doctrine in medicine. Health being the middle term between excess and deficiency, every day is giving, us a proof that where either of these extremes has become habitual, the system can only be let up or let down by slow degrees, so as to reach and rest at the middle point with certainty and without incon- venience. Professor Monro has furnished us with several very striking examples of this fact: and particularly among those who had acquired a habit of drinking very large quantities of spirituous potations. A man of this description who had broken both bones illustrated. of one leg, and was put, for a more speedy recovery, upon a diet of milk and water and water-gruel, was hereby'thrown into a low fever with an intermitting pulse, twitching tendons, and delirium ; during which he got out of bed and kicked away the box in which his leg was confined. A by-stander and friend of the patient's, of the same irregular habit, ventured to tell the professor that he would certainly kill him if he did not allow him ale and brandy ; since, for several years antecedently, he had been accustomed to both these as his common drink ; a little of each was, in consequence, permitted him ; but the patient's friends did not tie him down to this little; for, extending the grant of an inch to an ell, they instantly gave the man a Scot's quart of ale and a gill of brandy, which was his usual allowance for the evening; he slept well and sound; the next morning was free from delirium and fever; and, by a perseverance in the same regimen, obtained a speedy cure without the least accident.'* * Edin. Med. Ess. Vol. v. Part 11. Art. xlvi. f 18 cl. m. H^MATICA. [ord. iv. GENUS II. ILEMQRRHAGIA. HEMORRHAGE. FLUX OF BLOOD WITHOUT EXTERNAL VIOLENCE. Oen. II. The term haemorrhagia, or hemorrhage, is derived from the Greek Term how ,£iiM, " sanguis," and 'pnyw/zt, " rumpo." Dr. Cullen has adopted fcyTuiien: the same name for an order of diseases ; but there are few parts of rectiyfand ^is arrangement that are more open to animadversion, and which in with gene fact have been more animadverted upon, than the present. The pJobatjoii. order of hemorrhages, or fluxes of blood, ranks in Dr. Cullen's sys- tem under the class pyrexiae, or febrile diseases. Pyrexy, however, is only an accidental symptom in idiopathic hemorrhages of any kind, and has hence been omitted by all, or nearly all, other noso- logists in their definitions : while Dr. Cullen himself has found it impossible to apply it to many hemorrhages, among which are all Profusions those that are called passive; and he has hence been obliged to transfer the whole of these to another part of his system, notwith- standing their natural connexion with the active, and to distinguish them by the feeble name of profusions, instead of by their own proper denomination. Blood, from whatever organ it flows, may have two causes for its issue. The vessels may be ruptured by a morbid distention and impetus ; or they may give way from debility and relaxation, their tunics breaking without any peculiar force urged against them, or their exhalants admitting the flow of red blood, instead of the more attenuate serum. To the former description of hemorrhages, Dr. Cullen has given the name of active ; to the latter that of passive. The distinction is sufficiently clear ; and, under the names already employed in the preceding genus of this system, will lay a founda- tion for the two following species :— 1. HAEMORRHAGIA ENTONHJA. ENTONIC HEMORRHAGE. 2. ------------ATONICA. • ATONIC HEMORRHAGE. cl. hi.] SANGUINEOUS FUNCTION. [ord. iv. 119 SPECIES I. HAEMORRHAGIA ENTONICA. ENTONIC HEMORRHAGE. ACCOMPANIED WITH INCREASED VASCULAR ACTION; THE BLOOD FLORID AND TENACIOUS. As the outlets of the body are but few, and all of them communi- Gen.IL cate with numerous organs, we cannot always determine with strict Q^cai *' accuracy from what particular part the discharge flows. We have, pathology. however, sufficient reason for the following varieties :— x Narium. Entonic bleeding at the nosei /3 Haemoptysis. -------spitting of blood. y Haematemesis. -------vomiting of blood. } Hasmaturia. . ------- bloody urine. e Uterina. -------uterine hemorrhage. £ Proctica. ------- anal hemorrhage. The great predisponent cause of active hemorrhage, wherever it Predispo makes its appearance, is plethora or congestion. A plethoric dia- no thesis will, however, only predispose to a hemorrhage somewhere or other; and hence there must be a distinct local cause that fixes it upon one particular organ rather than upon another. The chief Local local cause is a greater .degree of debility in the vessels of such organ cau6e than belongs to the vascular system generally. But there are other and more extensive causes that operate upon some organs, and which consist in an unequal distribution of the blood and its peculiar accumulation in some vessels rather than in others. Thus, some organs acquire developement and perfection sooner than others, of which the head, peculiarly large even in infancy, furnishes us with a striking example : and, in the promotion of such developement, the flow of the blood is directed with greater force and in greater abundance. And hence, while the coats of the blood-vessels in this Hemor- organ are yet tender, and destitute of that firmness which they themJe"* derive from age, we have reason to expect hemorrhage as a fre- wnence' quent occurrence and particularly from the vessels of the nostrils; because there is in the nose, for the use of the olfactory sense, a And why considerable net-work of blood-vessels expanded on the internal young par- surface of the nostrils, and covered only by thin and weak integu- ioni- *^ merits. And on this account, we see why young persons are so much more subject to bleedings from this organ than those in mature life. Haemoptysis, or spitting of blood, takes place more commonly JJ^JJJP^* a few years later, and when the animal frame has acquired its full And why growth, and consequently the vascular system its full extent or Ion- J^^nfe. .20 m.] HiEMATICA. [ord. Iv. Gen. II. Spec. 1 Hae otor- rhagia en- tonica. Entonie hemor- rhage. Why a rare occur. rcnce after thirty-five. Whence hsemate- meais; anal hemor- rhage ; and he- morrhages from other abdominul or pelvic organs. Active he morrha^e frequently a result of incidental causes: as violent exertion external or internal: gitude. Antecedently to this, the impetus and determination of blood are greater in the aorta and its extreme ramifications than in the pulmonary artery, because more of the vital fluid is demanded for the progressive elongation of the very numerous arteries that issue from the former : and, consequently, a greater tendency to plethora exists in this direction till the age of about fifteen or eighteen than in the direction of the lungs. Till this period of life, therefore, we have no reason to expect hemorrhage from the respi- ratory organs. When this term, however, has arrived, the bias is thrown on the other side ; and the vessels of the corporeal and of the pulmonary circulation being equally perfected, the tendency to accumulation will be in the latter, in consequence of their shorter extent. This tendency will continue till about the age of thirty-five; which is exactly correspondent with the observation of Hippocrates, who has remarked that haemoptysis commonly occurs between the age of fifteen and that of five and thirty. We have explained why it does not often occur before fifteen, but what is the reason of its seldom occurring after the latter period ? Dr. Cullen has ingeni- ously explained it in the following manner. The experiments of Sir Clifton VVintringham, he observes, have shown .that the density of the coats of the veins compared with that of the arteries is greater in young than in old animals ; from which it -may be presumed that the resistance to the passage of the blood from the arteries into the veins is greater in young animals than in old ; and while this resist- ance continues, the plethoric state of the arteries must be perpetu- ally kept up. The very action, however., of an increased pressure against the coats of the arteries gradually thickens and strengthens them, and renders them more capable of resistance ; whence in time they come not only to be on a balance with those of the veins, but to prevail over them ; a fact which is also established by the ex- periments just adverted to. After thirty-five, therefore, the constitutional balance become? completely changed, and the veins instead of the arteries are chiefly subject to accumulation. The greatest congestion will usually, perhaps, be found in the vena portarum, in which the motion of the venous blood is slower than elsewhere ; and such congestion alone will frequently act upon the neighbouring arteries, and induce what may be called a reflex plethora upon them in consequence of their inability of unloading themselves : and hence, the chief origin of haeraatemesis, and hemorrhage, and various other hemorrhages from the abdominal and pelvic organs. All these organs, however, are exposed to hemorrhage from inci- dental causes, as well as that constitutional change which has a tendency to produce the disease vicariously. Thus, hemorrhage in all of them is occasionally produced by violent exertion, as great muscular force ; vehement anger, or other passions or emotions of the mind ; severe vomiting, or coughing ; suppressed evacuations of various kinds, especially hemorrhoids of long standing, catamenia, habitual ulcers, issues, or chronic erup- tions of the skin :* as also by the wound of a leech swallowed ac- * Percival's Essaya, 11. p. 181. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 121 eidentally.* But in this last case it is probable that the living prin- Gen. H- ciple of the stomach is in a state of weakness, as in all other cases hx^ot- ' in which exotic worms are found to continue alive under its action : tr^£ia en" since we know that this action when in full vigour is sufficient to Entonic destroy oysters, frogs, slugs, leeches, and various other cold-blooded J1*™^ animals in a short time. Haemoptysis is also said by many writers suppressed to have been produced by leeches accidentally taken into the sto- t;0ns. mach by a draught of water.! But it is probable that in this case $£*£[tJ, there is a deception : and that the blood discharged by coughing wound of a from the trachea has first passed into it from the stomach and mouth, b^ted e Local stimulants are also an occasional cause. Thus the vessels J^™"1^; both of the kidneys and rectum have been excited to hemorrhage mutants by an injudicious use of aloes, terebinthinate preparations, and °^",occa" pungent alliaceous sauces. And the former by cantharides, whether causes. applied externally or internally : for Schenck and other writers have given examples of haematuria excited in irritable constitutions by vesicatories alone.J Occasionally, however, all the various kinds of hemorrhages be- l^0T fore us have assumed a different character, and proved salutary and sometimea critical. Thus, cephalitis has often ceased suddenly on a free and ^^J,u. sudden discharge of blood from the nostrils; pneumonitis, from tary. what has been deemed an alarming haemoptysis ; visceral infarctions, from a liberal evacuation of the hemorrhoidal vessels ; a jaundice has been carried off by "a profuse hsematuria,§ and fevers of various kinds have instantly yielded to a spontaneous appearance of any of them. Such hemorrhages, however, though salutary in their onset, must Apt to pass be cautiously watched ; since, if not checked when they have ac- Sc°rorm° complished their object, they are apt to pass into a chronic or peri- odic form. Hence many persons have monthly discharges from the rectum ; others from the nostrils ; others again, occasional or peri- odic, from the lungs ; and a few from the stomach. || Tulpius gives a case of chronic haemoptysis that continued for thirty years ;1I and there are other instances of much longer duration.** There is also another reason for an early attention to spontaneous hemorrhages ; and that is, the profuseness of the discharge which Flow of sometimes takes place, and the alarming exhaustion which follows. pro?use,.tcn Dr. Banyer, in the Philosophical Transactions,!! gives a case of this sort, in which the discharge was from the bladder ; Biichner, another case from the same organ, in which it amounted to not less than four pounds :|J and other writers bring examples of its having proved fatal. The largest quantities, however, are usually lost from the nostrils. Largest Ten, twelve, and upwards of twenty pounds have been known to |0ust are gonerally • from the * Galen. De Loc. Affect. Lib. iv. Cap. t.—Riverius, Observ. Med. Cent. iv. n°»tli,s' Obs. 26. t Galen. De Loc. Affect. Lib. iv. Cap. v.—Borelli, Cent. i. Obs. 24. I Scbenck, Lib. vn. Obs. 124. ex Langio.—Hist. Mort. tlratislav. p. 58. § Scbenck, Obs. Lib. in. Serin, n. N. 258. i| Rhodius, Cent. n. Obs. 64.—Ab Heer. Introduct. in Archiv. Archci. 1T Lib. u. Cap. n. ** N. Act. Nat. Cur. Vol. i. Obs. i, tf Vol. xlii. : t Miscell. 1728. p. 1496. Vol. III. —16 122 cl. in.J HiEMATICA. [ord. iv Gen. II. Spec. I. Hxmor- rhagia cn- tonica. Entonic hemor- rhagia. Examples. o H. ento- nica nari- um. Entonic bleeding at the nose. Precursive symptoms common: but not al- ways to be ■net with. Occasional causes. Nostrils why re- garded as the seat ol mental irritation. flow away before the hemorrhage has ceased. Bartholin mentions a case of forty-eight pounds,* Rhodiu another of eighteen pou ;ds lost within thirty-six hours ;! and a respectable writer in the Leip- sic Acta Erudita, a third, of not less than seventy-five pounds within ten days ;J which is most probably nearly three times as much as the patient possessed in his entire body at the time the hemorrhage commenced. In the Ephemera of Natural Curiosi- ties is a case in which the quantity indeed is not given, probably from the difficulty of taking an account of it, but which continued without cessation for six weeks.§ In active hemorrhages from the nostrils, the epistaxis of many writers, the discharge is usually preceded by some degree of local heat and itching ; and occasionally by a flushing of the face, a throbbing of the temporal arteries, a ringing in the ears, or a pain or sense of weight and fulness in the head. Yet not unfrequently the blood issues suddenly without any of these precursories ; for, as we have already observed, the arteries distributed over the Schneiderian membrane are very numerous and superficial, and a very slight irritation is often sufficient to rupture them. That in- solation or exposure to the direct rays of the sun, a cold in the head, or cold applied to the feet or hands, coughing, or sneezing, especially upon the use of sternutatories, an accidental blow upon the upper part of the nose or forehead, or a jar of the entire frame, as on stumblingj^should be sufficient to prodtfce this effect, can easily be conceived; and these, in truth, are the common occasional causes : but it is singular that it should follow, in some highly irri- table idiosyncrasies, upon such very trivial excitements as have been noticed by many pathologists. Thu5\Bruyerin1 gives an example in which the nostrils flowed with blood upon smelling at an apple: Rhodius, upon the smell of a rose :1f and Blancard, upon the ring- ing of bells :** and when we find the same effect produced by various emotions of the mind, as terror, anger, and even a simple excitement of the imagination,!! we may readily trace by what means the philosophers and poets of the eastern world, and even some of those of the western, were led to regard the nose as the seat of mental irritation, the peculiar organ of heat, wrath, and anger ; and may discover how the same term *|s (ap or aph) came to be em- ployed among the Hebrews to signify both the organ and its effect, the nose and the passion of anger to which it was supposed to give rise. We have already observed that the quantity'of blood discharged by a spontaneous hemorrhage from the nostrils is sometimes enor- mous. This, however, is a more common result of passive than of active hemorrhage ; and is more usually found in advanced than in parly life : the two stages in which nasal hemorrhage chiefly shows itself. And where it frequently returns it is apt, like the hemor- I Anat; Renov- Lib- »• CaP- ▼!• t Cent. i. Obs. 90. I Lib. 1688. p. 205 § Dec. I. Ann. ill. Obs. 24S. || Bruyennus, De Re Cibaria. Lib. i. Cap. 24. IT Rhodius, Cent. in. Obs. 99. ** Blancard, Collect. Med. Phys. Cent. vi. Obs. 74. t+ Rhodius, Cent. I. Obs. 89. ol. m.] SANGUINEOUS FUNCTION. [orb. iv. ISA rhoids, to form a habit of recurrence that cannot be broken through <»en.il without danger, except by an employment of evacuants, or some aTi. ^,'to other drain.* nica na- if it be evidently connected with entonic plethora, or accompa- Entonic nied with the local symptoms just enumerated, it will afford a more o^n'ofe?' effectual relief than bleeding in any other way, and should not be Medical restrained till it has answered its purpose. Even a small portion of often re-' blood, not amounting to more than a table-spoonful or two, when ^^"j?* thus locally and spontaneously evacuated, has afforded, on some and should occasions, a wonderful freedom and elasticity to an oppressed and denize-* heavy head : and, when more copious, has probably prevented an strained. apoplectic or epileptic fit, as it has often formed a salutary crisis in inflammation of the brain, or fevers in which the brain has been much affected. But when these reasons do not exist, the bleeding should be In «>*«' checked by astringent applications. Cold • is the ordinary applica- checked at tion for this purpose, and it commonly succeeds without much trou- °°Jjcb ble. Cold water may be sniffed up the nostrils, or thrown up with what a syringe; but the exertion of sniffing, or even the impetus of the mcans" water alone, where a syringe is employed, sometimes proves an ex- citement that more than counterbalances the frigoric effect. Inde- pendently of which there. is an advantage in leaving -the blood to coagulate on the ruptured orifice of the vessel, which these methods do not allow. By means of a syringe, however, we can throw up, when necessary, astringents of more power than cold water, as vinegar, or the sulphuric acid properly diluted, or a solution of sul- phate of zinc, copper, iron, or lead, after which we should force up tents of lint moistened with the same, and particularly with extract of lead diluted with only an equal quantity of water, as high as we are able with a probe or small forceps, so as to form a tight com- press : the styptic agarics can be rarely used to advantage. The face may, at the same time, be frequently immersed in ice-water, or water artificially chilled to the freezing point; and the temples, or even the whole of the head, be surrounded with a band or napkin moistened with the same, and changed as soon as it acquires the warmth of the skin. When tents are used, they have sometimes been illined with moistened powder of charcoal, which, of itself, has proved an excellent styptic. Cold applied to the back will suc- ceed, but often fails ; it is more certain of success when applied to the genitals. . Emetics have occasionally been of service, and are recommended by Stoll.! The principle upon which they may be presumed to act will be noticed under haemoptysis. The bleeding has sometimes been checked by a sudden fright,! probably from the cold sweat that so often attends such an emotion : and Reidlin gives a case in which it was cured by sneezing ;§ but this was probably a case of atonic hemorrhage, in which the spasmodic action might assist in corru- gating the mouths of the bleeding vessels. •J. P. Frank, De Cur. Horn. Morb. Epit. Tom. vi. Lib. vi. Pars in. 8?o. Viennae, 1821. t Rat. Med. Part HI. p. 21. X Panarol. Pentecost, v. Obs. 27. f Linn. Med. Ann. l. Obs. 24. 124 cl. in.] 1LEMATICA. [0BD- Iv- Gen. 11. Spec. I. a. Hentoni. e;i narium. Entonic bleeding at the nose. Internal astringents not often necessary. |S H enlo- nicn Hae- moptysis. Entonic spitting of blood. Not easy to deter- mine from what quar- ter the blood flows. Symptoms indicating its proceed- ing from ihe lungs: from bran- ches ot the pulmonary artery: from bran- ches of the bronchial artery. Prognos- tics; favoura- ble: unfavour- sblc. Oocasional tz a uses. It is rarely necessary or even proper in this variety of hemorrhage to employ any internal astringent or other tonic : but if this discharge should be excessive, and produce debility, the same plan may be resorted to as will be recommended under the ensuing species. In H.EMOPTVsis or spitting op blooo, it is not always easy to de- termine from what vessel or even from what organ the bleeding pro- ceeds : for the blood may issue from the posterior cavity of the nostrils, or from the fauces as well as from the lungs. If, however, from the first, it will cease upon bending the head forward or lying procumbent, and- will probably flow from the nose: if from the second, we shall commonly be able to satisfy ourselves by inspection. Blood from the stomach is of a darker colour, thrown up by vomit- ing, and betrays an intermixture of food. If the haemoptysis produced be from the lungs, and belong strictly to the present species, and more especially if it be a result of etonic plethora, the blood will be chiefly thrown up by coughing ; and the discharge will be preceded by flushed cheeks, dyspnoea, and pain in the chest. There is usually, also, a sense of tickling about the fauces, which often descends considerably lower ; Salmuth asserts that he has known it extend to the scrobiculus cordis.* These symptoms, moreover, indicate that the blood flows from a branch of the pulmonary rather than of the bronchial artery. The blood is here of a florid hue, and the hemorrhage sudden and often copious. If a branch of the bronchial artery give way, the flow of blood is usually much slower, and smaller in quantity : there are no precursive symptoms, the blood is rather hawked or spit up intermixed with saliva, and, from being longer in its ascent, is of a darker colour. From its lodgment, however, in the air-vessels, it becomes a cause of irritation, and a frothy cough ensues, sometimes accompanied with a little increase of the pulse and other febrile symptoms, as a feeling of heat and some degree of pain in the breast, which subsides after the ejection, and returns if there be afresh issue. If the structure of the lungs be sound, we have no reason to prog- nosticate danger. On the contrary it often affords great relief to a gorged liver, and has proved critical in obstructed menstruation. Excreted with the sputum it is frequently serviceable, as we have already observed, in cases of asthma, pleurisy, and' peripneumony. But if it have been preceded by symptoms of phthisis, or a strumous diathesis, there is a great reason for alarm ; for we can have little hope that the ruptured vessel will heal kindly and speedily, and have much to fear from the fresh jets, by which the extravasated blood becomes deposited and forms a perpetual stimulus in an irritable organ. The general pathology has been already laid down. The inci- dental causes are misformation of the chest; undue exertion of the respiratory muscles, whether in running, wrestling, singing, or blow- ing wind-instruments ; excess in eating or drinking; or a violent cough. As a symptom or sequel, it occurs in wounds, phthisis, or the suppression of some accustomed discharge. *■ Trnf. in. Obs. 45. * l. in.] SANGUINEOUS FUNCTION. [or». iv. 125 In active hemorrhage from the lungs, venesection is one of the Gen> 'J* most important steps towards a cure ; and the blood should be drawn £ Hferito-" freely at once, rather than sparingly and repeatedly; though a second Dico H?~ and even a third copious use of the lancet will often be found expe- e, tonic' dientr Emetics have been recommended, but they are of doubtful l^oa.s °f effect. They augment the vascular volume by relaxing the capilla- Medical ries; but they stimulate locally by the act of rejection. • Drastic Bfeeding: purgatives are avoided because of the straining ; but the straining in J^*™: vomition is greater and more direct. purgatives Dr. Brian Robinson of Dublin, who was one of the most strenuous avoided. promoters of this mode of practice in his day, accounted for the benefit of emetics by the constriction which he conceived they pro- duce upon the extreme vessels every where ; but to act thus they should rather nauseate than vomit; for in nausea we have great Different vascular depression, and a cold and general collapse on the surface ; vomiting while vomiting is known to rouse the system generally and deter- "g^t? mine towards the surface. Upon the recommendation of Dr. Robinson, Dr. Cullen followed the plan in several cases : " but in Vomiting one instance the vomiting," says he, " increased the hemorrhage to creased the a great and dangerous degree; and the possibdity of such an accident *£?*e0r under Plethora, it is not at all to be wondered at that hemorrhage mue™t^ua, should in both conditions take place from the uterus very frequently, and perhaps mofe so than from any other organ For'reasons we shall have occasion to explain in a subsequent part Ordinary of this work, the uterus, from the period of the completion of the progress.0 female form, is stimulated, once in every lunation, to the secretion and elimination of a peculiar fluid, which exhibits the colour, though it is deficient in many of the properties of blood ; and for this pur- pose the uterine arteries are, at such seasons, peculiarly tuigid and irritable. There is hence always a tendency on such occasions to a hemorrhage in this quarter in females of a firm and robust texture, and of a plethoric habit. But if from cold or any other cause the uterine secernents do not at these seasons fulfil their office, and throw forth the proper fluid, the uterine arteries will be inordinately gorged; the regular stimulus will be greatly augmented ; pain, tension, and spasm will extend over the lojtis ; and the extremities of the vessels be ruptured, or their mouths give way by anastomosis ; and a con- siderable hemorrhage bej;he consequence. This is the ordinary period in which uterine hemorrhage takes place ; though it may occur during any part of the interval between Occasion the catamenial terms, upon any of the occasional causes that opeiate du'ced'by upon other organs, and form the preceding varieties : as it is also oll,er well known to occur at times, with great violence, during pregnancy and in child-bed. When we come to treat of diseases appertaining to the sexual organs, we shall have to notice some singular cases of precocity in female infants, and especially that of a regular menstruation. It is Has occur upon this principle alone that we can account for uterine hemorrhage bom"in-ew in new-born infants ; of which the medical records give several ex-fants- amples : and especially the Ephemerides of Natural Curiosities. In suppressed menstruation uterine hemorrhage affords relief to sometimes the spasms and pains that harass the loins, and the head-ache and difficulty of breathing which have usually preceded the lumbar dis- tress. But the discharge may be immoderate, and become habitual, but aptte And it is hence best to be upon our guard, and to use venesection j>e=vme. 1 i- • • i i i- < habi'ual. as a substitute ; and to prevent or diminish the spasmodic action by Treatment. gentle aperients and the sedatives already recommended in haemop- tysis ; after which the case will become a disease of suppressed menstruation alone, and must be treated according to the method recommended under that malady ; for a restoration of the Catame- nial secretion is its natural cure. I may here, however, observe Cure by that when the suppression of this secretion has been of some stand- lione,pa ing and an uterine hemorrhage has periodically taken its place, ac- companied with dressing pains in the whole'circle of the pelvic 128 cl. in. J H.K VIATICA. [ORU. IV. Gen. II. Spec. I. c H. entoni ca ulcrina. Enti.nic uterine he- morrhage. i, H. Ento- nicapruc- ticn. Entonic anal he- morrhage. How pro- duced. Sometimes a symptom of pile*; hut not ne- cessarily so. Precursive symptoms. Curative process. ^Mild ape- rients. Sulphur. Local'as- tringents when un- advisable. region, we can sometimes suddenly restore a healthy action to the organ by a plan of anticipation. For this purpose I have prescribed venesection about ten days before the return of the monthly parox- ysms ; and having thus taken oft" plethoric impetus, I have, a few days afterwards, recommended the hip bath to be used in a tepid state, every night, and persevered in till the period of relapse ; when I have often found that there has been neither tension nor spasm; that the loins have continued easy, and the hemorrhage has yielded to the natural secretion. In hemorrhage strictly anal the flux of blood issues chiefly from the hemorrhoidal vessels; and as these are large, and bat little supported by any surrounding organization, they readily give way both in an entonic and atonic state of the frame, and particularly in case of plethora, upon very slight excitement; as in straining to expel hardened feces, taking cold in the feet, or walking a little too far. Irritants introduced by the mouth have also proved a frequent cause of this variety of hemorrhage ; as an injudicious use of aloes, tere- binthinate preparations, or even pungent alliaceous sauces. The irritation of piles is also a very common cause ; and hence by some writers anal hemorrhage is only treated of as a symptom of that variety of this last disease which is known by the name of bleeding piles. But this is highly incorrect; as anal hemorrhage often occurs, and very profusely, where no piles have ever been expe- rienced. This power of hemorrhage when active, as it is called, or in an entonic habit, is usually preceded by a sense of weight and pain within the rectum, and sometimes by a load in the head. And it has often, as already observed, proved critical and. salutary, and carried off con- gestions from the abdominal viscera. It is however, peculiarly apt to become profuse, and to establish an order of recurrence ; and hence must be overpowered by the reducent and sedative plan re- commended in most of the preceding varieties, and particularly in that of haemoptysis. The aperients employed, however, should here be peculiarly mild and alterant; and sulphur, which does not readily dissolve in the course of the intestinal canal, and often reaches the rectum in an unmixed state, is one of the best, and is ofteif found strikingly serviceable. All stimulant foods, moreover, must be especially avoided ; and the ordinary drink should be water, soda- water, or lemonade. Here also we are liable, as in the case off hemorrhage from the nose, to employ local astringents, though it would be improper to use those that act generally, so long as plethora or an entonic habit continues. The patient may sit in a bidet of ice-water, or water cooled artificially to the freezing point, or may use a cold hip-bath, and have injections of cold-water, or astringent lotions, as of alum, zinc, or even lead, thrown up the rectum ; the latter of which should be in such proportion as to remain there for half an hour or an hour. cl. m.J SANGUINEOUS FUNCTION. foEi>. jv. V2U SPECIES II. H^EMORRHAGIA ATOMCA. ATONIC HEMORRHAGE. ACCOMPANIED WITH GENERAL LAXITY OR DEBILITY ; AND WEAK VASCULAR ACTION ; BLOOD ATTENUATE AND OF A DILUTED RED. Though the effect in this species is the same as in the preceding, Gen. It, the proximate cause, as well as the more obvious signs, are directly Sp*c* *'* opposite. The general pathology has been given in the introductory remarks to the genus, and the more common organs from which the hemorrhage proceeds are the same as already noticed under the preceding species ; and herice the varieties of that may be regarded as those of the species before us. When plethora is the remote cause, which it often is, it is atonic plethora, or plethora of debility ; but whatever has a tendency to ""* i« loosen or enervate the tone of the solidum vivum, or living fibre, why a will lay a foundation for this kind of hemorrhage. It is hence a ^"j*!*" characteristic disease of advanced age, as entonic plethora is of ease: of youth and adult life; and often takes place in those whose vigour is Sibilating reduced by meagre or innutritious food, close confinement without powers- exercise in a foul and stagnant atmosphere, or immoderate indul- gence in the pleasures of wine or sexual intercourse. Hence too, its frequent occurrence, as a symptom, in tabes, atrophy, struma, scurvy, and low fevers. The characters of the several varieties of this species, as dis- tinguished from those of the preceding, are as follow ; for it is not necessary to put the varieties themselves into a tabular form :— In hemorrhage from the nostrils, the blood flows without « n atom heat or head-ache. Zo^"" In that from the respiratory organ, it is usually produced with- w©ed'nff out even the exertion of coughing, and is often accompanied with a noU. scirrhous or calculous affection of the lungs ; the countenance is j^HaVmo- pale and emaciated. p'ysi*. In HEMORRHAGE FROM THE ALIMENTARY CANAL, the blood is dis- ^.iu'mgof charged without tensive pain : though there must necessarily be an W*1K'* . expulsive effort; and, from the inanition hereby produced, some ca Hmma- degree of nausea and faintness. AtQn!c%o- When evacuated by the urethra, there is, for the same reason, ,ni,i"s of faintness, but little or no previous pain. The most singular and ju.ntonica severest examples of hemorrhages from the urethra are those that "j*™*" have occurred during coition ; sometimes intermixed with semen, Aior.ic sometimes instead of it, and sometimes immediately after emission. „rine.y The individuals have been generally persons of highly irritable and ^"jl" delicate habits ; and who have weakened themselves bv fc>o free an during^. Vol, ITT.—17 'hl 130 cl. iii.] HAiMATICA. [ord. IV. Spec h in(mlgence in pleasures of this kind. Numerous instances of this S H.at'oni- sort of hemorrhage are given in the Collections of Medical Curiosi- tCuria.a!ma" ^eSl ana" especially in several of the German Ephemerides. Atonic There is little pain in atonic hemorrhage from the uterus : „°n£y and it generally occurs at the natural cessation of the menstrual sH.atonica flux, or within a few years afterwards. As a concomitant, hemorrhage Atonic ute- from this quarter is also frequently found in a scirrhous, cancerous, rhage.6"10' or otner morbid states of the uterus, in whatever period of fife these may occur ; which, however, they do most usually after the age of forty or fifty. Atonic hemorrhage from the anus ordinarily takes place spontaneously with little or no pain; but commonly with varices or congestion of the hemorrhoidal vessels, and is very apt to pro- duce a habit of recurrence. In all these varieties venesection must be had recourse to sparingly; and never, unless where we have satisfactory evidence of atonic plethora or congestion. It may sometimes be requisite to use the lancet in nasal hemorrhage, for the head may feel oppressed and drowsy : and it will still more frequently be necessary in hemorrhage from the uterus ; but the blood abstracted should rarely exceed seven or eight ounces ; and in all other varieties, as a general rule, it will be better to withhold our'hand, and to proceed at once with a tonic plan of treatment. Into this plan we may, in the present species, freely admit the use of general astringents in conjunction with their local application, however objectionable in the preceding ; for a laxity and inelasticity of the fibrous structure are among the chief symptoms we have to oppose ; and hence the mineral acids and metallic salts may be had recourse to with great advantage along with bitters : and with a few exceptions, we cannot well err in the selection. The preparations of iron may be rather too heating in haemoptysis, and perhaps in all atonic hemorrhages accompanied with much irritability. One of its mildest and best forms is that of a subcarbonate ; and perhaps the best mode of obtaining it in this form is by the celebrated composi- tion of Dr. Griffiths. The myrrh is also in his preparation a useful article for the present purpose, and we shall rarely do better than employ it. In the London Pharmacopoeia, it is given under the .name of mistura ferri composita. From the manifest power of opium to restrain most evacuations, it has often been employed in hemorrhages. It does not appear, however, to have any direct effect in checking the discharge ; and in entonic hemorrhages, and especially when employed early, has beqn highly mischievous. But where in haemoptysis there is a per- petual cough from irritation, or in uterine hemorrhages a frequent recurrence of spasmodic pains, it has been tried with considerable .success. And the same remark will apply to hyoscyamus, and " various other narcotics, which seem to be only useful on the same account. Cinchona, which is peculiarly objectionable in the preceding spe- IkwIZsm". cies, may here be had recourse to with considerable promise. It ?*rm»\ however, to be chiefly serviceable in uterine hemorrhage, £ H. atonica proctica. Atonie anal hemor- rhage. Medical treatment of atonio hemor- rhage. Blood should be abstracted with cau- tion. Free rise of astringents end other tonics. Opinm how far useful. Cinchona where most UL.nr.J SANGUINEOUS FUNCTION. [•*».»-. W where the disease depends upon a laxity of the extremities of the ^en. *'• vessels, which are therefore readily opened by every irritation applied Hatmor- to the system or to the diseased part. Whether in this case it .acts rha«ia at0" altogether as a bitter, as supposed by Dr. Cullen, or partly also as Atoniche- an astringent, it may be difficult to determine ; but the question is TreatmCTt not of importance. For other general roborants to which it may be necessary to have recourse, the reader may turn to the treatment of limosis dyspepsia,* or indigestion; and he may govern the patient's diet and regimen by the general plan there laid down. The local astringents and refrigerants, already recommended Local as- under the former species, may be here employed with even less n^ref'ige^ reserve : and where the bleeding has become chronic, which it is L6"'"-. . c i-i 1 . • 1 i • • i ■ ii Stimulants tar more,hkely to do than in entonic hemorrhage, or has been so in what profuse as very considerably to exhaust the system, a little wine or JJJf UKr some other cordial should be administered as soon as we are con- sulted : for, however small the* vessel that is ruptured, its orifice is incapable of contracting from a total loss of tone : and hence a diffusible stimulus gives it the irritation it stands in need of, and forms a salutary constringent. A striking case of this kind has illustrated. already been given in treating of accidental hemorrhages from ex- tracting teeth :f and it is not long since that the author was re- quested to attend in a similar hemorrhage from the nose. The patient was a lady of about fifty years of age, of slender and deli- cate frame, who had for some years ceased to menstruate. The bleeding had continued incessantly for three or four days, during which she had been restrained to a very low diet, and allowed nothing but toast and water for her common drink. She was faint, felt sick, and had a feeble pulse, and must have lost many pounds of blood, though no exact measure had been taken. I gave her, instantly, a free draught of negus made with port wine, prescribed camphor mixture with the aromatic spirit of ammonia, had the nostrils syringed with equal parts of tincture of catechu and water, and applied a neckerchief wetted with cold water round the temples, directing it to be renewed every ten minutes. In half an hour the hemorrhage ceased, and on the ensuing day I found no other symp- tom than weakness, for which a nutritious but inirritant regimen was prescribed. A few days afterwards, the hemorrhage returned from sneezing or some other incidental stimulus, and was restrained, as I was told, for I did not see her, by a recurrence to the same plan. I recommended, however, carriage-exercise, and an excursion to the sea-coast, which was immediately complied with, and there was no recurrence of the disease. To effect the same intention, I have occasionally advised cardiacs Far'.^'[dex combined with astringents in baematemesis, where the discharge of blood has been profuse, and has continued for some days, and the patient has become considerably exhausted : and I do not recollect an instance in which the plan has proved unfriendly. In like man- ner, in very great faintness or deliquium produced by a copious and * Crass I. Or*. I. v"oJ. I. p. 139. loO. t Vol* I. p. 68. 132 .i. ui.] HAEMATIC A. |«i>. iv. Gp.n. it. Spkc. II, Hsmor- T I) o^'iati Io- nic* Atonic hn- morrlia^e. Treat ment, Acetate of lead. Its evils Corrected by opium, ltd pro- posed by Reynolds: and since by Latham: »cetw» cide : and which is intended to embody that extraordinary decline ciesl *P of all the corporeal powers, which, before the system falls a prey to confirmed old age, sometimes makes its appearance in advanced life without any sufficiently ostensible cause, and is occasionally succeed- ed by a renovation of health and vigour, though it more generally precipitates the patient into the grave. Extenuation or leanness is not necessarily a disease ; for many Extcnua persons who are peculiarly lean are peculiarly healthy ; while some leanness there are who take pains to fall away in flesh that they may increase gu^'1"" in health and become stronger. Hut if an individual grow weaker from enu- as he grows leaner, it affords a full proof that he is under a morbid 134 cl. nr.j ILEMATICA. [ord. iv. Gf.n. Ill Marasmus- Emacia- tion. Waste from dis- eases of some or- gans great- er than from those of others; as peculiar- ly noticed by Pem- berton. Exemplifi- cation. Causes of this differ- ence ex- plained. Glands of supply what. Glands of waste what. This expla- nation how for applica- ble to the species be- fore us: influence ; and it is this influence, this conjunction of extenuation with debility, as noticed in the definition, that is imported by the term marasmus, and its synonym emaciation. It is curious to observe how much more easily the body wastes under a disease of some organs than of others : and it would be a subject of no small moment to inquire into the cause of this, and to draw up a scale of organs effecting this change from the lowest to the highest degree. Dr. Pemberton, in a work of considerable merit, published many years ago, threw out some valuable hints upon this subject, which it is to be lamented that he did not afterwards follow up to a fuller extent The following passage is well worthy of notice, and aptly illustrative of what is here intended. " Let us take," says he, " the two cases of a diseased state of the mesenteric glands, and a diseased or scrophulous affection of the breast. In the former we shall find there is a great emaciation ; in the latter, none at all.—In an ulceration of the small intestines, great emacia- tion takes place ; in scirrhus of the rectum, none.—In a disease of the gall bladder, which is subservient to the liver, the bulk of the body is diminished ; but in a disease of the urinary bladder, which is subservient to the kidneys, scarcely any diminution of bulk is to be perceived. In an abscess of the liver, the body becomes much emaciated ; but in an abscess of the kidneys, the bulk is not di- minished. " If we examine into the function of those parts, the diseases of which do or do not occasion emaciation, we may perhaps be led to the true cause of this difference of their effect on the bulk. In order, however, to understand more clearly how the functions of these parts bear relation to each other, it may be necessary to pre- mise that the glands of the body are divided into those which secrete a fluid from the blood for the use of the system, and those which secrete a fluid to be discharged from it. The former may be ter- mined glands of supply ; the latter glands of waste. " The smaller intestines, in consideration of the great number of absorbents with which they are provided for the repair of the system, may be considered as performing the office of glands of supply. Large intestines, on the contrary, may be considered as performing the office of glands of waste : insomuch as they are furnished very scantily with absorbents, and abundantly with a set of glands which secrete or withdraw from the system a fluid which serves to lubricate the canal for the passage of the feces, and which itself, together with the feces, is destined to be discharged from the system. The glands which secrete a fluid to be employed in the system, as well as the glands of direct supply, may be considered the liver, the pan- creas, the mesenteric glands, perhaps the stomach, and the small intestines ; and the glands of waste are the kidneys, breast, exha- lant arteries, and the larger intestines." The first set are, in fact, the general assemblage of the chylific organs ; and it is upon their direct or indirect inability to carry into execution their proper function, that the first of the species we arc now about to enter upon, that of atrophy, is founded in all its varie- ties. How far these remarks will apply to the other species of tlic cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 135 present genus is not quite so clear. The seat of the third and Gen. in. fourth may be doubtful, perhaps variable ; that of phthisis, or the Emacia-US fifth, admits of no debate. Are the lungs to be regarded as an organ ^"tjcu]ar. of waste or of supply ? The question may be answered in opposite b; to phthi ways, according to the hypothesis adopted respecting the doctrine SM' of respiration. They throw off carbonic acid gas. Do they intro- duce oxygene or any other vital gas into the circulating system ? As an organ of waste, we cannot, upon the principle here laid down, account for the emaciation which flows from a diseased condition of them. If it can be substantiated that they are an organ of sup- ply, they confirm and extend the principle. Will this principle, moreover, apply in dropsy, in which there is even more emaciation than in phthisis ? The subject is worth enucleating ; but we have not space for it, and must proceed to arrange the five species that appertain to the genus before us :— L MARASMUS ATROPHIA. ATROPHY. 2. -------- ANHjEMIA. EXSANGUINITY. 3. ----.---- CLIMACTEBICU6. DECAY OF NATURE- 4.--------TABES. DECLINE. 5.--------PHTHISIS. CONSUMPTION. Most of these follow in regular order, as genera or species in most rare'*Ds^ of the nosological arrangements, and are set down as subdivisions other nose- of macies or marasmus. By Dr. Cullen, phthisis is regarded as a loe,8ts- ,niere sequel of haemoptysis, upon which we shall have to observe in its proper place: while atrophia and tabes are given as distinct dis- eases under the ordinary head, only that for macies or marasmus he employs marcores as an ordinal term. The common distinguishing Species marks are, that atrophy is emaciation without hectic fever ; tabes, caiTy^istln- emaciation with hectic fever ; and phthisis, emaciation and hectic guisbed fever coupled with pulmonary disease. And such, with the excep- tion of phthisis, is the distinction continued by Dr. Cullen in his Sy- nopsis. But in his Practice of Physic he informs us that his views upon this subject had undergone a change, not only in respect to the subdivisions or varieties of these two diseases, but as to the dis- eases themselves. " I doubt," says he, " if ever the distinction of objection tabes and atrophia, attempted in the Nosology, will properly apply; ° as I think there are certain diseases of the same nature, which some- times appear with, and sometimes without fever."* This is written in the spirit of candour that so peculiarly characterizes this great man. But I cannot thus readily consent to relinquish a distinction replied to. which has received the sanction of so many observant pathologists, and which appears to me to have a sufficient foundation. It is dif- ficult, undoubtedly, to assign a proper place to all the varieties, or subdivisions of these species ; but this is a difficulty common to many other diseases equally ; for we perceive fevers, nervous affec- tions, and those of the digestive organs, perpetually running into each other in different varieties, while we find it convenient to ar- N Vol. if. Part in. Book i. Sect, mdcxviii. 136 cl. m.] HiEMATICA. [OBD. IV. Gen. III. raI)ge amj describe them as distinct diseases notwithstanding. And, &* with the caution attempted to be exercised in respect to the species tion- before us, I trust that the reader will not discern a greater transgres- sion of boundary in the present than in various other cases of gene- ral allowance. SPECIES I. MARASMUS ATROPHIA. ATROPHY. COMPLEXION PALE, OFTEN SQUALID : SKIN DRY AND WRINKLED I MUSCLES SHRUNK AND INELASTIC : LITTLE OR NO FEVER. Gen. HI. The specific is a Greek term deduced from «, privative, and ®?EC# l. retQM, "nutrio," and is literally, therefore, innutrition : a designa- Urigm and » r ' ...... , .. : „ . c . . meaning; of tion peculiarly significant, as the disease in all its forms or varieties the^specific seems ^Q De dependent on a defect in the quantity, quality, or appli- cation of the nutrient part of the blood : and thus lays a foundation for the three following varieties: x Inopiae. Blood innutritions from scarcity or Atrophy of want. pravity of food. fS Profusionis. Blood deprived of nutrition by Atrophy of waste. profuse evacuations. y Debilitatis. Nutrition not sufficiently intro- Atrophy of debility. duced into the blood by the chylific organs, or not suffi- ciently separated from it by the assimilating. * m. Atro- In order that the body should maintain its proper strength and pi«? ,n°" plumpness, it is necessary that the digestive organs should be supplied wan°t*y °f w*tn a ProPorti°n of food adequate to the perpetual wear of its re- Generic spective parts : for this wear, as we all know, produces a waste; and Myology. nence tne emaciation sustained by those who suffer from famine, in which there is no food introduced into the stomach, or from a meagre or unwholesome diet, in which the quantity introduced is below the ordinary demand. It is this condition that forms the first of the subdivisions or varieties, the atrophy of want, under which the species before us is contemplated in the present arrangement. {hu'profu- But the orionis. some part of it may be in a state of inordinate wear and waste, as wa8°tehy °f in very severe and protracted labour, in which the supply is rapidly caui'la" carried off by profuse perspiration, or in rupturing or puncturing a nttionP a" large artery, in which the same effect is produced by a profuse he- ^ommued. m0rrhage. Any other extreme or chronic evacuation may prove ,. in.] SANGUINEOUS FUNCTION. [ord. iv. 137 equally mischievous, as an excessive secretion from the bowels, from Gem. III. the vagina, from the salivary glands, from the breasts; as where a/jn ,\trol delicate wet-nurse suckles uvo strong infants. And h. nee the on- l'bm1iaprofu" gin of the second of the above varieties, or the atrophy of waste. \u.,pby of Now. in all these ^a^e?, wherever the system is in possesion of gj^ive an ordinary portion of lealth, there is a strong effort made by the <*i< "di- • ' 7 «• i 11 ,,,re *UP" digestive powers to recn:t the excessive expenditure -by an aodi- ,,iie.i by tional elaboration of nutriment; aud the instinctive effort runs J^™^' through the entire chain of action to the utmost reach of the assi- milating, powers, or those secernents with which every organ is fur- nished to supply itself with a succession of like matter from the common pabulum of the blood. Hence the stomach is always in a s'ate of hunger, as in the case of famine, profuse loss of blood, or recovery from fever ; all the chylific organs secrete an unusual quantity of resolvent juices, an almost incredible quantity of food is demanded, and is chymified,*chylified and absorbed almost as soon as it enters the stomach ; the heart beats quicker, the circulation is increased, and the new aud unripe blood is hurried forward to the lungs, which more rapidly expand themselves for the purpose, to be completed by the process of ventilation : in which state it is as rapidly laid hold of by the assimilating powers of every organ it seems to fly to, and almost instantly converted into its own substance. Such is the wonderful sympathy that pervades the entire frame; and that runs more particularly through that extensive chain of action which commences with the digestive and reaches to the assimilating organs, constituting its two extremities. So loiiar as the surplus of simply is equal to the surplus of expendi- While this to -ii V. „. i . .l continues ture.no perceptible degree of waste ensues; but the greater the,hereiBne demand the greater the labour, and the turmoil is too violent to be ^?ua" long persevered in. The excited organs must have rest, or their action will by degree* become feeble and inefficient. And if this take when other- place while the waste is stiil continuing, emaciation will be a neces- j^m"va- gary consequence even in the midst of the g eatcst abundance : and f'<-'y ■« p">- we hence obtain an explanation of the variety of emaciation before us, constituting the second. Thus far we have contemplated the animal frame in a firm and Pahtoion- healthy constitution : and have supposed a general harmony of ac- rmiionPcoii- tion pervading every link of the extensive chain of nutrition, from ,;nued- the digestive organs to the assimilating powers. But we do not niu-tratinn i /• i • • i v.- i ' n .i i of the cau- always find it in this conditi >n ; and occasionally perceive, or think ^o< atony we perceive, that this necessary harmony is intercepted in some part J[°mdebi~ or other of its tenour : that the digestive powers, or some of them, do not perform their trust as they should do, or that the assimilating powers, or some of them, exhibit a like default; or that the blood is not sufficiently elaborated in its course, or becomes loaded with some peculiar acrimony. And hence another cause, or rather an assem- blage of other causes, competent to the dise-ise before us. It is from the one or the other of these sources, that we are 'Iiyh*['d^i'. most, perhaps in all, cases to derive the third modification of thisrtatia. disease, which is here distinguished, for want of a better term, by £b7j5j* of that of atrophy of debility. The disease under this form is often This varied tr ¥ft .« vervcom- Voi.. in. — is -o io$ cl. in.] HiEMATICA, [0B». IV. system One extre- mity of a chain of or- gans pecu- liarly sym- pathetic with ano- ther. Illustrated. How the or- gans be- some pri- marily af- fected not always manifest. Gew. hi. very complex, and it is difficult to trace out what link in the great y&MBAtro- chain of action has first given way. Most probably, indeed, it is tluis d9b'U somotimes one link, and sometimes another. But from the sympa- Atrophy of thy which so strikingly pervades the whole, we see at once how easy oflerfex- il is for an unsoundness in one quarter to extend its influence to tended from another, till the disease becomes general to the system. Yet I am u.e°whoT8 much disposed to think that the atrophy so conspicuous in feeble habits, and the feeblest periods of life, as infancy and old age, com- mences most usually at the one or the other end of the chain, and immediately operates by sympathy on its opposite. This remark is in consonance with a very common law of life, by which impressions are more powerfully and more readily communicated from one extreme of an organ to another, than they are to any of the intermediate points. It is hence the will operates instantly on the fingers, the stomach on the capillaries of the skin ; and that the irritation pro- duced by a stone in the bladder is felt chiefly in the glans penia. And hence the close correspondence which we have already seen to prevail between these two extremities of the nutritive function in the case of want and hunger. Where atrophy is connected with a morbid state of the digestive organs, we have a little light thrown on the nature of the disease, but not much. For first, indigestion does not necessarily produce this effect, since it is no uncommon thing for dyspeptic patients to become plethoric, and gain, instead of lose, in bulk of body. And next, the morbid state of these organs may be a secondary instead of a primary affection, and be dependent upon a general hebetude, or some other unsound, condition of the assimilating pcwers, consti- tuting the other end of the chain ; and hence exercising a stronger sympathy over them than over any intermediate organs whatever : as the digestive organs themselves, if the disease should have origi- nated in them, may exercise a like sympathy over the assimilating powers, and hence produce that general extenuation, which, as we have just observed, is not a necessary consequence of dyspepsia. It is at least put, 1 think, beyond a doubt, that more than one set of Organs are connected in the atrophy of debility. Wh<;:e this atrophy takes place in infants at the breast or young mpuotHo* children, it is ushered in by a flaccidity of the fleoh, a paleness of atrophy, the countenance, sometimes altei nating with flushes, a bioated promi- nence of the belly, irregularity of the bowels, pendulousness of the lower limbs, general sluggishness, and debility, and, where walking has been acquired, a disinclination to motion, with fretfulness in the day, and restlessness at night. There is at first no perceptible fever, no cough or difficulty of breathing : but if the disease continue, all these will appear as the result of general irritation, and the skin wili become dry and heated, and be covered over with ecthyma, impetigo, or some other squalid eruption. The breath is generally offensive, the urine varies in colour and quantity ; and in infants at the breast, the stools are often ash-coloured or lienteric, or greenish, loose, and griping. The appetite varies; in some cases it fails, in others it is insatiable. Where these gymptoma. or the greater part of them occfir to au Symptoms lo infant gj.. m.] SANGUINEOUS FUNCTION. [orb. iv. 139 infant at the breast, it becomes us, in the first place, to be particu- Gen« iJi- larly attentive to the manner in which it has been nursed, in respect y MEAtro- to cleanliness, purity of air, warmth, and exercise : we have next phi* debiii- jto turn our attention to the nurse's milk ; and afterwards to an ex- Airophyof animation whether the infant is breeding teeth, or has worms, or cause'•ten there be any scrophulous taint in Jhe blood. For the last we have doubtful. no immediate remedy ; the rest we must correct as we find occa- sion. And if we have no reason to be satisfied upon any of these points, it may still be advisable to change the milk. It is not easy to detect all the peculiarities of milk that may render it incapable of affording full nutrition: and there is reason to-believe that one infant may pine away on what proves a healthy breast to another, I have given this advice in some dilemmas, and have often found a wonderful improvement on its being followed. In children on their feet, who are confined to the filth and suffoca- in children ting air of a narrow cell, the common habitation of a crowding doubtful? family, from Sunday morning to Saturday night; w who are pressed into the service of a large manufactory, and have learnt to become si part of its machinery before they have learnt their mother tongue; there is no difficulty in accounting for the atrophy that so often pre- vails among them. The appetite does not here so much fad as the general strength ; their meals are, perhaps, doled out at the allotted hours by weight and measure ; but still they are falling victims to emaciation ; and are affording proof that air and exercise are of as much importance as food itself; that there are other organs than those of digestion upon which the emaciation must depend : and that, unless the supply furnished by the food to the blood-vessels be sufficiently oxygenized by ventilation, and coagulated by exercise, the blood itself, however pure from all incidental acrimony or he- reditary taint, will never stimulate the secernents of the various organs to which it travels, to a proper separation of its constituent principles, and a conversion to their own substance. In all these cases, therefore, the proximate cause seems to be Proximate lodged principally in the assimilating powers of the system ; and hen"* beT whenever the digestive organs grow infirm also, it is rather by sympa- reasonably ~ o ~ * •* j i conjectures thy with the former than by any primary affection of their own. in most There is a singular case of atrophy quoted by Sauvages, to which aTrophia he has given the name of lateralis, and which unquestionably imvraiis ot belongs to this variety. It occurred in a young child, and took w'hat.seo,, possession of just one half the body ; the left side from the axilla to the heel being so completely wasted that the bones seemed only to be covered with skin, while the right side v\as fat. Under the influence of topical antispasmodics and sudorifics continued for seven years, the writer of the account tells us that, he began to get better—'• melius habere ccepit."* In the atrophy of debility common to old age, the cellular mem- Symptoms brane, that is the part containing, as well as the parts contained, mo'd'agf* seems rather to shrivel away, in many cases to be carried away by absorption, and the muscular fibres to become dried up and rigid + No*. Meet. Cl. x. Ord. i. Ex Collect. Acad. Tom. m. p. 695, 140 cl. in.] ILEMATICA. [ord. iv Gen. III. Spec. I. y M Atro- phia debili- latis. Atrophy of debility Proxiiuite cause ex plained. General mode »f treatment. rather than loose and flabby. In this case the assimilating powers seem to have done their duty to the last, and like an empty stomach when loaded with gastric jui e in a moment of sudden death, to have preyed u;>on and devoured themselves : since it is probable that nearly all the animal oil, and more than half the bulk of the muscles and of the parenchyma.of many of the organs is carried off in tin- same manner ; for t'uitall these are capable of b. ingcunverted into ;t like sibstanee is clear, ,-iice all of them are transformable into adipocire by a ch<-mi;-al action after death, and into a steaton.alous material i>y a morbid action of the living power, while every other organ continues m gooil health ; and there are many facts thatleadto the conclusion that all, under the circumsiam-es before us, a-e ca- pable of yielding a common substitute for the natural food of the system. ITre, therefore, we are to look for thp proximate cause of the disease towards ihe other end of the chain, or among thechylific viscera. And we shall not in general look in vain. Not, indeed, that we shall always, or even commonly, find it in the stomach or in the liver, for the appetite may not fail, thouj.fi its demand is but small and is easily satisfied ; and it probably digests what is introduced into it. Yet here the greater part of the food rests; or rather it passes through the intestines v ith very little into the lacteals; insomuch that many of our most celebrated anatomists have thought, as I have already had occasion to observe,* that the mesenteric glands of old people become obliterated ; while Ruysch contended that mankind pass the latter part of their lives without lacteals, apd that he himself was doii g so at the time of writing. The mode of treatment needs not detain us. Y\ here the disease depends upon a want of wholesome food, or of food of any kind, the cure is obvious : where upon profuse evacuations, it falls within tie precincts of some other disease, and is to be governed by its reme- dies. And where the cause is an infirm condition of any part of the chain of nutritive functions, from the chvlmc to the assimilating organs, the same tonic course of medicine that may be advisi-able in the one case, will be equally adviseable in the other. The bowels should be k^ptin a state of regularity; mercurial alterants may some- times be required, though less frequently than' under one or two varieties of tibes; the diflerent preparations of iodine will often exercise a healthful stimulus, and prove the deobstruent that is stood inneed of; the bitters and astringents enumerated under oyspepsy may also be had recourse to, according to the peculiarity o ' *he case ; and cleanliness, fresh air, exercise, and cold bathing will complete the rest. The atrophy of old age is to be met by the richest foods, wine, and the warmth of another person sleeping in the same bed. * Y»l. i. p. 318. Parabysma Mesentericnm. ci,. m.] SANGUINEOUS FUNCTION. [oe». iv. 141 SPECIES II. MARASMUS ANtLEMIA. EXSANGl 1NITY. FACE!, LIPS, AND GENERAL SURFACE GHASTLY PALE ; PULSE QUICK AND FEEBLE ; APPE1 iTT. IMPAIR I.D ; ALViNE EVACUATIO.NS IRREGU- LAR, BLACK AND FETIU, OCCASIONALLY WITH SEVERE GiilPINGS '. LANGUOR AND EMACIATION EXTREME. Tin: specific name for this disease is sometimes written anemia, ^EM•I|j• but incorrectly ; for the aspirate ought lo be retained, and is so Anwniia indeed, in common usage, as in auhemous, vulnerary or styptic, from '(rCt"[?ct the same root; enharmonic; errhine; cachexy; amphemera; an- mia thelmintic. The most striki.,g peculiarity of the ariection is that the s-.nk.ing blooi'lessness of the exterior precisely corresponds with that of the the disease: interior ; since dissections show that the largest and dec pest vessels are nearly as destitute of blood as those on thr surface. It is in »nd by this ghastly pallor of the whole exterior as directly expressive of the d',flcrs from same condition within that this disease chiefly differs from th; atrophy Atrophia. of want, of waste, and of debility, which constitute the diflerent mod'.ncalioi'S of the preceding species. The disease itself las often been referred to, and, at times, de- h™ been scribed, by th« old writeis, as Becher,* Albert,! and Janson,J and "tmeriy: still more lately by Hoffman, De Haen, and 5s* nfamm. .-everal of jutoftea their cases, howevpr. are confounded with the difiiicnt forms of the clwly. preceding species, and consist of nothing more !han an exhausted state of the blood-vessels from hemorrhage or other profuse evacu- ations, in one case, indeed, from haemorrhoids.6 And hence, Lieu- Attempts t« taud and Isenflamm undertook, in the middle ot the last century, to [hi'.edy dis'inguish the real disease from those which were thus confounded with it; tracing out the separate causes and symptom.1- i.nd marking them by different names ; as anaemia chlorosis, and anaemia cause- Anosmia cutiva, which were the appellations of Lieutaud ;' and a. vera, and „„a''^"con- a. spuria, which were those of Isenflamm. These distinction, po'iva of however, seem to have made less impression on the world of nedi- a vera cii.e than they ought to have done : for v. e find M. de Sauvages in ^i/JJ,""* the ii.st edition of his Nosologia Methodica, published two years flamm. subsequently to Lieutaud's Nummary, following Mrach and Ramaz- ,epded to zini, in describing anaemia, if, indeed, he has described it at all, as by ^au~ Chlorosis ... . . . — ... . rhachialji- * Diss. Resolutio casus practici Anaemias, Sanguinis miros fructus reprsesentanus. ca 0f gail, Leid. 166S. v«sea. t Diss. De Anaemia. Hall. 1732. | Diss. De Morbis ex Defectu Liquidi vitalis. Lugd. Bat. 1748. i Robin, Journ. de Medicine, Tom. xxxu. p. 48. fl Precis de la M€dici»e Pratique. 1761 ■ 142 «.. m.] HJ3MATICA. [ok». iv. Spec i" a modification of spurious chlorosis, or pallor, under the name of Marasmus chlorosis rhachialgica* EMa*""*' ®f 'ate years^ however, something more of light, and far more jtsango,- 0£correct (]esc,-iption, has been thrown upon this very extraordinary Se^or^; maladv bv- the contributions of several writers, and particularly of year*. Professor Haile. of Paris, and Dr. Combe, of Edinburgh. Nothing Combo. can be more different than the occupations, habits, and modes of life of two distinct classes of individuals who are hereby brought for- ward as the subjects of anhannia. And yet the close resemblance, and, allowance being made for incidental circumstances, we may say the identity of the symptoms exhibited in situations so perfectly unlike, furnish an adequate proof of an identity of disease. illustrated 'fne most strictly i liopathic example, and the one most free from Combe. influential incidents, is that, of Dr. Combe.t I he patient was forty- seven years of age ; was born in the country ; and for the most part had been occupied in agricultural employments; he was married, but without a family ; was leading a regular and temperate life; had enjoyed perfect health ever since childhood, and had never been blooded. At the time of his applying to Dr. Combe for advice he had been un.ell for a'-out two months, or something more; his chief complaint having been loss of strength., uneasiness in the head, and a sickly complexion. " I wis much struck," says Dr. Combe, BeBerin- u Dv njs peculiar appearance. He exactly resembled a person just disease. recovering from an attack of syncope. His face, lips, and the whole extent of the surface were of a deadly pale colour: the albuginea of his eye blueish : his motions and speech were languid : he com- plained much of weakness r his respiration, free when at rest, became hurried on the slightest exertion : pulse eighty and feeble : tongue covered with a dry fur: the inner part of the lips and fauces nearly as coloirless as the surface." His bowels were very irregular . though generally relaxed ; the stools very dark and fetid ; urine copious and pale ; appetite impaired, and latterly a rejection of almost every kind of food ; constant thirst ; no pain referable to any part, nor any determinable derangement of structure. Frtgress. These symptoms continued with little variation for about three months, with the exception that, for a short time, he appeared to be improving. Yet upon the whole the disorder gained ground ; the feeble pulse was easily excited; a copious perspiration followed upon any exertion ; the veins on the arms and neck could be felt on making pressure, but the colour of the blood did not appear through the skin. At one time an affection of the liver was sus- pected ; at another, from the thirst and great flow of urine paruria mellita.; but none of these indications were stationary. Tonics did no service, nor a sea-voyage which was tried, nor the use of a cha- lybeate spring. He grew gradually weaker, continued to lose flesh, but, with a strong resemblance to the delusive confidence of phthi- sis, his spirits remained for the most part undepressed, and he still looked forward to a speedy recovery. Meanw hile all the symptoms * Nos. Med. Cl. x. Cachtxi*. Ord. vi. Icteritie. Gen. xxxv.—Ramazz. De Mor- bis Artifici. Cl. I. u. + Case of Anaemia. Transact, of tke Medico-Chir. Sop. of Edin. Vol. i. p. l». iv. 14 J gives proof of disturbance, and appears enlarged even to an external Gen- hi« examination, while the hypochondria are free from such affection. M^asmus Such then seems to have been the proximate cause, though unde- Anhoemia. veloped by dissection, if we may be allowed to hazard a conjecture itySansum upon a subject involved in so much obscurity. Yet the exciting primate cause seems still more effectually to elude our penetration: for the cause constitution of the individual seems to have been strong and hearty, toTeht! and every thing in his situation, occupation, and habits of life, ap- f™^,, parently concurred in promising him a long continuance of health, more ob- In various cases of the disease, however, that have occurred, we Yeft'iiis have some degree of insight into the occasional as well as into the sometimes proximate cause. And I now particularly allude to the endemic pem appearance of this complaint at Anzain near Valenciennes, as de- scribed by Professor Halle in M. Corvisart's Journal.* At Anzain is a large coal-mine reaching to two or three adjoining Existence villages. It was in one of the galleries of this mine that the com- ease at "" plaint made its appearance, and to this it was confined, though Anza,n- no difference had hitherto been detected between the contaminated gallery and the rest. It is of the same depth, being a hundred and DcBCru>- twenty fathoms from the level ground, and excavated in the same immTin the manner, but is longer and hence floes not so readily admit of an ^ahu"eyit efflux of pure air. Its temperature is 64° Fahrenheit, it exhales an occurred. odour of sulphuretted hydrogen gas, which renders respiration diffi- cult. Some caustic mineral, perhaps some metallic salt, appears to be dissolved in the water that drips from the mine, as it produces blains or blisters on any part of the body to which it is applied. Yet the water has been occasionally drunk to allay thirst, and the mine had been worked for eleven years without any such complaint as that before us : and it is, hence, obvious that some new combination of vapour, incapable of detection by the senses, had found vent into the atmosphere of the gallery ; or some new mineral substance had become dissolved in its percolating water; which had a direct power of loosening and destroying the tone of the restorative system, at the commencement of its chain. The symptoms in their general features, were strikingly similar to Symptoms those we have just described; and seem only to have been modified described* by the peculiarity of the exciting cause, being often, though by no Sometimes means always, accompanied from the first with severe gripings, and nied wfth more violent affection, of the abdominal viscera, and hence more g^L rapid in their progress. Dr. Combe is inclined to think from these Hence su«- symptoms that this disease was not a strict idiopathic anhaemia, but ttml to y a modification of rhachialgia, the colic of lead or arsenic, and that it Jjjjjjj **." is hence more nearly allied to the chlorosis rhachialgica of Sauvages than to the anhaemia Chlorosis of Lieutaud. But in no instance buterronc- do I find the back-bone ache, or spine-ache, from which rhachialgia 0Uily" derives its name and by which, together with an extension of this aching over the upper and sometimes the lower extremities, with a strong tendency to paralysis, it is specifically distinguished. Neither pnpii's* * Journ. de Medicine, Chirurg. Pharm. &c. Par MM. Corvisart, Leroux, et Boycr. Tom. ix. p. S. Paris Ann. xm. See a Translation of this in Ihe Edinb. Joutn. Vol. in. p. 170. Vol. III.—1? 146 ei.. m.j li/EMATICA. [OKP. IV. Gen. HI. Spec.H. Marasmus Anhaemia. Exsangui- nity. Fifty pa- tients at one time, and the number daily in- creasing. An acute and chronic state of the disease. General symptoms. Occasional colic. Four pa- tients se- lected for trial, and nent to Paris. biuanostic history. indeed is the colicky pain itself to be regarded as a pathognomic sign, or necessary attendant: for of the four patients who were sent for examination and treatment from Anzain to Paris, while two suf- fered from it, the other two were without any such symptom. Nor did the treatment usually found most serviceable in rhachialgia prove of much, if indeed of any, benefit in the Anhaemia of Anzain; so that the medical superintendents who had at first embraced this idea, found themselves obliged to abandon such a course and the view of the disease on which it was founded, and to regard it as a direct ex- emplification of idiopathic anhaemia. At the time of opening their correspondence with the School of Medicine at Paris, fifty patients, all belonging to the same gallery, had been attacked with the disorder, three of whom had died, and the number of patients was almost daily increasing, notwithstanding that the gallery was at this time shut up. Some of the sufferers had been ill for fifteen, others for twelve, others for eight months: and many were recent cases. It was obvious, however, that those were the most unfortunate subjects, and exhibited the highest de- gree of severity who had been attacked while actually employed in the gallery : while those who did not complain till it was closed, passed through it, not indeed with speed, but in a more favourable way. So that the disorder seemed capable of being divided into two distinct states or varieties, an acute and a chronic. The general symptoms under the former, independently of those of colic, were pallor of skin, great emaciation, weak, feeble, quick, contracted pulse, palpitations of the heart, anhelation, extreme debi- lity so as to render walking difficult; bloated countenance, habitual perspiration, especially at night; stools black or greenish. These symptoms often continued without much change for many months, sometimes for upwards of a year ; when they were united, mani- festly from augmented weakness, with head-ache, frequent faintings, intolerance of light and sound. Where colic was an accompaniment there was much griping pain in the stomach and intestines, inflation of the abdomen, and at times, towards the close, purulent stools. Four patients were selected out of the aggregate body to be sent to the School of Medicine at Paris for examination and advice. They were all young ; their ages being from sixteen to twenty-one: one of them had worked in the mine for six years, the others for ten or eleven ; and as they had all been ill for nearly a twelvemonth, it is obvious that they had been attacked while labouring in the gal- lery ; and were hence regarded as having received the complaint in its acute state. We have already observed that of these four two had experienced colicky pains from the first, and two had not been troubled with them. The pulse varied from seventy to a hundred and four strokes in a minute, but the stroke was extremely feeble and scarcely per- ceptible ; the least excitement, moreover, would accelerate it almost beyond the power of counting. The stomach appears to have been generally capricious ; they cL.ni.] SANGUINEOUS FUNCTION. [onu. iv. 14) could relish food if allowed to exercise a choice ; but one of them Gen. HL was subject to frequent vomiting ; and in all the digestion was m™0-1!" manifestly imperfect, as the food was partially discharged with little Anhaemia: change, intermixed with black or greenish feces. The mesentery, nityf"sui as we have already observed, seemed considerably enlarged to the touch, but was destitute of pain on pressure : nor did the enlarge- ment extend to any other region. So extreme was the weakness that none of these patients were Weakness able to walk more than a few steps without palpitation of the heart,exueme and being compelled to sit down, and especially on mounting a stair-case. Yet the same delusive hope, the same eparsis or mental stiiiaccem- elation that often accompanies consumption, and appeared, as we 5efusiveVi,h have already observed in Dr. Combe's patient, was generally con- hoPc spicuous in the cases before us. Even the death of one of them did not seem to destroy this enviable feeling. " We were afraid/' says Professor Halle, " lest the melancholy fate of the first patient should have had an influence on the minds of his companions ; but we had here no difficulty to encounter. The hope that the opening of his body would put us upon a more successful mode of treat- ment, predominated in their minds, without taking away their regret for his loss." It is thus we sometimes meet with a few cordial drops intermixed with the bitterest cup of suffering, and enabling the patient to support his trial not only with composure but with an elevated spirit. The individual who thus fell, a sacrifice seems to have been Fatal case. attacked with more than ordinary severity at the very onset of the disease : and was one of those who had to contend with the pains of colic in addition to the specific symptoms. Mercurial inunction was early tried, but abandoned in a few days from its being found to augment the pulse and increase the tendency to fever. When he reached Paris he had been ill for eleven months, having previously been employed in the mine for a period of eight years. He at length gave manifest proofs of hectic fever, the remissions of which became gradually shorter, till at length the fever assumed a continued type. But though the skin was burning hot it did not lose its pale- ness, nor was the slightest blush discernible on the tongue, the lips, or the conjunctiva: a remark which is indeed equally applicable to all the rest. He seems to have sunk under the pressure of debility alone, his most prominent symptoms at last being those of great difficulty of breathing, a feeble and intermitting pulse, and cold extremities. The appearances on dissection were, as nearly as may be, those Appear- of Dr. Combe's patient, as we have already described them. The dilaecUon parenchymatous viscera were all pale, diminished and shrivelled, «• already with the exception of the heart which preserved its natural size. glva Even the spleen which, in the preceding case, retained its proper colour, and does not seem to have had its size much interfered with, was here of a reduced magnitude, and of the same spongy softness which the preceding case disclosed. The almost utter bloodlessness of all the vessels, however, formed Bloodless the predominant feature. " In the three cavities all the vessels, as predomi- well arterips as veins, were destitute of coloured blood, and contained "ant fea- tnre. 148 ct. m.] JLEMATIOA. [obd.iv. Gen. Ill Spec. II. Marasmus Anhaemia. Kssangui- nilv. Modes of treatment. Mercury. Emetics, sudorifics, acids, seda- tives, tonics, sti- mulants. The two last classes in combi- nation most suc- cessful. Camphor and ether, bark and iron. Diet. only a small quantity of serous fluid. No blood was found m the aorta, as far as its crural sub-divisions, nor in the accompanying veins, nor in the system of the hepatic vessels, nor in any of the sinuses of the brain. Upon making a deep incision into the flesh of the thighs there flowed out a small quantity of liquid and black blood, but from no other part whatever. The flesh of the muscles which cover the thorax was exceedingly red, but that of the extremities much less so. And we are told that the same destitution of blood which distinguished this case, occurred also in all the other dis- sections that were made at any time : so that the want of colour in the interior precisely corresponded with that of the surface, and of the whole capillary system. " This condition therefore," observes M. Halle, " may be regarded as peculiarly dependent on the dis- ease ; as exhibiting itself by manifest signs during its entire progress; and as reaching its height when it is on the point of terminating, and has reached its last stage." From the extensive spread of the malady there was a pretty ample opportunity of putting various plans of treatment to an effective test; and the opportunity was not neglected. Mercury, as we have already observed, did not seem to answer. Two cases recovered under its use; but in general it produced febrile excitement, and hence no credit was given to it even in the instances of restoration. Emetics, sudorifics, acids, sedatives, tonics, and stimulants were all tried simultaneously, or in succession. But by far the most successful, as, indeed, the most rational plan, and that most corresponding with the nature of the proximate cause we have endeavoured to illustrate, consisted in a combined employ- ment of the two last of these classes, stimulant and tonic medicines, with a free use of opium where the tormina required it, and the em- ployment of gentle laxatives on the return of constipation. The best stimulants appear to have been camphor and ether ; the best tonics, bark and iron. While this plan was continued the patients generally improved in strength, lost their palpitation on walking, and evinced a slight return of colour ; and in every instance in which this process was discontinued at too early a period, they appear to have relapsed ; and only to have renewed their advantage upon a re- turn to the same treatment. The diet was generous and nutritious as it ought to be, and altogether harmonized with the pharmaceutic intention. J. m.] SANGUINEOUS FUNCTION. fonB.iv. 149 SPECIES III. MARASMUS CLIMACTERICUS. DECAY OF NATURE. CLIMACTERIC DISEASE. GENERAL DECLINE OF BULK AND STRENGTH, WITH OCCASIONAL RE- NOVATION, AT THE AGE OF SENESCENCE, WITHOUT ANY MANIFEST CJfUSE. For the ground-work of this species of marasmus I am entirely Gen. Iff. indebted to Sir Henry Halford's elegant and perspicuous description §f0^j_H*' of it in the Medical Transactions. The disease has hitherto never work de- appeared in any nosological arrangement, but it has characters suffi- siTH^Hai- ciently distinct and striking for a separate species. In several of its j°rd: an.d features it bears a strong resemblance to the marasmus or atrophy new'tono- of old age described under the first species ; but it differs essentially "ulswfica- in the instances which it affords of a complete rally and recovery : tion. and, if the train of reasoning about to be employed in developing its physiology prove correct, it will be found to differ also in its chief seat and proximate cause. The ordinary duration of life seems to have undergone little or Pathoiogf. no change from the Mosaic age, in which, as in the present day, it varied from threescore and ten to fourscore years. In passing through this term, however, we meet with particular epochs at which the body is peculiarly affected, and suffers a considerable alteration. These epochs the Greek physiologists contemplated as ciimacte- five ; and, from the word climax (xA<,u*g), which signifies a grada- gr!eef*! tion, they denominated them climacterics. They begin with the thoiogiita. seventh year, which forms the first climacteric ; and afterwards regu- lated by a multiplication of the figures three, seven, and nine, into each other; as, the twenty-first year being the result of three times seven ; the forty-ninth, produced by seven times seven ; the sixty-third, or nine times seven ; and the eighty-first, or nine times nine. A more perfect scale might perhaps have been laid down ; but the general principle is well-founded ; and it is not worth while to correct it. The two last were called grand climacterics, or climacterics em- Grand cii- phatically so denominated, as being those in which the life of man raacteric,J was supposed to have consummated itself; and beyond which nothing is to be accomplished but a preparation for the grave. With the changes that occur on or about the first three of these periods we have no concern at present; and shall hence proceed to that which frequently strikes our attention as taking place about the tourth or in the interval between the fourth and fifth. This change is of two distinct and opposite kinds ; and it is necessary to notice ioO cl. m.] ILEMATICA. [°ni)- IV- Gen. III. Spec. HI. Marasmus climacteri- cus. Decay of nature. Climacteric disease. Sudden re- novation of power occasion- ally found in advanced life. Sometimes an equally sudden de- cline with- out any manifest cause. Subject obscure and diffi- cult. Explana- tion of the chief seat and proxi- mate cause of the dis- We sometimes find the system at the period before us exhibiting all of a sudden a very extraordinary renovation of powers. The author has seen persons who have been deaf for twenty years abruptly recover their hearing, so as in some cases to hear very acutely ; he has seen others as abruptly recover their sight, and throw away their spectacles, which had been in habitual employ- ment for as long a period ; and he has also seen others return to the process of dentition, and reproduce a smaller or larger number of teeth to supply vacuities progressively produced in earlier life. Under the genus Odontia, in the first class and first order of the pre- sent system, several of these singular facts have been already no- ticed, and examples given of entire sets of teeth cut at this period. That the hair should evince a similar regeneration, of which instances are also adduced in the same place, and of which Forestus affords other examples,* is perhaps less surprising; since this has been known to grow again, and even to change its colour after death.t But I have occasionally seen several of these singularities, and espe- cially the renewal of the sight and hearing, or of the sight and teeth, occur simultaneously. And hence Glanville spoke correctly when he affirmed that " the restoration of gray hairs to juvenility, and re- newing exhausted marrow, may be effected without a miracle." On the other hand, instead of a renovation of powers at the period before us, we sometimes perceive as sudden and extraordinary a de- cline. We behold a man apparently in good health, without any perceptible cause, abruptly sinking into a general decay. His strength, his spirits, his appetite, his sleep, fail equally ; his flesh falls away ; and his constitution appears to be breaking up. In many instances this is perhaps the real fact; and no human wisdom or vigilance can save him from the tomb. But in many instances also it is an actual disease, in which medical aid and kindly attention may be of essential service ; and upon an application of which we behold the powers of life, as in other diseases, rally ; the general strength return ; the flesh grow fuller and firmer, the complexion brighten ; the muscles become once more broad and elastic ; and the whole occasionally succeeded by some of those extraordinary renovations of lost powers or even lost organs to which I have just adverted. The subject is obscure ; and it is as difficult perhaps to account for either of these extremes—for the sudden and unexpected decline, as for the sudden and singular restoration. That the decline how- ever is a real malady, and not a natural or constitutional decay, is perfectly obvious from the recovery. And hence Sir Henry Hal- ford, in reference to the period in which it occurs, and by which, no doubt, it is influenced, has emphatically denominated it the Climac- teric Disease. Under the first species the author observed that the great chain of the organs of nutrition extends from the chylific viscera to the as- similating secernents ; that these form the ends of the chain ; that a powerful sympathetic action runs through the whole : but that this action is more powerful between the one end of the chain and the * Lib. xxxi. Obs. 6. + Eph. Nat. Cnr. passim. cl. m.J SANGUINEOUS FUNCTION. [orb. iv. 151 other, than between any of its intermediate links. He observed fur- Gew. in. ther that in the atrophy of old age the failure of action seems to Mafasmus1' commence and to be chiefly seated at the chylific or chyliferous end, dimacte- and that the assimilating secernents exhibit the same failure only Decay of afterwards and by sympathy : that the lacteals become generally, c°|mrue,:te_ and sometimes altogether obliterated, while the assimilating process ric disoase': is supported by an absorption, first of the animal oil deposited in the cellular membrane, then of this membrane itself, and, lastly, of much of the muscular and parenchymatous structure of the general frame. In the disease before us the reverse of all this seems to take place ; and for its origin we must look to the assimilating powers constituting the other end of the chain. The patient falls away in flesh and strength before he complains of any loss of appetite, or has any dyspeptic symptoms ; which only appear to take place afterwards by sympathy. And that the mesentery and lacteals are not paralyzed and obliterated, as in the atrophy of old age, is incontrovertible from the renovation of power and reproduction of bulk that form an occa- sional termination of the disease. In watching carefully the symptoms of this malady, when totally Description. unconnected with any concomitant source of irritation either mental or bodily, we shall often perceive that it creeps on so gradually and insensibly that the patient himself is hardly aware of its commence- ment. " He perceives," to adopt the language of Sir Henry Hal- ford, " that he is tired sooner than usual, and that he is thinner than he was ; but yet he has nothing material to complain of. In process of time his appetite becomes seriously impaired ; his nights are sleepless, or, if he get asleep, he is not refreshed by it. His face be- comes visibly extenuated, or perhaps acquires a bloated look. His tongue is white, and he suspects that he has fever. If he ask advice, his pulse is found quicker than it should be, and he acknowledges that he has felt pains in his head and chest; and that his legs are disposed to swell; yet there is no deficiency in the quantity of his urine, nor any other sensible failure in the action of the abdominal viscera, except that the bowels are more sluggish than they used to be." Sometimes he feels pains shooting over different parts of the,body, conceived to be rheumatic, but without the proper character of rheumatism ; and sometimes the head-ache is accompanied with vertigo. Towards the close of the disease, when it terminates fatally, the stomach seems to loose all its powers; the frame be- comes more and more emaciated; the cellular membrane in the lower limbs is laden with fluid ; there is an insurmountable restless- ness by day, and a total want of sleep at night: the mind grows tor- pid and indifferent to what formerly interested it; and the patient sinks at last; seeming rather to cease to live, than to die of a mortal distemper. Such is the ordinary course of this disorder in its simplest form when it proves fatal; and the powers of the constitution are inca- pable of coping with its influence. Yet it is seldom that wc can Rarely aP. have an opportunity of observing it in the simple form, and never, 8impie perhaps, but in a patient whose previous life has been entirely tl,r:' 152 cl. m.] HjEMATICA. [okd.iv. Gen. Ill- Spec. Iff. Marasmus chmacta- ricus. Decay of nature. Climacte- ric disease. but mostly connected with other affections: which often chiefly ag- gravate it; and render it fatal. Disease more com- mon to men than wo- men. Explana- tion. Common causes of excitement. Illustrated. Further illustrated. healthy, and whose mind is unruffled by anxiety. For if this com- plaint, whatever be its cause, should show itself in a person who is already a prey to grief, or care, or mental distress of any kind, or in whom some one or more of the larger and more important organs of the body, as the liver, the lungs, or the heart, has been weakened or otherwise injured by accident or irregularity, or is influenced by a gouty or other morbid diathesis, the symptoms will assume a mixed character, and the disease be greatly aggravated. It is these acci- dents indeed, that for the most part constitute the exciting cause, as well as the most fearful auxiliary of the disease; for, without such, it is highly probable that the predisposition might remain dormant; and that many a patient who falls a sacrifice to it would be enabled to glide quietly through the sequestered vale of age to the remotest limit of natural life, and at length quit the scene around him without any violent struggle or protracted suffering, with an euthanasia sometimes, though rarely, attained, but ardently desired by us all. Sir Henry Halford has remarked, that the disease, according to his experience, is less common to women than to men. The author's own experience coincides with this observation. And we can be at no loss to account for the difference, when we reflect on the greater exposure of the latter than of the former to those contingencies which so frequently become occasional causes or auxiliaries, and which, at the period now alluded to, strike deeper and produce a much more lasting effect than in theheigh-day and ebulliency of life. There are some events, however, that apply equally to both sexes, and which very frequently lead to this affection ; and that is, the loss of a long tried and confidential friend; of a beloved or only child ; or of a wife or husband assimilated to each other in habits, disposi- tion, general views and sentiments, by an intercourse of perhaps thirty or forty years,' standing. This last, as it has occurred to me, is a more marked and more frequent cause of excitement than any other. I have seen it in some instances operate very rapidly : and have my eye at this moment directed to the melancholy fate of a very excellent clergyman, between fifty and sixty years of age, the father often children, who were all dependent upon him, and whose benef„pe would have enabled him, in all probability, to provide for them respectably, had he lived ; but who, having lost the beloved mother of his family while lying-in of her tenth living child, was never able to recover from the blow, and followed her to the grave in less than three months. I have at other times seen the same effect produced as clearly and decidedly, though with a much tardier step, and unaccompanied with any sudden shock. I attended not long since a lady in the Edge- ware Road, who died of a consumption at the age of fifty-four. Her husband, though not a man of keen sensibility, had attentively nursed her through tlie whole of her lingering illness, and had lived happily with her from an early period of life. He was aware of her approaching end, and prepared for it: and, in a few weeks after her decease, seemed to have recovered his usual serenity. Not iong af- terwards, however, he applied to me on his own account. I found him dispirited, and losing flesh ; his appetite was diminishing, and CL. in.J SANGUINEOUS FUNCTION. [ord. n. 153 his nights restless, with little fever, and altogether without any mani- Gem. III. fest local disorder. The emaciation with its accompanying evils MPEC* UI" nevertheless increased, the general disease became confirmed, and ciimacte-" in about five months he fell a sacrifice to it. D°™- of Occasionally, however, where the climacteric temperament, if I ™uro- may so express myself, is lurking, a very trivial accidental excite- riediscas*. ment proves sufficient to rouse it into action. " I have known," 2fnc"i°"'LJ l>* TT CT li*» 1 /»• USB 8 GUI %" says cur Henry Haltord, " an act of mtemperance, where intemper-,imes »«y ance was not habitual, the first apparent cause of it. A fah*J which Bheht' did not appear of consequence at the moment, and which would not have been so at any other time, has sometimes jarred the frame into this disordered action. A marriage contracted late in life has also afforded the first occasion to this change." It has in some instances followed upon a cutaneous eruption, of which the following case will afford a very striking example, and show in the clearest colours the general want of tone which under this morbid influence prevails throughout the system. Most of my readers of this metropolis have heard of, and many of Explained them have perhaps had the pleasure of being personally acquainted tag exam" with- the late James Cobb, Esq. Secretary to the East India Com- Ple- pany, the history of whose life, from his intimate and extensive con- nexion and correspondence with the most brilliant and distinguished characters of the age that have figured either in political or fashiona- ble life, and more especially from his own fine taste and commanding talents, and his unwearied efforts to patronize merit in whatever rank it was to be found, ought not to have been withheld from the world. In November 1816, this gentleman, then in his sixty-first year, and blessed with one of the firmest and most vigorous constitutions that I have ever known, applied to me for an erysipelatous affection of the face. It was troublesome, and for nearly a fortnight accompa- nied with a slight fever, and a good deal of irritation. It subsided at length, but left a degree of debility which called for a change of air, and relaxation from public duty. He made a short excursion to France, and returned much improved, but evidently not quite res- tored to all the strength and elasticity he formerly enjoyed. Insensibly, Gradual and without any ostensible cause, he became emaciated, walked *0nry pro"1 from Russel Square to the East India House with less freedom than p«M~of the usual, and found his carriage a relief to him in returning home. His appetite diminished, his nights were less quiet, and his pulse a little quickened. Atone time he complained of an inextinguishable thirst, and voided an unusual quantity of urine, so as to excite some appre- hension of paruria mellita. But the urine evinced no sweetness, and both these symptoms rapidly disappeared under the medical treat- ment laid down for him. The general waste and debility, however, continued to increase; his natural cheerfulness began to flag occa- sionally, and exertion was a weariness. At this period an inflam- Au^p"*rt mation commenced suddenly on the left side of the nates, which soon factual me- produced a tumour somewhat larger than a goose's egg, and suppu-tMlMU- rated very kindly. Sir Gilbert Blanc and Sir Walter Farquhar were now engaged in consultation with myself, as was Dr. Hooper after- wards. It was a doubtful question what would be the result of this Vol. ILT.—?o 154 cl. m.] H.EAIATICA. [on* rr. Gem. ui. abscess? It might be regarded as an effort of nature to re-invigorate Mafamn the system by a critical excitement; and in this view of the case eiimacte- there was reason for congratulation. But it was at the same time Decay of obvious that if the strength of the system should not be found equal ciimMte- to this new source °f exhaustion, and could not be stimulated ricdiseaso. to meet it, the abscess might prove highly unfavourable. The tu- mour was opened, and about a quarter of a pint of well-formed pus discharged; but the morbid symptoms remained without alteration, and the cavity seemed rather disposed to run into a sinus along the perinaeum than to fill up. The opening was enlarged, but no ad- vantage followed : it was evident there was too little vigour in the * system to excite healthy action. The abscess was alternately stimu- lated with tincture of myrrh, a solution of nitrate of silver, and red precipitate; but the surface continued glassy with a display of pale and flabby granulations that vanished soon after they made their appearance. Mr. Cline was now united in consultation, and con- curred in opinion that the wound was of subordinate importance, and Disease would follow the fortune of the general frame. The issue was still advances, doubtful, for the constitution resisted pertinaciously, though upon the whole the disorder was gaining ground. Yet even at this time there was not a single organ we could pitch upon, with the excep- tion of the abscess, that, gave indication of the slightest structural disease. The lungs were perfectly sound and unaffected ; the heart without palpitation ; the mind in the fullest possession of all its powers; the head at all times free from pain or stupor, even after very large doses of opium and other narcotics : the bile was duly secreted : the urine in sufficient abundance ; and the bladder capable of retaining it without inconvenience through the whole night. The pulse, however, was quick, the stomach fastidious, and the bowels irregular, sometimes costive, and at others suddenly attacked with a diarrhoea that required instant and active attention to prevent a fatal deliquium. The wound continued on a balance : there was energy enough to prevent gangrene, but too little for incarnation. A clearer example of the disease before us cannot be wished for or conceived. Unfortunately, its progress, though retarded by the arms of medicine, was retarded alone. One of the last recom- mendations was a removal into the country : but Mr. Cobb was now become so debilitated and infirm, that this was found a work of some difficulty, and required contrivance. His Royal Highness.the Duke of Sussex, however, being kind enough to accommodate our patient with the use of his easy and convenient sofa-carriage, for as long a period as he might choose, he proceeded without much fatigue to a house provided for him on the borders of Windsor Forest. The distance was now become too considerable for me to attend him, mtaation" s.tatedty' and I visited him but once or twice afterwards. He con- tinued, however, to decline gradually, and, in about a month from the time of his going to Windsor, sunk suddenly under a return of the diarrhoea. Sat In the Fog™™ of this disease medicine will generally be found to treatment, accomplish but little. The constitutional debility must be met by tonics, cordials, and a generous diet: and a scrupulous attention r;l. hi.] SANGUINEOUS FUNCTION. [ord. iv. loo should be paid to such contingencies of body or mind, as may form Gem- m- an exciting cause, or aggravate the morbid diathesis if already in a Maf^a, state of activity. Congestions must be removed where they exist, ei>»»ete- and every organ have room for the little play thnt the rigidity of ad- Pec"* of vanced life allows to it; and where aperients are necessary, they (*'„,»%*- should consist principally of the warm and bitter roots or resins, as tie ducme. rhubarb, guaiacum, and spike-aloes. In many instances the Bath water, and in a few that of Cheltenham, will be also found of colla- teral use : and especially where we have reason to hope that a bene- ficial impression has been made on the disease, and that the system is about to recover itself. The last remark 1 shall beg leave to offer, I must give in the words of Sir Henry Halford himself. If not strictly medical, it is of more than medical importance ; and I have very great pleasure in seeing it put forth from so high an authority, and finding its way into a professional volume. " For the rest," says he, " the patient must Advantage minister to himself. To be able to contemplate with complacency Sent'sueing either issue of a disorder which the great Author of our being may, mbiJj!iltt0M. tn in his kindness, have intended as a warning to us to prepare for a himself. better existence, is of prodigious advantage to a recovery, as well as to comfort; and the retrospect of a well-spent life is a cordial of infinitely more efficacy than ail the resources of the medical art.*' SPECIES IV. MARASMUS TABES. DECLINE. GENERAL LANGUOR ; DEPRESSION OF STRENGTH, AND, MOSTLY, 01 SPIRITS ; HECTIC FEVER. Tabes is a Latin term of doubtful origin. The lexicographers Gen. III. derive it from the Greek riptu, " macero," varied in the Doric dialect ofiBin'of^" to txkx,—whence Scaliger makes a compound of rxxopiot, " ma- the specific cerans vita," " a consuming life, or life of consumption ;" and hitherto" supposes that such a word existed formerly, and that tabes is a de- dearly ex- rivative from it. This is ingenious, but nothing more. Tab-eo, or tab-es, is most probably derived from the Hebrew jxn (tab), literally " to pine away or consume ;" which is the exact meaning of the Latin terms. Tabes is sufficiently distinguished from atrophy, by the presence ?ow.di*-, of hectic fever; from climacteric decay, by the tendency to depressed from th» spirits, as well as its appearing at any age; and from consumption, ci^ of "the by the local symptoms of the latter. genus. Its ordinary causes are commonly supposed to be an acrimony in the blood from an absorption of pus, or the introduction of some poisonous substance, as quiksilver or arsenic : or a scropulous taint: I5« cl. m.] 1LEMAT1CA. 0*1'- ,v- Gfn. m. or an irritation produced by excess in libidinous indulgences: thus Mafwrnu. laying a ground-work for the four following varieties. Tabes. x Purulenta. Purulent decline. 0 Venenata. Decline from poison. y Strumosa. Scrophulous decline. $ Dorsalis. Decline of intemperance. a m. Tabes In the first of these varieties the absorbed pus may be con- puroient" templated as' acting the part of a foreign and irritating substance,* decline. an(j as acting upon a peculiarity of constitution : but unless the latter be present, pus will rarely, if ever, be found to produce a tabid frame : for, as already observed under hectic fever, if absorbed pus be capable, independently of idiosyncrasy, of inducing a decline in one instance, it ought to do so in every instance; yet this we know is not the case, since buboes, empyemas, and other apostems and abscesses of large extent, have been removed by absorption, and yet, no tabes has accompanied the process. It is said to occur more frequently where an abscess or a vomica is open ; in consequence of pus becoming more acrimonious by the action of the air. But this supposition is altogether gratuitous : and where hectic fever ac- companies a sore or open abscess, it is more probably from increased irritation on the edges or internal surface of the cavity, as already observed when treating on psoas abscess. Q m. Tabes In tabes venenata, Dr. Cullen conceives that one cause of ema- Dedme*' ciation is produced by an absorption of oil from the cells of the from poi- cellular membrane into the blood, for the purpose of inviscating the acrimonious spiculse of the poisonous substance. This may perhaps be true in some instances : but by far the greater number of poisons that enter the blood, whether by deglutition or inhalation, act by a chemical rather than by a mechanical power. Let them, however, act as they may, the hypothesis is not necessary to account for the emaciation : for the acrimony with which the blood is hereby con- taminated, is alone sufficient to excite and maintain the hectic ; as the hectic is alone sufficient to wear away the strength and sub- stance of the system, and produces the waste. It is a disease, as Scheffler has observed, chiefly common to miners and mineralogists :t and, next to these, is to be found, perhaps, most frequently among the labourers in chemical laboratories. There are other poisonous irritants which are altogether ingenerate or hereditary, that, by their perpetual stimulation, ultimately produce the same effect; as those of chronic syphilis, cancer, and scurvy. y m. Tabts A more common cause, however, than any of these, is to be found suum'o'ui in a state of the system which has apparently a very near relation to &H?" that of scroPhula' though it is difficult precisely to identify them. eUu«. The variety from this cacse is, hence, frequently treated of under the head of scrophula or struma ; but as it is peculiarly con- nected with a morbid condition of one or more of the organs of 3Mrmst°Dg' ml' ? TabC ^'"k^* Edin# 1732—Lentilins, Jatromneanfai t Ton der Gesnndheit der Berglente. Chemnitz, 1770. L.in.] SANGUINEOUS FUNCTION. [ord. int. 157 nutrition, including those of digestion and assimilation, and is uni- Gem. IH. formly accompanied with emaciation, irritation, and some degree of y jf.cT^* hectic fever, it more properly falls within the range of the genus "fumo«a. marasmus than that of struma, and constitutes a peculiar variety of o/meJeme- DECLINE. ,ie decline. Of all the contaminations that lurk in the blood, and are propa- Different gable in a dormant state, that of scrophula, consisting, as for the mofwdhs. present we must allow it to do in the acrimony before us, shows ^dilhary itself sooner than any of the rest. It is curious, indeed, to observe the different periods of time that hereditary diatheses of a morbid kind demand for their maturity, unless quickened into developement by some incidental cause. Scrophula very generally shows itself in infancy ; phthisis, rarely till at the age of puberty ; gout, in mature life ; mania, some years later ; and cancer still later than mania. Scrophula runs its course first, and becomes dormant, though rarely extinct; phthisis travels through a term of fifteen or twenty years, and if it do not destroy its victim by the age of thirty-eight, generally consents to a truce, and is sometimes completely subjugated. All the rest persevere throughout the journey of fife : they may indeed hide their heads for a longer or shorter interval, but they commonly continue their harassing^ till the close of the scene. When the strumous taint is excited into action in infant life, it Scropbu- generally fixes itself upon the chylific or chyliferous glands, espe- Sn"nfan", cially when they are in a weakly state ; most commonly upon the chiefly ma- mesentery, and to this quarter it often confines itself; insomuch the mesen- that " I have frequently," says Dr. Cullen, " found the case occur- jjjjjjj,. ring in persons who did not show any external appearance of scro- phula ; but in whom the mesenteric obstruction was afterwards dis- Disease covered by dissection."* It is supposed by Dr. Cullen, and by Cy^bsuuc- most pathologists, that the emaciation is, in this case, produced in- tior>- variably by an obstruction of the conglobate or lymphatic glands of expiana" the mesentery, through which the chyle must necessarily pass to the lion; thoracic duct. That an obstruction thus total may occur, is not to not aatis- be altogether disputed, because the lymph has been found stagnated faetory in its course by such an obstruction of lymphatic glands in other parts : but I have already observed that it is an interruption of very rare occurrence :t so rare that Mr. Cruikshank affirms he never saw such a stagnation on the dissection of any mesenteric case whatever. And that a scrophuious enlargement of the gland? of the mesen- tery does not necessarily produce a total obstruction, is certain, be«- cause children, in whom mesenteric enlargement can be felt in the form of knots protuberating in the abdomen, have lived for a consi- derable number of years, sometimes ten or twelve, and have at last died of some other disease. And hence, it is perhaps more fre- Probably quently the hectic fever kept up by the local irritation of the mesen- by°irritL tery, and the general acrimony of the scrophuious taint in the blood, that produces the emaciation in this case, than the pressure of a scrophuious infarction. " The mesenteric decline," says Dr. Young, " is generally pre- Description. * Pract. of Phys. Part in. Book i. § mdcvi. t V©1.1, p. 319. Cl. i. Orsl. u. Paxabysma Mesenteri^m. tion and hectic. 15S cl. hi.] ILEMATICA. [°BD- IV- Gem. m. ceded by more or less of a headache, languor, and want of appe- y MCTabes tite. It is more immediately distinguished by acute pam in the back .trumosa. an(j i0jng Dy fuineSs, and, as the disease advances, pain and tender- Si ruinous * * J or mesen- ness of the abdomen. These symptoms are accompanied or suc- dma.de" ceeded by a chalky appearance, and want of consistency in the alvine evacuations, as if the chyle were rejected by the absorbents, and left in the form of a milky fluid in th intestines ; and the func- tions of the liver were at the same time impaired, the natural tinge of the bile being wanting. The evacuations are also sometimes mixed with mucus and blood , and are attended by pain, irritation, and tenesmus, somewhat resembling those that occur in a true dysen- tery. Occasionally, also, thi-e are symptoms of dropsy, and espe- cially of ascites ; as if the absorption of the fluid, poured into the cavity of the abdomen, were prevented by local obstacles : the ab- sorbent glands, which are enlarged, being rendered impervious, and pressing also on the lacteals and lymphatics which enter them and pass by them." The appetite is generally good and often ravenous; probably produced by some remote irritation acting sympathetically on the stomach ; as that of the mesentery, or more likely that of the assimilating powers that constitute the opposite end of the chain of nutrient organs, and which, from thoir morbid excitement, pro- duce a morbid waste, and demand a larger supply than they receive. Worms of- As worms are easily generated, and multiply in the digestive organa asVn ef- when in a state of debility, they have often been found in a consi- f»ct, and derable number in this disease, and have sometimes been mistaken mistaken for the cause of the malady instead of the effect.* Balme gives a for a cause. cage m wj1jcjl tnev were equally discharged by the mouth and anus.j In the strumous enlargements are occasionally found calcareous concretions, such as often appear in the joints when weakened by arthritic affections.J or in other weak organs : and hence similar concretions are sometimes discovered in the lacteals and the liver.§ Where the irritation or inflammation is considerable, the intestinal canal is peculiarly apt to unite in the morbid action, producing, with many of the symptoms we have just noticed, hectic fever, and form- ing what has often been called the v;.Br.is infantum remittens. 3 M. Tabes The decline from an intemperate indulgence in libidinous plea- Deciine'of sures has been denominated t vbes dorsalis, from the weakness ranee?8" wmcn it introduces into the back, or rather into the loins. It is a Described disease of considerable antiquity ; for we find traces of it in the «Jt waiters, oldest historical records that iictve reaeiii'u our own day : and it is • 'Hi'1"^ Parti' ,JlarJy d-Mcrib;:d by Hippocrates under the name of <1>©I£IS aat«a. N£iTIAS,ij literally " humw tabi-^,' froiu tne frequent t.nd .1. volun- tary secretion of a gleety matter, or rather of a dilute and imper- fect seminal fluid. He explains it to be, as a disorder of the spinal marrow, incident to persons of a salacious disposition, or who are newly married, and have too largely indulged in conjugal pleasures. He represents the patient as complaining of a sense of formication, * Chesneau, Lib. v. Obs. 27. J Journ. de Med. 1790. Sept. N. I t Douin, Journ. des Scavans, 1690.—Monro, Med. Trans. 11. Art. 18. 8 Histoire de l'Academie des Sciences, &c. 1684. (J Uepi raw «0ws Ua6a>v. Opp. p. 639. as also Uspi Neww, ii. Opp. p. 479. cl. in.] SANGUINEOUS FUNCTION. [ord. iV. 159 or a feeling like that of ants creeping from the upper part of his Gen- hi- body, as his head, into the spine of his back, aud tells us that when f bribes he discharges his urine or exciements there is at the same time a rf<"aiis. .■ i. i • i i Decline of copious evacuation of semen, in consequence ot which he is inca-iutempe. pable of propagating his species, or ans ver;r,g the purpose of mar-raDC8" riage. He is generally r.ho:t breathed «uid weak, especially alter exercise : he is sensible of a weight in his head, Ins memory is in- constant, and he is affected with a failure «.f sight and a ringing in his ears. Though withou- fever at first, he at length becomes se- verely feverish, and dies of that variety of remittent which the Greeks called leipyria, a sort of causus or ardent fever attended with great coldness of the extremities, but with a burning fire and intole- rable heat within, an insupportable anxiety and unconquerable dry- ness of the tongue. This description is fully confirmed by Frofes- Confirme* sor Frank in his history of the miserable condition of two young y men who had induced the same disease by a habit of self-pollution, one of whom, together with extreme emaciation, suffered excrucia- ting [Tains in every limb from head to foot, was incapable of stand- ing, and subject to epileptic fits; while the other, after a long career of acute suffering in various ways, was at length seized with a he- miplegia.* From this sketch it is obvious that the disease is one of great danger, though it is occasionally combated with success. In the Hopital des Enfans Maiades at Paris, the fatal eases are calculated by M. Guersent, one of the physicians to the establishment, at from five to six in every hundred of boys, and from seven to eight in every hundred of girls, whose names enter into the tables of mor- tality.! Upon the treatment we shall offer a few remarks towards the close of the species. Dr. Cullen does not think that the quantity of seminal fluid dis- Waste of charged by undue indulgence can ever be so considerable as to ac- auTdnot■ count for this general deficiency of fluids in the body, and the debility ^B«a* that accompanies it, and adds that we must therefore seek for ano- bycuiien-. ther explanation of these evils. "And whether," says he, "the effects of this evacuation may be accounted for either from the quality of the fluid evacuated, or from the singularly enervating pleasure attending the evacuation, or from the evacuation's taking off the tension of parts, the tension of which has a singular power in sup- porting the tension and vigour of the whole body, I cannot positively determine ; but I apprehend that upon one or other of these suppo- sitions the emaciation attending the tabes dorsalis must be account- ed for."} It is not difficult to trace this result in a less doubtful and more but eipii- direct way. The sexual organs, both in males or females, have a moro'direc* close and striking sympathy with the organ of the brain; and the "'ft, f^" fluid they secrete with the nervous fluid. Whence Willis conceived closely that the fluids of both organs are the same, and hence expressly ac- w/thPth«ze brain. * Dt Cur. Horn. Morb. Epit. Tom. v. p. 359. t Diet, de Medicine. Art. Carreau. X Pract. of Pbys. Part in. B. i. § mdcx. 160 cl. hi. J HAEMATIC A. l0Jtv'IV- OEM. III. Spec. IV. S M Tabes dora alis. Decline of intempe- rance. Henea sen- sorial power weakened by immo- derate in- dulgence. and parti- cularly by chronic aud invo- luntary emission. Exempli- fied. counts for the debility* Morbid salacity is no uncommon cause of madness, as we shall have occasion to observe hereafter. Irritation of the uterus shortly after child-birth, is a still more frequent cause of the same mental affection. The testes are not capable of secreting their proper fluid till the sensorial organ has acquired, or is on the point of acquiring, maturity, so that both become perfect nearly at the same time; the mere apprehension of failure when in the act of embracing has at once, in a variety of instances, unnerved the or- gasm, and prevented the seminal flow so effectually that the unhappy individual has often required many weeks or even r.-.oidhs before he could recover a sufficient confidence to render the operation com- plete ; while, as Dr. Cullen has correctly observed, the evacuation itself, even when conducted naturally, produces a pleasure of a singu- larly enervating kind. It is in truth a shock that thrills through all the senses ; and heuce in persons of an epileptic temperament, has been known, as we shall have occasion to observe more fully here- after, to bring on a paroxysm while in the act of interunion. It is hence easy to see that an immoderate excitement of the gene- ric organs, and secretion of seminal fluid must weaken the sensorial powers even at their fountain; and consequently that the nervous and muscular fibres throughout the entire frame, and even the mind itself must be influenced by the debility of the sensorium. This we might suppose if there were no chronic flux from the seminal vessels. But when we consider the effect, often produced on tli^ general frame by the discharge, or rather the irritation of a single blister; or, which is perhaps more to the purpose, of a small seton or issue, we can be at no loss to account for all the evils that haunt the worn-out de- bauchee, and especially the self-abuser, from involuntary emissions of a seminal fluid however dilute and spiritless, in connection with the dreadful debility we have just noticed, and which is the cause of this emission. The nervous irritation which results from this debility is the source of the hectic by which the miserable being is devoured: and hence the heavy terrors and insupportable anxiety, corporeal as well as mental, the sense of formication and other phantasms, the flaccidity of the back and loins, the withering of the entire body, the constant desire of erection with an utter inability of accomplishing it, which haunt him by day and by night, and throw him into a state of despondency, A fearful picture, which cannot be too frequently be- fore the eyes of a young man in this licentious metropolis in order to deter him from plunging into evils to which he is so often exposed.! Even where sexual inability has not taken place, the system, by an habitual excess of libidinous indulgence, is not unfrequently roused and kept up to such a state of excitement as to produce hec- tic fever, and great debility, or other derangement of the spinal cord. Of this we shall hereafter have to give a most appalling example J in a young debauchee, who, at the age of forty-five, fell a sacrifice chiefly to this enervating propensity, after refusing to take the warn- * Phann. Ratioiialis de Medicament. Operat. Pars 2. 1675. T Lewis's Essay upon the Tabes Dorsalis. Lond. 1758.—Brendal, Diss, de Tabe Dorsali. Goett 1748.—Swediaur, Vol. i. p. 281. Spermacrasia Asthenics. t See Paraplegia, Vol. iv. Cl. iv. Ord. iv. Gen. vm. Spec. vi. cl. i«.] SANGUINEOUS FUNCTION. [ord. iv. 161 ing that a constitution, naturally feeble and rhachetic, was well cal- Gen- ***• culated to offer; but which might by care and prudent nursing have Mafasnioj' held out to the ordinary term of old age. The upper limbs were, I*1^"* for years before his death, motionless and rigid; and the spinal marrow, through a considerable portion of its length, was found dis- organized and liquescent. Much of the medical treatment it may be proper to pursue has General been anticipated in several of the preceding species. treatmenr. The first variety, in which the decline is dependent on the stimulus Treatment of an abscess or sore, or the introduction of pus into the circulation, decline"e can only be cured by a cure of the local affection. The strength may in the meanwhile be supported by a course of inimtant tonics, as cinchona and the mineral acids, nutritious diet, gentle exercise, and pure air. And, if stimulants be at any time employed with a view of acting more directly on the morbid irritation arid changing its nature, they should be limited to the milder resins, as myrrh, or the milder terebinthinates, as camphor, and balsam of copaiba. In decline from the inhalation of metallic or other acrimonious ^'•♦rient vapours, if Dr. Cullen's hypothesis were established, that the ema- fromep^!f ciation is a mere result of the vis medicatrix naturae, and produced sonousi*- by an absorption of oil from the cellular membrane for the purpose of sheathing the minute goads of the poison, it would be our duty to follow up this indication and employ inviscating demulcents, both oils and mucilages. But this practice has rarely been productive of any success : and we have much more reason to expect benefit from a use of the alkalies, which, by uniting with the metallic salts, if they still exist in the circulation, may disengage their acid princi- ple, reduce the metallic base to a harmless regulus, and, by the new combination hereby produced, form a cooling, perhaps a sedative neutral. The first step, however, is to remove the patient from the deleterious scene to an atmosphere of fresh air, then to purify the blood, whether we employ the alkalies or not, with alterant diluents, as the decoction of sarsaparilla, and afterwards to have recourse to bitters, astringents, and the chalybeate mineral waters. In strumous decline, the mode of treatment should run precisely Treatment parallel with that for most of the species of parabysma, or visceral deciiiw?0Ui tcrgescence, already laid down under their respective heads, and particularly with that for mesenteric parabysma, to which the reader may turn.* In the treatment of tabes dorsatis, or decline from intemperate Treatment indulgence, our attention must be directed to the mind as well as fromTn-0 to the body ; for it is a mixed complaint, and each suffers equally. J^jUj6™^ A summer's excursion with a cheerful and steady friend, into some untried and picturesque country, where the beauty aud novelty of the surrounding scenery may by degrees attract the eye, and afford food for conversation, will be the most effectual step to be pursued if the symptoms be not very severe. The hours should be regular, with early rising in the morning, the diet light, nutritive, and invigorating, and a little wine may be allowed after dinner; since it will almost * Vol, i. p. 318. Cl. i. Ord. Ii. Vol. Til.—1\ tQZ cl m.] HA5MATICA. Le«*- 1V- s **€ IV* a^ways De found that the patient has too freely indulged in wine Marasmus" formerly ; and he must be let down to the proper point of abstinence rfcTn °y degrees.* The metallic tonics will commonly be found of more Treatment use thart'the vegetable, with the exception of iron, which is gene- rally too beating; though the chalybeate waters may be drunk, if sufficiently combined with neutral salts. The local cold bath of a bidet should be used from the first, and afterwards bathing in tho open sea. If the disease have made such an inroad on the constitution that travelling cannot be accomplished ; if the mind be overwhelmed, the back perpetually harassed with pain and feebleness, and the nights sleepless with hectic sweats and a frequent involuntary dis- charge, two grains of opium, or more if needful, should be taken constantly on going ,to bed ; diluted acids, vegetable or mineral, should form the usual beverage, and a caustic be applied to the loina on each side. Hippocrates recommends the actual cautery, and that it should descend on each side of the back, from the neck to the sacrum. Savine-bougies have been prescribed by some writers as a topical stimulus ; but a bidet of cold water is preferable; with injections of zinc or copper, at first not rendered very astringent, *>ut gradually increased in power; SPECIES V. MARASMUS PHTHISIS. CONSUMPTION. COUGH : FAIN OR UNEASINESS IN THE CHEST, CHIEFLY ON DECCtfBI- TURE : HECTIC FEVER : nELUSIVE HOPE OF RECOVERY. Gen. III. Consumption, or phthisic as it is sometimes called by old medi Ar"C*e-V' cal writers> is by Dr. Cullen contemplated as nothing more than a rbdiv""1 seclue! of naBmoptysis, instead of being regarded as an idiopathic .ions1 of affection ; and his species, which are two, can only be v.ewed, and so appear to have been by Dr. Cullen himself, as separate stages in the progress of the complaint; his first species being denominated phthisis incipiens, and characterized by an absence of purulent ex- pectoration ; and his second, phthisis confrmata, distinguished by the presence of this last symptom. taT . 'rh!s' however, is a very unsatisfactory, as well as a very unscien- thS *A .. V^W ?f the subJect' and ev»dently betrays the trammels of Dr. .hackies of Culien s classification ; since he seems only to have placed the dis- »* do-in- ease m this position because he could find no other to receive it: for he admits in his First Lines that « phthisis arises also from other 2TSE2T causes besides hemoptysis."! It is highly probable, indeed, that a sequel ihan a * See Wichmann, De Pollutione Diarna, frequentiorj, sed rarius observata Tabe- ffiisf 8CTatU* * + Pk" *' **0ok ,v- Ch- '• S "«=t. Dcccut'. Collea unsatisfac- tory : bl resulting ci» m.) SANGUINEOUS FUNCTION. [g*d. iv. Wz phthisis occurs, or at least commences, more frequently without Gen. Ill, hemorrhage from the lungs than with it, and consequently that Maiasmus* haemoptysis ought much rather to be regarded as a symptom or Phthisis. sequel of phthisis, than phthisis of haemoptysis. ti«o!oinl,r " Haemoptysis," observes Dr. Young, in a work that has the rare advantage of combining great research and learning, comprehensive judgment, and a s'udy of the present disease in his own person, " is usually enumerated among the exciting, or even among tiie more remote causes of consumption ; but in a healthy constitution, hae- moptysis is not materially formidable ; and it is conjectured that when it appears to produce consumption it has itself been occa- sioned by an incipient obstruction of a different kind."* So that, on a concurrence of the two, we may commonly adopt the opinion of Degault, and call it an haemoptysis from consumption, rather than a consumption from haemoptysis.t Of the three varieties we are about to describe, we shall find haemoptysis a frequent cause of the second, but rarely of either of the others. These varieties I have taken from Dr. Duncan's very valuable " Observations" on consumption : they are evidently drawn from a close and practical attention to the disease, and arc as follow; tt Catarrhalis. Catarrhal consumption. /J A postematosa. Apostematous consumption. y Tubercularis. Tubercular consumption. In the first variety, the cough is frequent and violent, with a « wistine- copious excretion of a thin, offensive, purulent mucus, rarely mixed M.Vifthiiu with blood ; generally soreness in the chest, and transitory pains ca«n"haii«, shifting from side to side, It is chiefly produced by catching cold, conaumrl or the neglect of a common catarrh.J t,0"• In the apostematous vabii.ty, the cough returns in fits but is 0 Distinc- __ dry : there is a fixed, obtuse, circumscribed pain in the chest, some- M^PnThi^ times pulsatory ; with a strikingly difficult decumbiture on one apostema- side; the dry cough at length terminates in a sudden and copious B°«Mtema- discharge of purulent matter, occasionally threatening suffocation : g°" [£„' the other symptoms being temporarily, in a few rare instances per- haps permanently, relieved. When haemoptysis is the cause, the disease generally appears under this form. In the tubkrculaii variety, the cough is short and tickling ; and y Distinc- there is an excretion of the watery, whey-like sanies, sometimes Mephthiri» tinged with blood ; the pain in the chest is slight; and there is tubercoia- mostly an habitual elevation of spirits. Usually the result of a scro- beJcuiarU* phulous diathesis. tCioTun,p In Dr. Duncan's observations, consumption or phthisis is intro- duced as si genus, and consequently the varieties now offered as so * Treatise on Consumptive Diseases, p. 45. t Sur les Maladies Veneriennes, la Rage, et la Phthisie, &c. 12 Bord. 1733. X Histoire des Phlegmasies ou Inflammations Chroniques, fondee sur les Nouvellej Observations de Climque, et d'Anatomie Pathologique, &c. Par F. J. V. BroussaU, *>o«t, en Med. fer. Tom. j. Paris. l*0fcV 164 cl. in.] ILEMATICA. [OKD. IV. Gin. Ill Spec. V. JUarusmus Phthisis. Consump- tion. Dyspeptic phthiiis of Philip, what- Subdivi- ■iuns of Bayle: of Portal: of Morton and Sau- vages : Phthisis and phthoe of the Greeks. many species; yet as the tubercular may run into the apostematous variety, and the catarrhal into both', according to the peculiarity of the constitution, and other concurrent circumstances, and more es- pecially as a common cause may produce all of them in different idio- syncrasies, the present subdivision wjll perhaps be found the most correct. Dr. Wilson Philip, has formed another variety (with him species) of consumption, to which he has given the name of Dyspeptic Phthisis, and which he supposes to be produced by a previously diseased state of the digestive organs in which the lungs ultimately participate. " Drunkards," says he, " at that time of life which dis- poses to phthisis, frequently fall a sacrifice to this form of the disease; and those who have been long subject to severe attacks of dyspepsia, and what are called bilious complaints, are liable to it.—What is the nature of the relation observed between the affection of the lungs, and that of the digestive organs in this species of phthisis ? is the one a consequence of the other, or are they simultaneous affections, arising from a common cause ? they are not simultaneous affections, jfor the one always precedes the other. In by far the majority of cases in which both the lungs and digestive organs are affected, the affection of the digestive organ precedes that of the lungs. In some instances, we find the affection of the lungs the primary disease: but in these the case does not assume the form above described, but that of simple phthisis ; and the hepatic affection, which is always the most prominent feature of this derangement in the digestive organs, does not show itself till a late period of the disease, and then little, if at all, influences the essential symptoms."* These remarks show clearly that dyspeptic phthisis is a sequel of a prior disorder, rather than an idiopathic affection ; and, as such, needs not be pursued further in describing the present species. If it outlast the primary malady, or this disease, as is sometimes the case, is converted into it, the digestive organs recovering health, and the lungs appearing to concentrate the morbid action in them- selves, it is then reduced to a case of simple or idiopathic phthisis of the one or the other of the varieties now offered. It would however be tedious and of no practical use, to notice the different ramifications into which consumption has been followed up by many of the most approved pathologists that have touched upon it. Among modern writers, more especially, it hasfceen very unne- cessarily subdivided : thus Bayle gives us six species, derived from supposed organic causes ;t of most of which we can know nothing till the death of the patient; Portal fourteen,! the first two of which, the scrophuious and plethoric, are peculiarly entitled to attention, while the rest are drawn from other diseases with which it is often complicated, or of which it is a sequel. In Morton and Sauvages the divisions and subdivisions are almost innumerable. The Greek pathologists are not chargeable with the same error ; for in general * Trans, of Medico-Cltirnrg. Soc. Vol. vii. p. 499. t Reehercb.es sur la Phthisie Pulmonaire. Par. I8J0. X Observations sur la Nature et le Traiternent de la Phthisie Pulmonaire. w tonr. 8vo. Pans, 1809. ql. m.J SANGUINEOUS FUNCTION. [ord. ivr 165 they treat of the disease, under two branches alone, phthisis and Gen. HI. phthoe; the first importing abscess of the lungs, or the apostematous Mejawnua" variety of the present classification, and the second ulceration of the Phthisis. lungs, embracing perhaps the greater part of the other two. The tionSUrap terms are those of Hippocrates, and they are thus interpreted by Aretaeus.* Of the varieties here noticed, by far the most frequent is the Tubercuiai tubercular ; concerning which it is necessary to offer an explana iv'most' tion, as the term tubercle has been used in very different .senses by ,requont- different writers, and as the morbid change it imports has been de- rived from very different sources. The term considered etyrnologically is a diminutive "of tuber, a Meaning of bump or knot of any kind; in the present work phyma ;| and has 'xpiained. hence been conveniently applied to minute prominences generally : 1nabI^:. though, when accompanied with inflammation, they are usually called papui*': papulae or pimples, and when filled with a limpid fluid, vesicles: and vesicles: if the vesicles, or rather the yesicular cysts, be supposed to possess y atl"" an independent, or animalcular life, hydatids. There is not an organ of the body but is capable, as well in its Tubercles substance as its parenchyma, of producing tubercles of some kind or *™"Ty 0nT. other ; and occasionally of almost every kind at the same time ; for s*°> »nd Bonet, Boerhaave and De Haen, as well as innumerable writers in kind™'* our own day, have given striking examples of clusters of cystic tubers, or enlarged tubercles, of every diversity of size existing both in the abdomen and in the thorax, formed in the interior of their respective viscera, or issuing from the surface of their serous membranes, some of which are filled with a limpid fluid, otheis with a gelatinous, a mucous, or a puriform ; and others again with a cheesy, pulpy, or steatomatous mass : in some instances indeed sarcomatous; though wherever a morbid growth of this last kind exists, it is for the most part firmly and directly connected with the organ which gives rise to it without the intervention of a cyst. Tubercles therefore, as well in their effect as in their minuteness of size, may be regarded as the seeds of by far the greater number of tuberosities, unaccompanied with inflammation, that exist in the body ; and it is not improbable that even a certain degree of inflam- Tubercles mation itself is often favourable to their growth aud general spread. rar°,ured In their origin they seem to be single cysts, or often perhaps single by some follicles, but as they enlarge, the interior is at times divided by reti- hXmma. culations of vessels, or membranous bands or distinct cells, thus exhi- R""e'ftom biting almost every variety of the animal structure ; while the exter- single nal tunic usually becomes stouter, sometimes duplicate, and at times ncie.°r cartilaginous. If we suppose a single follicle of a serous membrane, as that of the Progress t wnrfta lungs for instance, to become gorged or obstructed by a contained eninrge- fluid, some degree of increased action will immediately take place ment from the distention hereby produced ; a fresh supply of fluid will be forced into it, and its walls will either burst or become enlarged * Morb. Chron. i. 10. t See Vol. n. p. 217. 166 ct. m.] HJEMAT1CA. [obd. iv, Gem. III. Spec. y. Maraainua Phthisis. Consump- tion. Healthy organize* I forms pro- duced ynd maintameil by the law of instinct; uniformly operating to definite ends. Henco where this power has no exist ence,the products indefinite an.I Hno- snalous. Hence monster- growths in every part •f the body. Singular exemplifi- cations. Hence the Anomalous contents of tubercles. from, perhaps, the diameter of a pin's point to that of a pea, the grandines of Wesser, or any magnitude beyond. Now what is this power, or in what does it reside, that thus en- larges the walls of that most simple of all animal structures the folli- cle of a serous or mucous membrane, or builds up the walls of a cyst, where no such utercle is ready made? To resolve this question we must recollect that all the fluids of supply, while circulating in the animal system, possess a principle of vitality from the chyje itself to the ejected semen, as has been sufficiently shown by Mr. Hunter; while many of them have a tendency to run into, or rather instinc- tively to elaborate organized forms'. This is particularly the case with the coagulating j.artof the blood, and especially, as Sir Everard Home has shown, when it possesses an intercourse with the red par- ticles, and there is reason to believe that this is the case also with other fluids, besides the coagulating lymph, of which the vital action of the impregnated egg furnishes us with a clear and impressive ex- ample : for we here find vascularity, muscular and nervous fibres, instinct, and sensation produced from a pulpy fluid that but a few days before had none of these properties, and which in the mean while has had nothing communicated to it but the animal heat of the sitting hen, or the culinary heat of an oven, either of which will answer equally. Now under the code of healthy action all this vital power, as we have formerly had occasion to observe,* is directed to definite or instinctive ends, instinct being nothing more than the law of simple life, whether in animals or plants, in a state of operation, and directed to a given effect. But where the instinctive power or the law of health has no existence, the tendency to organization must produce the most anomalous, and oftentimes the most marvellous results: and hence the existence of monster-growths at times in every organ of the body ; of which the most curious, as well as the most illustrative of the doctrine before us, are those abortive attempts at the production of single organs or structures, as a tooth, a lock of hair, a fleshy mole, or polype, an imperfect finger, a vesicle or blad- der, a mass of imperfect brain (one of the most common of such pro- ductions), a ball of fat or suet, and sometimes even imperfect fetuses, or many of their members, in the simplest niduses in which various animal fluids, possessing a vital principle, can obtain a lodging; of which innumerable instances are treasured up in the Acta Curio- sorum of the physiologist. We have hence reason to expect something of the same kind in the cysts or niduses we are now immediately adverting to ; which, however, in many cases possess so little energy of action, as never to exceed the size of a small shot, or to consist of more than an insipid fluid rendered glairy or caseous by an absorption of the finer particles of the material effused or secreted; but which by being united with-a few corpuscles of red blood, or of carbonaceous matter, become not unfrequently of a black or chocolate hue, the melanosis of Bayle, but not that of Breschet and Laennec: * Parabysma Hepaticum. Vol. i. Cl. I. Ord. n. Gen. rr. Spec. r. cl. ut.] SANGUINEOUS FUNCTION. [okd. rv. 16? and which by other unions or other changes produced, perhaps, by Gen. Iff. the anomalous operation of the still inherent principle of life, fur- vff^J,^" nish us with all those appearances which dissections bring to light i'hthwh. on the surface or in the substance of the lungs, or whatever other tion.8ni"p" organ may chance to be affected. Such seems to be the origin of tubercles whenever they make their appearance. Many writers conceive lhat for the growth of all Some wri- sueh foreign bodies it is absolutely necessary that inflammation should ,,enrse" but take place, a H that the whole of the i\ew matter must be supplied j'n"™t"\ from the sanguiferous system immediately : a doctrine rather upheld riJmma- by Mr. Hunter's followers than by himself, arid directly opposed, as '^"j^Vmd M. Cuvier has justly observed* by the absence of all the signs of always inflammation in by far the greater number of passing cases, at least p till the morbid growth has fully established itself, and operates by mechanical pressure on some other excitement. While other physi- others ologists have limited such morbid growths to the operation of the formation8 absorbent system, or to minute bladders containing a limpid fluid of »ubereie« ■ • i i i ■• , ..- i i i • • totheab- wlnch they have caned hydatids ; the term being sometimes em- sorbem sys- ployed as a mere synonym of bladders or turgid vehicles of serum, 'f/^hyda- in the language of Boerhaave, " hydatides., sive vesu-ulae sero tur- :>ds: the gentes ;"t and at other times importing a parasitic animalcule form- tmseJ-* ing a subdivision under the genus taenia of Lumens, and of which 2j^gnjn we have already spoken under turgescence of the liver.;}; sense*: in Dr. Baron has lately brought forward a new hypothesis, founded .,yn™'ymous upon this latter basis, which has the great merit of aiming at much with vesi- conciliation of opinion, and much simplicity of view, as well as an serum: by appeal to a wide body of well substantiated facts. Waving the ques- °l0ht?"**" tion of theanimalcular origin of the hydatid, as contended for by Dr. parasitic Jenner and others, and resigning the critical meaning of the term Hyi™the"is tubercle as a diminutive substantive, he employs tubercle, vesicle, '. Raron' m , i • ..... tismean- and hydatid, as nearly synonyms Tubercles in their incipient state ing of vesi- being with him, " small vesicular bodies with fluid contents,"§ the ck-', hyda- hyditids of his friend Dr. Jenner. and vesicles being parallel with tid.rnd both and distinguished from tumour as follows : " 1 would employ the word tubercle to denote those disorganizations that are composed of one cyst, whatever may be its magnitude, or the nature of its con- tents'; and by tumour I would understand those morbid structures that appear to be composed of more than one tubercle "il From this source Dr. Baron derive^ tumours of almost every kind, varied merely by the peculiarity of the constitution, or the concomi- tant circumstances of the organ in which their vesicular or hydatid form first makes its appearance ; and hence ramifying into encysted tumours however diversified in their contents, whether limpid, gela- tinous, cheesy, pultaceous, medullary or steatomatous ; sarcoma- tous tumours, schirrous tumours, cartilaginous tumours, cancer, and the fungus haematodes. He limits their formation to the absorbent Affirms system alone ; conceiving the sanguiferous to have little or nothing Urue from the absorb- ent system * Anatomie Generale. Tom. iv. p. 517. t Epist. Anat. ad Fred. Ruysch. p. 82. alone, I Vol. i. Cl. i. Ord. in. Gen. iv. Spec. i. $ Inquiry illustrating the Nature of Tubercnlated Accretions, &c. p. 214. J Inquiry, at supra, p. 213. 168 cl. hi.] HiEMATICA. [ord. rv. Gen. UI. to do with the morbid productions ; and upon this point it is that he Mr'smus' is chiefly in a state of challenge with the ablest supporters of the Phthisis Hunterian doctrines. ^onsumjj- ^^^ ^cts accumulated in Dr. Baron's volume are of high value, conceft"0 ant* he has amply succeeded in calling the attention of the profession with the to a peculiarity of morbid organization, which, since the time of MusTand Boerhaave and De Haen, has rarely been studied as it deserves; but hence at Dv generalizing in so great a degree the meaning of distinct terms the follow- and the nature of distinct growths, he has not been so successful as iiume/' could be wished in reducing the subject to the desirable simplicity Hypothesis fle has aimed at. rsYizfrV As all the divisions of the animal frame are equally possest of a wowths living principle, there is no reason why morbid growths, as already may o.;%i- observed, may not equally take their rise from any of them, whether stru^tu'rJ',"7 blood-yessels, absorbents, or nerves ; nor does it seem by any means luchWtuber- necessary* admitting the seed of such growths to be a tubercle, that cuiur ori- such tubercle should be an hydatid, whether a simple vesicle or a no?beehy- parasitic animalcule. datid in any Under this explanation of the subject the following passage from Dr. Baron is a clear expression of daily facts. General The tubercle " may be pendulous, or embedded in any soft part, umfe^this or it may be found between the layers of membranes, and wherever vie"r- the textures are of such a nature as to admit of its growth. It may be so small as to be scarcely visible, or it may require a very great magnitude. Single tubercles are often seen in a viscus, while all the rest of the organ is free from disease, and its functions are performed in an uninterrupted manner. But it is evident that the same state of the system, whatever that may be, which calls one {ubercle into existence, may generate an indefinite number : that they may be diffused through the whole of a viscus, leaving nothing of its original texture, or they may occupy any portion of it, or extend to the contiguous parts and involve them in the same form of disease."* Such the Such is the general progress of the mode of phthisis immediately wberrcie.°in before us : and which, according to the degree of increased action the lungs. in the lungs at large, or in the part that is particularly affected, may be either slow or speedy ; though never perhaps so rapid as in the apostematous variety. main km- ** tne organ or tne general constitution be not much predisposed1 dormant" to a generation of tubercles, a few may remain for a long time inert, five :"in°a and. without any multiplication whatever ; but there is often a pe- Bin^dfathp- cuJ*ar diatnesis that favours such a complaint, and facilitates its siTma* "~ being called from a latent state into an active manifestation by a spread ra- thousand little accidents ; and which, when once excited, encourages the growth of tubercles in great abundance, and finds a rich and and in va- ready sod for them, not in one organ only, but in every one. There Bans' ot~ is a case strikingly illustrative of this form of the disease in one of the volumes of the Medico-Chirurgical Transactions,! furnished by I? eV£n*,n, Mr* LanSstaff- The Iittle Patient who died before die age of pu- mischief in * Inquiry, ut supra, p. 216. * Vol. it. ex. m.j SANGUINEOUS FUNCTION. [oiid. iv. 109 berty, had, together with a very diseased state of the lungs, various °eh. HI. tumours formed in different parts of the body, particularly above Mfrasmuav" the clavicle and in the axilla : they were about the size of an egg, *hthisia. and on examining them after the death of the patient, were found to -tion?ump~ possess a cellular capsule, and appeared to issue from the cellular membrane ; their internal structure was semi-cartilaginous, and they contained a white pulpy substance, mixed with a small quantity of grumous blood. " On removing the sternum a quantity of bloody fluid flowed from the left side of the thorax. This side of the chest appeared filled (except the small cavity produced by the fluid which escaped) with broken down coagulated blood, and a pulpy mass in consistence and appearance so exactly like the cerebrum that I think an anatomist would have been deceived and led to imagine it to be brain, if he had been asked to give his opinion from the structure without know- ing the place in which it was formed. The pulpy mass had accu- mulated in such an enormous quantity on the pleura pulmonalis, as to push the heart considerably beyond its usual situation into the right side of the chest, besides having encroached on the abdominal cavity. A perpendicular section of the disease proved it to be formed of a congeries of variously sized tumours, some as large as a small lemon, and all possessing delicate cysts. The consistence of these tumours was chiefly a brain-like mass, mixed with coagulated blood: but the largest kind were not unlike those described in the axilla and above the clavicle. In the section the lung was recog- nised, but so much condensed by the surrounding disease that it must have been completely useless in respiration, for a considerable time previous to the boy's death. This appearance also proved that the tumours had grown more from the surface than the substance of the lung : and this opinion was corroborated by the state of the lung on the right side, the tumours then occupying chiefly the sur- face beneath the pleura, many of which had by their growth occa- sioned absorption of that membrane ; which allowed of their grow- ing into the cavity of the chest; and would have produced, if the child could have lived much longer, a morbid growth like that on the left side. Some of the tumours on the external part of the lung were as large as a walnut: there, was also a progressive series of them, from the size of a pepper-corn to the magnitude above mentioned. They projected considerably from the lungs ; their ex- ternal appearance was delicately white, as if possessed of low vas- cularity ; figure roundish without any central depression, and each had its cyst. Their internal arrangement, more especially the larger kind, was a blended admixture of a semicartilaginous and pulpy matter with small coagula of blood." In this case the abdominal organs were little affected, except in being pushed somewhat lower down than is natural by the pressure of the diaphragm from above. The spleen and one of the kidneys were slightly affected with tubercles, but the stomach, intestines, liver, mesentery, and peritonaeum, were perfectly free from misaf- fection. In other instances, however, even where there is less utter g^*'^ disorganization, the disease affords a far more evident proof of as- »ai wKw^ Vol. III.—32 170 ci. in.] HiEMATICA- [okd.iv. Gen. III. sociate action in thc organs of the chest and abdomen, though it Emus' should be observed, as we have already had occasion to remark Phthisis. under uyspepsy,* that when the morbid action commences in the abdominal organs, it far more readily passes into those of the chest, same ac tion. But these cases ex- treme. ™me ne-the than when it commences in the chest, into those of the abdomen; instances of which have been sufficiently noticed under the compli- cated species of parabysma.t These, however, are extreme exam- ples ; for in most cases of tubercular phthisis, the disease has made far less progress at the time of its proving fatal, and is often confined to the seat of the lungs alone, and even to an evolution of tuber- cles of minute size and uniform simplicity of contents, mostly con- sisting of a whey-like or cheesy material, produced by an absorption of the finer parts of the fluid which most probably filled it at first, and more or less discoloured from circumstances already adverted to. A certain but low degree of inflammatory action, however, as already observed, seems to favour a more rapid formation of fresh tumours, and an enlargement of those already in existence; and the same may be observed of the accompanying hectic fever. If this be decided and considerable, the disease may run its course in four or five months, and sometimes sooner. If the hectic be unde- cided and only occasional, the disease may play about the system for some years, and at length prove equally fatal. If the inflamma- tory action exceed the low degree we have just adverted to, ulcera- tion and suppuration usually follow, and the tubercular form passes into, or is united with the apostematous. Phthisis, as already observed, is a disease of high antiquity as well as of most alarming frequency and fatality. So frequent, in- deed, is it, as to carry off prematurely, according to Dr. Young's estimate, and the calculation is by no means overcharged, one-fourth part of the inhabitants of Europe :{ and so fatal that M. Baylewill not allow it possible for any one to recover who suffers from it in its genuine form.§ I can distinctly aver, however, that I have seen it terfhinate favourably in one or two instances where the patient has appeared to be in the last stage of the disease, with a pint and a half of pus and purulent mucus expectorated daily, exhausting night-sweats and anasarca ; but whether from the treatment pursued or a remedial exertion of nature I will not undertake to say. Dr. Parr affirms that he has witnessed six cases of decided phthisis recovered from spontaneously. The ordinary period of the con- sumptive diathesis has been stated to be from the age of eighteen to that of thirty-five, occasionally anticipating the first, and over- passing the second, of these limits; the mean term of its proving fatal has been fixed at about thirty ; and the annual victims to its ravages in Great-Britain, Dr. Woolcombe has calculated at fifty-five thousand. || During the last half century it is said to have been considerably on the increase; but this is perhaps chiefly owing to the greater Sourse may ha rapid and why : er tardy and why: or may pass into the apos- tematous form, and why. Extent and fatality of phthisis: altogether incurable in the opinion of Bayle. This opi- nion op- posed by occasional /acts- Supposed rango of the con- sumptive diathesis. Mean rato of fatality. Said to be on thc in- crease ; hut perhaps erroneous- Explained. * Vol i. Cl. i. Ord. i. Gen. v. Spec. vn. t lb- Cl. I. Ord. n. Gen. iv. Spe*. VII. I On Consumptive Diseases, Ch. in. p. 20. 5 Rocherches snr la Phthisie Pulmonaire. Par. 1810. fl rtetnark? on the frequency and fatality of different disease*, &c. 8ro. Iron*. 1808- *:l. in.] SANGUINEOUS FUNCTION. |orj». iv. IT I number of infants of delicate health who are saved from an early Gen. III. grave by the introduction of a better system of nursing than was Ma^imus formerly practised ; yet who only escape from a disease of infant Phthisis. life to fall before one of adolescence or adult years. And for the tion!ump same reason savages rarely suffer from consumption, as they only rear a healthy race and lose the sickly soon after birth. The question however concerning the actual range of tht con- At what sumptive diathesis, or, in other words, at what period of life con- hfeTs con- sumption is most frequent, is still open to inquiry. It was a common ™™$™ doctrine among the Greek physicians, and it has very generally de- quent; scended to our own day, that phthisis rarely occurs before fifteen or of0themo after thirty-five years of age; and Dr. Cullen has entered into an ^e*lg a„a ingenious argument to show why it should be so. Yet the tables of ouiien, that have been kept in most parts of the world seem to indicate the ^osld by contrary ; or that, at least, as many die of this disease and even the tables originate it after thirty-five or forty years of age as antecedently to places!" this period. One of the first pathologists who appears to have called the public attention to this general concurrence of the tables and bills of mortality, is Dr. Woolcombe ; and he particularly adverts to At Piy- the proportions observed in the Dispensary at Plymouth, as being coUectad. the chief source from which he drew his calculations. He tells us that of seventy-five deaths from consumption, which occurred within the range of this establishment, ten took place before the age of fifteen, sixteen between fifteen and thirty, and forty-nine above the age of thirty ; twenty-three of these forty-nine, moreover, being above the age of forty.* Dr. Alisonj has given the result of various other tables most of which are in consonance with Dr. Woolcombe's. Thus Bayle, in Hospital of his Treatise on Consumption, notices a hundred cases above fifteen La(;hail,e' years of age, all of which terminated fatally in the hospital of La Charite" at Paris, and after the following proportions : thirty-three below the age of thirty, and sixty-seven above it, of whom, forty- four were upwards of forty .J So Haygarth, in his account of the Chester. deaths from phthisis in the course of two years at Chester, makes ■ the total a hundred and thirty-five, of which, twenty-five occurred before the age of fifteen, forty-two between fifteen and thirty, and sixty-eight above thirty ; forty-four of these last being above forty.§ " In the practice of the New Town Dispensary at Edinburgh, Dr. Edinburgh. Alison tells us there have been fifty-five deaths from phthisis in the last two years, of these, eight occurred before fifteen years of age; thirteen between fifteen and thirty ; thirty-four after thirty ; and of these last twenty-four after forty." So in Sussmilah's table of deaths at Berlin in 1746, out of six Berlin, hundred deaths from phthisis, two hundred and fifty-one are stated to have occurred before fifteen years of age ; seventy-three between fifteen and thirty ; and two hundred and ninety-six above the age of thirty ; two hundred and thirty of which occurred after the age of forty. * Remarks on the frequency and fatality of Diseases, &c. p. 75. t On the Pathology of Scrophuious Diseases. Trans, of the Medico-Chir. Soc. Edin. Vol. i. J Bayle, p. 42. § Phil. Trans, bur. lxr. 172 cl. in.] 1LEMATICA, !.<»»■ *v- Gen. III. Spec. V. Marasmus Phthisis. Consump- tion. Warring- ton. Carlisle. The result apparently at variance with the doctrine of the Greek schools. This doc- trine ex-* plained: and modi- tied: and thus not opposed to th« ubove calcula- tions. Consump- tion pri- mary and secondary: idiopathic or sequen- tial Why fre- quent in early life. Why fre- quent in Uter, lift;. In this last table a greater number of deaths took place within the first fifteen years than in any fifteen years afterwards. And a like surplus occurs in the calculations at Warrington recorded by Dr. Aikin : the proportions being twenty-four below the age of fourteen, thirty-six between fourteen and fifteen, and the same number above the age of forty-five.* While at Carlisle, as we learn from Dr. Heysham, out of two hundred and fourteen deaths, fifty- nine anticipated the age of fifteen, sixty took place between thi9 period and thirty ; and ninety-five above the age of thirty, six.ty-one of these being above that of forty.! The general result, therefore, seems, at first sight, to oppose in a very striking degree the doctrine of the Greek Schools, and those who have followed them, and to show that the age from fifteen to thirty is most exempt from consumption, while that above thirty or even forty to the close of life is most distinguished by fatality from this disease, though the period below fifteen is also seriously invaded by it. But the doctrine of the Greek Schools relates to idiopathic con- sumption as the product of a phthisical diathesis; or, in other words, affirms that this diathesis, when not called into action by accidental excitements, is most disposed to show itself between the ages of fifteen and thirty-five. And, thus modified, it is probable that the doctrine holds good to the present day, notwithstanding the apparent contradiction of the tables now adverted to. For with respect to the cases of consumption that anticipate the age of fif- teen, by far the greater part of them are secondary instead of pri- mary or idiopathic affections, and follow as sequels of a strumous habit that has previously shown itself in a morbid condition of the mesentery or some other organ, with which the lungs at length as- sociate in action ; though but for such an incidental excitement they would probably have remained quiescent for several years longer. In many instances indeed they are, to the last, Irather tabes strumosa, strumous or mesenteric decline, than phthisis or con- sumption properly so called, though included in the bills of mortality or other tables under this last name. And as we have already ob- served that variolous and vaccine inoculation carry various sickly infants through the period of infancy, who would otherwise have fallen victims to the small pox, yet who a few years afterwards, from the same sickliness of constitution, sink beneath the assault of decline, or phthisis, we see sufficient reason for the greater number of early deaths in our own day from what is ordinarily called con- sumption, and what often is strietly so, though of a secondary or catenating, instead of a primary or idiopathic kind, than was known lo the Greek authorities, whose doctrine, relating to idiopathic phthisis alone, is not hereby interfered with. In respect to the exuberant cases that occur in later life than thirty, they are, for the most part, far less a result of a phthisical dia- thesis, than of an accidental exposure to causes peculiarly operating upon the lungs, and exciting them to a morbid action, so as to * Phil. Trans. Vol. 1'iv. * Milne, on Annuities, Vol. tt. p. 464. gl. in.] SANGUINEOUS FUNCTION. [ord. iv. 173 produce the disease, whether there be any hereditary taint, or pre- Gen. in. disposition to consumption, or whether there be none. Marasmus" These causes are chiefly thc habitual influence of a higher degree |*hihisis> of heat or of cold, and especially the latter, than is consistent with tion."1™ that euthesy or perfection of constitution on which sound health ,ncidente- depends; and particularly the mischievous influence of a tempera- ture perpetually varying from high degrees of heat to those of cold ; and a like mischievous exposure to irritating gases, or spicular dust perpetually inhaled in various chemical or handicraft occupations, of which we shall have to speak more particularly in the sequel. Above thirty years of age the stations of mankind are usually fixt, and whether healthy or unhealthy, they cannot easily be abandoned. If, then, we examine the kind of consumption which takes place above this age, we shall find it, in by far the greater number of cases, confined to the lower classes—to those engaged in the occupa- tions just noticed, or who have injured themselves by intemperance ; while the classes above them, who have passed safely through the period of from fifteen to thirty or forty years of age, and are free from the incidental excitements alluded to, rarely add to the number of deaths from consumption ; and may be regarded as having, in a considerable degree, lost whatever predisposition they had to the disease in an anterior stage of life. Thus again confirming the correctness of the earlier and more common doctrine upon this subject, which refers chiefly to consumption as issuing from a phthisical diathesis. There is hence a material difference very generally discernible in Difference the nature of the disease as occurring in earlier life, or during the a" occur" natural range of the predisposition, and as occurring from incidental j£s >» eat" excitements afterwards. The first is usually, though not always, of and during the tubercular variety ; the last, as usually of the catarrhal, or ^ d^**" apostematous, most commonly of the catarrhal modification, origina- *'*; and as ting from habitual irritation, and repeated and neglected inflamma- fromTncf- tion, not at first of an unhealthy character, for the most part more ^J^ af_ active than tubercular inflammation ; and, where suppuration does terwards. not take place freely, leading to a dark-hued or hepatised induration, ?Ubercuhu' The causes of phthisis, then, are of two kinds, the predisponent, *® ,*jjei and those that excite the predisposition into action, or operate even or aposte. where there is no predisposition whatever. predispo- Of the nature of the predisponent cause, we know little more than nent and i hat it appears to appertain to a peculiarity of constitution which cause"? will be noticed presently. The exciting or occasional causes are Exciting very numerous, as mechanical irritation of the lungs from swallowing meltms!"1" a piece of bone ; the dust of metallic or other hard substances per- petually inhaled ; frequent and sudden changes of temperature or exposure of the body to cold when in a heated state and unprepared for it; overaction in speaking, singing, or playing on a wind instru- ment ; the irritation of various other diseases, as worms, scrophula, syphilis, or measles ; the sudden suppression of a cutaneous disease that has continued long and formed a part of the habit, as itch ; or of any habitual discharge as that of menstruation, or blood from the hemorrhoidal vessels, when the discharge has become periodienl: 174 cl. ni.] HiGMATICA. [ORD. IT. Gen. Ill Spec. V. Marasmus Phthisis. Consump- tion. Mechani- cal irrita- tion. Fine acun- ted dust floating in the air. In some places en- demic from this cause. Irritation from a lodgment of a bony fragment in the eso- phagus or stomach. the irritation of a too rapid growth of the body, and that of various passions perpetually preying upon the individual; as mortified ambi- tion, disappointed love, hofne longing,* when at a remote distance from one's friends and country. Examples of consumption from a mechanical irritation of the lungs are peculiarly numerous, and they furnish cases of every variety of the disease according to the habit or idiosyncrasy, though the apostematous is less frequent than the rest. So common is this complaint among persons employed in dry-grinding, or pointing needles in needle-manufactories, that Dr. Johnstone of Worcester informs us they seldom live to be forty, from the accumulation of the dust of the grind-stones in the air-cells of the lungs, and the irritation and suppuration which follow.! It appears to be little less common among knife and scythe-grinders; whence, according to Dr. Simmons, the disease thus originating is called the grinder's rot,| and Wepfer gives an account of its proving endemic at Waldshut, on the Rhine, where there is a cavern in which mill- stones are dug and wrought, the air is always hot even in the win- ter, and a very fine dust floats in it, which penetrates leathern bags, and discolours money contained in them. " All the workmen," says he, " become consumptive if they remain there for a year, and some even in a shorter time ; and they all die unless they apply early for assistance."§ And, hence, Dr. Fordyce had much reason for regarding the dust of the streets of London as a serious cause of pulmonic disorders ;|| though it is a cause that has been much diminished since the introduction of paving and watering. As these are causes that operate at all ages, consumption among such persons occurs at all ages also ; in patient^ however, beyond forty it may, for the most part, be regarded as a strictly original disease, the consumptive diathesis having, by this time, as already observed, gradually lost its influence. And it is on this account that Dr. Alison regards the tubercular or strumous form as rarely taking place after the age of thirty-five or forty,H thus confirming the ancient, and, indeed, the common opinion, how much soever opposed by the tables we have already referred to. A lodgment of some fragment of a bone even in the esophagus has, in like manner, been a frequent cause of phthisis, which has often been protracted through a long period of time. Thus Claubry gives a case of this kind which had continued for fourteen years, and the patient seemed to be in the last stage of a consumption when he was fortunate enough to bring up the piece of bone spontaneously, in consequence of which he recovered, though for the preceding four years he had laboured under an haemoptysis.** Mr. Holman describes a similar case that had run on for fifteen years, accompanied with * R. Hamilton, in Duncan's Med. Com. xi. p. 343. t Mem. Med. Soc. v. 1799. p. 89. J Practical Observations on the Treatment of Consumptions, 8vo. 178a $ Observations de Affect. Capitis. 4to. Schaff. 1727-8, quoted by Young on Consumptive Diseases, p. 206. ' ^ || Trans, of Soc. for the Improvement of Med. and Chir. Knowledge. Vol. I. 252. IT Observations on Scrophuious Diseases, &c. Trans, of the Medico-Chir. Society of Edinburgh, Vol. i. 1824. •»««.» j ** Sedill. Journ. Gen. Med. xxxiv. p. 13. 1809. cl. iii.] SANGUINEOUS FUNCTION. [oh©, ar. IKS cough, haemoptysis, and hectic diarrhoea; and which was also speedily Gem> 'H* relieved in consequence of the bony fragment, three quarters of an Marasmw inch in length, and apparently carious, being suddenly coughed up £hth«"'«- after the discharge of a pint of blood.* tionTmp" A moderate use of the vocal organs, as of any other, tends to rrritatToa strengthen them, and to enable public speakers, singers, and per- f«>m «a formers on wind instruments to go through great exertion without ratonseof inconvenience, which would be extremely fatiguing to those who are ^an*Cj„ but little practised in any of these branches ; but the labour is often speaking, carried too far, and the lungs become habitually irritated, and hae- ^m^5'or moptysis succeeds. I have known this terminate fatally among wind-in- clergymen ; who have lamented, when too late, that in the earlier part of life they spent their strength unsparingly in the duties of the pulpit. Hence, Dr. Young observes from Rammazini,t that public speakers, readers, and singers, are most liable to pulmonary diseases, and that Morgagni and Valsalva have confirmed the observation. Cicero himself felt it necessary, as he tells us in his book on orators, Evidenced to retire from the forum for two years, during which he travelled into in ,cero* Asia, and afterwards returned with renewed vigour to the duties of his profession ; and Moliere died of haemoptysis, immediately after performing, for the fourth time, his Malade Imaginaire.J There are many diseases that have a peculiar tendency to ex- irritation cite phthisis from their close connexion with the lungs or affinity pat^etfe™1" to hectic fever, which is one of its most prominent symptoms. Thus, action- neglected catarrhs form a frequent foundation, and measles for the same reason. Whether the tubercles found in the substance of the lungs in the tubercular variety of consumption, be, in every instance, strictly scrophuious, may admit of a doubt; that they are so in many cases is unquestionable ; and hence scrophula becomes very gene- rally an exciting, and not unfrequently, perhaps, a primary cause, of this disease. " There is a case by Lissardet, of a fatal consumption which succeeded to a psora, supposed to have been too hastily cured ; and another by Cauvet of a more favourable termination, under similar circumstances, the dartre having re-appeared. It has occurred more than once to myself, that the lungs have been attacked during the cure of cutaneous affections, and, in one instance, fatally, even where no hasty mode of treatment had been pursued. "§ The tendency of the syphilitic poison to produce phthisis has been noticed by almost every writer from the time of Bennet, who particu- larly dwells upon it;|| but whether this would be adequate to such a purpose without an hereditary predisposition is uncertain. And the same remark may be made respecting worms which Morgagni has stated to be a very common cause.IT Indeed any habitual irritation, in any part of the alimentary canal, seems, capable of exciting a sym- pathetic action in the lungs; and hence Wilson in Dr. Duncan's Annals, gives a case of hectic in a child produced by swallowing a * Lond. Med. Journ. vn. p. 120. t On Consumptive Diseases, p. 264. I Van Swieten, Aph. iv. § 1201. p. 49. § On Consumptive Diseases, p. 269. || Vestibulum Tabidorum, 8vo. 1654. Leyd. IT De Morb. Thoracis. Lib. ii. Ep. Anat. xxi. 43. 176 cr.. in.] ILEMATICA. foui>. iv. Gem. Ill, Spec. V. Marasmus Phthisis. Consump- tion. Causes. Irritation from rapid growth. Irritation from sud- den vicissi- tudes of the atmo- sphere. This the most com- mon and active of all irritations. Severe ra- vage in the channel fleet, 1800. Mortality in Great Britain from this cause. At Paris andVienna. In places less exposed to its causes. Consump- tion most frequent at Bristol; not merely among oc- casional visiters, but permanent inhabitants. nail two inches long, which remained in the stomach fifteen months, and was. then thrown up, and succeeded by a recovery of health.* Rapid growth is always attended with debility and consequent irri- tability of the entire system ; and, where there is a predisposition to consumption, this also becomes often its harbinger, unless great cau- tion is observed on the occasion. Richerand relates a case of this kind that terminated fatally, the individual having grown more than an English foot in a year.t I have known a still more rapid growth without any other inconvenience than that of languor ; but in this case there was no phthisical predisposition. Where the chest labours under any misformation we can readily trace another cause of excitement, and are prepared to meet the ex- amples that from this source so frequently occur to us in practice. But it is less easy to explain by what means persons otherwise de- formed, and particularly those who have had limbs amputated should be more liable to consumption than others; yet this also is a remark that has been made by Bennet,| though I do not know that it has been supported by concurrent observation. Of all the occasional or accidental causes of phthisis, however, frequent and sudden vicissitudes of temperature are probably the most common ;§ so common, indeed, and at the same time so ac- tive, as often to be a cause of consumption in constitutions where we cannot trace any peculiar taint or predisposition whatever. Several hundred cases of phthisis from this cause, among which were many fatal ones, occurred in the channel fleet that blockaded the port of Brest in April 1800, as is particularly noticed by Dr. Trotter. The summer was hot and dry, the duty very severe; and the sailors, wet with sweat, were frequently exposed to currents of air at the port-holes; and little time was allowed for refitting.H Hence the most frequent examples of consumption are to be found in those countries which are most subject to changes of temperature. In Great Britain, it is calculated that this disease carries off usually about one-fourth of its inhabitants; at Paris, about one-fifth; and at Vienna, one-sixth; while it is by no means common in Russia, and still less so in the West Indies ; for it is checked in both regions by the greater uniformity of the atmosphere whether hotter or colder. H It is a sin- gular fact, and not well accounted for, that of all places which have hitherto been compared, the proportional mortality from consump- tion appears to have been the greatest at Bristol; and this, not among its occasional visiters, but its permanent inhabitants ; and yet, as though in defiance of experience, this very place has been chosen as the great resort of consumptive persons.** Nor does its mineral water seem entitled to any higher compliment than its atmosphere. Dr. Beddoes affirms, in direct terms, that it is of no manner of use ;| \ and Dr. Thomas, in more measured language, speaks nearly to the same * Vol. 1.1796. t Sedill. Journ. Gen. Med. xx. p. 255. t Tabid. Theatr. p. 99. 5 Broussais. ut supra.—Hastings, Essay on Bronchial Inflammation. || Medicina Nautica. Vol. in. p. 325. t * ^no^c*' it?r" ^ Rrrm?,rlV£? the freq»ency »«. IT42. § Chron. Diss. i. 10. 1?. ul. in.] SANGUINEOUS FUNCTION. [ono. ly. H9 completely the animal oil is absorbed and carried off, not merely Gen- ih« from the surface and from the interstices of the muscles by which Marasmus' the form chiefly becomes emaciated, but from every organ what- PhthisiB. ever: and, in the appearance of the teeth, affording an additional tion"ump proof to those already offered us when treating of obontta,* that }j^^t these peculiar bones are not extraneous bodies, destitute of vascu- *<"<> of the larity, but possessing the same organization as other bones ; render- ed yellow by a deposite of animal oil, and blanched by its removal. Professor Camper, and most physicians with him, affirm that this appearance accompanies all the varieties of the disease ; but Dr. Foart Simmons limits it to the tubercular alone ; and conceives it to be a distinguishing characteristic of this form of the disease or of a predisposition to it. And he remarks further, that of those who are carried off by tubercular phthisis, the greater number will be found never to have had a carious tooth.t The earliest symptoms of phthisis, in whatever manner excited, Origin ana are insidious, and show themselves obscurely. The patient is, per- theedisease. haps, sensible of an unusual languor, and breathes with less freedom First 8t*se' than formerly, so that his respirations are shorter and increased in number. He coughs occasionally, but does not complain of its being troublesome, and rarely expectorates at the same time : yet, if he make a deep inspiration he is sensible of some degree of uneasi- ness in a particular part of the chest. These symptoms gradually increase, and at length the pulse is found quicker than usual, parti- cularly towards the evening : a more than ordinary perspiration takes place in the course of the night; and if the sleep be not disturbed by coughing, a considerable paroxysm of coughing takes place in the morning, and the patient feels relaxed and enfeebled. This may be said to form the first stage of the disease : and it is the only hope- ful season for the interposition of medical aid. The malady is now decidedly established; the cough increases in Secan<1 frequency, and from being dry is accompanied with a purulent mucus, varying, according to the peculiar modification of the disease, from a watery whey-like sanies, occasionally tinged with blood, to a spu- tum of nearly genuine pus : which, as Aretacus has well observed, may be livid, deep-black, light-brown, or light-green; flattened or round; hard or soft; fetid or without smell. In many cases it is very scanty; and we may also add with Aretaeus, that in some con- sumptions there is no expectoration at all; for in the apostematous variety the sufferer has sometimes died before the vomica has broken. The uneasiness in the chest, only perceived at first on making a deep inspiration, h now permanent and attended with a sense of weight: the hectic fever has assumed its full character ; the patient can only lie with comfort on one side, which is usually the side affected ; and the breathing, as Bonnet has remarked, is frequently accompanied by a sound like the ticking of a watch. The strength now fails apace ; the pulse varies from about a hundred to a hundred and twenty or thirty ; the teeth, from a cause just pointed out, in- * Cl. i. Ord. i. Vol. i. p. 64. t Practical Observations on the Treatment of Consumption. By Samuel Foart Simmons. M.D. Sro. London, 1779. 1 Bu cl. ur.] ILEMATICA. [OKI). IV. Gen. UI. Spec.V. Marasmus Phthisis. Consump- tion. Third stage. Frogress varied in different cases from habit or idiosyn- crasy. Sometimes peculiarly rapid; es- pecially in the aposte- matous va- riety. crease in transparency, and the sclerotica of the eye is pearly-white; " the fingers," to continue the elegant description of Areta?us, as given by Dr. Young, " are shrunk, except at the joints, which be- come prominent; the nails are bent for want of support and become painful: the nose is sharp, the cheeks are red, the eyes sunk, but bright, the countenance as if smding ; the whole body is shrivelled ; the spine projects, instead of sinking, from the decay of the muscles : and the shoulder-blades stand out like the wings of birds." The third stage is melancholy and distressing, but usually of short duration. It commences with a depressing and colliquative diarrhoea; but till this period, and occasionally indeed through it, the patient supports his spirits and flatters himself with ultimate success, while all his friends about him are in despondency, and find it difficult to suppress their feelings. The voice becomes hoarse, the fauces aphthous, or the throat ulcerated, with a difficulty, of swallowing. Dropsy, in various forms, now makes its approach : the limbs are anasarcous, the belly tumid, or the chest fluctuating; and the op- pression is only relieved by an augmentation of the night-sweats or of the diarrhoea ; for it is generally to be found that the one set of symptoms is less as the other is greater. '* A few days before the patient's death, he is frequently unable to expectorate from apparent weakness, and sometimes dies absolutely suffocated: but much more commonly the secretion of pus, as well as the expectoration, has ceased ; as if the capillary arteries had lost their power, or the fluids of the system were exhausted. There is also sometimes a degree of languid delirium for some days, and occasionally a total imbecility for a week or two: though, in general, the faculties are entire, and the senses acute, the patient being perfectly alive to the danger and distress of his situation, and retaining, even when his ex- tremities are becoming cold, a considerable quickness of hearing and feeling. The closing scene is often painful, but it sometimes con- sists in the gradual and almost imperceptible approach of a sleep which is the actual commencement of death."* Such is the common progress and termination of the disease ; but it varies considerably in the character and combination of its symptoms, and particularly in the tardiness or rapidity of its march, according to the habit or idiosyncrasy of the individual, or the variety of the disease itself. Where the constitution is firm, and the hereditary predisposition striking, it commonly assumes the apostematous form, and runs on to the fatal goal with prodigious speed, constituting what among the vulgar is called, with great force of expression, a gallop- ing consumption. In this case, the activity of the lymphatic, and, indeed, of every other part of the general system is wonderful: the whole frame is in a state of estuation and greedily preying upon itself. The animal spirits are more than ordinarily recruited, and all is hope and ardent imagination ; the secernents play with equal vigour, and the skin is drenched with moisture, the bronchial vessels are overloaded with mucus, vomica after vomica becomes distended with pus. and the bowels are a mere channel of looseness. The Younjr, On Consumptive TVseftseg, p. op ci. m.] SANGUINEOUS FUNCTION. [onn.iv. 181 absorbents drink greedily ; and animal oil, cellular membrane, pa- Gen. HI. renchyma, and muscle, are all swallowed up and carried away, till u^jnus' every organ is rapidly reduced to half its proper weight and bulk, Phthisis. and the entire figure becomes a shrivelled skeleton. So swift was ti°n?ump* the progress of the disease in the case of the Duchess de Pienne, ^jf^""^1! that M. Portal informs us she died in ten or twelve days from the destroyed first alarm. in ten days. If before this an extensive vomica burst suddenly and with a wide suffocation opening into the trachea, or larger bronchial tubes, suffocation bumingeof follows instantly. If its aperture be small, a purulent matter, often m|"f V°J diversicoloured, is expectorated in the course of a violent fit of if the apcr- coughing : the expuition then ceases for a few days, and at times, de'athTess' with an apparent relief to the patient but it returns in a short time, sudden, and is always ushered by an increase of the febrile state for the certain. preceding four and twenty hours. The breath now becomes tainted, and is offensive to by-standers ; thc appetite is lost, and the lightest foods and most desirable dainties produce a sense of increased lan- guor and anxiety. The patient becomes daily more emaciated : all the symptoms just noticed are exacerbated, till at length a superve- ning colliquative diarrhoea first diminishes, and then totally sup- presses the expectoration, and the sufferer turns himself unexpect- edly on his back, and, in a very few days afterwards, draws up his legs, and in this position usually expires suddenly. On other occasions, the march of the consumption is remarkable Sometimes for its tardiness. This is particularly the case with the tubercular [ard" a y variety when not quickened in its pace by returns of haemoptysis, f'"^^ Hoffman gives instances of two or three who lived under the disease bercuiar for thirty years : and in the Edinburgh Communications is the case vane,-v- of an individual who passed nearly the whole of a long life under its influence, who was consumptive from eighteen to seventy-two, and died of the complaint at last. Of two hundred cases, however, selected by M. Bayle, a hundred and four died within nine months, which may hence be regarded as the mean term. Dissections concur in showing, in almost every instance, an indu- c-bserva- rated and ulcerated state of the lungs, while the changes thus ex- direction. hibited vary greatly in the morbid structure they develope ; the more White and obvious of which, though perhaps constituting the two extremes of fonred°" these changes, are the white and the dark-coloured or hepatised knobs. knobs. The first seems to move forward to a state of inflammation The firs: with a slow and pausing step, and forms the basis of the tubercular ^ownt. variety before up. The second is more rapid and uniform in its action, and constitutes the catarrhal or purulent modifications. While, not unfrequently, we meet with both these appearances in- Both often termixed in every possible proportion Yet we perceive, concur- comUna-,n rently with the diagnostics of the disease, that its most frequenttion- form is the tubercular; so much so indeed, that M. Laennec has confined his attention to this variety alone, and will hardly admit of any other.* The tubercles are found indiscriminately in all parts Tubercles, of the cellular texture of the lungs, but more abundantly at the tefof.*"10 * De I'Auscultatiou Mediate ; ou Traite, du Diagnostic des Maladies des Poumons, V.\ Par R. T. H. Laennec, D.M. &c. % tomes. Paris, 1810. 182 cL.in.j JLEMATICA. [o»p. iv. Spec."!" uPper and Postc"or P"13- As already observed, they exhibit every Marasmus" diversity of size ; are often very minute, but more generally consist cowum of those circumscribed nodules or indurations which Wesser has tion. called grandines. They are whitish and opake, like small absorbent ^hat'as8*' glands, but sometimes more transparent, like cartilage, with black thoyap- dots in their substance. They augment by degrees till they are Shrsection. half an inch or more in diameter; but in general when they have acquired the size of large peas they begin to soften in the centre, and then open by one or more small apertures into the neighbouring bronchia?, or remain for a longer time closed, and constitute small vomicae, containing a curdy half-formed pus. Occasionally, as we This varie- have stated, they are found to unite into large abscesses.* Now as strictly a we have before observed from Dr. Baillie that nothing like a gland lous'dis- *s to De found in the cellular membrane of the lungs in a sound state, ease; constituting the seat of these tubercles, and as scrophula selects for its abode a glandular structure, tubercular consumption cannot per- but closely haps with strict propriety be called a scrophuious disease : yet as the untempered fluid contained in the tubercles resembles that of scrophula, and, more especially, as this variety of consumption is very generally found in constitutions distinctly scrophuious, the ana- logy between the two is extremely close, and has often led to a similar mode of treatment. M. Portal, indeed, contends that glands exist in great numbers through the whole structure of the lungs, but rather from analogy than from demonstration. And to the same effect M. Laennec ; " the tubercles in the lungs," says he, " differ in no respect from those situated in the glands ; and which, under the name of scrophula, after being softened and evacuated, are often followed by a perfect cure." Here, however, he tells us, the hollows are not incarned or filled up with a new material, but have their surfaces covered with a seini-cartilaginous membrane, which, as they thus heal or cicatrize, leave as many sound fistulas as there were formerly tubercles.! Apostejj168 ln some cases, proper abscesses or larger vomicae are found with- dissection. out any trace of tubercles ; and especially when the disease has fol- lowed rapidly upon peripneumony, or taken place in persons of Cflamma- robust habits or entonic plethora. And, where the catarrhal syrap- tionfound toms have been striking, and,.in the increasing hoarseness and free on dissec- discharge of muculent pus, have evinced extensive inflammation on the surface of the trachea, M. Portal has found the whole extent of Se'Tungf the tube lined by a crust resembling bone. In some instances, the sometimes lungs, from the accretion of new matter, have weighed not less than wewid!"' five ?r six Pounds, which is nearly four times their ordinary weight; sometimes but in others, they have been so reduced as, in the language of the andX' same writor- to leave " a vacant space" in the chest; or, in that of Sued ?** Baykj' "to be shrivelled into leather." On this account, breath- ing would be impossible if it were not that the lungs in a state of health are capable of containing ten times as much air as is received by an ordinary act of inspiration : and hence are capable of losing * Young, ut supra.—Portal, Observations sur la Nature et le Traitement de In Phthisie.—Bayle, Recherche* snr la Phthisie Pulmonaire. Par. 1810. * De 1'Ansculutien Mediate, &c. ut supra. ct. in.] SANGUINEOUS FUNCTION. [ord. iv. 183 a very large portion of their capacity without suffocation. In some Gen. III. cases, one lung has been entirely destroyed, and the office of res- m"^' piration maintained by the remaining lung alone for many years.* Phthisis. In other cases, blood, and even pins, have been thrown up from tiou.,urap" time to time in considerable quantities, without the least trace of ulceration, or breach of continuity in the membrane or any part of the structure of the lungs.t Many ingenious experiments have been invented to distinguish Pus and between pus and mucus, in order to determine the actual nature of distinguish^ the disease. Such trials may gratify the curiosity of the pathologist, *^'et:h .. but from the variable, and frequently complicated nature of the ex- tinction af pectoration, as well in the most dangerous as in the earlier stages "Up*,,'"1 of the complaint, we can derive little assistance from this distinc- ance- tion. Mr. Hunter, as a test, employed muriate of ammonia, having Hunter's observed that a drop of pus united with a drop of this fluid is ren- dered sopy, while neither blood nor mucus is affected by it.j Mr. Darwin's. Charles Darwin Hen miserandc puer! si qua fata aspen rumpas Tu Marcellus eris— proposed a double test of sulphuric acid, and a solution of pure potass. If, on the addition of water to pus dissolved in each of these separately, there be a powerful precipitation, the matter made use of is determined to be pus : if there be no precipitation in either, it is mucus. But the simplest and truest character of pus, Home's de- as was first observed and described by Sir Everard Home is, that it mUon' is a whitish fluid composed of globules contained in a transparent liquid : that it does not coagulate by heat; and is only condensed by alcohol. The presence of the globules, as remarked by Dr. Young's Young, may be easily determined by putting a small quantity of the test" liquid between two pieces of plate-glass. If it be pus we shall per- ceive on looking through it towards a candle placed a little way off, the appearance, even in the day time, of a bright circular corona of colours, of which the candle will be the centre ; a red area, sur- rounded by a circle of green, and this again by another of red; the colours being so much the brighter, as the globules are more nu- merous and more equable. If the substance be simply mucous, there will be no rings of colours ; though a confused coloured halo may sometimes be perceived by the mixture of mucus with blood or some other material. As, however, consumption is by far more frequently a tubercular than a strictly purulent disease, and, perhaps, more generally fatal under the former than under thc latter modification, the distinction here sought for is of less importance. It is of more consequence of »">pof> to ascertain whether morbid excavations from any cause, ulcerative determine or tubercular, have taken place at all; and to this point the attention ra„fD^r hollows * Boneti Sepnlchr. Lib. i. Sect. ii. Obs. 167.—Parotti, Raccolti d'Opuscoli place. Scientiiici, xlvi. p. 275. t De llaen, Ratio Med. I. xi. p. CO.— Willan's Reperts, 170S, March 20. * See Apostema commune, Vol. n. 134 cl. m.j ILKMATICA, [okd. iv. Gen. ill. of physicians has been peculiarly directed, for thc purpose, if possi- niar^smus' D^e' 0I* obtaining a criterion. Phthisis. It is now well known that M. Avenbrugger of Vienna suggested, consump- mQre ^ hjJf & century ago? the possibility of determining whe- Sundry in- ther mere were such morbid hollows, or other diseased condition of aMieTfor the chest by the means of percussion by the hand :* and that M. Jo'le!"1" Corvissart was so much impressed with the importance of the sug- Avenbrug- gestion, that he not only translated Avenbrugger's work on the subject from the German into the French tongue, but recommended cussion warni6' "is method warmly in his Clinical Lectures and employed it so supp'oned generally in his practice, as to obtain for it a considerable degree of sari?orvis" reputation. There is no doubt of its giving us correct information at times : but the whole process is accompanied with difficulties which we shall notice presently, and in its application is also of limited Limited use. To remedy these evils M. Laennec, from an early period of applfcntiou l'is hTe, conceived it possible to obtain the same end, and with much remedied greater exactness, by an acoustic instrument.! His mind was directed thoscope of to the fact, that if the ear be applied to one end of a beam of wood, First hint we may distinctly hear the scratch of a pin when made at the other upon this end : and, taking advantage of this hint, he first made a roll of a Progress of sheet of paper wound up close, and well tied, when " applying," tioV8668 savs ne' " one eno- °f ** t° the region of the praecordia, and placing the ear at the other end, 1 was as much surprised as gratified on hearing the heart beat more clearly and distinctly than 1 had ever done by a direct application of the ear itself." And, hence, he foresaw that the same instrument might also be employed to ascer- tain a variety of modifications in the pulsation of the heart and the larger arteries. Having experimented upon a series of substances he found that bodies of such a density as folded paper, wood, or cane, were best Form of the calculated for the purpose ; and he at length fixed upon a cylinder cy n er. Qf wootj Qf a |oot ]ongi aru] an mcn an(j a na]f jn diameter, with a bore or canal in the centre three lines in diameter. To render this instrument more portable he luade it divisible in the middle, like a German flute, thc parts however being united by a screw. Chest- When this cylinder, to which he gives the name of a stethoscope, Mode of and which in our own language may be called a chest-sound, is EffecCtain°n' aPPued to the chest of a healthy person in the act of speaking or health. singing, nothing is heard but a kind of low murmuring, more effelt'in' <"stinct in some parts of the chest than in others ; yet where, an unsound ulcer or other morbid excavation exists in the lungs a very singular LlnfrSIora- change takes place ; for the voice of the invalid is no longer heard cic organ, by the disengaged ear, but comes entire to the observant ear that is applied to the end of the cylinder opposite to that affixed to the chest. This phenomenon ivl. Laennec ascribes to the greater de- gree of strength which the vocal sound exercises in a cavity of wider calibre than the bronchia? themselves. And the opinion is rendered probable as the same phenomenon occurs when the cylinder is ap- * Inventum Novum ex Percussione Thoracis Huinani, ut signo, abstrusos interni pectoris morbos delcgendi. Vienn. 8vo. 1761. t De l'Auscultation Mediate: ou Traite dtt Diagnostic, &c: ct. m.] SANGUINEOUS FUNCTION. [6rd. rv. 185 plied to the trachea or larynx. To this apparent transfer of the Gen. III. voice to the chest the experimenter has given the awkward name of Marasmus* pcctoriloquism or mediate auscultation of the voice. And as the PMisis. same instrument, or with slight variations, is capable of determining lion. the morbid changes that take place in the breathing or contraction quismV'or of the heart, he hence employs it in like manner to obtain a mediate mediate auscultation of the respiration, or of the pulsation of the heart, or tion of the the aorta. For the first of these two purposes however the canal vA0,cflci in should be gradually widened at thc end applied to the chest, in a peculiar funnel-form, to an ascent of about an inch, and then suffered to re- dfsseeaS6g 0f turn suddenly to its general calibre. For the second purpose, the respiration; canal should be entirely obliterated, which may be easily done by a heart. plug of the same kind of wood; the pulses being propagated fie0dWfoT°dl" through the cylinder by vibratory chords.* thesepur- Percussion and auscultation are in the present day used simul- percussion taneously by many physicians in France, and among the rest by M. JJJjjJ j-JJU Laennec himself, and their comparative pretensions have been ably employed estimated in the same country by Dr. Collin,! as they have in our „l^1Uy|an6' own by Dr. Forbes. J The diseases in which the former method is chiefly employed are in what phthisis, dropsy of the chest, chronic pleurisy, chronic peripneumony, percussion emphysema of the lungs, pneumo-thorax, or a morbid communica- j^irfed. tion of the interior of the lungs with the thoracic cavity, and hyper- trophy of the heart, or a morbid enlargement of its substance. In the use of this kind of exploration the patient should be in a How to be sitting posture, the points of the fingers brought close together may app w ' be employed, or the flat of the hand, and either upon the naked chest or with the body-linen drawn tight over it. The action of To what percussion is applied, as circumstances may direct, to the fore-part applied. e of the chest, the sides, or the back. In the first of which cases the patient is to hold his head erect, and throw back his shoulders, that the chest may be protruded, and the skin and muscles drawn tight over its bones, by which the sound is rendered most distinct. In striking the lateral parts of the chest the patient is to hold his arms across his head, so that the walls of the thorax may become tense, and the sound rise distinct as in the former instance. If the back be operated upon, the patient is, for the same reason, to bend for- ward, and draw his shoulders towards the anterior part of the chest, hereby rounding the dorsal region. The degree of percussion is to be varied according to the subject and the place ; so that a more powerful impulse is to be employed in a fat or robust than in a slender and emaciated subject; for the stroke that is sufficient to educe a clear sound hi the latter case, may draw forth none in the former. The amount of the sound must depend upon the general sum of Amount of i i o a Ins sound I he hollow contained in the chest, as in striking a cask, to which how mea- sured. * De l'Auscultation Mediate; ou Traite de Diagnostique des Maladies des Poumons et du Coeur, &c. Par R. T. H. Laennec, D.M. &c, 2 Toms. Paris, 1818. t Des Diverses Methodea d'Exploration de la Poitrine et de leur Application au Diagnostics des ses Maladies, 8vo. Paris, 1824. X Original Cases, with Dissections aud Observations illustrating the Use of the Stethoscope and Percussion, &c. 8vo. London, 1824. Vol. III.—2? 18(J Gen. III. Spec. V. Marasmus Phthisis. Consump- tion. Clian»39 from a state of health of three kinds. Stronger than natu- ral. Dull or obscure. Totally wanting. Difficulties appertain- ing to per- cussion. CL. 1II.J 1LEMATICA. [ord. iv, Mediate ausculta- tion pos- sessed of superior ad- vantages. When cm- ployed as a test of the voice, it gives vari- ous distinct measures, resonance: pectorilo- quism : hffigopho- nism: Metallic tinkling. Indications of these. M. Avenbrugger very forcibly compares it. And hence to deter- mine whether this amount be more or less than it ought, it is neces- sary we should become first acquainted with its character in a healthy state, and accustom ourselves to the percussion of those who are well. Its changes from this standard are of three heads ; it may be greater or stronger than natural; dull or obscure ; or totally wanting. The first takes place where the cavity or hollow is en- larged, as in emphysema of the lungs, which, so to speak, resemble a cask comparatively empty, or rather containing a large volume of air : the second in edema of the lungs, severe catarrh, or the earlier stage of peripneumony ; in which the interior is more than usually occupied with dense matter: and the third in a tuberculated or hepatised state of the lungs, or when they are crowded with any other morbid secretion or induration, so as to be choked up, and leave no room for resonance. The chief difficulties attending the diagnostic of percussion are the long habit required for its use before it can be employed with any advantage, and the peculiar tact or address with which the stroke must be applied to produce its proper effect: the limited power of our having recourse to it in many cases of females on the score of delicacy ; and its occasional uselessness, perhaps deception, in other cases. Thus it is altogether unavailing in patients pos- sessing much corpulency; and although it affords a pretty clear indication in hydrothorax, when the chest is but partially loaded, and in peripneumony before suppuration has taken place ; yet as no sound is yielded when the chest is quite full of fluid, and a very dif- ferent sound to what was at first elicited when a vomica has burst, both these diseases may be mistaken in their most important stage. In nervous coughs, asthmas, dyspnoeas, and polypous concretions about the heart in young subjects M. Avenbrugger himself admits the total inability of his method. The diagnostic of auscultation has some advantage in most of these respects. It is employed, as we have already observed, for three distinct purposes ; as a test of the voice, of the respiration, and of the action op the hkart and aokta. When employed for the first purpose, or that of determining the state of the voice, it affords, under different circumstances, four different kinds of measure : as that of its degree of intensity, which M. Laennec has denominated its resonance; its articulation, to which, as above stated, he has given the name of pectoriloquism; its suppression, or under-tone which, from its supposed resemblance to the voice of goats, he has called hegophonism; and its vibratory clink, distinguished by the name of metallic tinkling. The first of these tests, when existing in a higher tone than natural, is supposed, for the most part, to indicate a certain degree of induration in the substance of the lungs. The second, or that of pectoriloquism, we have already noticed": it is a measurer of tuberculous excavations communicatisg with the bronchia. The third indicates, in the opinion of M. Laennec, a flattening of the bronchial tubes. And the fourth a morbid communication of the interior of the lungs with the cavity of the chest ri.. m.j SANGUINEOUS FUNCTION. [ord.iv. \i>: Where the stethoscope, or chest-sound, is employed as a mea- Gen. III. surer of the respiration, it runs parallel with the modifications ofMa^mus" percussion, and determines its intensity, its atony, and its absence ; pm»**- and detects also its combination with foreign sounds. Under the tion.sUmp first modification it strikes the ear like the strong and sonorous ^fof re- breathing of children, into which the action of the trachea greatly spiration. enters ; and on this account, the present modification is distinguished us^ntensTty by M. Laennec by the name of puerile, or tracheal. It occurs espe- {■£[!„„£, cially in cases in which an entire lung, or a considerable portion of puerile or both, is rendered impervious to air, and especially in acute diseases. 1,™^^. The modifications of a weak or absent respiration upon the use of Develops the cylinder indicate a general obstruction in the respiratory organ, ness or ah- and only vary in the degree or extent of such morbid change ; and sence: hence, as in the parallel modifications of percussion, they become tests of certain different stages of hydrothorax and peripneumony. The foreign sounds with which the cylinder detects the respiration Develop** a to be occasionally combined, are various kinds of rale or rattle, to lion with which the inventor of the present method has given the name of ere- °^rdg. pitous, and subcrepitous, mucous, sonorous, sibilous. The first or astherattip. crepitous rattle, is denominated from its resembling in sound the Jaufe'!0"' crepitation of salt in a heated vessel, or that emitted by frying butter. It is supposed to be a pathognomic sign in peripneumony on its first attack, and occurs sometimes in haemoptysis. The subcrepi- Suberepit- tous is an under-sound of the same kind, and indicates an edema- OUB ratt e' tous state of the lungs. The mucous rattle is that peculiar kind of Mucous stertor called " the dead rattles" by the vulgar of our own country, dea^'ranies though in a less degree of intensity. It is produced by a transmis- «f »|»e vui- sion of the breath through fluids accumulated in the trachea or bron- chiae, and measures the extent of such accumulation in catarrhal phthisis, ha3moptysis, and other important diseases. The sonorous Sonorous and sibilous rattle are of less importance as diagnostics, and exhibit „us rattle. considerable ramifications in their character. The former gives sometimes a loud, and sometimes a deep snore, and sometimes the cooing of a wood-pigeon ; the latter consists of a whizzing, or whis- pering tone, or of chirping like that of birds, often alternately ceasing and renewing its murmur. Both descriptions indicate some partial obstruction of the bronchial tubes ; the latter perhaps of the smaller cells. But the method of mediate auscultation is also employed to deter- Develope* ., j c .1 the strength mine the degree of the strength and action of the heart, and action And it is supposed to do this in four distinct ways : by measuring "nf f„Ufhj"! the extent of the pulsation ; its shock or impulse ; its sound ; and «nct ways. its rhythm. In a healthy person, of moderate stoutness, and well-proportioned ^l"™"*. heart, the action of this last organ, upon an application of the ste- tion as to thoscope is not found to extend beyond the range of the cardiac region, or the space comprised between the cartilages of the fifth and seventh ribs, and under the lower end of the sternum. It is, however, often traced, in a state of disease, through the whole of the left, or the right side of the chest, as well as in the regions pos- terior to them : which is generally owing to the feebleness of the its extent. 188 cl. in.] HiCMATlCA. [<*»• ""■ Gen. III. heart, and the extenuation of its walls. It may therefore be taken Ma^mus' as a general rule, according to M. Laennec, that a perceptible contra extent °f the heart's action is in the direct ratio of its thinness and tion.SUrap weakness, or inversely to its substance and power. A wide range of sound is often, indeed, traced when the heart is enlarged ; but in this case its walls are morbidly slender; and the enlargement consists in a mere dilatation of its ventricles. And hence this dis- eased extent of action is often traced in particular kinds of a hyper- trophy of the organ. Measures The heart is also frequently found to be hereby affected in the tioVaVto shock or impulse of its stroke. The stouter and thicker the walls impulse. 0f me heart, the more violent is the impulse, insomuch that, as we have already had occasion to observe, the bed-clothes have some- times been seen to be hereby elevated. This impulse is peculiarly caught hold of by the stethoscope : and is in some cases so ener- getic as even to lift up the observer's head, and to give an unplea- sant shock to his ear. In proper hypertrophies, therefore, or such enlargements of the heart as are opposed to the preceding, in which the natural cavities are not much interfered with, and the augment consists altogether in a thickening of the parietes, we have reason to expect the present effect; which, in like manner, becomes a pa- thognomic sign of such a disorder, and indicates its existence. Measures The stethoscope, also, measures the sound of the heart's pulsa- tionMui tion. When the action of the heart is peculiarly violent, as in vehe- sound. ment palpitations, the individual himself becomes sensible of a pecu- liar sound, as well as of an increased impulse ; and it has, indeed, in a few rare cases been heard at a distance from the patient's person. Now the application of the stethoscope heightens the sound of the pulsation considerably at all times, insomuch that in its ordinary tenour of health it communicates a certain degree of sonorous vibration which cannot be perceived otherwise ; the sound, how- ever, produced by the contraction of the ventricles, and which is accompanied by the stroke of the pulse, being much clearer than that produced by the contraction or systole of the auricles, so that there is at all times to the ear of the experimenter a double or alter- nate sound, consisting of a louder volume succeeded by a lower. Variation The seat of this double sound, in a state of health, is the cardiac sound in region, to which it is limited ; but in a state of disease it spreads extent. much wider, and is heard distinctly in other places. The sound, moreover, varies from the standard of health both in intensity and ofathetion in hebetude- Where the diameter of the heart is enlarged by a dila- aound in tation of its cavities, whilst its walls are weakened and rendered intensity, thinner, the sound is loud and distinct; but where, on the contrary, its walls are considerably thickened and enlarged, the cavities remaining but little disturbed, the sound is morbidly dull or obscure; and where the same organic thickening exists in considerable ex- cess, the contraction of the ventricles produces a mere shock or impulse without any sound whatever. The sound moreover is not only varied in its intensity but in its oninetion vil)rat.ion ^rora a natural state. It is sometimes accompanied with a wuncfas peculiar hissing like that of a pair of bellows, and is in this state cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 189 cither continuous or intermittent, indicating, according to M. Laen- Gen. III. nee, a spasm or some other temporary and partial obstruction of the M^mus' first organs of the circulating system. At other times the accom- rhulisis. panying noise is like that of a rasp or file ; which is always perma- tion.sump' nent and evinces a permanent obstruction in some of the orifices of °°iJhbgned. the heart'. And in one or two instances Dr. Collin has observed it enhar hiss- combined with a crackling like that of new leather, which he sup- Hoke Me poses to be a pathognomic indication of an inflammation of the peri- ,hM?fa cardium, from his having traced this affection in a person who died like that of during its existence. ^w lea" The stethoscope is also supposed to detect in a peculiar degree Measures the rhythm or relative duration and succession of the ventricular tioVaVto and auricular contractions. These are sometimes alternated with >tsrhytnm- considerable but irregular intermissions, and sometimes far too rapid in their succession ; both which changes from the rhythm of health indicate that kind of organic affection which is dependent upon deli- cacy of constitution, and is often congenital. They do not how- ever augur the existence of any dangerous or even very serious malady. It appears from this general outline that the method of mediate General auscultation may be advantageously applied in one or all its forms of mediate to a detection of various important diseases of the chest, and espe- ft.ueculta- cially to the' different varieties of phthisis: that it may be more generally employed than that of percussion, since corpulescency will seldom prove a bar to its use ; and that it is often more definite in its results. Notwithstanding, however, all the ingenuity that it evinces, it yet often must often be found an imperfect guide in deciding on the actual iectguTde: state of a disease, or even indicating the disease itself, to sav nothinff ?.od ttt a" „,. • i • i ■ i i 1 times re- ot the long and repeated experience which is absolutely necessary to quires long its being employed with precision. For first, it gives us a very expenencc' doubtful kind of information concerning the existence of tubercles or vomica? till they have actually broken, and produced numerous excavations, and consequently is of little use in the earlier stages of the disease. Next, as it has been observed by M. Laennec himself Exempiifi- that some persons have an habitually relaxed state of some of the Lalnneo bronchial vessels from hooping-cough or chronic catarrh, or a few hin»selt- minute excavations in the organ of the lungs without any serious deviation from a state of ordinary health ; as also that patients occa- sionally recover from the tubercular species of consumption and have the interior of the hollows or fistula? hereby produced, not filled up, but lined with a semicartilaginous membrane, thus effecting a natu- ral cure,—the phenomenon of pectoriloquism will here be as dis- tinct as in a morbid state of the pulmonary organ, and consequently may often lead the piartitioner astray. And lastly as the stetho- scope is limited or nearly so to the ulcerative forms of phthisis, the disease may exist in the catarrhal variety, and still elude its power. For these and other reasons little dependence is placed on this Hence lit- instrument by M. Rostan, and still less by M. Fodere; nor is it IoV/ros- likely to obtain a very extensive use in our own country. It has J,Rt£e™d 190 cl. in.] 1LEMATICA. [okd. iv. Gen. Ill, Spkc.V, Marasmus Phthisis. Consump- tion Pathology and prac- tice unsa- tisfactory and un- settled. View'-of Boerliaave as opposed to that of Stahl. Of Stahl, as opposed to that of Morton. Of Bril- louet as opposed to Cullen. Of Rush, as opposed to Salva- dori, and May. also been employed to ascertain tho existence of pregnancy, but with very doubtful success. Such is the general history of phthisis. The pathology and prac- tice are in a most unsatisfactory and unsettled state : nor can any thing be conceived more contradictory than the writings upon both these subjects. Boerhaave regarded consumption as a local dis- ease, or conversion of all the blood and chyle into pus by means of an erosive ulcer seated in the lungs : Stahl as a general disease un- affected by pus or any other acrimony. The latter ascribed con- sumption to the very abundant use of bark which was then prevail- ing in Europe : while Morton regarded bark as his sheet-anchor in effecting a cure. Consumption, according to Brillouet and many other writers, is identic with scrophula, and is only to be cured by tonics, alkalies, corrosive sublimate, or other mercurial alterants em- ployed for the cure of scrophuious affections.* According to Cul- len, though it has an apparent connexion with scrophula, the analogy affords us no assistance in the treatment, and thc remedies for the one are of no avail in the other. Dr. Rush contemplated it for the most part as an entonic or inflam- matory disease, and particularly in its first stage, though it is some- times accompanied with a hectic or even a typhous fever. And hence his principal remedies were salivation, or bleeding, which he sometimes prescribed fifteen times in six weeks, emetics, nitre in large doses, a milk and vegetable diet, walking in cold air even during an haemoptysis, and afterwards severe exercise. The hard- ships of a military life, says he, have effected cures in a multitude of cases of confirmed consumption; and a riding post-man has been relieved more than once by the pursuit of his occupation.! This bold practice excited many followers, and was tried with variable success upon a large scale. But a practice of an opposite kind equally bold, and which soon became equally popular, was proposed at the same time by M. Salvadori of Trent.| Consumption, in the view of this pathologist, is an atonic instead of an entonic disorder from the beginning, a disease of direct debility and not of inflam- mation ; and hence is only to be cured by an active plan of stimu- lants and roborants from the first. The patient's diet is to consist of copious meals of meat and wine, and his chief regimen to be that of climbing hills, or precipitous steeps in the morning as quickly as he is able, till he is out of breath and bathed in sweat, and then augmenting the perspiration by placing himself near a large fire. Mr. May, who adopted the same general principle, seems to have postponed the gymnastic part of the process till the symptoms were alleviated, and to have called in the aid of medicines which Salva- dori regarded as superfluous. May's medicinal means were emetics, bark, and laudanum, night and morning; and for diet, he prescribed soup, meat, wine, porter, brandy and water, eggs, oysters with proper condiments. Swinging was interposed twice-a-day ; and horse-exercise was to complete the cure.§ * Journ. de Med. 1777. t Med. Inquir. and Observ. I. 8vo. Phil. 1789. II. 1793. v. 1802. * Del Morbo-Tisico, 2 Vol. 8yo. Trent, 1787. 6 Lond. Med. Journ. ix. 1788. cl. iii.} SANGUINEOUS FUNCTION. [ord. iv. 191 Many later writers believe consumption to be very generally pro- Gen. HI. duced by a habit of drinking vinegar daily to improve the figure : Erasmus' and Dessault relates a case in which this effect was produced in the Phthisw. course of a month.* Galen recommends vinegar as the best refri- tio".8Ump* gerant we can employ: and Dr. Gregory, in 1794, gave the case of ^'P,6888^}1 a patient who recovered by using three dozen lemons daily. Dr. Bed- ■«. Galen, does felt justified in declaring fox-glove a cure tor consumption as g"'rVGre~ certain as bark for agues :t, Dr. Barton affirms he has never known °f Beddoes but one case cured by it, though others may have been palliated :| to* BaVton and Dr. Parr asserts roundly that it is more injurious than bene- and Parr. ficial.§ Contradictory, however, as are these statements with each other, These coh- they are chiefly so, as being either too highly coloured or too indis- vi'wfca? criminate. We have already considered phthisis under three varie- pabieofap. ■,.n. t • n • • i • i proxima- ties or modifications, chiefly in respect to its being deeper seated or tion: more superficial; the apostematous lying lowermost, the tubercular somewhat higher, and the catarrhal on the surface. But each of as the dis- these, as it occurs in different constitutions, or under different cir- different"568 cumstances, may exhibit very different symptoms, and demand a very ^j'^8;-. different, and perhaps an opposite mode of treatment. And hence ferent ha- most of the principles on which the preceding opinions and modes J^",,"*3' of practice are founded, may derive authority from particular exam- verydiffer- ples of success ; and are so far correct, though, perhaps, none of0ftreat- them will apply to the whole. So considerable, indeed, are the m*|£e shades of distinction from this multiplicity of causes that every sepa- every sepa- rate case of consumption should be allowed to speak for itself, and should86 must call for much deviation from the widest line of treatment we bp«»£ ^ can ever propose to ourselves under the form of general rules. lay down The continuance of the disease when once produced may depend, pt8a°tYcne. as we took occasion to observe when discussing the nature of hectic Funda- fever,|| on the state of the constitution, or on the local irritation; "rmcipies for the hectic may be kept up by either, and so long as this conti- [°njgdatt„ nues we can have no expectation of recovery. In the first place, in the the local irritation may be small, while the constitution itself is bad, Ueatment* and does not dispose the parts to a healing condition. And, secondly, the constitution may be good, while the local irritation is so considerable that there is not remedial power enough in the former to subdue it. How far both these principles have been kept in view by pathologists at large, in their treatment of phthisis it is difficult to determine, though they ought never to be lost sight of: yet the general intentions by which they seem to have been guided, General in the midst of all the contrariety of practice we have just noticed, that have are the following : X' thologistt I. To take off inflammatory action. II. To correct the specific acrimony. * Stir les Maladies Veneriennes, la Rage, et la Phthisie, 12 Bord. 1739. t Essay on the Causes, Early Signs, and Prevention of Pulmonary Consumption.. 1799. X Collections for a Materia Medica, 8vo. Philadel. 1798. I Med. Diet, in verb. Phthisis, Vol. ii. p. 410. * See Epaneius Hectica, Vol. u. p. 135. 192 cl. m.j ILEMATICA. [ord.it. Gek. III. Spec. V. Marasmus Phthisis. Consump- tion. Treatment. First inten- tion : to take off in- fldiiimato ry action. When the habit is ro- bust, and the symp- toms se- vere, the actively reducunt plan may be expedi- ent end im- perative. Weeding. Nauseat- ing. Aperients. Digitalis. Sudorifics. III. To support under debility. IV. To subdue the local irritation and improve the secretion. V. To excite a change of action. I. If the patient be of a robust habit and in the prime and vigour of life, and if the symptoms indicate considerable inflammation, whether in the lungs or bronchias, such as, in the former case, fixed pain and weight in the chest, increased by lying on one side, with a dry but troublesome cough ; and in the latter a general soreness rather than pain in the chest, frequent and violent cough with a copi- ous excretion of a thin, offensive, and purulent mucus ; and, in both cases, with a full and strong pulse, the fever though remissive, making an approach towards a cauma, constituting the plethoric spe- cies of M. Portal, and the inflammatory of Dr. Rush, there can be no question that our object in both these cases should be to diminish the vascular action by every mean in our power. Copious bleeding by venesection should be had recourse to with all speed : and though we shall seldom be called upon so closely to follow the steps of Dr. Dover as to repeat the operation fifty times in succession* before we desist, it may be necessary to follow it up rapidly to the third, fourth, or fifth time. M. Portal, in the catarrhal variety, bled a man, seventy-eight years old, three times with the happiest effect. Immediately after the use of the lancet, we should employ small doses of ipecacuan or antimonial powder, so as to maintain a nausea till the pulse is lowered. Where the symptoms approach to peri- pneumony, the latter is to be preferred; where they lean to an inflam- mation of the mucous membrane of the bronchiae, the former, of which three or four grains may be given three or four times a-day. and will often prove expectorant, and unload the mucous follicles of the air-cells. The bowels should, in the mean time, be thoroughly opened by neutral salts or uniting three or four grains of calomel with the nauseating powder : and after tins the fox-glove may be had recourse to with a considerable promise of success. Von Helmont first employed this last medicine as a specific for scrophula : but the only specific influence we know it to possess is on the kidneys, and on the action of the heart and arteries. It is for this last effect that we look to it in the present instance; the only effect in all proba- bility that renders it of any advantage in consumption. In catarrhal phthisis it seems sometimes, however, to improve the character of the exspuition, and to render it less thin and acrid : but this is, per- haps, a collateral result of the diminished action of the arterial sys- tem : for an increased flow of genuine mucus, like that of genuine pus, depends upon only a small augmentation of vascular energy: since, if the vessels be urged beyond this, the secretion is hot, watery, and acrimonious. If sudorifics be ever advisable in any modification of phthisis, it is here we may expect to find them of use. Bennet indulged the hectic morning-sweats as a mean of abating the symptoms, and Moreton observes that nothing is gained by checking them. But it * Ancient Physician's Legacy to his Country, 8ro. Lond. necessary narcotics. CL.111.J SANGUINEOUS FUNCTION. [ord. iv. 193 is perfectly clear that they very greatly add to the debility, and never Gen« ih< prove critical. It has been proposed by others, however, to over- MMasmua* come the morbid sweats by exciting a sweat of a different kind: £htnisi» "for it is as practicable," says Mr. Watt, " to cure sweating by tionf""11'* sudorifics, as diarrhoea by cathartics."* There is something plau- J[reg8ttim?m' sible in this remark, and the experiment might, perhaps, be allowed lention. to form a part of the reducent plan before us. But the author has Mud dia- never tried it, and even in the state of the disease we are now con- pJXmbie templating, he would prefer mild diaphoretics or relaxants to drastic »° drastic sudorifics. 8Weatinff' When a sufficient inroad has thus been made upon the inflamma- "fterwarda tory diathesis, we may content ourselves with an administration of neutiafs: the cooling neutrals, of whicli nitre is one of the best. It may be given in almond-emulsion in the proportion of a scruple to half a pint; and, if the cough be still troublesome, may be conveniently and when united with some light narcotic, as the extract of hyoscyamus or"" white poppy. The diet and general regimen are points of great importance ; but upon these we shall have to speak presently. It is not often, however, that phthisis commences with the inflam- Phthisis matory action we have thus far contemplated.! Its ordinary march violent in* is unostentatious and insidious ; and it takes possession of the fair ils attack and delicate, rather than of the firm and athletic frame, and chiefly in those possessing this figure who can trace it in their ancestors and have hence reason to apprehend an hereditary taint. II. Of the proximate cause of this predisponent diathesis we know Socond cu- nothing : it is generally supposed to have a near analogy to that of t^ntlon!" scrophula; and when called into action it commonly shows itself in J° c°"«t the form of the tubercular variety: the tubercles themselves, though acrimony. not occurring in a structure strictly glandular, bearing a consider- able resemblance to scrophuious indurations. And, on this account, How far as there are various medicines, and a particular regimen that seem treatment4 to have a beneficial effect upon a scrophuious habit, the same have f"?r ?cro_ been often resorted to for the cure of consumption. Thus, sea- piicabiePto water, the alkalies, almost all the metallic salts, and especially those cuu^va- of mercury, have been repeatedly tried, but apparently with very "«y>. doubtful success. Mr. Spaldin, in the American Medical Reposi- Muriate«f tory, gives the case of a patient who had taken nearly two pounds SQd8~ of potash and soda, intermixed like common salt, with his ordinary food; and, he states with considerable benefit, after fox-glove, sul- phuric acid and bitters had been successively found to disagree ;J and Dr. Trotter affirms that among seamen in scrophuious consump- tion, as he calls the tubercular, salt and salt diet have proved of eminent service, but that the most effectual remedy is cinchona with Cinchona sulphur.§ Yet though serviceable in particular cases of tubercular phut. consumption, this class of medicines is far less efficacious than in strumous affections ; and the remark of Dr. Cullen, which he has confined to two or three varieties of them, may be extended to the whole. " In scrophula," says he, " the remedies that are seem * Cases of Diabetes, Consumption, &c. Sro. Paisley, 1808. t See Epanetus Hectica, Vol. II. p. 138. | Vol. v. p. 220 § Medicina Nautica, VW. III. p. 359. v ol. Ill—25 194 cl. m.] ILEMAT1CA. [ord. IV. Gen. III. Spec. V. Marusmns I'lnhlbiri. Consuinp- '•(in. Treatment. Second iu- tciuiou. Meicury. Metallic ■alts tried generally Out with- out suc- cess. Of silver: I.ead: Zinc: Arsenic: Manga- nese : Cobalt: Copper: Burytcs: Vegetable narcotics. Iodine. Tartorized antimony in diluted ilo?os : ingly of most power are sea-water and certain mineral waters, but these have generally proved hurtful in the case of tubercles of the lungs. I have known," he adds, " several instances of mercury very fully employed for certain diseases in persons who were sup- posed at the time to have tubercles formed, or forming in their lungs : but though the mercury proved a cure for those other dis- eases, it was of no service in preventing phthisis, and in some cases seemed to hurry it on."* Nor have any other metallic salts been of more use than those of mercury. Dr. Roberts has had the spirit and perseverance to run through the whole range of such of them as can in any way be thought applicable to this complaint; and has also had the candour, after a sufficient scale of trial in St. Bartholomew's, a candour how sel- dom to be met with, to confess that none of them were administered with success. The experimented list consisted of silver in its nitrate; lead in its superacetate, combined with opium for counteracting its deleterious effects; zinc, in its sulphate and oxyde ; and the preci- pitate from the sulphate of potash, combined with myr-h ; arsenic in the neutral salt formed by a combination with potash ; manga- nese in its white oxyde, in doses of ten grains every six hours; cobalt in its black oxyde, in doses of from one grain to four; am- moniated copper; and muriate of barytes. And with a like want of success, he tells us in addition, were employed the vegetable nar- cotics, aconite, hyoscyamus, stramonium, belladonna, as also toxi- codendron.! We may hence, I think, nearly conclude with Dr. Cullen, that, " the analogy of scrophula gives no assistance in this matter."| And it is probably on this account that M. de Fodere has treated of tubercular and scrophuious consumption as two dis- tinct forms of the disease. § The preparations of iodine have a fair claim to attention here as well as in scrophula ; though, as we shall afterwards have occasion to observe,!! great caution is necessary in employing them ; while it is only where the affection is pretty evidently tubercular that we have any reason to expect success from their use ; and even here, only by an incipient state of this variety. I have found a local applica- tion of the ointment relieve the cough and pain in the side in some cases more effectually and more permanently than the tartar emetic eruption. And if the erythema hereby produced should prevent a continuance of the application,^ we may substitute the form of pills or of tincture ; giving half a grain of the iodine in either mode of preparation, two or three times a-day. This part of our subject, however, ought not to be closed without briefly adverting to the practice which has lately been adopted by some pathologists, of giving very small doses of antimony in the form of tartar emetic dissolved in a large body of some simple menstruum and continuing it for an almost indefinite period of * Pract. of Phys. Vol. n. Sect, dccccvii. p. 293. t Med Trans Vol. jv. p. 1»9 j Pract. of ph „t . 5 Lemons surjes Epi4emies et l'Hygiene Publique. Tom. ii. Paris, 1823 \] \ ol. v. p. 208. ' «T For its other troublesome effects see Yol. v. Cl, vi. Ord. i. Gen. H Spec I Kmphrma Saru-rr* Broncnccele. p. 20F. P i.l. tit.] SANGUINEOUS FUNCTION. [orb. i.v. 1*3,3 time ; but whether this be recommended with a view of destroying Gen. III. any specific acrimony, or of allaying general irritation, I cannot Man»m»i determine. Dr. Balfour dissolves two grains of the emetic tartar £htnhs^m-, in six ounces of water, and prescribes an ounce of this mixture, tion. that is, a third part of a grain of the tartarized antimony, to be taken |™*nm^!" every hour, and a smaller quantity where this is found to nauseate, teotion. M. Lenthois, in his Meiiiode Preservatif, apparently with a view of "'Xd"by- imitating the great processes of nature in her manufacture of those ™£™j metallic and other mineral waters which have been taken with most thois. success, gives it in a far more divided state, and consequently with a much larger quantity of menstruum. He first dissolves a grain of tartarized antimony in eight tabic spoonfuls of distilled water, and then adds to the entire mixture six or eight pints of water in addi- tion, and sometimes not less than twelve. The solution thus weakened is employed by the patient for common drink in every case and stage of consumption, either alone or with some other drink at meals, or occasionally with wine : it is taken without limita- tion at all seasons and hours. How far this method may answer I cannot say from personal practice : but the success of M. Lenthois is rendered suspicious from its pretended extent; for he hereby prevents the disease, as he tells us, if it be not begun, and cures three out of four where it is. III. But though in consumption we can avail ourselves but little Third cu- of the treatment that applies to scrophula, and know nothing what- tent!or.m ever of the nature of its specific acrimony or miasm, we see enough ^°dosr"g^ to convince us that consumption, in its general character is, like lity. scrophula, a disease of debility : and that wherever it exhibits an excess of vascular action, it is merely in consequence of being planted upon a plethoric or entonic temperament. And hence another principle, conspicuous in most of the remedial plans to which it has given birth, is that of supporting the system while labouring under its influence. This principle is well founded, but of difficult application ; and, An frnport- like the opposite principle of reduction, has been often carried to p7eVhu"Cof an extreme. During the last century Salvadori in the Tyrol, and '!{?£"£ 8p' in the present day Dr. Stewart of Edinburgh, are justly chargeable HySaii^ with having done this by a very general allowance of nourishing [l00"nCH^"c', diet in conjunction with pure or diluted wine, bark, steel, and other cxiremo, tonics ; exercise on horseback, and affusion with vinegar and cold by'stlZ- water. In its ordinary course, the disease itself is not only peculiarly art> prodigal of animal strength, but peculiarly protracted in its dura- tion, while the fever, though remissive, rarely subsides altogether, j*; or allows any interval of which we can avail ourselves. In some instances, however, it does all >\v such interval, and cs-i" ^mc;.: pecially where it has continued for a long period, and has broken re'i.is^r ' down the general vigour of the frame ; in which case Moreton n|!°r"ya'us occasionally found the inflammatory form, with which it commenced, reni•.: converted into a low intermittent, sometimes assuming the quotidian, "IViiVcor- but more generally the tertian type; beginning with cold fit.?, and ^i^1" succeeded by intense heat and profuse sweats whieh exhausted the in inert. I9t> CL. III. HEMATIC A. [oRr>. iv Gen. III. Spec V. Marasmus Phthisis. Consump- tion. Treatment. Third in- tention. I'iruct to- nics may have been here some- times em- ployed with suc- cess. Chisholm's success with cold affusion. With hard Rsercite. But this must not fb»m a ge- neral prae- tice; and ftiust often yield to another poarse. Tho Strength rosy ho supported by negative pjcans. jJl^eding rarely »1- iowaiblu in it delicate frame. Pmetles lew »bjee- f ionsWe: patient, though they left him in high spirits during the intermis- sions.* And, in such instances it is possible that the tonic and stimulant plan of bark, wine, and even high-seasoned dishes, with cold air, cold bathing, and active exercise, so warmly eulogized by the writers just referred to, as well as by many others, may occa- sionally prove successful; and particularly where the disease is of the apostematous or catarrhal variety, and there is no constitutional taint to oppose at the same time. And it is here also, if any where, that the bustling and violent exercise so strenuously recommended by Dr. Rush and Dr. Jackson have a chance of proving beneficial, Dr. Chisholm tells us that in particular cases he has found both these plans of decided service : the cold affusion in the case of a near relative of eighteen years of age, on whom it was employed with great caution, the fluid, consisting of vinegar and water, being first applied moderately warm, and only to the chest and arms, by a sponge, and afterwards gradually extended over the body, and of a descending temperature, till at length it was used cold, and the mixture exchanged for water alone. The beneficial result of hard exercise in the case referred to is still more striking. The patient was a sergeant, captured among others by the army of Hyder Alley, and though labouring under the worst symptoms of phthisis, and suffering at the same time frorn colliquative diarrhoea, was compelled to keep up, in a hurried march, with the other prisoners, at the point of the bayonet. After the first two or three days, the sergeant, who had hitherto almost sunk at every step, became more able to march ; and, before his arrival at the place of destination, all the symptoms of his disease vanished, A scanty allowance of rice was his only food.t But these are plans which cannot be brought into general prac- tice ; and, in supporting the strength of the system, we are ordinarily compelled to pursue a very different course : a doctrine in a few rare instances admitted even by Dr. Stewart himself. The first means by which we are to aim at accomplishing this is of a negative kind ; and consists in saving the frame as much as possible from the profuse exhaustion it is daily sustaining, by calm- ing the febrile irritation, and checking the colliquative sweats, which, as already observed, are never of a critical kind, "• I have sometimes succeeded very decidedly," says Dr. Young in a note to the author, while the first edition was printing, " in checking the sweats by Dover's powder: but 1 do not know that the progress of the disease has been much retarded by this palliation." Bleeding, however plausible, and even advantageous when the pulse is full and strong, and the pain in the side acute, can rarely be allowed when the frame is delicate and irritable, and the pulse small and weak. Where the local distress is considerable, it may be had recourse to as a palliative, but never carried beyond a few ounces, nor repeated without great hesitation. To emetics there is less objection, but vomiting is here to be * See Epanetus Hectica. Vol. 11. p. 137. I Climate and piseaecs of Tropical Countries, &c. 8vo. p. 112. Lond. J822. , l. m.] SANGUINEOUS FUNCTION. [ord. iv. 197 preferred to nauseating. The latter, though it lowers the pulse, Gen. in. produces considerable fatigue and distress. The former emulges Marasmus" the bronchial glands, and diminishes the local irritation by trans- £bthisis. ferring it through the means of a general glow and m sture over tion. the system at large, fbe dose may be repeated three . four times ^fj™-"'" a week, and should have its power limited as nearly as n.ay be to a temion. ■ •..,. * . J * and vomit- smgle inversion of the stomach. ine prefer- In tho selection of emetics some judgment is required, for those nauseating. should be carefully avoided, which, like me antimoiiui preparations, Emetics to. produce loose evacuations, and excite considerable sweating. The wnhYudg- ipecacuan is perhaps one of the simplest and the best. Dr. Sim- ment- mons, however, preferred the sulphate of copper, giving first of all half a pint of water to the patient, and then the blue vitriol from two grains to twenty, according to his age and strength, dissolved in an additional cup-full of water. In general, he found that the moment the emetic reached the stomach it was thrown up again, upon which the patient was ordered to swallow another half pint of water: which was sufficient to take oft the nausea.* The reason that prohibits nauseating, prohibits also the use of Fo*-giove fox-glove : for, though the pulse may be diminished, nothing more is abie?nov obtained, and even this is obtained at too great an expense of sen- |^iattaewaan'1 sorial power in the degree of debility we are now contemplating : habits: and the remark will apply to most of the narcotics, whether of the »» are most umbellate or solanaceous order. The neutral salts answer Letter, "otic SiT" and especially nitre ; and there is no modification of the disease in ben*la- . flllll soli- which this may not be given, and will not prove an excellent refri- nacere. gerant as well as sedative. The general error, however, has been in ^us'lfse- administering it too freely, as in doses of fifteen grains or a scruple : fol: in which case it becomes a direct irritant, and does much more harm than good. Seven or eight grains at a time, as already observed, is but should c i . A- j xi.- ■ -i mi i_ . be given a far better proportion, and even in this quantity it will answer best c.nsider- jf considerably diluted. It is often united with narcotics ; but these *cbd!y dila" are never found of use unless to palliate the cough or local distress ; for otherwise they increase the heat and quicken the pulse. Most of the acids may also be employed for the same purpose, j*«i(!s often and with equally good effect. They may, indeed, be regarded in vicJabio0.' the joint character of sedatives, refrigerants, and astringent tonics : and have hence every claim to attention. The mineral have been Vegetable most commonly in use ; but, from their erosive quality, they cannot to mineral, be thrown insufficient abundance into the circulating fluids : and on this account the vegetable are to be preferred ; and, of the vege- especially table, the fermented acids, which, though somewhat less grateful mented. than the native, seem to be more effectual as tonics. The acetous Acetous acid was employed freely by Galen, diluted widi water, who regarded by'cXn, it as the best refrigerant we can select, ft is continued to the pre- *M e'"- i i \ t - i i • • . ■ i i ■ pioved by sent day among the Moorish physicians at i unis, and, according to .i,-'Moor- the late M Orban, with decided success. He observed its efforts, Jfi^''5"1" during three months, upon one patient who appeared to be labouring it* *urceas under a confirmed phthisis from a neglected catarrh. The quantity Dy orbwu * Practical Observations on the Treatment of Consumption. &c 198 cliii.j HAEMATIC A. [onn. iv. Gen. III. Sr-KC. V. Maras.iius Phthisis Oonsump tion. Treatmenl Third in- tention. Tried with success by Orban him- self. In our own country by Roberts. Summary of its bene- ficial ef- fects. Mischiev- ous where no moibiii excitement: and why. of vinegar drunk in the course of every twenty-four hours was seven fluid-ounces intermixed with seven times as much rain-water, and sweetened with two ounces of refined sugar, f his apozem was accompanied with astringent and tonic piiJs composed cineHy of alum and sulphate ot iron, of each of which two grains and a half were taken daiiy. The diet allowed was very siender, and consisted of nothing more than vermicelli or millet, boiled in water, and sea- soned with a little oil and salt. Of this, only two meals in the four and twenty hours were allowed for several weeks. And, on the pa- tient's becoming very costive under its use, tiio Moorish physician paid no attention to the symptom, but told M. Orban, that a consti- pated state of the bowels was the best symptom that couid occur, and that the more strikingly this prevailed the more certain he was of a cure. M. Orban left this patient in a state of convalescence bordering on perfect health ; and, on ins return to r ranee, pursued the same plan, with the exception of the iron, which he omitted as too stimulant, and found it, in many cases, eminently successful, though not in all.* It has since been tried in our own country and has often proved equally advantageous. Dr. Roberts has paid parti- cular attention to its effects ; and, upon a pretty extensive scale, has been satisfied with them. One of his cases was of a very unpro- mising aspect; and consisted of a young gentleman, seventeen years of age, whose elder brother had died of phthisis two years before. The cough, which, in the morning was very considerable, was ac- companied with expectoration sometimes streaked with blood; a confirmed hectic preyed upon him, and the night a\veut was so pro- fuse that his nair was drenched with it. ■'■ My patient," says Dr. Roberts," was at once relieved by the use ot the acid, and, in a short time, so lost his complaints, that, by my advice, he discontinued thc remedy."! The acetic and acetous acid seem to have been employed indiscriminately; over which the citric, which was also tried, did not seem to have any advantage. The acetous was usually given in half-ounce doses with an ounce of infusion of cascarilla, and a little mucilaginous powder or syrup, the dose being repeated three or four times a day. From these facts, as well as from a host of others of the same kind that might be adduced, the acetous acid appears to be a powerful sedative. It diminishes action generally, checks night-sweats, re- strains haemoptysis, retards the pulse, and produces costiveness. It becomes, hence necessarily a refrigerant; and it is probable that its refrigerant depends entirely upon its sedative power. That it is also an active astringent is known to every one ; but this seems to be a distinct quality ; for simple astringents, as bistort and catechu have no pretensions to be sedative ; and the metallic salts, with the ex- ception of those of lead, arc directly stimulant. On account of this sedative quality, vinegar, when drunk in abundance, where there is no morbid excitement to suppress, becomes often highly mischievous: for, by unduly taking oil' the action of the assimilating powers, it pre- vents the secretion both of flesh and animal oil, and hence produces Med. Trans. Vol. v. Art. xvin. t Med. Trans, nt supra. u.. in.] SANGUINEOUS FUNCTION. foan. rv. 199 emaciation or a slender form ; and is at times expressly resorted to Gen. III. for this very purpose by young and thoughtless females who are £*EC' v* afraid of becoming too corpulent. This effect also is often ascribed Phthisis"" to its astringent quality, yet improperly ; for it is the character of [Jon!ump" astringents to increase the solid contents of the frame, and give Treatment. breadth as well as firmness to the muscles. In haemoptysis, I have tention!" carried the use of acetous acid much farther than was prescribed by Dr. Roberts, and with manifest and unmixed advantage. The proper astringents have also not unfrequently been employed proper as- in phthisis for the same negative purpose of producing strength by J."^8"^.. checking the exhausting discharges of sweat, pus or mucus, blood, viceabic. and often diarrhoea; but they have rarely proved successful. Some Exempiifi- degree of benefit seems occasionally to have been derived from the *'''" oak~ use of oak-bark, several of the agarics* given in the form of lozenges, egarics: and the acetate of lead ;t but they have far more generally been em- jead. ployed without success or with more mischief than advantage. The most direct means of supporting the system would be by Tonics those tonics that unite an astringent with a bitter principle ; but we ^"astrir? have already observed that the system is usually, and particularly in gent and a the beginning and at the height of the disease, in too high a degree dpi" prm" of irritation for a convenient use of any medicines of this kind : though where the complaint has lasted for many months, and appears more use- to be rather of the tubercular, or catarrhal, than of the apostema- g^'""/^^ tous variety, these may sometimes be employed with great success, disease The Angustura bark generally agrees better than the cim bona, and beginning.0 to this myrrh and iron mav at such times be added in increasing Aneuatura i i-ii " 1 /> • r h*'* often doses, and particularly as prepared in the mistura fern composita ot agrees and the London College. In the tubercular variety, the cinchona seldom f,"ptencel*u? agrees in any stage : Dr. Cullen conceives never ; and tells us that bcrcuiar even where the disease has assumed something of an intermittent Jhe'cincho- character, quotulir.n or tertian, and he has, on this account, been na seldom tempted to try it in free doses, he has in no instances succeeded so as to establish a complete cure. " For in spite," says he, " of large exhibitions of the bark, the paroxysms in less than a fortnight or three weeks after they had been stopped, always returned, and with greater violence, and proved fatal." In the latter stages of the apostematous variety, and especially where the vomicae are small and in perpetual succession, he thinks, however, it may be of service, in restoring a healthy action, and promoting a secretion of ge- nuine pus. In this last case, and here perhaps only, we may venture with cold batb. success on the use of the cold bath. In a more irritable state or stage of the complaint, the tepid bath may occasionally prove serviceable ; and, where it does so, should be repeated three or four times a week, or even oftener. Of the effect of the banos de tierra Banos dc of the once celebrated Solano dc Luque I cannot speak from per- ^"h-bath. sonal knowledge. It consists in burying the patient up to the cirri in fresh mould. It would be most obvious to suppose that this was * De linen. Rat. M<•<.'. Tom. u. 567.—Dufresnoy, in Cervisart, Journ. Med. Cent, m Wl. 1804. t Rwell in SMile', Journ. Gen. Med. xnv.~ Hildebrand. ib. xxxvi. 200 ex. in.] HiEMATICA. t0K»- 1V« Food light and with long inter- vals. spiration by a protracted chill, but that Van Swieten tells us thc smell of fresh earth is serviceable, and approves of it on this account. It has since been recommended by "^r. Simmons and M. Ponteau. Before, however, the nectic, or the gjn-n-al irritability of the system has so far subsided as to render tonics advisable, our chief dependence for giving support to the system must be upon diet ;iud regimen. The diet should be of the lightest kinds, and i't very small pro- portion, or with long intervals of rest ; for some d< yree of exacer- bation, in the stage of the disease we are now contemplating, is always produced by the process of digestion. Under limosis expert we have already seen how very small a portion of food is necessary for the support of life, when neither mental nor muscular exercise are made use of; and, though hectic fever itself is a source of very great exhaustion, this exhaustion will be less in proportion as we produce less excitement, whether from eating or any other cause. And hence Vie most cautious physicians, from the time of the Greeks to our own day, have concurred in recommending food in small quantity as well as of the lightest materials. It is not merely the stomach and its collatitious organs that are hereby put at rest, but the circulating system, the assimilating powers, the brain, and the intestines. And hence there was much judgment in the remark of the Moorish physician to M. Orban in the case just adverted to, in which the diet was peculiarly reduced and slender, that costiveness, so far from being an evil, was one of the most promising symptoms that eould occur, and which rarely required any attention. It gives proof in reality, that the secernents of the larger intestines are quiescent, that the lacteals have absorbed nearly the whole of the mat-"-ials introduced into the stomach, and that there is scarcely any refuse matter to irritate afterwards, or be carried off in the form of feces. The food itself should consist principally of milk and the farina- ceous parts of plants, if it be not limited entirely to these: and upon a diet of this kind, in conjunction with temperate air and ex- ercise, the Greek physicians placed their only hopes of a cure. What milk Whether it be necessary to pav that strict attention to the different Uo^sTJi1 kinds of milk which we find in many writers of established repu- tation 1 cannot fully determine. Galen recommends woman's milk, as lightest of all, then ass's, next goat's or ewe's, and lastly cows ;* and Van Swieten adopts the recommendation of Galen.t Mare's milk lias since been proposed as preferable to all these: but the analyses published by different chemists vary so much from each other, that it is difficult to come to a conclusion. If the experi- ments of Stipriaan may be depended upon, mare's milk contains most sugar and least cream, butter or caseous matter ; and woman's milk most sugar and least butter and caseous matter next to mare's, with most cream next to sheep's.! Whence mare's milk should be * Opp. Tom. vi. ISO, 131. edit. Basil. 1642. t Comment. Tom. iv. Sect. 1211. edit. Lugd. Bat. 1764. * See Crell's Chemische Annates, § yih. p. 188. 1794, Food prin- cipally milk and the farina •f plants. Iea»t heat ing. Analyses of Sti- priaan. cl. iii.] SANGUINEOUS FUNCTION. [okd. iv. 201 the lightest of the whole, but less nutritive than woman's. Accord- G]EM' lin- ing to Parmentier, however, ass's milk contains a less proportion of Marasmus' caseous matter than any of the rest. Phthisic. Peculiar properties may sometimes be given to milk by the food tionSUmp" fed upon ; and hence Galen endeavoured to render it more astringent Ti^dTi-1' by placing the animal, that was to furnish it, in pasturage, enriched en-.jor.. for the purpose with agrostis, lotus, polygonum, andmelyssophyllum. properties And as the patient became convalescent, and could bear a richer of milk . i 11 i 11 i m- communi- nutriment, he was allowed to sail down the a iber and use the cows ci-bio oy milk of Stabiae, which was peculiarly celebrated for its excellence. {{,'2 u°p00o. When ass's milk cannot conveniently be obtained, its place may Artificial be supplied with what has been called artificial ass's milk, which is aiS'*milk- a mixture of cow's milk and animal mucilage, diluted in a farina- ceous apozem, rendered slightly sweetish and aromatic by eryngo. The ordinary form consists in boiling eighteen contused snails with an ounce of hartshorn-shavings, of eryngo-root and pearl-barley, in six pints of water to half its quantity, and then adding an ounce and a half of syrup of Tolu. Four ounces of this are usually taken morning and evening with an equal quantity of fresh milk from the cow.* The chief foods which have been allowed in the general treat- Vegetable ment of consumption in its earlier and middle stages, in conjunction muei as nr- cise, says he, by any means to be despised though not equal to that Mlr^'mJs of the saddle. Hoffman and Baglivi adopted the same opinion, and £h,n<»'9- laid it down in terms nearly as unqualified. Where phthisis is a ti°n8Ump" secondary disease, and dependent upon some obstruction of the di- Third?™1" gestive viscera, exercise of this kind may, in many instances, be em- temion. ployed as an important co-operation with other means even from the Ba>giilvi1.n: beginning; and to such cases of consumption Desault judiciously j^L1!™^ limits it. In the present day it has been revived by Dr. Stewart sauit. under a variety of ingenious modifications, and appears in many cases to have afforded relief: but the constitutions of mankind must strangely have altered since the days of Sydenham, if the severity of horse-exercise could at that period have been employed as a specific remedy in consumptions of every kind. Stoll did not find it so in the middle of the last century ; for he tells us that if a consumptive pa- tient mount his horse he will ride to the banks of the Styx as surely as if he were in a pleurisy.! And Stoerck died consumptive though in the habit of riding, killed by an haemoptysis apparently produced by this exercise. J IV. Another part of the curative process in the disease before us, Fourth cu- has consisted in endeavouring to subdue the local irritation, and im- tention. prove the secretion from the lungs. This has been chiefly attempted j£° ,gmcpl!£ve by fumigations, medicated airs, expectorants, and sedatives. tion from Bennet was strongly attached to the first of these, and thoughtthe ln"5' they proved peculiarly detergent, and enabled the patient to throw up a more laudable discharge with increased facility. He sometimes Fum^a- employed aromatic herbs which were immersed in hot water, over somatic which the patient held his head surrounded with clothes to confine herbs- the vapour, which was thus inhaled with every inspiration. But he or terebin- seems to have placed more dependence on an inhalation of the fumes resins," of various terebinthinate resins, as frankincense, styrax, and turpen- "g,^^ tine itself, mixed into a powder or troche with a few other ingre- tions. dients, and burnt on coals : to which he sometimes added a consider- able proportion of orpiment. And such was the success ascribed to this practice, that Willis, not many years after, resolved the greater exemption of certain parts of England and Holland from coughs and consumptions, to the turf and peat fires which the inhabitants were in the habit of using, and the arsenical principle which was intermix- ed with the material. In our own day terebinthinate fumigations Fumiga- havebeen very extensively tried in consequence of the warm recom- tar. mendation of Sir Alexander Crichton, who thought he had perceived great and decisive advantage from the aroma of pitch and tar dif- fused through rope manufactories, ships, and other places where these articles are in perpetual use.§ I have tried this repeatedly by heating a tin vessel of tar over an oil or spirit-lamp, and thus impreg- nating the atmosphere of the chamber with the powerful vapour that arises. In doing this, however, we must be careful not to burn * Opp. p. 629. t Rat. Med. i. J Quarin, p. 162, 16S. § Practical Observations on the Treatment and Cure of several varieties of Pul- monary Consumption; and on the Effects of the Vaponr of Boiling Tar in that Dis- ease. Lond. 8ro. 1823. 20tf cl. m.] HiEMATICA. [obi;, iv. gem. hi. the tar; for in such case the room will be filled with an empyreuma- Mwtsmus" tic smoke that will greatly augment the patient's cough instead of Phthisis, diminishing it: and it will be also advisable, as recommended by tion.8ump Dr. Paris,* to add about half an ounce of subcarbonate of potash to Fourth°in-t' everv pound of tar, for the purpose of neutralizing its pyroligneous tention. acid, the fume of which will otherwise ascend and prove irritating. internal In those states of the disease in which terebinthinates, as myrrh, myrrh: benzoin, or copaiba, may be taken internally with a prospect of suc- anrTc'- cess'tms kma" °^ fumigati°n will sometimes prove useful also: and it paiba. is hence far better adapted to the tubeicular and catarrhal than to the apostematous variety. In a chronic state of the first two, I have sometimes thought it serviceable; but I have more frequently used Hospital it without any avail. The experience of Dr. Forbes, physician to mem"of the General Military Hospital, who has tried this remedy in a parti- Forbes. cular ward of this establishment, upon an extensive scale, very closely coincides with these remarks. Of nineteen cases of phthisis, of which he has given us an account, it neither cured nor improved any; on eight it had no effect; and mischievously suppressed the secre- tion, injured the breathing, and increased the disease in eleven. In cases of chronic catarrh, where the secretion constitutes the disease, and tonics and astringents are useful, it often succeeded. Of thirty-two cases narrated, it had no mischievous effect on any ; no effect whatever on eighteen; improved six ; and cured eight.! Pneumatic Pneumatic medicine, which, about thirty years ago, was in the me icine. njgnest popularity, does not appear, when candidly examined, to Oxygene have been more successful. Oxygene gas has, in almost every in- stance, proved so stimulant, and so much increased the signs of inflammatory action, that though it has seemed occasionally to afford a momentary relief in a few cases, it has rarely been persevered in more than a fortnight, by which time it has often suppressed thc usual expectoration, and produced an haemoptysis.^ Hydrogene There was much more reason and ingenuity in recommending an ?as inhalation of hydrogene intermixed with common air than of oxy- gene : since the effect of this gas in destroying the irritability of the living fibre is known to every one; and it was hence a plausible con- jecture that by being applied immediately to the seat of the disease it might sufficiently subdue the inflammatory impetus, change the action of the ulcerated surface, improve the secretion, and annihilate the hectic. The experiment has been tried at home and abroad upon a pretty extensive scale, by employing different proportions of hydrogene, so that the patient has twice a-day breathed from a pint to a quart of gas at a time, diluted with from twelve to six times its measure of common air; and making every allowance for an exaggeration of statement in those who have most warmly engaged in the practice, it seems difficult not to concede that it has proved serviceable in various cases. On wba* A combination of hydrogene with common air seems, indeed, to jjwraciple 1 useful. * Pharmacologia, Vol. n. p. SS9. edit. 1822. t Remarks on Tar-Vapour as a Remedy in Diseases of the Lu»*s, Illustrated with Cases by James Forbes, M.D. Svo. 1822. * FotircroT. Annalrs Chirur. iv. p. 8". 1710. cl. ili.j SANGUINEOUS FUNCTION. [ord. iv. 20) be beneficial in various other modes of application; but whether by Gen. III. lowering the ordinary stimulus of common air or by directly decom- Ma^mM posing and exhausting the nervous fluid communicated to the lungs, Phthisis. it is not easy to determine. In either way, however, it has an equal tion8U,np* tendency to indispose them to inflammatory action. Thus Clapier, JoulSlS-' in the Journal de Medicine, relates a case of confirmed consumption tention. cured by an habitual residence in a coal-mine ;* and expressly states cud-nUm. that the matter expectorated soon began to assume a more healthy appearance, and was excreted more freely. It is, in like manner, a common remark that the miners of Cornwall are more generally exempt from phthisis than most other persons :| and that butchers, Exhalation who are perpetually engaged in slaughter-houses, and surrounded by tar-houses: a vapour impregnated with hydrogene, possess an equal emancipa- tion. It is probably to this cause, if to any, we are to ascribe the of cow- benefit which Bergius found consumptive patients derive from a resi- 10US8,■ deuce in cow-houses,^ and which was not long since a fashionable mode of practice in our own country. Expectorants and demulcents have, also, very generally been em- Expecto- ployed for the same purpose; that of subduing the disease by exciting demui-n a healing action in the tubercles or ulcerations, indicated by improve-centSi ment in the expuition. Of the general nature and mode of action of these classes of medicines, we have already spoken at large in discussing the treat- ment of cough and asthma ;§ and our remarks, therefore, upon the present occasion will be but few. Where the irritation is considerable, and accompanied with much The best increase of vascular action, as in the commencement of the aposte- cents vege- matous and catarrhal varieties, the best demulcents, and, indeed, the }ageg.muci" only medicines of this kind we can employ as palliatives, are the vegetable mucilages,, as of tragacanth, quince seeds or gum Arabic. Where it is necessary to diminish the general action, these may be sometimes united with small doses of ipecacuan, or of squills ; which have the nauseating double power of exciting nausea, and unloading the mucous follicles ™^° of the bronchiae as expectorants. And, where the cough is very troublesome, and the pain acute, they should be united with narco- tics, as opium or hyoscyamus. In a more advanced stage of the disease, and through the entire course of the tubercular variety, except where haemoptysis is present, the expectorants, more properly so called, have often been employed with advantage. One of the oldest of these is sulphur, and perhaps Sulphur. one of the best; from its not readily dissolving in the first passages, it is carried to the rectum, and skin sometimes, with little alteration; and hence gently stimulates both extremities, loosens the bowels, and excites a pleasing diapnoe on the surface. It is in this way it appears to be serviceable in an inflammatory or tubercular state of the lungs. It was in high repute among the Greek and Roman physicians, who, when employing it as an expectorant, usually com- bined it with yolk of egg; and it has maintained its character to the * Journ. Med. xrill. 59. t Southey, Observations on Pulmonary Consumption, 8vo. 1814. . Ncue Schwed. Ahhandl. !"«?. P. in. p.29R. e. Vol. i. 208 a.. ui.J HifiMATICA. [okjj.iv. Gen. III. Spec. V. Marasmus Phthisis. Consump- tion. Treatment. Fourth in- tention. Balsams aud resins. Myrrh: Camphor: Copabia. Hydrodya- nic aoid. Cherry- laurel- water. present day. In the tubercular, or scrophuious variety, as it is often called, it has frequently been united with some other preparation, as diaphoretic antimony, with which it was joined by Hoffman, dulca- mara by Videt,* and cinchona by Dr. Trotter, t The vulnerary balsams and resins, however, have been more gene- rally had recourse to; but ought rarely, perhaps never, to be em- ployed in an early stage of the disease. Their action is common, and depends upon their possession of a terebinthinate principle; and hence they might be used indiscriminately, but that some of them are less stimulant and heating than the rest. Myrrh and camphor are among the least irritant, and may often be employed when we dare not trust to any other Copabia, though of somewhat greater balsamic pungency, has often been found essentially useful. Mar- ryatt was peculiarly attached to it: he gave twenty drops of it night and morning upon sugar ; and asserts that, when an ulcer has been formed, it ought never to be omitted ;J and Dr. Simmonds appears to hold it in nearly as high an estimation. § Many of the remedies already enumerated under the present head act with a sedative influence, and of opium we have already spoken. But there is a medicine which immediately belongs to the present place not yet noticed that has of late years been strongly urged upon the public in the warmest terms of panegyric, and by many cele- brated writers been regarded as a specific in consumption, and that is the prussic or hydrocyanic acid, or cherry-laurel water, which makes a close approach to it. M. Magendie has been highly san- guine concerning it in France,|| MM. Brera, Manzoni and BordalT in Italy, and Dr. Granville in our own country.** Yet not a single case of actual cure in confirmed phthisis has hitherto been ad- vanced by any of them. We have already noticed this powerful medi- cine as a most valuable subduer of nervous irritation in periodic nervous cough, and hooping cough ; and there can be no question that it will often be found capable of acting in the same manner in phthisis. But from the greater degree of debility and relaxation in this last than in the preceding diseases we have more to fear from the mischievous effects of the prussic acid, which cannot always be guarded against and which M. Magendie admits to have taken place occasionally with very fearful apprehensions ; such as vomiting, diarrhoea, great depression of spirits, prostration of strength, and even syncope. And hence, if it be employed as a palliative at all, it should be in the earlier stages of the disease; for in the later, where it is most wanted, it is altogether unsafe, and must yield to most of the forms of opium. And the same remark may be made concerning aconite, another of the famous counter-stimulants of tho * Medicine Expectante, Tom. in. p. 257. 8vo. Lyons, 1803. t Medicina Nautica, Vol. in. p. 325. 8vo. Lond. 1814. X Therapeutica. Lond. 1758. § Practical Observation's on the Treatment of Consumption. Lond. 1780. . (j Recherchcs Phyiiologjques et Cliniques sur l'Emploi de l'Acide Prussique ou Hydrocyanique dans le Traitement des Maladies de Poitrine, &c. Par F. Maeendie. D.M. &c. 8vo. Paris, 1819. 6 ' IT Storia della Febre Petccchiale di Ginova, &c. ** Observations on the Internal Use of the Hydrocyanic Acid in Pulmonary Com- plaints. &c. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 209. present Italian school of medicine, and with which M. Borda tells Gen« m« us he has sometimes snatched the patient from the jaws of death. Marasmus* V. The last part of the general therapeutic process which has Phthisis. been attempted in most ages, has consisted in endeavouring to di- tion.8Un,p" minish or carry off the local affection by a transfer of action. uve'inten*" Blisters have very generally been applied for this purpose to the tion. back or the chest. Their service is temporary, but often very effi- changeof cacious, and they ought never to be neglected. It was formerly the ^|j°enrw custom to render them perpetual by the use of savine ointment, or some other escharotic. But it is equally less painful and more be- neficial to let the skin heal, and renew them after short intervals. Setons, issues, and caustics, however, where the constitution is Setons, not very delicate, nor the habit very irritable, have proved far more caustics. powerful revellents, on account of their more violent stimulus and greater permanency of action. The actual cautery, though much Actual abstained from in modern practice from its apparent, rather than employed real severity, was in almost universal use in ancient times ; and, in bev^*y the mode described by Celsus, was undoubtedly a very formidable ancient* operation. When the disease, says he, has taken a deep root, the cautery must be applied under the chin, in the throat, twice on each breast, and under the shoulder-blades ; and the ulcers must not be healed as long as the cough continues. Dr. Mudge pursued this Sevora plan to a very considerable extent on his own person, and ascribes plied by his cure to the use of it. He applied a large caustic between the Jj|*" shoulders, which produced an eschar of nearly three inches in dia- person. meter, and held fifty peas ; but he confined himself at the same time to milk and a vegetable diet.* Bennet exchanged the caustic Severe uso for issues, which he placed in the groins and hams, under the arms, ° and between the shoulders, and kept sweet by peas of orris root; and asserts that he found the use of these highly beneficial. Yet setons are said by those who have employed them to be still more serviceable than issues. The obvious intention is to produce a revulsion ; and hence by transferring the morbid action to a part of less importance, to allow the lungs to return to a healthy condition. Such transfer may, by these means, in some cases, be rendered total, though, in general, the morbid irritation is only partially, in- stead of entirely, carried off. There are other means, however, by shometim?7 which it seems to be removed altogether, although they are means irritation' that are seldom put into our hands. belnene-by Thus M. Bayle's fifty-third case is that of a medical man who was tireiy car- nally prepared to meet his fate, and resolved to take no medicine HC whatever. At this time a severe rigor from an unknown cause at- Carried off tacked him, succeeded by a sweating-fit so profuse that his linen was roxysmof changed two-and-twenty times in a night, and even this was not epne«"»ra. sufficient. The paroxysm proved critical; and the disease was thus carried off by an ephemera.t Sir Gilbert Blane gives an account of a like singular and salutary J?*^"** change excited by a hurricane at Barbadoes, in 1780 ; which pro- * Radical Cure for a recent Catarrhous Cough, p. 78.. Svo; Lond. 1779. | Recherche* fir la Phthisie, fcr. ut supra. '"'•I.. Til.- >7 210 CL. III.] ILEMATICA. [ord. IV. Gen. III. Spec. V. Marasmus Phthisis. Consump- tion. Treatment. Fifth inten- tion. Suspended by a tooth- ache. Produced by a sud- den cute of some cuta- neous eruption, and re- moved by its resto- ration. Suspended by preg- nancy : and some- times radi- cally cured by it. How far any other disease may be employed as a preven- tive. Inquiry of Wells upon this^ubject. Whether an atmo- sphere pro- ductive 01' agues does not indis- pose to consump- tion. His inves- tigations support this idea. Those of Southey are not fa- vourable to it. duced such an effect on the air, or on the nerves of the sick, that some who were labouring under incipient consumption were cured by it; while others, who had reached a more advanced stage, were decidedly relieved, and freed for a time from many of their symp- toms.* Bennet relates a case of consumption which was suspended for two days in all its symptoms, except the emaciation, by a severe tooth-ache.t In Hautesierck's collection, we have an account of a recovery from a purulent expectoration, by the formation of a fistu- lous abscess in another part of the body, which was itself cured by an operation.J And we have numerous instances of consumption produced by a sudden cure of some chronic cutaneous eruption, and especially itch ; and of its ceasing upon a restoration of the primary complaint. There is, however, no affection that seems to keep a consumptive diathesis in sp complete a state of subjugation as that of pregnancy. Most practitioners have seen cases in which a fe- male has dropped all the symptoms of phthisis upon conception, and has continued free from the disease till her delivery. Suckling does not seem to continue the truce ; but if she conceive again shortly afterwards, she renews it: and there have been instances, in which from a rapid succession of pregnancies, the suspension has been so long protracted that the morbid diathesis has run through its course, and entirely subsided, leaving the patient in possession of firm and established health. As one disease, therefore, or state of body, is well known to have a frequent influence upon another, and consumption is found to be thus influenced by various affections, it is a question well worth in- quiring into whether there be any malady of less importance, which, like cow-pox over small-pox, by forestalling an influence on the constitution, may render it insusceptible of an attack of phthisis ? Dr. Wells not many years ago, very ingeniously engaged in an in- quiry of this kind ; and finding that it was common for the consump- tive in Flanders to remove to the marshy parts of the country where agues were frequent, began to think, not indeed that agues might give an exemption from consumptions, but that the situation which produced the former might prove a guard against the latter. And so far as his topographical investigations have been carried, and they have extended over some part or other of all the quarters of the globe, this opinion has been countenanced : for he has discover- ed that wherever intermittents are endemic, consumption is rarely to be met with ; while the latter has become frequent in proportion as draining has been introduced.§ The later inquiries of Dr. Southey do not support this hypothesis ; but the question is yet unset- tled, and well worth pursuing ; and Mr. Mansford who practises in the interior of Somersetshire, has still more lately published a work which, though not written as a defence of Dr. Wells's opinion* indi- rectly confirms it, by endeavouring to prove that a low, inland situ- * Observation* on the Diseases of Seamen, 8vo. Lond. 1786. t Vestibul. Tabid, ut supra. j Recueil d'Observations de Medicine, &c. Part n. p. 286. Paris, 1772. § Trans. Medico-Chir. Soc. Vol. m. p. 471. ex. in.] SANGUINEOUS FUNCTION. [ord. iv. 211 ation, like the vales of his own country, is far better calculated as a Gen* n/' residence for consumptive patients than the air of mountains or of M^mus' the sea-coast.* phthisis. t'onsump- tion. Treatment. Fifth in- tention. GENUS IV. MELANOSIS. MELANOSE. SECRETION OP A BLACK MATERIAL, MORE OR LESS INSPISSATED ; STAINING OR STUDMNG THE VISCERAL AND OTHER ORGANS. The tubercles and tubers of struma chiefly originate in the texture Gen. IV. of the glands, especially the lymphatic, and are often confined to withCbw them. There are other tubercles, as those of mesenteric tubes, that tubercular spread rapidly into different textures, and sometimes originate in them. But there are none that seem to commence or extend over so large a field as those we are now about to describe, or so seri- ously to affect the constitution. There is not indeed a single organ »nd more of the simplest or most complicated kind, from the cellular texture "anliny of to the unravelled elaboration of the brain, which is not occasionally "iem;. * sometimes loaded with them ; while in various parts the black pigment which diffused: gives them their hue, is found diffused in extensive sheets, without tubercles, or the pulpy matter that fills their cysts ; transforming the natural colour of the organs to which it is conveyed into its own morbid jet. The last change has hitherto been found chiefly in the bones, but and may sometimes also in the membranes, and even the parenchyma of or- ?oundPge-8 gans, constituting, in the language of M. Breschet, false membrane %*£$ dif- or membranous expansions on the surface of the mucous and other textures ; and it is hence possible that examples may hereafter be met with of a generally oiffused as well as a generally tubercular form of the disease. But as the second, with a few local excep- but the tu- tions, is the only mode under which it has hitherto appeared, we ufemiiy have at present but one species of the genus, which we shall pro- k.Mffn •Pe* ceed to describe under the name of MELANOSIS TUBERCULARIS. TUBERCULAR MELANOSE. * Inquiry into the Influence of Situation on Pulmonary Consumption. By J. G. Mansford, &c. 8ro. 1818. 212 CL. III. IL©MATieA. [OKD. SPECIES I. MELANOSIS TUBERCULARIS. TUBERCULAR MELANOSE. THE BLACK SECRETION PULTACEOUS, IN ENCYSTED TUBERCLES, PEA- SIZED OR WALNUT-SIZED ; SCATTERED IN GROUPS OVER MOST OF THE ORGANS ; CHIEFLY BELOW THE SURFACE, SOMETIMES UPON IT : FEVER MOSTLY A HECTIC : GREAT DEBILITY. Gen. IV. Spec. I. Only lately noticed: except among animals. Charbon, what. Morbid de- nigratjon. Cause, pro gressw&nd treatment obscure. Most strik- ing symp- toms. Incursion. It is singular that this very striking disease should not have been traced, or rather perhaps not have attracted the attention of patho- logists till a few years back; at least in the nosology of man. For it has been long observed in many kinds of quadrupeds, as the dog, cat, hare, but especially the horse ; and among the veterinary sur- geons of France has obtained the name of charbon, or maladie char- bonneuse. It is, however, to the ingenious anatomical researches of MM. Breschet* and Laennec that we are indebted for our first knowledge of the disease as it exists in man, and for the very appro- priate generic name of melanosis, or morbid denigration, by which it is now generally distinguished ; though it is necessary to observe that M. Bayle has employed this term, in a somewhat dif- ferent sense, and appropriated it to those dark-coloured or hepatised indurations which are occasionally found in the lungs of consump- tive patients, affected with the catarrhal or ulcerative modification, as distinguished from the white tubercles with which they are stud- ded in the tubercular variety. It is to the labours indeed of MM. Breschet and Laennec, and to a valuable but unfinished tract on the subject by Messrs. Cullen and Carswell, of Edinburgh,! that the author will chiefly have recourse in furnishing his account of this malady; concluding with such remarks of his own, in respect to the general nature and physiology of the disease, as may seem to be called for. The cause, progress, diagnosis, and mode of treatment of tuber- cular melanosis are at present obscure and unsatisfactory. From the few cases before us, the individual labouring under it exhibits, when he first applies fpr help, a considerable degree of febrile ex- citement, debility, and oppression in the thorax or abdomen ; most commonly about the pleura or in the loins : as though the flow of the blood were impeded in its orbit, and the sensorial energy were exhausted by some preternatural and morbid action. These, how- ever, are not the introductory symptoms: for the disease usually * Considerations sur1 une Alteration Organique, &c. in Magendie's Journal de Physiologic. t On Melanosis, Transactions of the Medico-Chirurg. Soc. of Edinb. Vol. I. 8yo. 1824. ■■r.iu.] SANGUINEOUS FUNCTION. [ord. iv. 213 commences with catarrhal or rheumatic affections after exposure to Gen' Iv- cold, succeeded by shivering fits. The patient seems generally un- Mehfno'sui" well for the first five or six weeks after this attack; but when it «ubercu- has once firmly established itself, and evinced the thoracic or abdo- Tubercular minal signs just adverted to, it proceeds with a rapid and fatal step, p^'11'^8" and in about a fortnight he falls a victim to the hectic fever, for it is Fatal is- usually of this type, perspiration, emaciation, and debility by which sae" he is jointly assaulted : the j-rodromi or incursive symptoms, whether affecting the loins or chest, usually giving way before the closing scene arrives, and deceiving the sufferer, and sometimes even his medical attendant, into a belief that he is improving; when he suddenly sinks from debility alone. If the patient be examined accurately at this time a few tubercles Tuborcies or clusters of tubercles may occasionally be felt under the skin, espe- traced cially that of the abdomen or of the breasts. And sometimes also &££$}*' a cyst much larger than the rest may be found projecting, and even altered forcing its way externally through the integuments. In a few ^|" instances this larger cyst ulcerates, of which a striking example Exempli- occurred to M. Breschet in 1821, and is particularly noticed by Mr. Cullen. In the right groin of the patient, who was a female, an ulcerative surface was perceived about as large as a crown-piece, the bottom of which consisted of the ordinary black material of the disease before us, jetty as China-ink, of the consistence of cream above, but much more inspissated below, where it was in contact with the cellular texture. There were sufficient proofs that it was not a mere sloughing sore ; among which it may be observed that it was destitute of fetor, and that in its immediate vicinity, as well as in other parts of the body, as was afterwards ascertained by opening into them, there was a crop of defined melanotic tubers of different forms and diameters. One of the best marked instances upon record is the following, History which occurred to Professor Alison in the Royal Infirmary, Edin- f^tiie burgh. The patient's name was Rachael Bruce, and she was lifft: admitted on the third of June.* She complained of severe pains Alison's. shooting down from the loins to the inferior extremities, and to the o°TMliica- abdomen. She had similar pains in the right shoulder and arm, tion. increased in the night-time, or by motion. She had become weak and emaciated since her complaints began, and was liable to shiver- ing, followed by flushing and profuse perspiration, which increased her debility without relieving her pains. The abdomen was swelled, but did not fluctuate on percussion, and the distention varied in degree at different hours of the day. She had thirst with scanty, high-coloured urine, not coagulating by heat. The integuments of the abdomen were flaccid; and a hard, moveable tumour could be felt in the ileac and hypogastric regions. She was also liable to paroxysms of dyspnoea during the night. Her appetite was im- paired. She had a bad taste in the mouth, with white and dry tongue. Her bowels were reported to be regular; but she had occa- sional nausea. * Trans, of the Medico-Chir. Soc. of Edinb. nt supra, p. 275. 214 cl. iii.] ILEMATICA. [obd. iv. Gek. IV. Spec. I. Melanosis Tubereu- laris. Tubercu- lar Mela- nose. Whence originated. Progress. Fatal ter- mination Sometimes more rapid. Exemplifi- ed from Heme. Usual treat- ment. Suggestions upon treat- ment. Dover's powder with iodine She stated her complaints, which were of five or six weeks standing, to have commenced, after exposure to cold, with shivering and pain, and stiffness of the loins, and of the hip and knee-joints of the left side. The enlargement and induration of the abdomen had been remarked during the last fortnight only. Up to June the twentieth, being seventeen days from the time of admission, the symptoms continued with little variation. On the twenty-first were perceived several small painful tumours on the integuments of the abdomen, which she declared to have existed from the commencement of her illness. She was on this day exa- mined by a skilful accoucheur who reported the tumour felt in the hypogastric region to be unconnected with the uterus. On the twenty-fourth a copious sweating, with involuntary discharge of urine, was added to the other symptoms. From this moment there was great debility with decided hectic fever; and a tendency to sloughing of the sacrum. On the evening of the seventh she had vomiting of a dark coloured matter, and died soon after. The course is usually more rapid : and in the case of John Hous- ton, a shoemaker, admitted into the same Infirmary under the care of Dr. Home, extended only to thirteen days. His chief symptoms at the time of admission were those of pleurisy, with a severe cough and difficult expectoration. The bladder was also affected ; and on the eighth day, he was troubled with painful hemorrhoidal tumours, probably produced by the action of repeated purgatives with which his bowels had been treated. The other symptoms gradually dimi- nished, but the debility increased considerably. On the twelfth day, as we learn from a diary of the symptoms and treatment, furnished us by Sir Andrew Halliday, his pulse was a hundred and twelve; heat 98f Fahrenheit; was allowed a beef-steak, and a quarter of a pint of sherry. On the ensuing night he made complaint of great weakness ; his pulse quickened to a hundred and forty, and he died at four in the morning.* The treatment is yet to be learnt; and the cases before us afford little instruction upon the subject. The first was contested by little more than palliatives, as leeches, laxatives, anodynes, and Dover's powder. The second unfolds a bolder plan, though the patient still sooner reached his end. It consisted in venesection to sixteen ounces, two days in succession, and powerful purgatives, at first often repeated, of calomel, jalap, and sulphate of magnesia, &c. But this was not long continued, no benefit appearing to issue from it; and it yielded to sedative mucilages and a tonic diet.t In reasoning speculatively, we should speak with great modesty. But admitting the material which forms the tubercles to be a peculiar secretion, and that the constitutional excitement consists mainly in this new and stimulant action, perhaps it may, in future cases, be found useful to combine the two intentions of allaying the peculiar irritation, and, at the same time, urging the secernents to a renewal of their proper action ; or, in other words, to employ the conjoint force of sedatives and counter-irritants; which may be effected by * Lond. Med. Repos. Vol. xix. p. 44-?. ■*■ Sir Andrew Halliday, ut supra. cl. iii.] SANGUINEOUS FUNCTION. [ord. iv. 215 an union of opium, or Dover's powder, with the tincture of iodine. G™' lV« The great and beneficial influence, which the latter is well known to »f "no'sui" exercise in many cases over strumous tubercles, should indicate its 'ubercu- use on the present occasion. And it is also not improbable, from Tubercular the approach which the disease seems occasionally to make to the Meianose.^ more irritant cases of phthisis, in its excitement of the chest, and its nic acta. hectic fever, that the hydrocyanic acid might, at times, with great advantage, take the place of all other sedatives. Such coincidences of symptoms, moreover, show us clearly the place which melanosis should occupy in a digested nosological arrangement. Before hazarding a syllable upon the physiology of this very ex- Post-obii traordinary disease, it is requisite to put the reader into possession ance* of the general appearances afforded by post-obit examinations ; and the case already alluded to, as under Professor Alison's care, is admirably adapted to this purpose, if put into an abridged form. The body evinced great and general emaciation, and various small dark-coloured tumours, perceptible during life, were still dis- tributed over it. In the mamma; these were largest and most nume- rous : they were traced in cysts, and embedded in the cellular sub- stance; and when cut into were found to contain a deep black coloured matter, of a soft and pulpy consistence. Within the abdo- men? most of the cellular and adipose textures had disappeared. The peritoneum lining the parietes was of a blackish colour, and the black matter was irregularly deposited in stria;, and spots upon the inner side of the membrane, which had lost much of its natural trans- parency. The omentum presented a similar appearance, and seve- ral globular shining tumours of a black colour were appended to it, which, when cut into, poured out a similarly coloured fluid. Spots and tubercles of a like kind were traced in the serous or outer mem- brane of the i.itestines and between the folds of the mesentery. The ovaria were several times as large as their natural size, seated in front of the uterus, and occupying the lateral ileac regions. Their external surface had a dark, shining, lobulated appearance, with numerous ramifications of vessels upon the peritouaEal covering; beneath which, black matter was irregularly deposited in spots, giving a mottled appearance to the whole. When cut into their substance was uniformly black. The cellular texture still retained its consistence, and vessels containing red coagulated blood could be traced through it. Several distinct cysts or cavities were found in their substance, which poured out a black liquid when opened. The kidneys, liver, spleen, and the mucous or interior membrane of the stomach and intestines were all free from black matter, although it was deposited in the cellular tissue connected with these organs. On removing the breast bone and skull-cap it was observed that the whole texture of the sternum, the anterior portion of the ribs, and a great part of the parietal and occipital bones, were black, more brittle, and of softer consistence than natural, but without enlarge- ment or ulceration. The periosteum was nearly natural, but the whole inner table of the skull, when removed from the dura mater, was of a darker hue than natural, and, in some places, where thc bl^ck matter was deposited in irregular patches of the bone, thexf 216 cl. ni.J ILEMATICA, [ord.it. ^pec 1J' were corresP°nding stains on the surface of the dura mater. The Melanosis' substance of the brain was healthy, but a few black stria; were dis- i"ru'CU" cernible in the membranes, and the tunics of several of the vessels. Tubercular A large quantity of serum was effused under the arachnoid mem- Meianose. brane an(j m the ventricles. Wilhin the thorax the costal pleura and surface of the lungs were studded with black tubercles like those of the integuments, while some of them were larger. Thc substance of the lungs was dark, and some minute tubercles were embedded in it, and like spots were noticed beneath the pericardial coverings of the heart, which contained some coagulated blood in its cavities, and was softer than usual. Additional ft should further be observed, that in a few places in the present ances subject, but more generally in others, the black material varied mate- cas1onaSy"x riaHy from its ordinary degree of consistence, and, instead of being pulpy or nearly solid, was a fluent liquid; and that several of the tubercles were filled with a white, and brain-like substance, while those that surrounded them were of a deep jet. Early phv- The first opinion formed respecting the nature of these enlarge- opimon* ments by MM. Breschet and Laennec, was that the dark material denature was congested blood that had escaped from the capillary vessels into of the dis- the cellular substance by a rupture of their coats, or by anastomosis tohVorro" from relaxation. But this conjecture was soon found untenable, as neous. it was sufficiently ascertained that the material is a distinct secretion, Whether and is now supposed to be a secretion sui generis. Nor is another evtncedif- opinion of M. Laennec's much more tenable which advances that ftaent f tne bkid1 material evinces different stages of elaboration: that when eiaooration. first thrown forth it is pultaceous or nearly solid, and in a state of incorrmu crudity, but that it gradually matures, and advances to a state of ramollissement or fluidity. For it is well observed by Mr. Cullen that were this true, we should expect to find the largest cysts or reservoirs in the highest state of liquifaction, and the smallest in the highest state of solidity, the contrary of which is usually the course pursued. "uished ^ 's a'so Just'y remarked by the same able writer, that the charac- trom can- ters of tubercular melanosis completely distinguish it from cancer fung"sd and fungus haematodes; since it is well known to exist without local hsematodes. pain, and to propagate itself by cysts, and boundary lines, while both the others are accompanied with severe lancinating pains, and burst through every bond and extend their ravages in every di- rection. roints not The points which have not hitherto been touched upon, and which ed upon, seem chiefly to call for our attention, are thc singular unity of action Increased wm°h seems to exist throughout the whole extent of the secernent action system, in the production of the black material, during its state of who"lof e morbid excitement: and the apparent issue of this action, and con- iXtTs-1 seoiuently of the black material hereby produced from a single source tein.andits or organ. The first is too obvious, from the history already given, smile o"-a to neea" anv additional remark : and, unless I much mistake, subse- gan-. Firet quent examples will prove that the second has as firm a foundation. dear.1*" y Let the reader look back at Professor Alison's case, and pause over ^wseqond . n. Gen. IV. Dy a permanent supply, as the tide antecedently furnished is carried Melanosis' off. And if we attend to the curious economy which takes place in lariT"1 *n's SUDJect respecting the children of negroes, we shall also find this Tubercular material produced in very large abundance in a very short time: for mucosum' me infants of negroes, as we shall have occasion to observe more at of negro- large when treating of epichrosis or macular-skin,* are nearly fair Rapidity when first born, and only become coloured with the black effusion a with which fevv weeks afterwards; which at first gives little more than a tawney this is se- ,, , , ' .6 J creted in hue, but gradually advances to a jet. Both'aiso We shall also have occasion to notice in the same place, that this secreted in black die, like the pigment in melanosis, is on some occasions se- ft more • fluid and a creted m the form of a finer and more fluent liquid, and, in others, crete state. m a more inspissated state, and united with a coarser material, con- stituting the rete mucosum of Malpighi; who, moreover, gave it the name of rete from a belief that he was able to trace in it some- thing of a fibrous structure ; an idea that has not been realized by Both evin- Cruickshank or any later anatomist. And it is not a little singular rupulmsor that, as in melanosis we sometimes meet with a few patches or tu- ples of bercles of the preternatural secretion destitute of its colouring dye, and presenting a variegated appearance of black and white mosaic, so in the distribution of the natural pigment of the negro over the surface, we sometimes meet with the same casual obstruction to the flow of the black dye, producing that marbled skin which gives the individuals the name of pye-balled negroes. General Melanosis, then, seems to consist in a profuse and general secre- tion of a kind of rete mucosum, with the black pigment that is usu- ally united with it in intertropical countries, transferred from the exte- rior to the interior of the body; and deposited, like fat, or the water of dropsy, chiefly in the cellular texture : issuing, as already ob- served, from a radical point; and, from the great excitement hereby given to the secernent system generally, producing fever, emacia- tion, and other disturbances of the constitution, as in other excite- ments of the same system from acute anasarca or ascites. But what are the circumstances, or the peculiar state of habit that predisposes to a profusion of this rather than of any other secretion, we know no more than we do in the general and profuse secretions we often meet with of calcareous earth, saccharine urine, or even of fat. chemical The chemical analysis of MM. Barruel and Lassaigne would ana ysis. seem to show that the material of melanosis is a combination of fibrin, fatty matter, and the-colouring matter of the blood. But more critical examinations upon this subject are still requisite. * Vol. v. Cl. vi. Ord. in. Gen. x. Spec. n. vi. and compare with the introductory note to Gen. ix. Trichosis. i-l. iii.] SANGUINEOUS FUNCTION. [ORn. iv. 219 GENUS V. STRUMA. SCROPHULA. INDOLENT, GLANDULAR TUMOURS, CHIEFLY IN THE NECK ; SUPPU- RATING SLOWLY, AND IMPERFECTLY, AND HEALING WITH DIF- FICULTY ; UPPER LIP THICKENED ; SKIN SMOOTH ; COUNTENANCE USUALLY FLORID. The Greeks denominated this disease XOIPAS, the nosologists ofg3™',^* recent times scrophula, thus literally translating the Greek, and importing swine-evil, swine-swellings, or morbid tumours to which swine are subject. Celsus employs struma, which was common in his own day, and has well described the complaint under this name, which is therefore selected on the present occasion. It is probably 0"g\a of derived from er£«,i«*, " congestion," or " coacervation," as of straw struma. in a litter, feathers in a bed, or tumours in the body; in which last sense Cicero elegantly employs the metaphor in the phrase " struma civitatis," " the scrophula or king's evil of the state." The medical dictionaries and glossaries concur in deriving struma from the Latin struo, but the terminating syllable of the noun should rather prove it to issue from a Greek source. Dr. Stoll endeavoured to make a distinction between scrophula Djs,tincU°n and struma,* by regarding the one as a local, and the other as a con- between stitutional and hereditary disease; but although he has been fol- |cnrd^r„ma lowed by a few writers, as well in our own country as on the Conti- nent, it is a distinction which has been generally relinquished as neither useful nor founded on fact. Other animals are subject to this disease besides man. It is, as j?1'^ already observed, from the frequency of its appearance among swine other ani- that the Greek name, as well as the more recent one of scrophula, ™nBthan is derived. Among horses we meet with it at least as often, when j"j£WM it is called farcy; under which modification it is propagable by farCy. transfusion of blood from the diseased horse, not only to other horses, but to asses also, as has been lately proved by Professor Cole- man, at the Veterinary Institution. Sauvages, who has many spe- fjjjjj^ cies under the generic character, has two for the forms now referred chaiaeis' to. The porcine species he denominates scrophula Chalasis, and j^ *™£ the equine s. Farcimen. As it is not the intention of the present work to notice the diseases of other animals, otherwise than by an occasional and incidental * Prcrlect. p. SO. 220 cl. hi.] ILEMATICA. [oiu>. iv. Gkn. V. glance, we shall proceed to a contemplation of the present genw Struma. 6 , ' . . r . .. Scrophula. under the single species ot Mesenteric decline more pro- perly ap- pertains to the genus marasmus, where it has been given. 1. STRUMA VULGARIS. KING'S EVIL. The strumous and mesenteric decline, in the present classifica- tion atrophia strumosa, is often introduced as a second species : but though nearly allied to the present genus, it has so much closer a connection with all the subdivisions of the genus marasmus, and especially with that of atrophia, that the former is evidently its proper place; and we have accordingly treated of it under that genus. In Dr. Cullen's Synopsis, it is arranged under the genus scrophula; and in deference to his authority it was allotted a like position in the first edition of the Nosology of the present writer: but in the subsequent editions it will be found transferred to the position before us. SPECIES I. STRUMA VULGARIS. KING'S EVIL. Gen. V. Spec. I. Disease he- reditary. Sometimes ingenerato and origi- nal. Illustrated. In this case not always limited to a particu- lar temper- ament. Exempli- fied. TUMOURS CONFINED TO THE EXTERNAL CONGLOBATE GLANDS ; PEA- SIZED, OR CHESTNUT-SIZED ; APPEARING IN INFANCY OR YOUTH : SUBSIDING ON MATURE AGE : HEREDITARY. Scrophula though not a contagious disease is unquestionably hereditary :* and hence very generally dependent upon a peculiar diathesis. Yet, like many other hereditary diseases, it is also occa- sionally generated as a primary affection, without any hereditary taint that can be discovered. 1 had very lately a gentleman under my care who has been greatly afflicted with it for many years, and is now chiefly labouring under its sequelae: for the sores, which are in different glands and joints, and some of which have affected the bones, are healing : yet of eight brothers and sisters who have reached the middle of life, he is the only one who has discovered any tendency to such complaint, nor is it to be traced through any part of the family lineage as far as it can be ascended. When it occurs as a primary or ingenerated affection it is by no means always limited to any particular temperament or habit of body. The individual just noticed is of moderate stature, brown complexion, dark brown hair, and ruddy face ; and I am still occa- sionally attending a lady who has long been subject to the same complaint without any trace of hereditary predisposition, of a sallow countenance, dark eyes and hair, and of rather tall and slender make. * Kirkland, On the Present State of Surgery, Vol. n.—Kortum, Comment. fle Vitio Scrophuloso. Lecago, 1789.—Baumes, sur le Virus Scrophnlenx, &c. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 221 But where scrophula appears hereditary, and especially where it does Gen- Y- not show itself very early, it is often accompanied with a peculiar s™£ constitution. " It most commonly," says Dr. Cullen, " affects J^f8,™;^ children of soft and flaccid flesh ; of fair hair, and blue eyes ; smooth where he- skins, and rosy cheeks; and such children have frequently a tumid [^""4^ upper lip, with a chop in the middle of it; and this tumour is often pa nied considerable and extended to the columna nasi, and lower part of "u,^ $£. the nostrils." And it is a farther remark of Dr. Cullen, but which ^ttrac. I have not found to hold very generally, that, where it takes place in ter. children whose parents have given no signs of it, the latter have nevertheless evinced much of the habit and constitution by which the disease is ordinarily characterized. From all this we have a clear proof that king's evil is a disease of P™"™ of debility, operating by a specific influence on the circulating, and operating particularly on the lymphatic system.* Whether this influence be ^J^g1* the result of a specific matter is by no means so clear; however pjja^ common the opinion. It is also a general belief that this specific thVbya matter is from the first a specific irritant or acrimony. But this at ^^mt least is a mistake : for the disease is accompanied throughout with clear. diminished, instead of with increased irritability ;t and hence the %*$Z* power producing it must be of a sedative rather than of an exciting M^0 or actuating quality. And it is in this diminution of irritability that a3 gCro'phu- scrophula differs from all other atonic diseases, since the debility and J^.Tde- the irritability generally augment in like proportion, and maintain an creased ir- equal inarch. Early life is peculiarly characterized by an abundance of albumen, as its maturity is by an abundance of fibrin. Dr. Parr ascribes the p»r^gs^ scrophuious diathesis to a redundancy of albumen at this period, ?£> .tmote together with an excess of oxygene, and a deficiency of azote, evi-caU9e denced by the florid hue of the countenance. By this hypothesis he obtains a sort of lentor in the circulating system ; and accounts for the origin of scrophuious tumours by arguing that, since the mobi- lity of the lymphatic system is peculiarly affected and diminished, the viscid fluids will be most disposed to stagnate there, and parti- cularly in the lymphatic glands ; as they must necessarily stagnate most where the impelling power is least. It is here, indeed, rather than in any other modification to tubers Hence, ijt- or tubercles, that we find most to oppose to the opinion of those phy- toe u.ePdoc siologists, as M. Broussais, and Dr. Alison, who ascribe the origin £$** of all tubercles to the existence of a higher or lower degree of tubeicks inflammation. Yet it is singular that, at the same time, we here ([amm'atioi-. meet with proofs of the most advanced state of a living action in **,£ ™re the morbid growths themselves ; the most perfect specimens of vas- living ac- cularitv and sensation ; and particularly where they originate in a *!™§u. glandular texture, which is their proper seat. This living property, £"*»«» however, they do not seem capable of retaining long ; for they soon ,ub<,rcies. run through their career of vitality, and become decomposed. Such fdutonf^r was the short-lived date, according to the first physiological poet of a short Rome, of those monster-growths which sprang in the infancy of the iC'trate.i. * Garn, Kranken geschichten. p. 121. T Richter, Chir. Bibl. Band. vm. p. 222 cl. in.j ILEM AT1CA. [OKD. IV. world, but were soon cut off by nature, as incongruous with her laws, and hateful to her survey. Caetera de genere hoc monstra, ac portenta creabat, Nequidquam ; quoniam Natura absterrult auctum ; Nee potuere cupitum set at is tangere florem, Nee reperire cibum, nee jungi per Veneris res.* These sprang at first, and things alike uncouth: Yet vainly ; for abhorrent Nature quick Check'd their vile growth ; so life's consummate flower Ne'er reach'd they, foods appropriate never cropp'd, Nor tasted joys venereal. £rrmedly ^S occurrmg m early life, when, as we have already observed, from ade- there is a peculiar abundance of albumen, with a comparatively less a°bumenf Poruon of fibrin or coagulable lymph, it is highly probable that a morbid deposition of albumen forms the commencement of the stru- chemicai mous tuber. And such indeed seems to be proved by the chemical mentnande tests to which Dr. Abercrombie has put them.t It is at first, per- progress. haps, deposited in a soft state, and involved in the structure of the gland; the gland being, in other respects, vascular and organized, and probably capable of performing its functions. As the disease advances,-the proportion of albumen seems to increase, while at the same time it assumes a more concrete and structural figure, and stages61" ev*nces a vascular and sensitive character. " In this first state of * enlargement," says Dr. Abercrombie, " these glands present, when cut into, a pale flesh-colour, and an uniform, soft, fleshy texture. As the disease advances the texture becomes firmer, and the colour rather paler. In what may be regarded as the next stage, we observe portions that have lost the flesh-colour, and have acquired a kind of transparency, and a texture approaching to that of soft cartilage. While these changes are going on we generally observe, in other specimens, the commencement of the opake white structure which seems to be the last step in these morbid changes, and is strictly analogous in its appearance and properties, to the white tubercle of stages the lungs. In a mass of considerable size we can sometimes ob- co-ordinate. serve all these structures, often in alternate strata : some of the strata being composed of the opake white matter, others presenting the semi-pellucid appearance, while in other parts of the same mass, we find portions which retain the fleshy appearance. In the most , advanced stage the opake, white, or ash-coloured tubercular matter is the most abundant, and this afterwards appears to be gradually softened, until it degenerates into the soft, cheesey matter, or ill- conditioned suppurations so familiar to us in affections of this nature." The morbid growth, therefore, as it recedes from its more vascular and vital elaboration, gradually subsides into the simple pretension of coagulated albumen, of which i> consisted at first. In the second stage the part is probably susceptible of active inflammation, and healthy suppuration, or suppuration making a near approach to that i of a healthy character. In its closing stage, it seems incapable of * Lncret. De Rer. Nat. v. 845. t On the Nature and Origin of Tubercular Diseases. Trans. Medico-Chir. Soc. Edinb. Vol. i. p. 6«6. Gen. V. Spec. I. Struma vulgaris. King's evil. cl. ui.J SANGUINEOUS FUNCTION. [ord. iv. 223 healthy action, and only passes into that peculiar state of softening Gen. V, which arises from a simple decomposition of the tubercular or- sf^a' *' ganization. vulgaris. We have already described at some length the probable origin of a^d ""' tubercles in other textures, chiefly in the serous and mucous mem- J??* |n^o branes of organs, and in the structure of the lungs. The remarks the differ- now offered will enable us in some degree to judge in what respect "spumous the tubercles of proper glands, as those of the lymphatics and the a^^Jr mesentery, are assimilated to these, and in what respects they differ from them. The subject, however, is still open to inquiry, and much remains to be accomplished before a full and satisfactory result is likely to be obtained. Be the proximate cause of scrophula, however, what it may, as Occasional the remote cause is of a debilitating kind, we can readily see what are likely to prove occasional and co-operative causes; or those calculated to call the remote cause into a state of activity. They whatever must consist of every thing that directly lowers and reduces the tone tone"" the. of the living fibre, and puts the system out of that state of firm and Bystem- vigorous elasticity which is the best prophylactic against the disease, and keeps the scrophuious diathesis most effectually in a state of subjection. And hence we find the common debilitating powers of cold, damp, meagre or unwholesome food, want of cleanliness, and a close and suffocating atmosphere, the most usual incidental sources of strumous affections.* But for these, a scrophuious predisposition might remain dormant in the constitution through the whole of life; and descend to, and disorder the next generation, without having in the least disturbed the present. But the moment any of these occasional causes become adjuncts with the scrophuious diathesis, scrophula, rather than any other disease they are also calculated to promote, will make its appearance, and commence its ravage. And hence the fre- quency of this disease in large manufacturing towns, and in higher and colder latitudes than 45°. Heat, as a relaxing and debilitating power, tending to produce Heat a languid action, is also a frequent cause wherever this power is applied eacesf ■vl-'8" in excess and habitually: and particularly where, like cold, it is com- or variable. bined with sudden variations of temperature. It is hence that scro- Scrophula phula is no unusual attendant upon Hindoos, Hottentots, and ^idoos, ° Negroes: and especially in the children of settlers in intertropical Hn'j,t^ols- regions, upon their quitting such regions for countries of a milder grocs. temperature, and which but for the previous influence exerted on their frames, would prove one of its most powerful preventives. The T£flnen,C6 influence of excessive cold, however, is much more rapid than that more rapid of excessive heat, and far more obvious to the senses. Yet it is often ;{^u^nan sustained with impunity where the constitution is firm, and the cold that of rarely subject to vicissitudes; and especially where there is no other ^;n cer debilitating cause to contend with, as the depressing passions, a ^far-ces sedentary occupation, scanty and innutritive diet, damp and impure sustained air, or any kind of personal neglect or uncleanlincss. And it is on m;,yhunim ■* Treatise on the Nature and Treatment of s.rophula. &c. t'.y Eusebius Arthur Uovd, &c. 8vo. Lond. 182! 224 cl. in.] HiEMATICA. [oitn. iv. Gen. V. Spec. I. Struma vulgaris. King's evil. Heucc less scrophula in cold mountain- ous regions tb'in crowded cities Ho.iital des Enr'.ns Malades. London- Manchester compared with the village of Waverton : with that of Reyton. Rafford. Hence, scrophula a disease of weak vas- cular ac- tion. Heat and cold chiefly injurious from irre- gular vicis- situdes. The evil of cold coun- teracted by various to- nic powers of a coun- try life. Local in- juries. Depressing passions. Adverse fortune. this account we meet with a far smaller proportion of scrophula in early life among the peasantry of higher latitudes and mountain- scenery, as that of Scotland and Switzerland, than among the me- chanics of crowded and warmer cities. " I was told," says Dr. Ali- son, " by one of the physicians at the Hopital des Enfans Malades, at Paris, where upwards of five hundred children die annually, whose bodies are almost uniformly opened, that he believed nearly one half of the bodies he saw opened had scrophuious tubercles in some part or other."* This is indeed a higher aggregate than is to be found in the metropolis of our own country, and obviously includes mesen- teric or strumous tubers, of which we have treated already, as well as every other modification of scrophula. But the same writer calcu- lates from data furnished by Dr. Perceval, that the proportion of scrophuious fatal cases among children at Manchester, at the time Dr. Perceval wrote, generalizing them as above, could not be less than a third of the whole infantine mortality ; whilst at Waverton, a country parish near Chester, it appears from the same documents that the deaths from scrophula, in children under five years of age, did not amount to a fourth part of this proportion. In the bordering village of Reyton the difference appears to have been still greater ; for the whole mortality of children under five years of age in this last parish, compared with the same period of parallel mortality at Man- chester, was only as two to seven; not more than one-seventh part of the children born in this village appearing to die before they had attained their fifth year. " I examined lately," says Dr. Alison, " a register which I know to have been kept with great accuracy for nearly four years, of the deaths of a country parish in Scotland, that of Rafford, near Forres, the population of which parish is almost exactly a thousand persons. Of forty-two deaths that had occurred in that time, two only, or one in twenty-one, were below the age ot" two, and three only, or one in fourteen, below that of five years:" while in the town of Manchester, to which we have just referred, Dr. Perceval assures us, on an average of twenty years, that the proportion of deaths under two years to the whole deaths was 1 to 2.9.t To add any thing further is unnecessary. Scrophula is manifestly a disease of weak vascular action, and is sure to be found in abun- dance where other diseases consociate that issue from the same soil, and largely to add to their fatality. Extreme heat and cold, though powerful predisponents, are far more injurious when flowing in irre- gular vicissitudes than when in an uniform tenour, and the mis- chievous effect of the latter is often counteracted where combined with the tonic powers of a pure and dry atmosphere, a regular plan of diet and exercise, the salubrious exhalations from growing vege- tables, and the grateful stimulus of their odours in village-scenery. For the reasons just urged, scrophula has, at times, been called into activity by local injuries, the depressing influence of severe grief, or a sudden reverse of worldly prosperity. It is also sometimes joined * On the Pathology of Scrophuious Diseases. Trans. Medico-Chir. Soc. Edin. i. p. 383. t Perceval's Works, Vol. ui. p. 107. cl. in.j SANGUINEGU:-' FUNCTION. [okd. iv. ZZb with, or follows rickets ; and is frequently a sequel of small-pox, Gen- v« yaws, and several obstinate cutaneous affections. s^uma' But though scrophula usually commences in the lymphatic glands J^'s*™- it often extends beyond them: as gout, that ordinarily shows itself Ei"fndScv first in the small joints, and rheumatism that begins in the large ^phaiic8 joints, spread not unfrequently to the membranes and the muscles, giauds; I have said that under the influence of the scrophuious diathesis the circulating system is weakened generally ; and hence also we to the eyes, frequently find the eyes, the mucous glands of the nose, the ton- giisfand.'1 sils, and even the joints and bones successively yielding to its °^®ror~ influence. The disease for the most part shows itself early in life, though 0risin ai"* rarely before the second, and commonly not till the third, year of scrophula. infancy ; from which period it continues to prey on the system till the seventh, when, in ordinary cases, it gradually subsides and dis- appears. If the predisposition be not considerable the attack is sometimes postponed till after the seventh year, and has occasionally been retarded till the age of puberty, after which, however, we have very seldom any manifestion of the disease. The first tumours we meet with are usually upon the sides of the D!^ndosig neck, below the ears, or under the chin ; confined to the lymphatic vancing glands in these parts, and only spreading to the salivary when the dis- syroPtomB- ease has considerably advanced. The tumours are, perhaps two or three in number, moveable, soft and slightly elastic, of a globular or oval figure, without pain or discoloration of the skin. In this state they continue for a year or two : after which they grow larger, and become more fixed; and acquire a purplish redness. They then give that feeling of greater softness, and at length of fluctuation, to which we have just adverted; after which the skin, in one or more of them, becomes paler, and a peculiar liquid is poured forth at several small apertures, apparently like immature pus, but growing daily less purulent, and at length assuming a cheesy or curd-like form. The tumour or cluster of tumours then subsides; but others rise in the neighbourhood ; and in this manner the disease proceeds, fresh tu- mours forming, chiefly in the course of the spring, as the older dis- appear, and the same process is continued for several years : after which the ulcers heal spontaneously with puckered and indelible in- dentations, provided the disease terminates favourably : but if not, other parts of the system, as we have already observed, become tainted with the morbid influence, and add to the sum of distress. If the attack fall upon the eye-lids they become inflamed, are swollen and red, and pour forth, from their minute glands, an erosive but vis- cid secretion which glues them together at night, so that in the morn- ing they are opened with difficulty. The adnata partakes of the irri- tation which is at length communicated to the whole globe of the eye, and not unfrequently to the cheek, from the acrid discharge that flows down. An unsightly lippitude and cversion of the lower eye- lid is hence a very common result of a scrophuious attack on this organ. In like manner the disease, in this unfavourable and aggravated £mle;imca state, often makes its assault on the limbs, and fixes on the liga- on the Vor.. III.—?n 1226 cl. ui.j ILEMATICA* [om>. iv. Gen. v. ments, cartilages, or even the bones themselves; and particularly siruma' * whenever any injury occurs to a joint. An indolent tumour first Kiif"'s evil snows ltse^ which tardily advances in magnitude with a kind of iin'ibs,S|igV- smothered inflammation, and at length opens on the surface from bones".'-""4 one or more minute ulcerations which discharge the sanious kind of Nearly re- fluid we have already noticed. And it is here we perceive how white-* nearly scrophula is related to hydarthrus or white-swelling; and how swelling, readily the former may become a cause of the latter, as already ob- served under that species. If the strumous diathesis be excited by the fracture of a bone the broken ends unite with great difficulty, and sometimes not at all. A specific tumour forms in the seat of the injury, the soft parts are often affected with a weak inflammation, and ulcerate slowly ; and the bone is rendered carious. If the in- jury occur in the middle of a cylindrical bone an exfoliation may take place in a long course of time ; but if at its extremity, it will become spongy, enlarged, and disorganized. If a cure be at length effected, the enlargement will remain and the articulation be lost: yet amputation will be of no use while the part continues under the influence of the scrophuious taint. sometimes Jn the worst and severest stage of the disease, the entire system system con- appears to be contaminated ; hectic fever ensues, and sometimes tammated. tubercular phthisis which gradually puts an end to the contest. Vrineipieto ln attending to the cure, we must not be unmindful of. the prin- H) in at- eiple we have endeavoured to establish, that scrophula is a disease of ternptinga debility, principally affecting the lymphatic system, accompanied Modified with diminished irritability. And it hence follows that our chief stimulant dependence must be upon a tonic and stimulant plan, so modified plan. as t0 meet the patient's age, idiosyncrasy, and manner of life. Diflerent How far an acrimonious principle may be generated, after the stimulants, disease has become aggravated and general, it is difficult to say: How far an but in its commencement, and while confined to the lymphatic regenerated glands, and, indeed, through the whole of its ordinary and milder ""JJJd" course, it induces diminished rather than exalted irritability, and con- state of sequently gives no proof of an actuating or acrimonious source. Sedatives'' Yet such a source has been supposed even from its first appearance: tics w"00" an(* hence sedatives and narcotics have found a place among the employed, most celebrated of its remedies: while, as the chemical character of wh^em- the acrimony has been also pretended to be developed, and has been ployed. declared to be a specific acid, another class of remedies had recourse to has been the alkalies. Often of That the latter are often of considerable service ought, I think, not a* cor6- freely to be admitted ; but we have assuredly no proof that they be- aridity,°but come beneficial as correctors of acidity. They are gentle stimu- aa stimu- lants admirably adapted to the debilitated and indolent condition of louts. the vascular system they are intended to excite : and hence, in whatever form they are given, have a chance of doing good. And it is to this principle we are perhaps to resolve all the advantage that lias been stated by different writers, and in different ages of the world, to have resulted from the use of burnt-sponge, burnt cuttle- fish, shells of all kinds, burnt hartshorn, and even burnt secundines, which last were at «ne time in high request, and are to be found as rum.] SANGUINEOUS FUNCTION. [oiu>. iv. 237 a sovereign remedy in Schroeder's Pharmacopoeia.* All these have Gen. v- in our own day deservedly yielded to the carbonate of soda, or.sub- g^ma carbonate of ammonia : which, in a more elegant and concentrated vulgaris. form, offer whatever virtues may be contained in the older medi- carbonate' cines; and still more lately to the different preparations of the alkali, gu^0cdaarbo. not long ago detected by M. Courtois in kelp and other salt-worts, nate of and denominated iodine ; for a more particular account of which, iodTn'c"'8' the reader may turn to the treatment of BRONCHOCELE.t The author f*jmi'u" has, at this moment of writing, among other patients, who have been benefited by this plan, a lad about thirteen years of age with weak eyes, inflamed and irritable conjunctiva, and such an enlarge- ment of the parotid gland on each side as to make them nearly meet, so that the mouth opens with uneasiness. He has now applied the ointment of iodine for three weeks, and at the same time taken half a grain twice a-day in the form of a pill, and is essentially improved in every respect. Lime-water, aud the muriate of baryte, which last was thought by Lime" Dr. Adair Crawford to be nearly a specific, if they have any preten- Muriate of sions whatever, can only derive them from the general principle ofbarjte- their being stimulants, and especially of the lymphatic system. And °ther 'j™- the same may be observed of petroselinum, sarsa, mezereon, balsam muhvit!.1 of sulphur, calamus aromaticus, and horse radish, all of which have had their votaries in their day. Muriate of soda or common sea-salt possesses a like character ; Muriate of and has undoubtedly been found of far more use in many cases. Its has, hence, been employed very freely both internally and externally. In the latter case very generally through the medium of the bibulous Bibulous marine plants, which contain it in a larger proportion, and have been pi"its°as applied to the strumous tumours in the form of epithems as sea- extendi wrack (fucus, vesiculosus:) sea-tang (alga marina,) and sea-oak (quercus marina.) Thc mineral waters of every description, have in like manner Mineral been had recourse to, chalybeate, sulphureous, and saline ; and, per- supposed haps, as Dr. Cullen observes, with nearly a like reputation and sue- H,"8^1 by cess ; though it is by no means improbable that some waters may from their prove a more remedial stimulant or alterant to some constitutions, JH'Jf" and others to others. And we thus possess a more plausible reason for their being advantageous than that offered by Dr. Cullen ; name- ly, that " if they are ever successful it is the elementary water that is the chief part of the remedy :"{ which he tells us in another place " may be of use by washing out the lymphatic system."§ Stimulant external applications, besides sea-water, have also been °'iietex. tried, and undoubtedly been often found serviceable ; as a long con- mulanu. tinued friction of the hand over the scrophuious protuberances, mer- curial or ammoniacal plasters or the convenient form in the London Mercurial. Pharmacopoeia that combines both these ingredients ; irritant oint- ments, the aura of voltaism, or moderate shocks of electricity. Electricity. The means of this kind, however, to which we have recourse, Excitement at first .» ■,.. „„„ should be * Lib. v. p. 288. gen(tc t Vol. iv. Cl. vi. Ord. i. Gen. ii. Spec. I. Emphyma Sarcoma Bronchocele. J Pract. of Phys. Vol. iv. mocclii. J Id. Vol. iv. mdccli. 228 ex. m.j ILEMATICA. [ok»- "'• Gen. V. Spec. I. Struma vulgaris. King's evil. nifferent kinds of tonics. Colts-foot mostly de- pended on by Cullen. Metallic salts. Calomel. Salivation injurious. Plummcr's pill. Aeids. Tonic me- dicines hitherto tried, not highly useful. Tonic re- gimen more ser- viceable. Narsoties, whether external or internal, should always be gentle at first, how- ever we may venture upon augmenting them afterwards. If we stimulate violently, we shall do mischief rather than good, and add to the debility instead of diminishing it. Scrophula is a strictly chronic disease; it never has been, and never can be cured rapidly ; and wherever any beneficial influence has been produced upon it, it has always been, as in the use of the alkalies, and of mineral wa- ters, by lenient means and patient perseverance. But we have to increase the power as well as to take off the ir- ritability : and hence tonics seem to be as much demanded as stimu- lants ; and have in fact been as generally made use of. It is very singular that of this class of medicines the only two which Dr. Cullen has thought it worth while to notice are bark und colts-foot; of the first of these, he speaks very doubtfully ; while he seems to depend more on the second than on any other remedy whatever. This opinion he expresses in his Practice of Physic, pub- lished in 1783 ; but, in his Materia Medica, published six years af- terwards, he gives it the same high character, and tells us that he was induced to try it in scrophuious cases upon the testimony and re- commendation of Fuller. He employed both an expressed juice of the fresh leaves, and a decoction of the dry; but preferred the for- mer, of which he gave " some ounces every day," and affirms that " in several instances it has occasioned the healing up of scrophuious sores." He admits, however, that neither of them were in some trials sufficiently effectual. The metallic salts have been more generally used, and have at least acquired a higher reputation ; though, with the exception of calomel, I do not know any of them that can appeal to any decided testimonies in proof of their success ; and even calomel may perhaps be regarded rather as an alterant or mild stimulant than as a tonic. Salivation has always done harm ; and on this account also mercury in every form must be given in minute doses. Combined with some preparations of antimony, and particularly with thc precipitated sul- phuret, as in Plummer's pills, it is said to have been chiefly servicea- ble. But in my own practice I have not found this medicine of any manifest service in the present disease. The acids have also been tried, but are of little or no avail. They who regard the scrophuious taint as consisting in an acid acrimony, are apt to lay hold of this fact in support of their hypo- thesis. A better reason for their inefficacy is perhaps to be found in their sedative property which we had occasion lo notice at some length when treating of phthisis. Upon the whole, however, the tonic class of medicines has thus far proved considerably less decisive and important in the treatment of scrophula than we might fairly have conjectured. Yet a tonic regimen of sea-air, sea-bathing, liberal exercise, and a diet some- what generous is of the highest consequence in promoting improve- ment, and ought by no means to be dispensed with. The Infirmary at Margate is on this account a noble institution, and cannot be too liberally supported. Of the specific benefit of narcotics, as hemlock, henbane, foxglove, cl. iii.] SANGUINEOUS FUNCTION. [ord. iv. 229 solanum, asclepias, vincetoxicum, and many others, I have yet to he Gen- v« persuaded. They may possibly be of some use in quieting the irri- g,™' tation occasionally produced by congestion and mechanical pressure y^'s*""- . where the tumours are peculiarly indurated and large; and in such n.a"6at*1"' cases may assist in softening and diminishing them. And they !,,0^db.do- may perhaps operate in the same way where, in the later and more malignant stages of the disease, the secretion is become virulent, the open ulcers irritable, and a foundation is hereby laid for hectic fever. But I can conscientiously say, with Dr. Cullen, that they have often but often v •. !■ i.j- ii i disappoint. disappointed me, and have not seemed to dispose scrophuious ulcers to heal. The local applications, like the internal remedies, should be Local ap- slightly stimulant; and where the tumours have broken, usually whCearp'0the consist of digestive ointments combined with the caustic metallic tuniour9 ° , nave salts of mercury, zinc, or copper ; and of digestive lotions of a dilute broken. solution of alum or nitrate of silver. These are well calculated to coincide with the general intention ; but we must not expect a sound cure till the morbid impression is set at rest in the constitu- tion, or utterly extirpated from it. 230 cl. ui.] ILEMATIC A. [ord. iv. Gen. VI. Only one known speeies. GENUS VI. CARCINUS. CANCER. SCIRRnOTJS, livid tumour, intersected with firm, whitish, divergent bands, found chiefly in tiik secernent glands ; pains acute and lancinating ; often propagated to other farts ; terminating in a fetid and ichorous ulcer. Of this genus there is biit one known species: for the division into occult and open, or indolent and ulcerative, introduced by Hip- pocrates and continued till the time of Boerhaave, is unnecessary in pathology, and incorrect in nosological arrangement; as the dis- tinctions it contemplates arc nothing more than so many stages or modifications of the same disease in different habits, or affected by different concomitants. This species is what is generally described under the name of 1. CARCINUS VULGARIS. COMMON CANVKR : and it is not necessary to alter the term. SPECIES I. CARCINUS VULGARIS. COMMON CANCER, TUMOUR BURNING, KNOTTY ; WITH DARK, CANCRIFORM VARICES ; ULCER, WITH THICK, LIVID, RETORTED LIPS. Gen. VI. There is a soft, fungous and bleeding ulcer, possessing the name f™"' L °^ fum?us hasmatodes, which has by many writers of celebrity been hamV supposed to be of a cancerous origin ; and under their authority it sometimes |ias been so regafded in the author's volume on Nosology : but as cttaedrabut *4 seems.t0 differ n"om cancer in its constitutional influence and in BMrtrlctiy some of its local characters, it is better to contemplate it as a ma- ••■ lignant ulcer of a peculiar kind: and in the present work it is referred, to that genus according'. ci.nr..] SANGUINEOUS FUNCTION. [ord. rv. 231 Some writers have offered many other subdivisions, which are still Gen« v'- less entitled to a distinct enumeration ; as Bierchen, who has given c^cinus' us five, under thc names of the genuine, thc strumous, the syphilitic, vulgaris. the fungous, and the noma.* Of these, the first constitutes the spe- tan™" cies before us; the second and third are modifications of the same, f^of" only varied by the idiosyncrasy or incidental state of the constitu- different tion ; and the last two are depraved ulcers. Biercben The term carcinus (x.x%x.tioc,) is Greek, and imports a crab ; the g^^" disease being thus called from the cancriform or crab-like ramifica- thegoneric tions of the dark, distended veins of the cancerous tumour. The cancer question is of some consequence whether cancer be a constitutional whether 1111 it i ii- constilu- or a local, whether an hereditary or merely an occasional, disease, tionaior Much has been said, and well said, on both sides. Till of late years h^^ the disease was generally regarded as a constitutional affection, and local. will, for the most part, therefore, be found in the division of cachexies ge°r^[iy from Sauvages to Macbride, though Dr. Cullen has introduced it ;{*!,^led '" into his class locales ; and since his time many of the best writers view: of the present day, among whom are Dr. Baillie and Mr. Abernethy, ™balately concur in regarding it as local alone. If the disease be merely "c^nH: local it is difficult, and perhaps insuperably difficult, to say why a attending blow on a conglomerate gland, as the breast for example, should tv^er^n sometimes produce a cancer, but more generally not: or what that applied power is that excites the cancerous action in one person, from w'lich "™]Vi,"oinyg another, or perhaps a hundred others, remain free upon an applica- lo'nPi,1°J|_ tion of the very same injury to the same organ. A blow or the knee ?uti* naf af- often produces a white-swelling ; but ten thousand children receive fection- blows on the knee without any such effect following. In this case we resolve the difference of result, without a controversy, into the presence or absence of a scrophuious constitution : and without this view of the subject we should find ourselves at a loss fbi an answer. And unless we apply the same reasoning to cancer, we shall ever, I fear, remain at an equal loss. The cases, moreover, in which cancerous tumours are found in other parts of the body, after one or more than one has been extirpated, lead us by an easy thread to the same conclusion, provided the tumour has been removed in an early stage of the disease, and before ulceration h;is taken place; for it is possible that the specific matter of a cancer, generated and matured locally, may be absorbed and deposited on the organs which are afterwards affected, I.ut if the extirpation have taken place before the formation of the specific matter, it is not easy, except by a constitutional taint, to account for any subsequent appearances. It is still stronger in proof of an hereditary pr= disposition that other arju various members of the same family have exhibited the same disease ^"u/of a either simultaneously or in succession ; and that the descendants °f ^j'"; those who have been afflicted with it seem to have more frequently fcetion. suffered from it than others. It is not necessary to advance individual instances in support of these positions, though it may be noticed in passing that Buonaparte died of a cancer in the stomach, his father of . * Abhandl. von den wahren kennzeichen des Krebsschiidens, &c. Goet, 177.\>. 232 cl. hi. J HJSMATfCA. [oKD. IV , Gen. VI Spec. I. Carcinus vulgaris Common cancer. The two distinct views at- tempted to be recon- ciled. Whether a constitu- tional dia- thesis may be mani- fested by the fea- tures. Such mani- festation not lo be found in all hereditary predispo- sitions : but ;UU- pected by P.irr in cancer. His out- lines of it. Does not hold uni- foimly Cancer whether contagious. No suffi- cient ground for such a be- lief. a scirrhous pylorus.* The same remarks have been made upon a general survey of the disease in most ages ; and the doctrine of an hereditary influence has, in consequence, descended to us as a result of such remarks from the time of the Greeks and Romans. The truth seems to be, that cancer, like gout, is dependent upon a peculiar diathesis or state of the constitution, which disposes a scir- rhous tumour, or any other occasional cause, to produce a cancerous ulceration, and consequently to generate the specific matter of can- cer ; which matter, once absorbed into the system, even though, by a removal • f the local affection and the influence of a healthy habit, it should remain dormant or be kept in subjection, may augment the original predisposition, and transmit a seminium to the future race. How far a predisposition to cancer, whether original or derived, may manifest itself by external signs, I am not able to determine. Such an outward character is by no means constant in the fist of hereditary diseases. It is, perhaps, generally visible in those that affect the mind ; but far less so in those that affect the body. In phthisis, the predominant diathesis has a striking exterior ; in scro- phula, the outward and visible sign is far less distinct, though such a sign seems to prevail generally : in gout, there is no specific exterior that we can depend upon. Dr. Parr, however, has conceived that cancer has its outward character as well as phthisis, and that it is indelibly marked in the complexion : " for we have found," says he, " cancers more frequent in the dark cadaverous complexions, than in the fairer kind. The .complexion we mean is distinct from the darkness of the atrabilious or melancholic habits : a blue tint seems mixt wi*h the brown, and is chiefly conspicuous under the eyes, or in iu•'.; parts usually fair. This may, perhaps, be a refinement with- out »<:. r.dation, but \ i think we have often observed it. There is certainly no constitutional symptom by which it can be predicted, if, in women, a scanty and a dark-coloured catamenial discharge be not a prognostic of the future disease. Cancer has certainly been traced in females of the same family : and those who have escaped suffer from irregular anomalous pains, and different, often unaccountable, complaints."t The picture thus ingeniously drawn, is worth bearing in mind, but I have never been able sufficiently to appropriate it; and in the last two or three cases of cancerous breasts that have occurred to myself, the patients have been of fair complexion, and light hair : one of them indeed peculiarly so : the lady was about fifty, and had had a large and very handsome family, all of whom were so fair as to make a near approach to the phthisical exterior, though none of them have ever exhibited its pathognomics. Cancer has also been imagined by many practitioners of high respectability to be contagious ; of whom we may mention Bierchen, Sinnert, and Gooch : but there seems no sufficient ground for the continuance of such an opinion. Inoculation has been said to have produced the complaint; but, like many other specific acrimonies, it does not act very readily in this way, even if it act at all; for M. * Account of the last illness, decease, &c. of Napoleon Bonaparte. Bv Archi- bald Arnot, 1822. r J * Med. Diet, in verb" cl. in.J SAiNGULNEUUS FUNCTION. [ord. iv. 233 Alibert affirms that he inoculated both himself and several of his Gen. VI pupils, without any other effect than that of local inflammation ; and c^nus1- that even this did not always ensue.* It has been swallowed by vulgaris. dogs without any mischief.t c°nc"r.°n The parts most usually affected by cancer are the excretory Pa«s of the glands, and especially those that separate the fluids to be employed utnl™*1 in the animal economy, rather than those that secern the excremen- affec'e«i. titious part of the blood. The lymphatics are seldom primarily Lympha . ... tics not affected, though they may become tainted from their contamination readily with a cancerous part. " I never yet," says Mr. Pearson,- " metaffeaed with an unequivocal proof of a primary (cancerous) scirrhus in an absorbent gland."J And hence we behold a striking difference be- tween the nature of cancer and scrophula. But though the secern- ent glands are most open to the attack of cancer, any part of thc body may become its seat. We meet with it, however, chiefly in the breasts of females, the uterus, the testes, the glans, penis, the tongue, stomach, cheeks, lips, and angles of the eyes. The obstruc- tion commences in the minuter vessels ; and the adjacent parts are affected in consequence. Women are more subject to cancer than men ; and in these the Women mammas and the uterus are the organs most predisposed to its in- ."ctthan fluence. Celibacy, as well as the cessation of the menses, conduces m<>n- to its production or appearance ; and hence antiquated maids are mostly affected with it; and next to these, mothers who have not suckled their children, for we may lay it down as an axiom, in the language of Dr. Parr, that a milk abscess never becomes a cancer. Then follow women who are past child-bearing. And lastly, women who have borne children and suckled them with their own milk, and males incidentally exposed to its occasional causes. To w.ben men which We may add, that when Cancer occurs in men it is chiefly in ed! tha-Upa the lips, and when in children, in the eyes. mtfef- Of the remote cause of cancer we know nothing. While scro- when chii- phula has been supposed by some to be the result of an acid acrimo- £"";t,,e ny ; cancer has by others been supposed to be produced by a peculiar Remote alkali. Dr. Crawford, from a series of very curious experiments known.' upon the matter of cancer, thought he had ascertained this to consist ^ycu^re' G principally of hepatised ammonia, and found that this matter effer- acid *up- vesced with sulphuric acid.§ Ploucquet, however, affirms that it 0Therds,'aby sometimes effervesces with alkalies as well.II The taste discovers JJ^'J" nothing ; for to the tongue it is insipid and mawkish rather than acid or alkaline. Yet Parr, laying hold of Crawford's experiments, has Crawfordy . m. 11. hypothesis. boldly ventured to assert that the remote cause, or rather the cause parrshy- of the cancerous diathesis, consists in an excess of ammonia with a Potl'eb"- redundant developement of sulphur. When it was popular in the Linnean school to resolve almost all £iCvr(|bm,iI diseases into the irritation of worms, grubs, or insects existing ci-sor narasitically in different organs of the body, cancer was by some iatveB» theorists supposed to depend upon alike cause : and the hypothesis jj^"^ Ad«.u.' " Maladies de la Peau, &c. t Le Febure, Remede, &c. 1776. t Principles of Surgery, &c. Vol. I. p. £09, &c. s> Phil. Trans. Vol. Lxxx. 1791. |1 Init. Biblioth. Tom. 11. p. 'W Vol. III.—30 234 cl. ui.I HvEMATICA. [oun. iv. Gek. VI. nag been since adopted by several writers in our own country, as carclnus' Mr. Justamond who ascribed it to the larves of a particular species Comlno'n of insectsi an(l Dr- Adams, who referred it to hydatids.* Vermi- cancer. cles or the larves of insects have at times been found in the open ulcer of a cancer, as in the fetid discharge of many olher malignant ulcers. These, as in other cases, have undoubtedly proceeded from eggs deposited in the sore as a nidus, though the worm or insect that has so deposited them has never been detected. Such appears to be the foundation of this hypothesis, which we have no authority for carrying farther, and which is rarely advocated in the present day. Occasional 'rne occasional or exciting causes are numerous ; but to account causes nu- „,.,».. • , 1 j i merous, for their efficiency it seems indispensable, as we have already ob- pVedUpoii- served, to suppose the existence of a cancerous predisposition or ii.>n exists, diathesis, since we see the same causes acting in innumerable in- stances daily, without betraying any tendency to such a result. Where this is present it may be produced by an external injury upon any of the parts most susceptible of cancer ; by an indurated and chronic tumour incidentally inflamed or irritated : an accumulation of acrid filth in the rugae of the skin which is a frequent cause of cancer in the testes, and particularly among chimney-sweepers : the hard and pungent pressure of a wart or corn in an irritable habit, of which the medical records offer various examples ; the acrimony of an herpetic eruption ; the general disturbance produced in the system by a severe attack of small-pox, or several other exanthems ; a sudden suspension of a periodical hemorrhoidal flux and a cessa- tion of the menses ; and, when in the stomach, by a previous life of ebriety or irregular living. With these severe cold seems also to co-operate, as the disease is generally admitted to be both more frequent and more virulent in the high northern latitudes than in the southern regions of Europe. enucerof When cancer takes place in the breast, it usually commences tho breast • Progress ' with a small indolent tumour that excites little attention. In pro- ^fewTip- cess °f timo-> tms tumour is attended with an itching, which is gra- tion. dually exchanged for a pricking, a shooting, and at length a lan- cinating pain, a sense of burning, and a livid discoloration of the skin. And, however difficult it may be to determine the precise point of time in which the scirrhus first becomes converted into a cancer, where these symptoms are united there can be no risk in calling the tumour by the latter name. Adhesive bands are now formed in the integuments which become puckered ; while the nipple is drawn inwards by suction, and in some instances com- pletely disappears : the tumour rises higher towards the surface ond feels knotty to the finger; at the same time that the subcutaneous vessels are distended with blood and show themselves in dark cancri- form varices. The march of thc disease may be slow or rapid, for it varies considerably in its pace ; but at length the integuments give way in a few points to the ulcerative process, and a small quantity of caustic ichor, or of lymphatic fluid tinged with blood from the eroded vessels, is thrown forth, sometimes with short and Observations on .Morbid Poison«. 'SL. hi.] SANGUINEOUS FUNCTION. [o\m. iv. ^35 deceitful relief:* the ulcerative process in the mean time advancing Gen. VI. and spreading wider and deeper till a considerable extent of surface cw^w becomes exposed, and a broad excavation is scooped out with a dis- vulgaris. charge of a peculiar and most Offensive fetor.j Here again the rfamser0" ulcersometimes affords a delusive hope of recovery by its granulating ; but the granulations are soft and spongy, and not unfrequently bleed from the loose texture of the new vessels, or their erosion by the cancerous mutter. It is rarely, moreover, that they extend over the entire surta.ee of the sore : for more generally, while one part is covered with them, another part is sloughing, and each of the .parts runs alternately into the action of the other. And not unfre- quently the lymphatic vessels become affected as high up as the axillae, and in their course betray a few smaller tumours. . But whe- ther this be a mere result of contiguous sympathy or of cancerous taint, is uncertain. Cancer, as we have already observed, rarely, if ever, commences in lymphatic glands, which show a peculiar in- disposition to the power of its seminium ; but they, at length, par- take of the disease in the course of its ravage: and hence all sucli suspected tumours are prudently removed when the knife has been resolved upon. Where the disease has spread widely or continued long, some of the muscles of respiration participate in the irritation, and the breathing is performed with difficulty. When cancer attacks the uterus it is known by tensive lancinating <*oncerof pains in this organ, shooting through the region of the pelvis; in- durations in the part sensible to the touch ; a preceding and im- moderate leucorrhcea, or menstruation ; sometimes both. The ulcerative process, as far as we are acquainted with it, is the same as already described ; and as soon as it has worked to the surface of the organ, there is a sanious, or bloody, or mixed discharge, characterized by the peculiar stench of the disease. By degrees, the labia swell and become edematous; and if, as sometimes hap- pens, the inguinal glands be obstructed, the edema extends along the thigh ; and the ulceration proceeds often to the rectum.J Cancer in the vagina which, however, rarely takes place, can Ccncerm easily be felt, and in the rectum the distinction is not difficult. The nature of the discharge, and the other symptoms just noticed, are sufficient to decide its existence. It is still more obvious in the penis. None of these symptoms assist us in determining its presence in Cnnc«<-i« the stomach : and hence how confidently soever it may be con- ni'ach0* jectured from the marks of an acute and burning pain, tenderness of the .epigastrium upon pressure, nausea, and rejection of food, and even an offensive fetor in the breath, the disease can seldom be com- pletely ascertained till after death. It is sometimes accompanied with vomiting, and sometimes not; and ordinarily the absence of vomiting is an unfavourable sign, as it has often been found to pro- * Pryssehriften Uitgegeven door het Gcnootsch. ter bevondering der Hcelkunde. Amsterdam, 1791. t On the varieties of Diseases comprehended under the name of Carcinoma Mam- mae. By Charles Bell, Esq. &c. See Medico-Chir. Trans. Vol. xii. * Clark'e, Observations r>n the Diseases of Females, &c, 8ro. lc.:' 16$ CL. IU.J 1LEMATICA, [oiU>. 1^ • Cancer in the testicle Chimney- sweepers' cancer. Gen. vi. Ceed from an induration of the coats of the stomach generally, camnus which has rendered it incapable of contracting, or from a cancerous vulgaris, ulceration and enlargement of the pylorus* which, upon the slight- est™" est pressure, readily admits the contents of the stomach into the duodenum. There is here, however, usually habitual nausea, though without vomiting. The progress of cancer in the testicle is often slower than in many other parts. In chimney-sweepers we can trace an obvious cause, which is that of soot lodged in its rugae, and irritating as well from its own acrimony as from that of perspiratory fluid with which it comes in contact and forms an union. A painful ragged sore with hard rising edges is first produced ; or, sometimes, a little indurated u art ; which, from inattention, increases in size, is repeat- edly rubbed off by the exercise of climbing, enlarges and deepens its sphere of irritation, grows more malignant, and at length is con- verted into a real cancer, andaffectsthe whole scrotum or the body of the testis. In whatever part of this complicated organ, how- ever, the disease commences, it is progressively communicated to the rest, the scirrhosity increases in size and hardness ; till the tumour often acquires an enormous and irregular magnitude, studded externally with numerous protuberances, and the shape of the testis, even before ulceration, is entirely lost. In the progress of the disease, the spermatic chord becomes affected, and the taint or irritation is communicated more or less to the viscera of the perito- nacal or lumbar cavities. From the cancerous effect of a highly irritable wart or crack on the scrotum of chimney-sweepers and smelters of metals, we may derive some idea of the formation of cancers on other superficial parts of the body from a similar beginning. These most frequently occur on the lips, nose, or eye-lids ; and oftener from a crack than from a wart. The edges of the sore become hard, and one or more tumours issue from them, which increase in size and gradually evince a cancerous character. On the tongue, the same disease sometimes shows itself; and more usually commences with a small wart or pimple near the tip, which hardens by degrees, grows highly irritable and malignant, and, spreading its influence through the entire organs, swells it to a pro- digious size, and renders it of a scirrhous induration. These local tumours are seldom entitled to be called cancers on their origin. They are almost always produced, as Mr. Earle has justly observed, by local irritation, and exacerbated by a continuance of the same cause ; and hence they rarely give much trouble on ex- tirpation ; and, perhaps, never endanger the constitution. A chronic malignancy may, however, convert them into genuine cacinomata.t Cancer is said, in a few instances, to have terminated sponta- cancer has neously. De Haen gives us one example of this :J and Parr affirms Pance? on the lips. Cancer on the tongue. Such tu- mours sel- dom true cancers on their ori- gin. terminated apontn- oously * Memoire sur le Vomissement, par M. Piedaguel. &c—Journal de Physiologie Experimental, par M. Magendie, J utile t, 1821. Paris. t On the Influence of local Irritation in the Production of Diseases resembling dancer. B7 Henry Earle, Esq. F.R.S. Medico-Chir. Trr.ns. Vol. xn. Art. xxm. *" Epist. De Cirutfi. p. 43. PL. in.] SANGUINEOUS FUNCTION. [okd. iv. 237 that he has seen six cases of the same in his own practice. But he Gen. VI. adds, in proof of its being a constitutional affection, that in every c^nnus1' case the cure was followed by some other disease, as an enteritis, vulgaris. fixed pains in the limbs, a sciatica, or an apoplexy, in one of these c«°nw.°n cases, the apoplectic attack occurred twice, and the last was fatal.* T,«ata>ent, In general, however, a cure is rarely effected but by the knife or Yet rarely a caustic, the use of which it does not belong to the present course ceptdby the of study to explain. Yet the progress of the complaint may perhaps £"''*- be arrested ; and we are often able, without cutting, to render it, at m'^beV least tolerable, for a series of years. In an early stage of the dis- Z'lou:*? ease relief may often be obtained by topical bleeding, as with treatment. leeches ; and topical refrigerant applications, as saturnine lotions, bleeding or sheet-lead in very thin layers, as the linings of tea-packages, an ™fap|,li' application which has of late been brought forward as something sheet-lead. new, but which was employed long ago, and may be found recom- mended in many of the older journals of established reputation.! The diet should be limited to the mildest nutriment, and wine be ruet ami sedulously avoided. At this period, indeed, whatever can pre-regimen- vent or lessen inflammation should be seriously studied, and ad- hered to. Ponteau relates the case of a cure produced by rigid abstemious- cured by ness alone, the patient taking nothing whatever but water for a nencea.b,ti" period of two months. J As however, the disease advances, and assumes more of a chronic in the ad- character, the activity of the smaller vessels may be gently urged, in th"disrim: order to relieve or prevent congestion. And where the irritation is BeD',e Bt'- 11 i i-i i ii muluntsev not great we may by degrees apply gentle stimulants also externally, temaiiy. and let the saturnine lotion be superseded by the acetated solution of ammonia, tar-water as recommended byQuadrio, or an illination of the surrounding parts with mercurial ointment, combined with a small portion of camphor. The internal medicines which have been chiefly trusted to for the internal cure of cancer are the lurid and umbellate narcotics and the mineral chiefly""i- tonics : the former apparently for the purpose of taking off irrita- eoticsand tion, and in some instances correcting the specific acrimony ; and nics. the latter for supporting the living power, and thus enabling the system to obtain a triumph over the disease by its own instinctive or remedial energy. Of the first class the chief have been the bella-donna and hemlock, Narcotics and particularly the latter, which appears to have been most pro- -estimated' mising. When Dr. Stoerck of Vienna published his work upon the Hemlock, successful exhibition of hemlock in cases of confirmed cancer, many by siow'ck of which were vouched for by the Baron Van Swieten, every practi- «<"! Van tioner was eager for examples upon which to try the experiment for himself. Solanum had been in vogue, but was just sinking into dis- repute from its numerous failures : and corrosive sublimate was the medicine chiefly confided in at St. Thomas's Hospital. Dr. Aken- *'airiy tried side. * Diet, in verb. Vol. i. p. 329. t Eph. Nat. Cur. Dec. i. Ann. iv. v. Obs. 161. X Nuoto Metodo per curare sicuramente ojni Canchero copertn, Sir,. Veneris, 1750.—fEuvres Posthnmes, Tom. i. 238 cl. m.j IUEMATICA. [orp. x\• Carcinus vulgaris. Common cancer Treatment liis result: often set viceable: Gen. vi. side, who was at this time prescribing the corrosive sublimate in the ' hospital, with what he thought a gratifying success, immediately ex- changed it for the conium, or cicuta as it was then called. He tried it upon a large scale in every stage and modification of the disease, and at first with the most sanguine expectations ; but his hopes gra- dually failed him as he advanced in the career of his experiments, and he was compelled to make very great drawbacks upon Dr. Stoerck's commendation of the medicine. He allows it, however, a certain portion of merit, and his account is drawn up with a de- gree of candour which entitles it to the fullest confidence, and appears to deal out the real truth. In recent states of the disease, where there was no ulceration, or none of any depth, he asserts that it often produced a favourable termination, and gives numerous ex- amples to this effect. But in inveterate cases, where the cancerous ulcer had made considerable j rogress,ats benefit was very question- able : it operated often for a very few days like a charm, diminished the pains and improved the discharge, but suddenly it failed to do the slightest good any longer unless the dose were very largely in- creased, upon which a like beneficial effect followed, but unfortu- nately of equally transient duration. The dose was in many in- stances again increased, and continued to be so, till at length the symptoms produced by the cicuta were as mischievous as those of the cancer itself, and Dr. Akeuside was compelled to abandon it.* We are hence in some degree prepared for the contradictory ac- counts of its effects which are furnished by different writers. De Haen asserts that it affords neither cure nor relief of any kind ;| Bierchen, that it aggravates real cancer, though sometimes service- able in scrophuious ;J and Lange, that it is altogether inefficacious.§ Fothergill is friendly to its use ;il and Bell and Pearon** recom- mend it both externally and internally, alone or in combination with opium. For this discrepancy of judgment we have in some measure en- its virus deavoured to account. Yet the advocates of the medicine have, »' been employed, it is hardly worth while to speak particularly. The cotics. same uncertainty has accompanied their use : and some of them, as aconite and dulcamara, have been rather supposed to effect what- ever temporary benefit has flowed from their employment by the general disturbance they produce in the system, whereby a transient stop is put to every other anomalous action, than by their sedative power. Of the metallic oxydes that have been brought into use, the only Metallic ones it is necessary to notice are those of mercury, iron, and arsenic. "J^ury The first has been uniformly found mischievous when carried to the iron, ar- extent of salivation. Loss asserts that by this means he has cured a s' cancer of the nose and face;"* but this was probably a spurious dis- Zm-uthan, ease of zaruthan, as it has been called by some writers. It has more w a ' generally been employed as a gentle stimulant or alterant. Many Mercury practitioners have preferred the corrosive sublimate in small doses : "iceabtaas but the submuriate is a far better preparation. .And even this is * 8-"''e • i i i c c rti » lL stimulant. given with more advantage in the form ot Plummers, or the com- piummer's pound calomel pill, than alone, a form that conveniently unites a pi,l: mild stimulant with a mild relaxant. To this, if the pain be acute, with opium. should be added a small quantity of opium ; at the same time care- fully guarding the bowels against constipation by any convenient aperient, if the pill itself should not prove sufficient. Iron has been tried in almost every state of combination, and \™^mo there is reason to believe that in some of these it has proved bene- form* ser vices ble. * Mat. Med. Vol. ii. Part n. Ch. vi. p. 264. t Introduction to the Theory and Practice of Surgery, I. " Journ. de Med. Tom. xxxvm. p. 36. $ Treatise on thc Eyes, passim. ' Mat. Med. loco citat "Ob-erv. Med. H. iv. Lond. 167..'. 240 cl. iii.j HjEMATICA. [ohd. i> G^Nic Y*- ficial. Thc ferrum ammoniatum appears to have been the most uarcinus' successful, and is still the most popular. Under thc name of flores vulgaris, martiales it was introduced for this purpose before the public as far Common ... • »r • j ut cancer. back as the middle of last century, by Francis Xavier de Mars, Fermm6"1' obtained, however, by a very uncouth and operose process. Dr. ammonia- Denman was particularly attached'to this metal in whatever form Preferred administered, and broadly affirms that, after having employed almost madi^es'' a" tne medicines recommended for this disease in every different by Den- stage, he has never found any of them possess the pretensions of man' iron ; and that the rest may be generally regarded as totally un- availing.* Its greatly stimulant power rather recommends it to us on the present occasion than proves an objection ; for it is the kind Effects pro- of stimulus we stand in need of to excite a new local action. It is its use. said to produce a very speedy mitigation of pain, an improved dis- charge, and a less fetid smell: and, even in hopeless cases, to render the disease less malignant and distressing: unfortunately, however, its effects, like those of conium, have rarely been found permanent; and it has closed its career as a palliative rather than as an antidote. Arsenic, But of all the medicines of this class arsenic has acquired the e«enajvo highest and most extensive reputation. This is a strictly oriental \nUorientai remecty' employed, as we shall have occasion more fully to observe remedy. when treating of elephantiasis, for every impurity of the blood. Who • first ventured upon it in Europe, for the disease before us is not very Employed satisfactorily known. It was common in the time of Hildanus, who by Theo- ascribes its introduction into practice by the monk Theodoric, who rte"year°ut fl°u"shed about the beginning of the eleventh century.t It has 1000. formed the basis of almost all the secret remedies for cancer which noVtnims* have at any time been current, whether external or internal, "from Jtas"h0f that of Fuschius, iri the fourteenth century, who united it with soot Guy. ' and serpentary, to that of Richard Guy who wrote upon the disease]: in the middle of the last century, and whose boasted arcanum was found to be a composition of arsenic, sulphur, hogsfennel (peuce- danum officinale) and arow's foot (ranunculus sylvestris.)§ Keai ef- Of the real effects of arsenic, as of several of the preceding medi- riouiiyde- cines, we labour under great obscurity from the discrepant reports scribed. which have been communicated. Le Febure with a host of prac- titioners antecedent to, and contemporary with himself, employed it both externally and internally, and regarded it as a specific.H Smalz thinks it serviceable.1l Schneider** and Justamond declare it to be useless, though the latter employed it locally as an escharotic. Hil- danusft and DeliusjJ assert it to be injurious ; and Schenck§§ and MeibomiHI give examples of fatal effects from its employment. * Observations on the Cure of Cancer, p. 77. | Cent. vi. Obs. 81. 4. Essays on Scirrhous Tumours and Caucers, 1759. § Richter, Clnr. Bibl. Band. v. p. 132. [j Remede epiouve pour guerir radicalement le Cancere occulte, et manifeste ou ulcere. 8vo. Paris. If Settene chirurgische und medicinische VorfiiHe. Leips. 1784. 8vo. ** Chir. Gesehichte, Tbeil. v. tt Accouut of the Methods pursued in the Treatment of Cancerous and Scirrhous Disorders. Lond. 1780. tl Dissert. Observut. et Cognit. Nonnnlla Cliirurg. Fasc. vi. >!* Obsvrv. Lib. 11. N. 30-i. , :j JJlumenbach. Bibl. Band. vm. p. 7C4. cl. in.] SANGUINEOUS FUNCTION. [oko.iv. 241 Fatal effects, indeed, it is easy to produce, provided a sufficient Gzn. VI, degree of caution be not employed in experimenting upon it. And, cecums1" in truth, it is not till lately that any very convenient form has been vulgaris. devised for trying its virtues without a risk of mischief; but the cancer.0" arsenical solution of the London College, for which we are indebted T«"»tme,,t- to Dr. Fowler, has given us a preparation of this kind. Yet even with this advantage we cannot boast of any certain success in the use of arsenic. It acts very differently on different constitutions, Acts dir- though generally speaking it proves beneficial; and in some cases dlfferenT*" may produce a radical cure. But more commonly, like the pre- constim- parations of hemlock and iron, it unfortunately loses its effects as mostly soon as the habit has become accustomed to its influence, and the d?es ,er" 1 vice: cancerous taint, or cancerous action resumes its victorious career, yet apt to And perhaps the only power that is capable of neutralizing cancer £*tatr- or keeping it permanently in subjection is the existence of a predo- fec.tsb' minant diathesis of some other kind. How far the remark may have How'far been made antecedently I know not, but from a pretty close atten- ^uVionof tion to the subject within my own sphere of observation, I have been a different led to conclude that cancer does not often make its attack upon may be of those who are constitutionally subject to gout, and seems to be Ugg™anent restrained by its influence. Seems to The list of external applications is still more numerous than that strained of internal. We have already glanced at the local treatment before Dr *»»* °f ulceration has taken place. After this period, sedative applications Local do not succeed, and moderate stimulants alone seem best to afford JXrTiccr- relief. In fact, the inflammation has now acquired much of the ation. character of a malignant erythema, and requires warmer applications than phlegmonic sores. Yet a cure is rarely to be effected except by a caustic or the knife. When the poison was supposed to be of Alkalies. an acid character a solution of the alkalies was employed to correct it, and the ammonia produced from burnt toads was at one time in Ammonia. very high repute. It was afterwards conceived to be of an alkaline "unit6toads nature; and various acids, and particularly the carbonic acid gas, onceinre- were regarded as the best antagonists. Who first employed it for Acids. the present pu/pose is not known ; but it stands recommended as a"dh"a^ early as 1776, in au article of Magellan, inserted in Rosier's Journal; and an easy and convenient mode of application has lately been contrived by Dr. Ewart of Bath. Dr. Crawford, however, for Muriatic the same purpose, preferred a lotion o>f muriatic acid diluted with aci ' three or four times its weight of water. Carrainati and Senebier Gastric applied the gastric juice of animals ; but poultices of carrots or char-Jchnr'Coai. coal have of late years been in more general reputation. All these have a considerable influence in correcting the oppres- The geue- sive fetor, and keeping the sore clean ; but whether they go beyond 0f these, this has been doubted. Yet even this is of great importance, since such an effect must necessarily give some check to the spread of the ulceration, afford solace to the patient, and probably improve the nature of the discharge itself. And hence many writers have been sanguine enough to expect an entire cure from such processes ; and others have given accounts of such cures nearly accomplished ; but which seems seldom, if ever, to have been rendered complete. Vol. Ill—31 za UI.j IliEMATICA. [oin>. sES". I1* Fomentations of hemlock and various other narcotics have been eareinus ' also had recourse to, and sometimes tepid baths of the same, in which twi"*' t'ie Pauent has been ordered to sit for twenty minutes at a time ; eancer. and temporary benefit has sometimes followed the use of these x«erco'ticnt' means ; but they have often been tried with as little avail as the suck- fomema- ling of toads, which was at one time a fashionable remedy, and es- Suckiinj of teemed of great importance, the animals being feigned to expire in toeds. agonies as the poison of the ulcer was drawn out, and its surface assumed a better aspect. Bouffey, who was a witness to their use, tells us, and probably with some truth, that they did more harm than good,* and dealt out more poison than they took away. The era of this invention is unknown, but it was still in use about half a cen- tury ago in our own country, if we may judge from one of the private letters of Junius to Woodfall, who, alluding to the princess dowager ©f Wales, at that time afflicted with a cancer that destroyed her in January 1772, asserts that " she suckles toads from morning till night, "t One of the best detergents appears to be arsenic finely levigated and sufficiently reduced in strength by an union with calamine or some other ingredient. It is also one of the best caustics, in a simple or more concentrated state, and was freely employed as such by Mr. Justamond. Guy's powder, which we have already noticed, is- used externally for the same purpose. We have already observed that sheets of lead, among other pre- parations of this metal, were applied to the cancer about forty or fifty years ago, and bound over it with some degree of pressure. But a pressure of a much severer kind, together with the use of the same metallic sheeting, has of late years been employed by Mr. Young and apparently in many cases with a very salutary effect, so far as relates to checking the spread of the disease, a diminution of the tumour, and an improvement of the nature of the discharge. The plan, however, has failed in many instances; and how far it may have produced in any instance a decided cure, the author cannot positively affirm. The sheet-lead is applied with a considerable tense- ness of compression by means of plaster-straps, tin;plates, folded- linen, and appropriate rollers. The force employed, however, is less severe at first, but progressively increased ; and the change of action is with much more reason ascribed to the sedative effect of the mechanical pressure than to that of the lead. After all, when the cancerous character of the tumour is once decidedly established there is little dependence to be placed upon any plan but that of extirpation by a caustic or the knife. The actual cautery as employed by M. Maunoir, of which we shall have to speak r «aut«ye more at large when discussing the genus uncus, may perhaps be most advantageously made use of in small cancers of the face, but the knife i3 the preferable instrument where the organ is large and extensively °Pwhichn affected- Mr> Bcl1 advises an early performance of the operation : s'a^e best Mr. Pearson, that we should wait till the extent of the disease has Kttwmed. fully unfolded itself, so that no morbid part may be left behind. Yet Ai^rnic powder a good de- tergent. Sheet lead in union with rijrjd coinprss- Litile de- pendence on any measure but extir- pation bv the knife * -loura. de Med. Tom. lxji. t G. Woodfall's Edition,'Vol. i. p. *"4l ex. ui.] SANGUINEOUS FUNCTION. [oki>. iv. 24o pome parts may be doubtful even at last, and, wherever there is thc t}RS- Y*' least suspicion of this, they should unquestionably be removed (. Irrinus' along with the more decided portion of the morbid structure. • vtiig«r.s. Even this remedy, however, can only apply to exterior organs, or cancer" to organs that can be brought down to the surface, for the uterus £u*a,!™0nnt' has been occasionally extirpated, in a few instances with success, tins mea- but far more frequently without any benefit, perhaps from the ope- pUcabio'to ration having been postponed till too late. In all other instances, "t"cr"al'n the practice is melancholy from the first. Thc die is cast almost, organs. if not altogether, irrecoverably: and all we can hope to accomplish is to postpone the fatal result, to mitigate the sufferings of the day. and soften the harsh passage to the tomb. GENUS VII. LUES. VENEREAL DISEASE. l/LCEKS OX THE GENITALS, INGUINAL BUBOES, OK BOTH, AFTER IM- PURE COITION ; SUCCEEDED BY ULCERS IN THE THROAT, COPPEtt- COLOURED SPOTS ON THE SKIN, BONE-PAINS AND NODES. The term lues is derived from the Greek Xvu, "solvo, dissolvo" Gen. VII. —" to macerate, dissolve or corrupt;" and, agreeably to the com- onhe'geno- mon rule of expressing the power of the Greek t» by a Roman y, »c terra. should be written lyes, as in the case of Lyssa and Paralysis, both of which are derived from the same root; but lues has been em- ployed so long and so generally that it would be little less than affectation to attempt a change : and in allucinatio, or hallucinatio, from the Greek xXva or xXwis, we are supported by a similar ex- ample of deviation from the common rule. It appears to have been known to the world from an earlv age, Aerimoni- t . .11 • Li j.\t ° ous fluids as I have remarked in the running comment to the volume ot J\oso- goc.eted by logy, that acrimonious and poisonous materials are, at times, secreted ca'mhic'of' by the genitals, capable of exciting local, and perhaps constitutional producii* ■affections in those who expose themselves to such poisons by incon- eases, tinent sexual intercourse. Celsus enumerates various diseases of l™^}™1" the sexual organs, most of which are only referrible to this source age: of impure contact; but the hideous and alarming malady which was ailudeTto first noticed as proceeding from the same source towards the close g^J8^ of the fifteenth century, and which has since been called almost rest merged exclusively venereal disease has suppressed, till of late, all atten- i"„*^ullls tion to these minor evils, in the fearful contemplation of so new and first ap- monstrous a pestilence : to various modifications ot wrwi> '• ■ n ol in thenf- 244 cl. m.j 1LEMAT1CA. [ORD. IV. fifes *VJI' ^ie an,e"or ana< slighter diseases of the same organs seem to have Venereal been loosely and generally referred ; as though there were but one uenthwm- sPecific poison issuing from this fountain, and consequently but one tury. specific malady. On which account, much confusion has arisen in merous"11 the history and description of the disease ; and syphilis, its most mistakes striking species, though commonly admitted, as we shall see pre- the history sently, to be comparatively of recent origin, is by Plenck,* RichterJ scripUon of Stoll,J and other writers of considerable eminence, regarded as of syphilis far higher antiquity; asserted by Lefevre de Villebrune,§ to have existed eight centuries before the expedition of Columbus to Ame- rica, and by De Blaguyll to have been extant in the Mosaic age. Huntere The keen and comprehensive mind of Mr. John Hunter first view of the called the attention of practitioners to the idea of different poisons confirmed ana" different maladies ; and the subject has since been pursued by by Aberne- Mr. Abernethy with a force of argument and illustrated by a range TationV" of examples that seem to have put the question at rest. Mr. Abernethy has sufficiently established that, independently of the specific disease now generally recognised by the name of syphilis, there are numerous varieties of some other disease, perhaps other specific diseases, which originate from a distinct, possibly from several distinct, poisons secreted in the same region from pecu- liarity of constitution, or causes hitherto undiscovered ; and which are accompanied with primary and secondary symptoms that often vary in their mode of origin, succession, and termination from those of genuine syphilis, though in many instances they make a striking approach to it; and to which, therefore, Mr. Abernethy has given the name of pseudo-syphilitic diseases. th^dis- '^^e aPProacni indeed, is often so close as to render it difficult, eases, so and occasionally perhaps impossible, to decide between them ; and !isearePdi&. hence whether these really constitute distinct species, issuing from tinct spe- distinct sorts of infection, or are mere varieties or modifications of modifiea- one common species produced by one common morbid secretion, common11 ^as not yet Deen sufficiently determined. In this ignorance upon species, the subject, it is better, for the present, to regard them in the latter, decisWery? as being the more simple view ; and with this preliminary explana- Jen!ent°"t t*on ^G expediency of allotting the two following distinct species present to to the genus lues will, I think, be obvious to everyone. regard them in the l8tt»r virw. J. LUES SYPHILIS. POX. SITHILODES. BASTARD POX. * Beobachtungen, &c. u. f Chir. Bibl. Band. i. Sect. ii. p. 163. 1 Prselect. p. 94. § Itetz. Annates, it. |t L'Art de gnerin Ies Maladies Veneriennes, he. cl. nr.] SANGUINEOUS FUNCTION. foRP. iv. 24o SPECIES I. LUES SYPHILIS. POX. I'LCERS ON THE GENITALS CIRCULAR, UNGRANULATING, THICKENED AT THE EDGE; THOSE OF THE THROAT DEEP AND RAGGED; SYMP- TOMS UNIFORM IN THEIR PROGRESS ; SPEEDILY AND UNIFORMLY YIELDING TO A COURSE OF MERCURY WHERE IT AGREES WITH THE CONSTITUTION : LESS CERTAINLY AND WITH MORE DIFFICULTY YIELDING WITHOUT IT. The vulgar term for the ulcers is Chancres, and the vulgar name Gen. VII. for the disease is Pox, formerly Great Pox* as contradistii,guished PEC" from variola or small-fox on account of the larger size of its blotches. It was also very generally called French Pox, as being supposed to be a gift to Europe from the French nation. There is some uncertainty concerning the origin of the specific Derivation term syphilis ; which Swediaur ascribes to Fernelius, but which "irk'term* assuredly existed long before his day ; and was probably invented I^miy/ by Fracastorio about the close of the fifteenth century, from the Greek w and p<;u», importing " mutual love ;" for such is the title by which he has designated his celebrated and very elegant poem upon this very inelegant subject. There is an equal uncertainty as to the quarter in which the dis- 0rigin of ease originated. It is usually ascribed to the American continent, disputed.1" and. believed to have been imported into Europe by the crews of ^"^ Columbus on his first or second return home in 1493 and 14^6 ; a fromAme- belief, however, which seems to be altogether without foundation, ""ws ofha for at the period even of the first return of this celebrated circum- ^oiumbw. .r -_..„,_„. . iii- i Question navigator in March 1493, it seems to have preceded this return by examined. some weeks ; since on his reaching Seville in the ensuing month of Appeared .... ' . . . ., . ,° -iii i • j "'Europe April, in order to join the Spanish army, it had already arisen and too early was spread over Auvergne, Lombardy, and various other parts offortb"- Italy; as, in the course of the summer months, it was observed in Saxony, Brandenburg, Brunswick, Mecklenburg, and especially Strasburg, as all the German writers' concur in admitting ;t and even at Cracow, in Poland, according to Strykowsky's Chronicle of Lithuania ; while Fracastorio, who was an eye-witness of the entire progress of the disease, and from his high medical reputation, and residence almost on the spot of its first appearance, more largely engaged in the cure of it than any physician of his day, asserts that * De Henry, La Methode curatoire de la Maladie Venerienne, vulgairement ap- pellee la Grosse Verole, &c. Paris, 8vo. 1662. t See especially Meiner, Sitten des mittel alten.—Stumf, Schweitzer Cbronick, Lib. xni__Stettler, Schweitzer Cbronick, Lib. vn.—Sprengel, Geschicte der Ar- neyknnde, Theil. n. 246 cl. m.] IL4EMATICA. Lokd- iv- Gen. VH. Jt vvaS cven ravaging a considerable part of Asia and Africa as Lues ' ' well as of Europe: " Europam" says he, "fere omnera, Asia? syphilis vero, atque Aphricae, partem non parvain occupavit."* The writer proceeds to notice the dispute that was then hotly engaged in as well concerning the nature as the origin of the disease, and again expresses his disbelief in its having been imported from America by the crews of Columbus. On this account he feels himself at liberty to give it a very early origin in his poem upon the subject, and describes his fictitious hero Syphilus as having brought down the disease upon himself and the world at large, as a curse for having insulted Apollo, while tending the flocks of king Alcithous. Protinus illuvies terris ignota profauis Exoritur : primus, regi qui, sanguine fuso, . Instituit divina, sacrusque in montibus aras, Syphilus ; ostendit turpes per corpus acbores, Insomnes primus noctes, convulsaque membra Sensit, et a primo traxit cognomina morbus : Syphilidemque ab eo labem dixere coloni. One of the earliest German writers who ascribed the disease to the return of Columbus is Leonard Schmauss, a physician of Stras- burg, whose works were published in 1518 ; but neither his history nor his arguments are in any degree satisfactory : while his coun- tryman Matern Berlen, a clergyman of Ruffach, and an eye-witness of the disease on its first appearance, assigns it a very different origin ; and in his history of the Italian expedition of Charles VIII. declares it to have been a punishment inflicted by the Almighty on this monarch and his subjects, in consequence of his having carried off the Dutchess Anne of Bretagne from the Emperor Maximilian, to whom she had been betrothed. Among the Spanish writers, there are two chiefly who ascribe the origin of syphilis to an American source: while others, by their silence upon the subject when detailing the particulars of the return of Columbus, give sufficient evidence that they disbelieved the report. Gonpaivo Of the two who thus contributed to spread it, one of them, Gon- de oviedo! calvo Hernandez de Oviedo, affirms that it was conveyed into Italy by Cordova's fleet, which however did not arrive in Italy (Messina) till May 24, 1495, and consequently not till two years after thc PapeWeda. disease had existed there. The other is Sapelveda, who, in a history of America, written in a good Latin style, towards the middle of the sixteenth century, roundly asserts that" ex Barbaricarum mu- lierum consuetudine Hispani morbum contraxerunt." But as this writer does not, like his contemporary Fracastorio, enter into the particulars of the controversy, his assertion can go no farther than to the weight of his own individual opinion in a controverted case. Antonio de Among those who have been most full in their accounts of the voyages of Columbus and the discovery of America, we may cer- tainly reckon Antonio de Herrera. He fixes the return of Columbus at the period above specified ; and is very particular in detailing the order sent to Lisbon to him, on the moment of his arrival, to follow * De Contajiosis Morbis. cl. in.J SANGUINEOUS FUNCTION. [ord. rv. 247 thc Spanish Court to Barcelona, to which city it was then removed • Gf.n. vn. the highly honourable reception thc circumnavigator received ; the ,S,™C'l' preparations which were immediately made lor his second voyage ; sy'pbiii*. the speed with which these preparations were accomplished ; and P°x" the instructions given to him on the occasion. Yet not a )iint is added that his crews were unhealthy, that the new recruits had any dread of the plague, to which, had he brought it home, they must have known they were about to be exposed, nor a single instruction to be provident of their health in this respect. He took leave of the royal pair with every mark of distinction, the whole court accompanying him to his house, as well at the time as when he quitted Barcelona. " Despidbse," says Herrera, " de los Reyes, y aquel dia le acompano toda la Corte de palacio a su casa, y tambien quando salio de Barcelona."* Linne'us stands alone in arranging syphilis as an exanthem, along Syphilis with small-pox and measles. He thought himself justified from the by "»£*« fever which occasionally accompanies the copper-coloured spots on nst'J1ntex" thc skin, in an advanced stage of its secondary symptoms : or per- His ground haps from the fever which, on the first appearance of the disease f°g"° do" unquestionably accompanied it, and uniformly preceded the erup- tions. For it is an extraordinary fact, to which all the contempo- Syphilis at raneous writers bear witness, that syphilis, when it first broke forth girded"a* upon the world, and, indeed, as it is described in Fracastorio's poem, c sPccio9 °f was not only called the plague, but was, in truth, a specific fever marktVat attended with most violent putrid symptoms, together with carbun- mnaCHgn^nt cles, buboes, and other glandular abscesses, which discharged a ma- and fataI lignant sanies, often fatal, and even, when recovered from, leaving SJ,mptomg" the most melancholy manes of its ravages. And hence, in many places, the infected were as much exiled from the community by a line of circuinvallation drawn around them, as in the case of plague. In Scotland, indeed, they were strictly prohibited all medical assistance, and inhumanly left to the effects of their own licentiousness. For Mr. Arnot gives the copy of an order from the privy council of Edinburgh, which equally banished to the island of Inck-Keith those who were affected with the disease, and those who undertook to cure it. 1" By degrees, however, the disorder appears to have assumed a Has grown chronic form, and at length so far changed its nature as to make its milder! y attack without fever, and to remain local except from absorption. It seems still, indeed, to be continuing its course of melioration notwithstanding the assertion of Dr. Swediaur,! that it has not assumed a more mitigated character at present than in former times ; for very severe cases are now much rarer, not only in private practice but even in public hospitals, than they were thirty or forty years ago. It is possible that this change may have been produced by two Meiiora- causes; firstly, by the virus wearing out its own strength and counted for, becoming milder as it descends to different individuals and genera- * Hist. Gen. de las Indias Occidentales, Decad. i- L. li. C. v. t History of Edinburgh, by Hugo Arnot, Esq. 4to. 1789.- 1 Beobacbtungen, &c. p. 172. M8 ex. in.] ILEMATICA. [OHD.IV. Gen. VII, Spec. I. Lues Syphilis. Pox. Syphilis distinguish- ed by symptoms local and constitu- tional Usually produced by impure coition : sometimes by other means. First stage, consisting of primary local symptoms. Chancres what. Bubo, its description and pro- gress. tions, and has to cope with the force of sound constitutions, and, perhaps also, with a perpetual instinctive power or vis medicatrix naturas, constantly labouring to subdue it: of which we shall here- after have occasion to offer other examples thai} the present. And, secondly, it is also highly probable that the frequent and, indeed, universal use of mercury for its extermination has succeeded, as a specific, in softening its violence, in the same manner as we know the virus of cow-pox succeeds in giving a milder character to small- pox even where it does not altogether answer as a prophylactic. Syphilis shows itself under two distinct sets of symptoms, local and constitutional, the latter of whicii is commonly, but not always, a sequel of the former. In whicii way soever it is produced it is usually by means of im- pure coition; though we shall have occasion to show presently that syphilitic matter coming in contact with any part of the surface of the body, where it is capable of burrowing and meeting with a little mucous sweat, or, perhaps, any other natural secretion, is capable of assimilating it to its own nature, and hence of introducing the disease into the system by absorption; and consequently with- out any breach of surface. And hence, as other parts than the sexual organs may be a medium of communication, no local symp- toms may in some instances ensue, and the constitutional signs be the first to manifest themselves. The earliest ordinary mark, however, that infection has taken place, is the appearance of one or more minute pimples of a pecu- liar kind, which are called chancres ; having a hard inflamed base, of a pale red hue, and an irritable apex, at which it opens with a small eye-let, becomes ulcerated, and discharges a small portion of limpid virus, that produces fresh chancres wherevej it spreads. In the common mode of infection the chancre shows itself on the pre- puce, glans, and orifice of the urethra in men, and about the labia, nymphae, clitoris, and lowermost part of the vagina in women. This mark sometimes appears as early as the third or fourth day after coition, more generally, however, a few days later; and in some instances, where the cutaneous absorbents possess little irritability, not till a lapse of several weeks. The chancre occasionally con- tinues blind, and degenerates into a hard and irritable wart, with which the genitals are frequently studded, sometimes as low down as the anus. Another local symptom is the formation of a bubo in one or both groins, evidently produced by an absorption of the virus first depo- sited, or, as is more commonly the case, multiplied in the ulcerated chancre, communicated to the lymphatics, and hence to the inguinal glands, which in consequence become inflamed and tumefied. The tumour, when first perceived, is small, but hard, fixed and diffused, with a somewhat obtuse pain. It enlarges gradually and becomes more acutely painful, so as to render walking troublesome ; and if not opened by the lancet, generally bursts by the time it has reached the size of a pullet's egg, and discharges a copious quantity of pus from a single hollow. In a few instances the suppurative inflam- cl. in.J SANGUINEOUS FUNCTION. [okd.iV. 249' niafion does not follow, and the tumour as it augments acquires a Gen- vh- scirrhous induration. Luef0' Sometimes, also, the inflammation extends by sympathy to the Syphilis. spermatic chord, which is inflamed and rigid through a great part of Fu-st stage. its course, while the testes themselves are tender and considerably °flC^l°°*1 SWOln. tion of And occasionally, from sympathy also, or an entrance of a part Xorrd.a ° of the received virus into the urethra, its mucous membrane becomes s?™etimea • a j j •> i • 1 i • • 1 ' uri-thra; inflamed and pours lorth a considerable secretion of pus or purulent with a pu- mucus, resembling that of blennorrhcea, or gonorrhoea as it is com- discharge monly called, or the purulent discharge from the eyes in purulent rambling ophthalmy. noHhtef!'" This was at one time mistaken for a genuine gonorrhoea, and the »"<* for- two diseases were very generally regarded as only different modifi- lakenibHt, cations of one and the same species. And some practitioners con- wne,'C8 tl,e tWO G1S~ tinue to be of the same opinion still, notwithstanding all the facts eases re- that have been adduced in proof of their being distinct maladies f^and'the produced by distinct kinds of contagion. The local symptoms of »ame- syphilis, chancres, and buboes, are perpetually occurring without distinction. gonorrhoea, and gonorrhoea without chancres and buboes. Inso- much, that there are not wanting practitioners who affirm that they never occur together unless the two venoms are received simultane- ously. And there is no doubt that this assertion is true in regard to a genuine gonorrhoea ; but, from the cause already stated, a large flow of pus or purulent matter, and a general irritation and enlarge- ment of the body of the penis, in appearance strongly resembling the symptoms of a genuine gonorrhoea, sometimes coincide with the primary signs of a syphilis, of which a very marked case occurred to the author not long ago, which he showed to an eminent surgeon of this metropolis who had antecedently been incredulous upon this point. And hence a like admission of Professor Frank who, however, does not speak very decidedly upon the subject; and has strangely placed syphilis not only with gonorrhoea, but with leucorrlwa, mu- cous piles, hernia humoralis, and a variety of other diseases, under one and the same indistinct genus to which he has given the name of medorrhce.* But the clearest and most incontrovertible proof of distinction between the two complaints immediately before us is, that in no instance whatever has a simple gonorrhoea, unconnected with bubo or chancre, produced those secondary or constitutional symptoms to which the proper local signs of syphilis are sure to lead, if not corrected in their progress. These symptoms are a peculiar affection of the mucous glands of Second the fauces and mouth, which eliminate syphilitic poison along with "oifststiiig their proper secretion; whence the tonsils, uvula, palate and tongue, d'ar*c„°"" progressively become sore and ulcerated, the voice is rendered con'stim- hoarse, and the swallowing difficult. The ulcers about the fauces gymptom,,, are of a distinctive character, being foul and rugged, with an 'unrated •i i i • • i i i i l'TORt ami excavated centre covered with a brown or whitish slough, and mouth. surrounded with a hard, red, elevated and erythematous outline. * De Cur. Horn. Morb. Epit. Tom. r. p. 149. Mannh. Syo. 17": Vol,. III.—3? 260 cl. in.J HiEMATlCA. [OKU. IN Gen. VII. Spec. I, Lues Syphilis. Pox. Second stage. Inflamed nyes. Copper- coloured spots on tho skin. Pains in the limbs and bones. Nodes Caries of various bones es- pecially of I he nose and palate. Counle- nance sal- low. Loss of hair and appetite. Hectic i'e- vf r. Disease re- mains in u local form lo an un- certain pe- riod : us well as dormant in the system. Local symptoms often ap- pear about four or five days after infection. Constitu- tional from a period of three weeks to six months- Has been said to lurk for several years, but very rarely if ever. Yet the assertion supported by Hahne- mann and llev. The mucous membrane of the conjunctive tunic of the eyes next suffers in the same way, and displays an inflamed surface with ulce- rations on the eyelids and angles of the eyes. The skin is in various parts covered over with copper-coloured spots, which at first de- squammate in scurfs, afterwards in scales, and still later in scabs; each of which leaves a foul ulcer that gradually grows deeper, and discharges an offensive and acrimonious fluid. As the disease advances, irregular pains shoot through the limbs, and are felt so severely at night as to prevent sleep. By degrees they strike into the bones, which become diseased, and in many places swell into nodes, which at length grow carious : while the ulcerations about the fauces spread at the same time, or even before this, to the adjacent bones of the palate and nostrils which are gra- dually eroded and carried away ; so that the speech is rendered nasal and imperfect, and the nostrils are flattened to the level of the cheeks. Finally, the countenance grows sallow, the hair falls off, the appe- tite is lost, the strength decays, and a low hectic preys upon the system, and at length destroys it. It is not easy to say how long the matter of syphilis, when once communicated, may remain limited to the local symptoms of chan- cres or buboes, or continue inert in the system where no local symp- toms have taken place ; or what period must intervene before a patient may be pronounced safe after having exposed himself to con- tamination. We have already seen that the primary or local signs generally manifest themselves within four or five days ; and, where the constitution has become infected without them, we have reason to expect the appearance of the secondary symptoms soon after three weeks, or from this time to six months : and, if this latter interval have passed without the slightest manifestation of mischief locally or generally, we have little reason to fear for the issue. It has been said, however, that the poison has lurked unperceived for several years : yet it is rarely that such an assertion is made except for the purpose of excusing some fresh infection. I should, indeed, have been disposed to think it had never been made otherwise, but that Dr. Hahnemann has referred to an instance or two to the contrary in which he places full confidence ;* and particularly that the late Mr. Hey of Leeds, whose authority is indisputable, has offered it as his opinion, formed from a variety of cases that had occurred to him during an extensive practice of nearly threescore years, that a man may communicate the disease after all its symptoms have been re- moved, and he is judged to be in perfect health ; and that a mother who has been once affected may convey it, notwithstanding an appa- rent cure, to two, three, or four children in succession, each of whom he supposes will have it in a milder form than the preceding one ; as though it were gradually ceasing in the constitution, though it still continues to show some degree of activity.! * Hahnemann, Unterricht f iir VVundarzte uber die VeneiischeB Krankheilen. 8vo. Leips. 1789. t Facts illustrating the Effects of the Venereal Disease. Bv William Hev Esq. F.K.S. 1816. >. . • ' <;l. hi.] SANGUINEOUS FUNCTION. [ord. iv. 251 It is obvious, however, that in syphilis, as in various other diseases ^jj"' produced by the absorption of a specific virus, different constitutions Lues are differently affected, and that some are far more susceptible of Syphilis. the morbid action than others. In many instances, it is received by Second simple contact alone and through an unbroken skin. It is generally, n"^0 perhaps, thus received in the ordinary course of connexion ; but some con- ir1 iil f '* stiiutions still more evidently thus in other cases, and by other organs ; tor it moresus- has been very frequently caught by sucking the nipple of an infected ^.'^soi wet-nurse ; by infected saliva communicated in kissing; by drinking than^ out of a cup that has previously been used by a syphilitic patient;* sometimes and it is said to have been produced by receiving infected breath,! ^mep^cony and lying in a bed which had been antecedently occupied by a person tact labouring under the disease :| in some of which cases, however, it 'J^en" seems necessary to suppose the existence of a cut or crack or some skin: by . . • • 1 1 1 ^ it v sucking an other breach of surface in the skin, and particularly about the lips, i„iected with which the syphilitic virus must have come into union. And it il^%cteii is hence easy to conceive how much more readily it may be com- breath: municated by the insertion of an exotic tooth,§ by bleeding or scari- J^oVof fication with an infected lancet,:l or by the attendance of an infected aonol(j*0,ie midwife,11 who has sometimes given the complaint both to the mother an infected and the child. ™tbe at- A very melancholy instance of infection is related by Dr. Barry tendance of Cork, communicated by a woman who was in the habit of drawing fectaend ' the breasts of puerperal patients, and who, upon examination, was ^J^, found to have chancres on thc lips and roof of her mouth ; probably example. caught from some impure person in the course of her vocation. From the numerous engagements of this woman, the disease had spread very widely ; and the rapidity of its progress was as striking as the manner of its communication. " The nipple," says Dr. Barry, "first became lightly inflamed, which soon produced an excoriation, with a discharge of a thin liquor: from whence red spreading pus- tules were dispersed round it and gradually spread over thc breast, and, where the poison remained uncorrected, produced ulcers. The pudenda soon after became inflamed, with a violent itching, which terminated in chancres that were attended with only a small dis- charge ; and, in a short time after, pustules were spread over the whole body. It finished this course, with all these symptoms, in the space of three months. The disorder made a quick and rapid progress in those who first received it, they not being apt to suspect an infection of this nature in their circumstances. The husbands of several had chancres, which quickly communicated the poison and produced ulcers in the mouth, and red spreading pustules on the body. But such of them escaped who had timely notice of the nature of the disease before the pudenda were affected. Some infants received it from their mothers, and to the greatest part of them it was fatal.'1** * Reid Diseases of the Army, &c—Gruner, die Veneriscbc Austebung durch sremeinschafftlische Trinkgeschirre. Waissenfcls. 1787. f Reid, ut supra. X Horstius. Opp. n. p. 315. § Watson, Medical Transacting, Vol. m. p. 32$, II Girtanner, die Venerischen Krankheiten, &c. p. 165. *T Act. Nat. Cur. Vol. vn. Obs. 75. Vol. ix. Obs. 94. ** Kdin. Med. Essays, Vol. in. Art. xxi. p. W. i'oZ CL. III.J IUIMATICA. [oni>. i\. Gen. VII. Spec. 1. Lues Syphilis. Tox. Second Some con- stitutions insuscep- tive o> ihe disease. Illustrated. 1 he Osti- »cks gene- rally insus- ceptive. Difficulty at times of distinguish- ing be- tween sy- philis and syphiloid lues. Hunter's pathogno- mics ; However applicable formerly, will not ap- ply now without much al- lowance and modifi cation. Exempli- fied. Where a wet-nurse and the infant she suckles arc both affected, and there is a doubt which has communicated it to the other, col- lateral circumstances will assist us much ; but where the one, as is usually the case, has constitutional symptoms, and thc other only local, the former must have had the disease longest, and consequently have been the source of contamination. Such, however, is the unsusceptibility of some idiosyncrasies, that the matter of syphilis like that of small-pox, seems to have no effect upon them, and they are proof against its activity. 1 once knew a young physician who finding himself to be thus naturally protected, fearlessly, and for the sake of experiment, associated himself with females in the rankest state of the disease, and escaped in every instance. In like manner Schenck* gives us a case of an infant rendered syphilitic through a diseased father, while the mother remain- ed unaffected; and Mauriceau and other writers, give cases of infants which have been fortunate enough to avoid infection though born of syphilitic mothers :| while Pallas asserts that the Ostiacks have a g neral immunity from the disease under whatever form it offers itselfj And, after all, the symptoms that characterize the disease, as well in its first and its second stage, are at times so nearly approximated by those which are occasionally traced in the second species of this genus, syphiloid lues or spurious syphilis, that it is often extremely difficult to distinguish them, and we are obliged to enter minutely into the history of the case in order to assist our decision. It was regarded by Mr. Hunter as a pathognomic character of syphilis, firstly, that it never ceases spontaneously ; secondly, that it is uniform and progressive in its symptoms ; and thirdly, that it is only to be cured by mercury. And such continue to be the doctrines of many of his warmest advocates to the present day. How far these characters may have applied to it on its first ap- pearance in Uurope, under the influence of European excitements, and when the general constitution of European nations was fresh to its virus ; or how far such characters may have descended to the mid- dle of the last century, not long after which Mr. Hunter was so deeply engaged in drawing up those masterly views of this disease which he at length gave to the public in 1786, it may be difficult to determine. But to maintain any one of these doctrines without much modification, and especially as criteria of genuine syphilis in the present day, after the wide field of experiments which nave been opened to us both at home and abroad, would be the height of in- credulity. For w€ have hundreds, and, perhaps, thousands of proofs, that instead of " never ceasing spontaneously," it has occasionally disappeared without any other care than that of cleanliness and a reducent diet; that, instead of being uniform and progressive in its symptoms, it has occasionally retrograded or disguised itself under a variety of peculiarities, according to the influence of habit, climate or idiosyncrasy ; and that instead of being only to be cured by * Observ. Lib. vi. N. 21. t Mauriceau, ii. p. 100. 377.—Eph. Xat. Cur. Cent. ui. iv. Obs. 18, f Reisen, in. p. iO. .ut. hi.] SANGUINEOUS FUNCTION. [ord. iv. 253 mercury, various other modes of treatment have been quite as sue- Gen.VII. cessful; while, in numerous cases mercury has added to the virulence Luef °* ' of the disorder, and introduced many of those very symptoms which Syphilis. have usually been regarded as indicative of its secondary stage. Insomuch that it has been almost as seriously made a question in Hence France whether there is any such disease as syphilis,* as it has been France in our own country whether there ever was such a disease as plague : *hm1^" the former being as much resolved into local uncleanliness or consti- have any tutional irritation, a> the latter has been into some modification of [stench typhus with incidental influences. This, however, is to run from one extreme of opinion to another ; Tnis °pi* and all we can fairly collect from such a collision of facts and opi- i;emeand nions, is a confirmation of the conjecture I have already ventured to deuced. throw out, that syphilis, like many other diseases, is capable of being greatly modified by contingent or habitual concomitants, or that it has actually changed its character, and is in a progressive course of melioration. In truth it is well known that Mr. Hunter himself found at times Admitted the secondary symptoms of syphilis intractable to a mercurial course, u,at sypw- and had the candour to acknowledge as much. Dr. Adams, indeed, i'^,1',""™8"" with all his warmth of attachment to the Hunterian code of doctrines, tractable has given an impressive case of this very kind, in which, in spite of "uryV ""*" the mercury, the disease carried its assault from the first to the second order of parts, by which is meant the bones. But then this anomaly is accounted for by their ingeniously telling us that if a constitutional disposition to the disease be formed the mercury cannot cope with it till such disposition comes into action ; which seems, as Mr. Guthrie has justly observed, to mean nothing more in plain language, than that " the disease cannot be prevented in certain constitutions from running its own course, when it may at last be cured." Of all the profession the medical officers of the British army seem Hunterian to have been first impressed with the expediency of re-examining ^"cslmt" and revising the established doctrines upon the subject before us, 0y7hi°raee* from having observed that mercury is little used in Southern Europe, dicai ofl$- and especially in Spain and Portugal, and that syphilis is suffered in British*0 a very considerable degree to take its natural course ; or at most to "my- , 1 i . .1 i- i • • n • l i '.rounds of be treated locally as ordinary sores, and constitutionally with only their doubt. herbaceous diluents or diaphoretics; while the primary symptoms evidently vanish under this simple remedial course, and secondary symptoms are at times not more common than where merpury is had recourse to and solely depended upon. Mr. Rose, surgeon to the JWsex- Coldstream regiment of Guards, was determined to put the question KeCn' to a test, and upon such a scale as might lead to something of a GuardB- decisive result. He forbore, in consequence, about the year 1815, to employ mercury for the cure of any case of syphilitic affection or suspected to be such, among the soldiers of his own regiment; and soon sufficiently perceived that though the cure did not advance so rapidly as under a judicious use of mercury, it nevertheless in every instance did advance; that it was not more severely followed by * See the anonymous but ingenious Pamphlet, Sur la Non-existence de la Maladie i^nenenne. Paris, 8vo. 1811. 2o4 cliii.] HjEMATICA. [ord. i\. Gen. VII Spec. I. Lues Syphilis. Pox. Communi- cation of the same. Repeated on a I >rgo scale by others in France: York Hos- pital : 0"ver Hos- pital : Chatham : Edinburgh; with like results. Guthrie's remarks. secondary symptoms or a syphilitic dysthesy than where mercury is trusted to as a specific, and that, of course, it was without the risk of those mischiefs to the general health which mercury is so well known to introduce where it disagrees with tne constitution. Having persevered in this mode of treatment, in his own opinion verv successfully, for apeiiod of nearly two years, he communicated its result to the public in the eighth volume of the Medico-Chi- rurgical Transactions,* with a long list of well diversified cases, and observations tr.ut cannot fail to make an impression on every one who reads them. The experimental course laid down by Mr. Rose was soon adopted by others, and, on various occasions carried into establishments which afforded'ample space for a satisfactory examination. It was tried in other battalions of the Guards as well in France as at home ; was introduced into the York Hospital at Chelsea, and various other hospital establishments, as at Dover, Chatham, and Edinburgh. " From these hospitals,'' says Mr. Guthrie, " I have seen the reports of nearly four hundred cases which have been treated with the same result, as far as regards the cure of primary ulcers ; each ulcer ap- pears to have run a certain course, which, as to extent, was much the same as in one of the same appearance where mercury was supposed to be necessary ; and at an indefinite period of time to have taken on a healing action ; and, in the greater number of instances, skinned over rapidly, leaving a mark or depression show- ing a loss of substance. With us, where the ulcer had the cha- racteristic appearance of chancre, dry lint alone was generally ap- plied to it. Where these signs were less prominent, a variety of ap- plications were used. But there were a great number of sores, both raised and excavated, on which no application made the least fa- vourable impression for many weeks. They did, however, yield at last to simple means, after remaining for a considerable time nearly in the same state, several of them having become sores of a large size previous to or in the first days of their admission. If they were ulcers without any marked appearance, and did not amend in the first fortnight or three weeks, they generally remained for five or seven weeks longer : and the only difference in this respect, between them and the raised ulcer of tiV prepuce was, that this often re- mained for a longer period ; and thatuleers, possessing the true cha- racters of chancre, required in general a still longer period for their cure; that is from six or eight to ten, twenty, and in one case to twenty-six weeks, healing up and ulcerating again on a hardened base. Those that required the greatest length of time had nothing particular in their appearance that could lead us to distinguish them from others of the same kind that were healed in a shorter period. Neither were any of these ulcers followed by a greater number of buboes, nor did they suppurate more frequently than in the same number of cases treated by mercury. On the contrary the ulcers were not so frequently, on the average, followed by them ; neither did they so often suppurate. But this may also be attributed to the ? Observations on the Treatment of Syphilis, fcc. Vol. vm. p. 349. 1817. cl. iu.J SANGUINEOUS FUNCTION. [okw. iv. 255 antiphlogistic means employed both generally and locally for their Gek. VIL relief."* And to this it may be added that M. Culluriei, the first jj"0, L surgeon in the Venereal Hospital at Paris, has been for years in the syphilis. habit of demonstrating to his pupils the possibility of curing every Practice of kind of ulcer that falls under his notice without mercury. He usually, ^Paris' indeed, has recourse to this medicine afterwards, but for the mere purpose of guarding against secondary symptoms. It is very candidly admitted, however, by Mr. Guthrie, that But longer although these experiments give the strongest proof of fhe possibility quired of curing venereal ulcers without mercury, yet tfiat a much longer ^j.*""', period of time is required for the cure. " I have every reason," says he," to be certain from former experience that almost all these protracted cases would have been cured in one half or even .one third of the time, if a moderate course of mercury had been resorted to after common applications had been found to fail." The result of this inquiry therefore should by no means induce us Hence mer to relinquish the use of mercury as of specific influence in general noMo'bf practice ; but it is of great importance as offering solid consolation "/'."f""^ to those who may be labouring under the disease with an idiosyn knowledge crasy or acritude of constitution that forbids the use of this specific, quirecfof and converts it into a poison instead of receiving it as a remedy. ereat im- It is admitted also that the cases of secondary symptoms occur secondary more frequently in the cure of primary symptoms without mercury ^"^f™.8 than where the last has been had recourse to. Upon the former quent plan of treatment Mr. Guthrie calculates the secondary symptoms Turytsnot to occur about once in ten times; in the latter, once in about "">*• seventy-five times. But it is singular that in the former case the tionato es- secondary symptoms are for the most part far milder than in the BuTlccon latter, the bones being rarely, if ever affected. " Insomuch," says d«y symp- Mr. Guthrie, " that some of my friends of great talents and experi- ^"when no ence have been induced from this to suppose that the greater seve- ^eI,cc"r^e rity of symptoms, which are frequently met with, have been caused severity of by the exhibition of mercury in the first instance, which aggravated {„", sJ™r the constitutional disease." Mr. Guthrie, however, ascribes thisc»bedt0 more lenient show and course of the symptoms to the stricter anti- cury: phlogistic means resorted to in the simple than in the mercurial ougif'and treatment; and endeavours to prove that mercury has no tendency to be ae- to produce any such aggravation, except when injudiciously em- otherwise.01 ployed, or it does not harmonize with the idiosyncrasy, or actual state of the constitution. It has been asserted, indeed, that in Portugal, where, as we have Symptoms already observed, mercury is rarely had recourse to, both the pri- m^e severe mary and the secondary appearances are much more virulent than *grhp°"yin in England, or under a course of mercurj : that the local ulcers are Ponugai: far more apt to slough and become gangrenous, and to run into "",„ l°hlan that encircling phaffedamic sore about the glans which has boon «'."•• °aTn.eU ........tt .i -i Black Lion: vulgarly denominated black lion; and that a greater proportional number of British soldiers, and even officers., formed part of thc public during the Peninsular war, than they are in the habit of * Observations on the Treatment of the Venereal Disease, Mcdico-Chirurg. Tran« Vol. vm. p. 657. ii56 cl. m.J HiKMATlOA. [0K1>. Gek. VII. Spec. I. Lues Syphilis. Pox. but errone- ously : and rather to be as- cribe I to intemper- ance, ;md a hotter tem- perature. Goneral de- ductions. First de- duction. Second de- duction. Third de- duction. Fourth de- duction. Fifth de- duction. forming at home. These facts have been especially noticed by Dr. Fergusson in a valuable paper on the subject ;* and they are virtu- ally admitted by Mr. Guthrie ; who, however, ascribes the malignity in every instance, to the accidental circun.stances of change of cli- mate, and incemperance of habit, rather than to the absence of mer- cury. " I do not think," says he, u the disease which the troops contrarted in Portugal was in the slightest degree more violent than the same kind of complaint at home ; neither do 1 place the least reliance on what has been said by others about a distemper called the black lion of Portugal, which 1 do not believe exists. But I perfectly coincide with him ('V. Fergusson) in opinion that the change from the climate of Jreat Britain to that of Portugal in the summer, with the different mode of life, does act most powerfully on our northern constitutions, and disposes strongly to inflammatory affections. It is this that rendered the same kind of wounds more dangerous to the British soldiers than to the natives; and it was to this disposition, increased by the greatest irregularity of conduct, and often by intemperance, a vice the natives are not addicted to, that we were indebted for the mutilations which ensued from the venereal disease." The following calculation of results seems to be a fair expression of the general facts ; and in the present state of the question they are too important to be omitted. They comprise the conclusion of the same able writer's remarks upon the subject. 1. " Every kind of ulcer of the genitals, of whatever form or ap- pearance, is curable without mercury. This I consider to be esta- blished as a fact from the observation of more than five hundred cases which I am acquainted with, exclusive of those treated in the different regiments of guards and which occurred in consequence of promiscuous intercourse. 2. " Secondary symptoms (and I exclude trifling pains, eruptions, or sore throats), that have disappeared in a few days, have seldom followed the cure of those ulcers without mercury ; and they have, upon the whole, more frequently followed the raised ulcer of the prepuce than the true characteristic chancre of syphilis affecting the glans penis. 3. " The secondary symptoms in the cases alluded to, amounting to one-tenth of the whole, have hitherto been nearly confined to the first order of parts ; that is, the bones have in two instances only been attacked ; and they have equally been cured without mercury. 4. " As great a length of time has elapsed in many of these cases without the occurrence of secondary symptoms as is considered satisfactory where mercury has been used, viz. from six to eighteen months. 6. u The primary sores were of every description, from the super- ficial ulcer of the prepuce and glans, to the raised ulcer of the pre- puce, the excavated ulcer of the glans, and the irritable and slough- ing ulcer of these parts. In the inflammatory stage attended by itching, scabbing, and ulceration, they were treated for the in<»1 idicn-Chir. Trans. Vol. it. in.J SANGUINEOUS FUNCTION. [ord. iv. 251 part by antiphlogistic and mild remedies ; in the latter stage, when Gen' VI,« the ulcers were indolent, whether raised or excavated, by gentle u!efc' l' Stimulants. Syphilis. 6. "The duration of these stages is very different, is often si^th de- increased by caustic and irritating applications, and is much influ- duction' enced by surgical discrimination in the local treatment. 7. lt The last or indolent stage, often continues for a great length Seventh de- of time, especially in the excavated chancre, and raised ulcer of the duc,lon prepuce. And it appears to me that, in these particular cases, a gentle course of mercury, so as slightly to affect the gums, will ma- terially shorten the duration of it, although in others it is occasion- ally of no service. 8. " Although the secondary symptoms do for the most part yield EiBh,h fle~ to simple remedies, such as venesection, sudorifics, the warm bath, ducllon' sarsaparilla, &c. without much loss of time ; that is, in the course of from one to four, or six months ; yet as in the primary ulcers, a gentle course of mercury will frequently expedite, and in particular persons and states of constitution, is necessary to effect a cure : and that a repetition of it will even, in some cases, be requisite to render it permanent."* There is yet one singular feature which remains to be noticed Wonderful before we close the history of syphilis, and which, so far as I know, nTemtoUi* has never yet been fully brought before the public eye, although tp^°n|,a0fgy. established by many of the best reports m the possession of the Army Philis. Medical Board ; and that is the great difference which exists in the naiVdfs- facility with which syphilis, and I may add, the affections that make Vyee"t}"..,1,e a near approach to it, as bastard syphilis, and gonorrhoea, are pro- dies: as pagated in the East compared with their propagation in the West ^mlSf,4 Indies. These reports have been submitted to me, by the friend- to ,he ship of the Director-General: and the chief conclusion I have been dic"iy" e" able to draw from them—and it is a conclusion that Dr. Gordon, who p°"^_ was kind enough to go over these reports with me, has long since tionate oe- arrived at from the same documents,—is, that every two regiments fhTw^st" in the East Indies furnish, at least, as many cases of both genuine ?"''.Ea-t and doubtful syphilis as are furnished by the whole army in the West Indies. But the following tables will give the reader an opportunity of Tables in calculating for himself, and will show that the difference is some- Tucfre- tiines much greater. The report from the whole of the West ^*- In_ Indies for the year 1323, which I take as being the latest, is as«besin follows: ,82S- Cases of Syphilis unaccompanied with secondary symptoms.............. 16 Doubtful or Bastard Syphilis...... ]."> Simple Buboes............. 3 Annual number of cases for the whole of the £ West Indies in 1823...........\ ' ' * Medico-Chirurg. Trans. Vol. vm. p. 676. Vol. III.—33 Zoz Gew. VII. Spec. I. Lues Syphilis. Pox. First, or Royal Re- giment at Trincomall in 1823. Additional tables. cl. ilu] HvEMATICA. [ord. n. Now the report from the 1st, or Royal Regiment alone, for the same year, stationed at Trincomali, gives 177 cases of syphilis without any subdivision into genuine and doubtful. In like manner, during a preceding year, while the 12th regiment of Light Dragoons furnished the following report: Cases of Syphilis ... .......4-1 Secondary symptoms.......6 Doubtful ulcerated penis......5 Buboes...........2 Cachexia Syphiloidea.......7 Gonorrhoea..........26 Hernia Tumoralis........15 105, the report for the same year, from the whole of the West Indies, givet Cases of Syphilid...........41 Buboes...........29 Hernia Tumoralis........40 110. All thc»e diseases returned as belonging to a com- mon family. But such combina- tion more strongly confirms tho remark. Hence a frequent difficulty of making re- turns upon this subject in the West Indies. Illustrated from Teg- art's re- port. W Ikmico the cause of this dif- ference. Whether like the plague, suppressed by tempe- rature of |tcat hf»nt From the uncertainty which still prevails respecting the specific nature of several of the above affections in the minds of many prac- titioners, they are returned as of a common family ; and however unscientific such an arrangement may be in itself, it, at least, ena- bles us to draw a more satisfactory general conclusion, as showing that none of the forms of disease which, in the widest latitude of the term can be referred to a syphilitic origin, are here kept back. I was, in effect, not a little surprised at finding how few reports respecting syphilis have been sent home from the West Indies, com- pared with those from the East, till Dr. Gordon convinced me, from the nature of those which have been received, of the difficulty of making out any such reports whatever in particular years ; and point- edly directed my attention to a remark in one of them, transmitted by Mr. Tegart, a highly intelligent inspector of hospitals at Barbadoes, as though offering an apology for the scantiness of his returns upon this subject: " One gentleman, Mr. Taylor, of much learning, and great experience in this island, who has resided here nearly thirty years, says that in that long period he has only seen two cases of primary disease. The fact is," continues Mr. Tegart, " that syphilis is almost unknown in this country :" alluding to the West Indies gene- rally. To what then are we to ascribe the wonderful contrast presented to us in these two colonies of the same empire ? Is syphilis regu- lated by some such law as that of plague, which, as we have already observed, seems incapable of existing in an atmospheric temperature above 80° or much below 60° ; and hence has never been able to obtain a footinr/ in Abyssinia or the south of Arabia, while it ha- .ex. in.J SANGUINEOUS FUNCTION. [ord. iv. 259 rarely appeared earlier, as an epidemy, than June or July, in our Gen.VH. own country ? or is it affected by any other meteorological influence ? Luef The question is of no small moment: for if it be either the atmos- pjj^1*- pherical temperature, or temperament of the West Indies that pro- Thisques- duces so striking and beneficial an effect upon the specific poison ^"inno0 of syphilis, it may be found that the best asylum we can provide even ment- . for those who are actually labouring under the disease, and in its Muiry may rankest form, m the same quarter : so that Barbadoes or Jamaica b^ j;""^. may in process of time become as general a resort for syphilitic pa- diaipur- tients, as Madeira or the South of France for consumptive. po8<" Till we are further acquainted, however, with the cause and nature Ge"M'{ of these discrepancies than we are at present, we must continue to process. provide for syphilis the best means of cure we may be able to do at home. And in pursuing this object, it is not to be wondered at, from Different the observations already offered, that plans of very different kinds, mod™ of and medicines of very different classes, should not only be had [„'a'™o"t recourse to in our own day, but should have been adventured upon every pe- at all times, even when the disease may be supposed to have raged nfl with a far greater degree of malignity than at present. From the number and repugnancy even of those that have ac- ncnner]infl" quired any considerable degree of reputation, there is no small diffi- cuity in culty in reducing them to any thing like an intelligible classification. ^[™gins Yet, upon the whole, we may observe that the medicines which have been chiefly had recourse to, or have been fount! most serviceable in curing syphilis or arresting its progress, are narcotics, diluent diapho- retics, diuretics, drastic purgatives, and those which introduce a large portion of oxygene into the system ; practitioners having directed their attention at different times to rendering the vascular fibres inir- ritable to the specific acrimony of the disease, to expelling it by some of the emunctories opening externally, or to dulcifying it by a chemi- cal combination. Of the narcotics, recourse has been chiefly had to opium, conium, Narcotic*. solanum, and belladonna, manifestly upon the principle of their being sedatives, and hence rendering the system inirritable to the syphilitic virus. This some of them accomplish in a very considerable and desirable degree; and particularly opium which has been mostly Opium. trusted to, and tried upon a wider scale than any of the rest. It "• **•»' moderates and alleviates every symptom ; and, from a cause not well palliative. ascertained, may be taken in very large doses with less inconve- nience in syphilis than in almost any other disease. From its pallia- Hecnnc*unV tive effects, it has been supposed by many practitioners capable of p^d'to producing a radical cure ; and numerous histories to this purpose £$",'• ° have been published by those whose judgments have been unduly cure; prejudiced in its favour. On these histories it is not necessary to enlarge : they have been long before the world, and have called forth other trials which have not proved equally successful. Narcotics in general, and opium beyond the rest, add considerably to the efficacy of other means, and particularly of mercury ; but of themselves they **«'#roM are not competent to remove the complaint, and consequently are not to be depended upon. The list of warm and diluent diaphoretics that have been employed J™*' 260 cl. m.j HiCMAT1CA. [onv. i\. Gen. VII. as remedies in syphilis are very extensive ; but it may be sufficient x,uos ' ' to enumerate the following: mezereon, guaiacum, sarsaparilla, sapo- Syphiiis. naria, baidana, smilax, and one or two species of asclepias or swal- Treatment. low-WOrt. Hon how All these are supposed to be serviceable by exciting a determina- faruseful-, tion to the skin, and throwing off the syphilitic poison, as various most so in other poisons are thrown off, from the surface : and in very warm warm ell- r . J mates. ciimates many ot them are said to operate a radical cure ; though the statements to this effect are rarely such as we can depend upon. Some of them, moreover, as the saponaria or soap-wort, and smilax or china-root, possess a viscid or unctuous principle, which has been supposed of use in obtunding the acrimony of the poison, and thus blunting its effects even before it is discharged from the body. The soap-wort has the advantage of being found in the hedges of our own country. rifiachicfly They have all had their day, and the only one at present in much employed request is sarsaparilla, of the actual amount of whose virtues it is dif- at present. gcuit to Speafc -^vithi precision. Like the lobelia syphilitica or blue car- dinal flower, which is a purgative plant, it owes its earliest reputation ^llv™tuees?f to the American tribes ; and when first imported into Europe by the Spaniards about the year 1563, it had the character of being a spe- cific for the venereal complaint. From being extolled, however, too highly, for it never fulfilled this character in the old world, it has since sunk, like many other useful medicines, into a very unmerited '^d^'Vi!8" c011^"?*' insomuch that Dr. Cullen allows but eight lines to its his- euiien. tory and qualities, in the course of which he tells us that if he were to consult his own experience, he would not give it a place in the Ma- teria Medica, as he has never found it an effectual medicine in syphilis or in any other disease.* The London College, however, have evinced a different opinion, for they have adopted it under various strongly forms: and Professor Thomson, of Edinburgh, has been so highly mended by satisfied with its antisyphilitic powers, that he has for some years Mhcapa°bie relinquished the use of mercury altogether in favour of a mode of of effecting practice, which consists chiefly in the employment of sarsaparilla.! yet less' Upon a very large scale he has met with very great success ; though, thanmer- h^e ^r* ^ose' he candidly acknowledges that the secondary symp- cury. toms of the disease, have required a longer time to be overcome under the new treatment than they would under a mercurial. There is also a much more powerful objection to its use; and that is, that the secondary symptoms are, in many cases, apt to return soon after the new treatment has been relinquished, or other symp- toms not essentially different. The fair pretensions of sarsaparilla auxiliary- aPPear to De those of a mild stimulant and diaphoretic. It is hence and highly in many cases a useful auxiliary to mercury; but I have chiefly found it where6™* succeed jn chronic cases, where the constitution has been broken down oury has perhaps equally beneath a long domination of the disease and a pro- duced dis- tracted, and apparently inefficient, mercurial process. In connection pa!">- with a milk diet and country air, and with a total abandonment of mercury, I have here often found it of essential importance, and have * Mat. Med. Part ii. Chap. v. p. 200. t Edinb. Med. an'! Sur?. Journ. No. Liir. P- H cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 261 seen an incipient hectic fall before a free use of it in a week. Its Gen. VII. best form is the old one of the decoction of the woods, of which three j^*0' or four pints should be taken daily. Syphilis. In France, the same plan ha"s been long in general use, and has Treatment. been found equally successful. Un account of the dearness of sar- carex are- sapardla when genuine, M. Ltiem.e Sainte-Marie has been induced German to try the Carex arenaria, or lierman sarsaj aiillaof our old dispen- sarsapa- satories, as Gleditch of Berlin had done before him ; and though he does not, like (jleditth, regard it as more efficacious, he affirms, after employing it for ten years, that it is at least, of equal value.* Its use is certainly worth reviving in the present day of economizing and experiment The syphilitic poison has also been often attempted to be thrown out of the body by exriting the excretories of some other organ than those of the skin or in conjunction with them. Thus the flammula Fiammula Jovis, or upright traveller's joy, the clematis recta of Linneus, which acts powerfully both on the surface and on the kidneys, is said to have been employed with great advantage, and was at one time in high and extensive estimation. It was given in the form of an infu- sion of the leaves, and Dr. Stoerck, with his usual liberality, assigns it an extravagant praise, informing us that it effectually subdues all the secondary symptoms of inveterate head-aches, bone-pains, nodes, ulcerations of the throat, and cutaneous eruptions.t i The lobelia syphilitica of the American Indians has a still fairer Lobelja claim to notice. It is a drastic purgative, uniting something of the syp stimulant and narcotic powers of tobacco, to which it has some re- semblance in its taste. In the simple life a. d inirritatmgdiet of the American tribes, it is possible that it may have proved as successful as it is stated to have been ; but it has completely failed in Europe. Of the antisyphilitics, whose influence seem* lo depend on their Oxygenous being loaded with oxygene, the principal are the mineral acids, and \^!P l~ the metallic oxydes. Of the first, the nitric has chiefly been made a subject of experi- Acids. ment in our own country, though the sulphuric has been employed BUiphuric. abroad.J How far it exercises a chemical power upon the syphilitic virus, and forms a n^w and blander substance with it, is uncertain. Its general effects are, as we might expect them to be, tonic and seda- Their pre- tive ; whence the appetite is increased, a greater rigidity or firmness anTeffects. is given to the living fibre, and a greater density to the coagulable lymph : the action of the bowels, and even of the bladder, being diminished. Besides these, it has a particular effect on the mouth approaching to that of ptyalism, for the gums are rendered slightly sore, the mouth and tongue become moist, and in India and other warm climates a real salivation is said to ensue. Under this change the syphilitic symptoms assume a better appearance, and especially those that belong to the primary set: but we have no decided case in which a perfect cure has been accomplished in our own country ; though Dr. Scott affirms that in India this has been common. Thc * Methode pour guerer les Maladies Vgneriennes inveter€es, &c. Paris, 1818. t Libellus quo demonstratur herbam veteribus dictum flammulam Joyis posse tutn exhiberi. Vienn. 1769. 1 Crato. Epist. v. p. 293. 262 cl. ml] H.EMATICA. [ord. IV. Gen. VIL Spec. I. Lues Syphilis Pox Treaiinent Aqua regia, said by Scott to produce a radical cure in India Has not beon found to succeed of hue. Metallic oxydes Arsenic. Gold. Antimony Mercury the only medicine to bfi relied on in every stage. All its pre- parations succeed if sufficiently introduced Us virtues and general action. acid he was in the habit of employing was a direct aqua regia as already noticed in the treatment of jaundice ;* and with the internal use of this, he combined that of the acid bath as there also particu- larly specified. His object was to effect a cure without incurring any of the evils so frequent upon a mercurial course ; and to this object the proposed plan has, in his opinion, given complete success. It would have been happy for the world it'tlus success had been per- manent and universal; bin the plan has since fallen in its reputation not much less in :ndia than in tiurope. The metallic oxydes have otfere.! a large field for experiment; and almost all the metals have been had recourse to in rotation, as cop- per, iron, antimony, mercury, arsenic, and even gold. The pretensions of arsenic are certainly considerable: it forms thc ordinary medicine employed in syphilis by the cabirajas or native Indian physicians, who depend upon it as a specific. They give it in the form of white arsenic in combination with black-pepper, as we shall notice more at large when treating of elephantiasis, for which also it is esteemed a powerful remedy. »The only auxiliary is a cathartic of manna dissolved in a decoction of nymphaea Nelumbo. Of the effects of any of the preparations of gold we know but little. Many of them were in high repute formerly as a cure for various cachexies, and are said to have been uted with success in syphilis.t They have since been repeated in France, and are reported to be entitled to all the distinction they have at any time attained; but as a train of experiments upon this subject is still in hand we may hope for more certain information in a short tune.J Antimony, and perhaps a tew other metals are useful auxiliaries; but, in fact, the only metal, and I may add the only medicine, on which we can confidently rely for a general cure of syphilis in all its stages in our own climate, is mercukv. This has been tried from an early period in almost every variety of preparation ; and, provided a sufficiency of it is introduced into the system, in every variety it has been found to succeed : so that in th • present day the peculiar form is regarded of less importance than on its first use ; though we may observe that it seems to be most rapidly efficacious in those forms that introduce the largest proportion of oxygene into the system. And as it operates chiefly, like most other medicines, through the medium of the circulation, when it once becomes mixt with the current of the blood it is equally efficient in the cure of a recent chancre, and a chronic ulceration of the throat. Mercury is an universal stimulant, and increases the action of all the secretories at one and the same time; for it operates simulta- neously on the intestines, the skin, the salivary glands, and even the bladder; though it displays itself chiefly by its action on the salivary glands. It has also, when given in moderate doses, considerable ♦Vol. i. Cl. I. Ord. ii. Gen. i. p. 288. | Agricola, Comment, in Pappium, Num. 1643.— Ochmen, Feldchirurgus, 8vo. Fr. aud Leips. 1750. I See the Report of A. S. Duportal, M.D. and Th. Pelletier, Apoth. Annates de phemic. Tom. i.xxvm. p. 38. ■ l. m.j SANGUINEOUS FUNCTION. [ord. rv. 263 pretensions to a tonic power, though this is overwhelmed by its stimu- Gen. VII. lant effects when the dose is consiuerably increased. It seems there- Luefc* * fore to unite most of the virtues of the preceding remedies, except- Syphiiia. ing tlie sedative ; and hence it is greatly improved by the addition Treatment. of opium and camphor, which give it the quality it stands in need of. Independently, however, of its combining in itself many of the Seems to virtues of the preceding remedies, mercury seems also to possess ^mefpeci- some specific viitut unknown to the rest; for we can associate all fionnto"jj|i" the general qualities by a combination of different medicines with- gmeral out producing the same result. Mercury, indeed, to these general ^n antla" quahties adds that of peculiarly stimulating the salivary glands, which philuic the other remedies employed in syphilis do not at all, or never in an equal degree ; but that its specific power as an antidote does not Thi8*0M. depend upon its being a sialagogue is clear, because while it has on its being sometimes excited salivation without effect, it has at other times pro- ' 8'u£" duced a perfect cure without any salivation whatever, for in some idiosyncrasies the salivary glands are not affected by its irritation. Dr. Cullen, however, who had a mortal aversion to considering Denied by any medicine in the character of a specific, denies that mercury is be"a specj- a specific in syphilis, as he does also that it is an attenuant of the Jjj;,"',^' blood, or an antidote to the disease. It is in vain to point out to him attenuate its specific influence upon the salivary glands, or its specific action theblo° ■ upon their mouths ; he denies the whole, and contends that mercury His hypo- might travel, and perhaps would travel for ever in some other direc- account for tion, were it not for the friendly interposition of the ammoniacal i1**"'0" salts of the blood, which he fancies to have a close affinity with mer- cury, as he supposes they have also with the salivary glands; in consequence of which, they take the mercury by the hand, and in- troduce the one stranger to the other :* thus solving the difficulty like divinity in the catastrophe of a drama. The result of the Hence in whole, in the opinion of Dr. Cullen, is that mercury cures the ve- iUsTrdy0" nereal tlisease, not by producing any change in the state of the f/™?*^0 fluids, but entirely by giving a stimulus to the excretories at large, tanttoaii by whatever contrivance it reaches them, and thus increasing the {orys*cre excretions, and washing out the poison from the body. That it does this is highly probable ; but this alone is not suffi- Jnt'* ™.w cient, for fresff poison is continually forming by the process of as- Cient to ac- similation, or the conversion of some part ol the fluids it comes in f;™},*,,, contact with into its own nature ; since if it were not so, and the effects. minute drop of virus that excited the disease at first remained with- out any increment, there can be no question that such a general scouring of the system would be unnecessary, and that the ordinary evacuations would be sufficient to throw it off. And hence we have not only to carry away the poison that is actually present in the ves- sels, but to prevent the formation of new. Now it is in this power of prevention that the specific virtue of Jje^liu mercury seems to consist; and this it is that renders it paramount to virtue all other remedies in the cure of syphilis. It is not only an evacu- consist.0 ant but an antidote ; for, as we have already seen, it quickens the ™s£tu< * Mat. Med. Part it. Ch. xvn. p. 443—450.—See also the present Work, Vol. i. "' 264 cl. ui.] HiEMATiCA. |or». iv Gen. Vii. action of other remedial means when united with them, and far LuesC" more speedily effects a cure even by itself than any of them. By Syphilis, what means, however, it becomes an antidote, or exerts its specific Treatment, power, we know not. The matter of a chancre mixed up with a quantity of Plenck's gummy solution of mercury has been applied to a sound person without occasioning either a chancre or any other Whetherby syphilitic symptoms. And it has hence been supposed that mercury eombina- neutralizes the syphilitic virus, and produces a third and harmless* v°nereaitbe substance. As it has been further supposed that it is by the disen- virus, or by gagement of the oxygene which the various preparations of mercury gagemeni introduce into the system, that this effect is accomplished. All this of oxygene. i3 ingenious and may be true, but the evidence does not come home to the conclusion. Even the experiment with chancrous matter and the mercurial solution has not been satisfactorily performed ; and if the result were as here stated, the matter while it has no power of assimilating the* solution into its own nature, as it has the fluids of the human body, may only have been rendered inert by simple dilution. We have said, that provided a sufficient quantity of mercury be introduced into the system, the particular preparation is of no great Oxymu- importance. Van Swieten preferred the oxymuriate, and every one merly pre- followed his example. Tlie calcined mercury came next into popu- othwpre- kmty ana" triumphed over every other form. It was the leading parations- article of most of the secret remedies that were sold for the com- calcine" * plaint, and especially of Keysets pills, the receipt for which was Ke'ser^ purchased with great formality by the French government, with an pills. express provision not to make it public till the inventor's death.* These pills, however, which consisted of nothing more than mercury calcined by a needlessly operose elaboration, and mixed up with manna, were found in many cases to irritate the bowels even when united with aromatics and opiates ; and hence they gradually yielded on the Continent to Plenck's solution, which still holds a consider- able sway. Mercurial in our own country, it is now most usual to employ the mercurial pill, or calomel, either alone or together with mercurial ointment. Yet, whatever plan is preferred, much caution is necessary in carry- L"nem'°-es m% '* "n*° effec^ '■> f°T tne °l(ler practitioners who employed larger ehievous doses, frequently did as much mischief to the constitution by thean- Caiomei: tidote as it had received by the infection. If calomel be employed, about two grains a day will commonly be found sufficient, guarded ointment! w^en necessary by a grain of opium, and if the ointment be prefer- red, half a drachm of the strong mercurial ointment may be rubbed Salivation jn ni^ht and morning, if the disease be not severe or of long stand- not always ? e> • • i- . , necessary, ing, it will not be necessary, with a little management, to produce salivation, which in most instances may be regarded only as a test that the system is thoroughly impregnated with the medicine : but in chronic cases, we ought not to be satisfied without it. oMamT *u tne course °f tne present work, and the observation is applica- !oks. ble to other doctrines than those of medicine, we have often seen * Des Dragees, ou Pilules de M. Eeyser. Par Richard de Haustesierck. Recueil d'Observations dc Medicine des Hopitaux Militaires, &c. Paris, 1766. (iL. ill] SANGUINEOUS FUNCTION. [ord. iv. 265 that extremes lead to extremes : and hence while many practitioners Gen. VIL have been reviving the attempt to cure syphilis entirely without mer- jje^c' cury, others have revived that of attacking it with very laige doses. Syphilis. The last has chiefly been confined to those who have been employed Treatment. in warm climates, and been friendly to the same practice in dysen- ®uved.m tery and yellow fever. In syphilis, however, they seem to have been somewhat more successful than in the other diseases, doubtless from the more decidedly specific influence of mercury over the former. The dose, with these gentlemen, is the usual one of a scruple, which m our own climate is repeated daily for three or four days in suc- cession ; but in warmer climates, four or even five times in twenty- four hours. In various cases the effects on the stomach and bowels are severe, and in all cases a considerable degree of nausea is ex- cited, and the appetite is entirely suppressed. But upon the whole the bowels and general system are for the most part less affected than might be supposed : ptyalism is often excited in two or three days, and a constitutional improvement speedily shows itself. So f"l£{jti,nea that where the treatment does not disagree with the idiosyncrasy, successful: the cure is rapid, and perhaps radical: the individual being usually set at liberty in a fortnight or three weeks. But such a practice Jj"*^** must not be attempted indiscriminately, and should indeed be used bie, and With great caution : for it has fallen to the author's lot to know of j!n^™8" not a few instances in which the constitution has been so completely broken down by the very onset of this energetic plan, as to require not two or three weeks, but many months before the patient was re- enabled to take his station in society: to say nothing of the viru- lence which has been added to all the symptoms of the case, whether primary or secondary, in dyscrasies or idiosyncrasies which are hos- tile to the use of mercury. There can be no doubt, indeed, that a long perseverance even in Small doses, under like circumstances, will not unfrequently produce as lamentable an effect. But in this case we can hold our hand much more easily on the first appearance of mischief. In all cases of the use of mercury, but particularly in cases of Caution salivation, care should be taken to avoid cold, and flannel should be when em- worn next the skin ; for it is important that the excretories should Ployed■ harmonize in an increased defluxion. It is also of importance that the diet be light and simple, as the pulse is usually accelerated, and, by a stimulating regimen, would be so much quickened as to do se- rious mischief Mr. Hunter lays no stress upon this point, but it ought by no means to be neglected. If a buboe have formed in the groin, the mercurial ointment is best rubbed in a little below it, as it would increase the inflammation if applied to the tumour itself. In about a week or ten days, the mouth will become slightly sore, when the further use and propor- tion of the ointment or other preparation must be regulated by the violence or duration of the complaint. Where salivation is deter- mined upon, the flux should be suffered to continue for about a month. . An injudicious use of mercury, or indeed any use of it, m highly »*£»« irritable habits, will -orr chines excite a very troublesome erythema Vm,. NT.—-I 266 ex. ui.] HiEMATICA. [ord. iv. Gen. VII. that spreads itself in trails or patches over the whole surface ; corn- Lues'0' * monly however commencing about the genitals and lower limbs. It syphilis. js accompanied with a painful tenderness and itching of the skin, and, Treatment, as the erythema meanders onward, the trails or patches first observed heal as new ones make their appearance. We have already glanced at this affection under the vesicular species of erythema.* Mercury must in this case be desisted from, the bowels be loosened with some gentle aperient, and the irritability opposed by sedative and mild eardiacs, as camphor, guaiacum, and sarsaparilla; and particularly by the mineral acids. SPECIES II. LUES SYPHILODES. BASTARD POX. THE GENERIC ULCERS INDETERMINATE IN THEIR CHARACTERS ; SYMPTOMS IRREGULAR IN THEIK APPEARANCE ; USUALLY YIELD- ING SPONTANEOUSLY ; VARIOUSLY AFFECTED BY A COURSE OF MERCURY. Gem. VII. I have already observed, at the opening of the present genus, PEC' ' that the species before us is designed to include a multiplicity of af- fections which in many of their signs have a close resemblance to syphilis, but differ from it in the progress of the symptoms as well as in the means that are necessary for a cure. Syphiiodic Such affections are of high antiquity, far higher, indeed, than tiquity. those of syphilis, and some of them appear to be glanced at in the sacred records. A few of them may perhaps have arisen in much later times, and may be arising at present.t By Celsus the subject Subject is touched upon scientifically: it has been taken up in modern times sue/by1" by Mr. Hunter with that spirit of inquiry which peculiarly distin- Aberneth"* guished him,:}: and has since been pursued by Mr. Abernethy, Mr. Carmichael, and various other surgeons and physiologists, with a satnte-6 kindred comprehension and genius :§ and the track which they have Marie. traced out in England is precisely parallel with the march which M. Etienpe Sainte-Marie has of late years pursued in France, conceiv- ing himself, according to his own account, to have been the original discoverer of these distinctions ; which is the more extraordinary, since this writer, as we have already had occasion to observe, believes in the exploded doctrine of the identity of syphilis and what is com- stM open monly called gonorrhoea. || The subject, however, is still in its em- * Vol. ii. Cl. m. Gen. vi. p. 237. t Pearson, Observations on the Effects of various Articles of the Materia Medics in the Cure of Lues Venerea. 2d Edit. p. 53. | Treatise on the Venereal Disease. § Surgical Observations on Diseases resembling Syphilis. Lond. 1910. fl Mefnode pour gtrerir les Maladies Veneriennes Inreterees, &c. Part?. ISIS gation. •-l. lu.j SANdTLNEOUS FUNCTION. [onn.it. -K bryo. Mr. Hunter considered his own remarks rather as hints for Gen. VII. others to prosecute than as a complete account of it. And though LueVaVphi- Mr. Abernethy has accumulated facts and cases, and ably illustrated lode«- them with observations that sufficiently establish these hints, and pox!"*1 give something of a body to the outline, we are still in want, as we have already seen, of distinctive characters, and cannot determine with any degree of accuracy whether the wide group of complaints that fall within the present range of contemplation, are mere varie- ties of a common species produced by a common poison, or distinct species dependent upon distinct poisons, as discriminate from each other as all of them are from proper syphilis. Under the last species we had occasion to notice Mr. Hunter's Hunter's pathognomic criteria of genuine syphilis : first, that it never ceases mic marks spontaneously ; secondly, that it is uniform and progressive in its °yPfX'.uw symptoms ; and thirdly, that it is only to be cured by mercury. Could this view of the disease be strictly supported, we should Caiiedin have a tolerably distinctive character by which to discriminate the uue'exper^ preceding from the present species ; but sufficient proof has been menU- offered that not one of the three points holds good without a consi- derable degree of modification, whether in respect to the primary or the secondary symptoms of these maladies. Very ingenious attempts have since been made to distinguish these Whether diseases, not by their general march and mode of cure, but by their guihabie immediate and prominent signs, that of the true syphilitic chancre J}7 'm'"e. in the first stage, and those of the peculiar nature of the spots, the direct nodes, or the ulcers in the second. But the close approach to sy- s,snl'• philis at times of misaffections whose history, when minutely investi- gated, has clearly proved them to have issued from other sources than syphilis, have in a great measure levelled all such land-marks, and nearly left us in extreme cases without a clue. It is, after all, therefore, rather from the general history of the dif- chiefly so ferent examples, in all their bearings, than from the individual symp- general ehis- toms, that we can alone arrive at any sound or satisfactory means of ^ jfs.,he referring them to a syphilitic or a different origin. If we can strictly eases. rely upon the assertion, or know, as a fact, that there has been no impure connexion ; if we cannot perceive that there has been any primary ulcer ; if we find that the symptoms, whether primary or secondary, readily give way spontaneously, or by other remedies than mercury ; or if we have proof, from the first, that they are exaspe- rated by this last medicine, whatever be the approximation of such symptoms to those of genuine syphilis, we may rest pretty well as- sured that the disease is syphiloid rather than syphilitic lues. In the first case, indeed, unquestionably so, and nearly unquestionably so in the second and third. It is well known that constitutional derangement in an irritable Oonstitu habit or idiosyncrasy, will often follow from other local causes of symptoms various kinds, and often from what is ordinarily of very slight import. J)™*^'1 It is hence that the general health in some persons suffers from such various i«- cutaneous eruptions as rose-rash, herpes, or itch. Gonorrhoea has ca perhaps at times, as we have already remarked, affected the consti- tution in like manner, and even thrown over the skin spots that have 263 cl. in.] 1LEMATICA. [ORB. .IV. Gen.VII. been mistaken for those of genuine syphilis. And there is hence LueVs'yphi- reason for believing that even an incidental and unspecific irritation BMUu-d °^ tiie PrePuce or tne glausi mav'in me s*me way, occasionally so Po" far stimulate thc march of the same disease as to exhibit a very close semblance to the raised ulcer, or the excavated chancre, or even tlie phagedasnic slough ; or passing by these first symptoms, that it may mimick as closely those of the second stage of the disease. And as it is now pretty generally admitted on all hands, that morbid and irritative secretions of various kinds, independently of those of sy- philis or even gonorrhoea, are thrown forth and accumulate in the sexual organs of contact, we can trace a variety of sources of both local and constitutional affection which, issuing from the same seat, .iometimes mav assume something of a family character; to say nothing of local di«- those more wonderful resemblances of the secondary symptoms of of'anysort. syphilis which have sometimes been found to occur without any pre- vious local contagion, and in the most unspotted purity of single life. foUbearl-scs "^ consideration, therefore, of such diseases or varieties of dis- ranged dis- eases, as are thus fuund to approximate the general character of from'^hose syphilis, though issuing from sources widely distinct, and possessing of genuine in the midst of such approximation a few discriminate marks, per- ,yp '"' haps at all times and under all circumstances, however they may hitherto have eluded the prying eye of the pathologist, is evidently thd hrCnCnt cauiuCitr8' d of those who have been attentive to the subject on a large scale ; but I refer more particularly to the collection of cases which Mr. Abernethy has printed in the work already adverted to. General The disease ordinarily commences with local symptoms, though sc.ip on. ^^ always: but the local symptoms have a less resemblance to those of genuine syphilis than the constitutional by which they are suc- ceeded. A few foul and highly irritable sores are unexpectedly discovered on the genitals, commonly larger than chancres, and less thickened and indurated, about the size of a sixpence, and fre- Propar quently sprouting with fungous granulations. Rarely, but very rare!"* rarely, they have tlie guise of a true chancre ; so rarely, indeed, that of the twenty cases contained in Mr. Abernethy's book, the fifth is the only one that answers to this description. These are sometimes succeeded by buboes; and sometimes not. And where buboes take the lead they run their course more rapidly, and with more violent inflammation than in the true disease, and spread to a greater number of circumjacent glands. These mostly, if not always, heai by the ordinary means without mercury, or constitu- tional symptoms of any kind. But not unfrequently, in a few weeks or months they are followed by a soreness and ulceration of the tonsjK copper-coloured spots over the body, and nodes or swell rj.. iii., SANGUINEOUS FUNCTION. [ord. i\. 269 ings of the periosteum in various bones; and sometimes these symp- Gen. VII. toms change their order of succession, or appear single. Lu«%p5- In a few instances, the constitutional symptoms take the lead and the lode»- local follow, of which Mr. Abernethy's fourth case affords an example. pax!" The patient here perceived, first of all, a small ulcer on the breast ^°„tftu* near the nipple, after having suckled a nurse-child about four months, symptoms It was of the size and shape of an almond, and was ascribed to the ukrfthe" child's having a sore nose and lips. A gland in the axilla soon swelledlead- and subsided : but in about two months the patient had a severe febrile attack, accompanied with a sore throat; from this she soon recovered, but had shortly afterwards a copper-coloured eruption scattered over the body; and upon the disappearance of this, white blisters about the pudenda which gave her pain in walking. About a week afterwards her husband found a sore on the penis covered by a black scab, of about the size of a sixpence, with a base neither hard nor thick, but with the surrounding skin much inflamed. Another formed in the course of the lymphatics towards the groin : the inguinal glands enlarged, and one of them suppurated ; and an eruption of a papulous erythema, ushered by a few febrile symptoms, followed in about three weeks. The sores were twice touched with lunar caustic, and, as well as the bubo, were afterwards washed with calomel in lime-water: they gradually healed. Both patients recovered, the wife with little assistance from mercury, having taken only a few compound calomel pills with small doses of nitric acid ; the husband without mercury altogether, except that a dose of calomel was once administered with other aperient drugs as a purge. f In all these cases, we meet with a virus that seems to be more Sjphiiodie active and irritating than that of genuine syphilis, but which, while IcuveTn) of the Greeks, JJ^°et and the haras or beras of the Arabians, was, by many of the Arabian confound;,: physicians, and very generally among the people, supposed, in *,*t>the various cases, to terminate in juzam or elephantiasis, as though this also was nothing more than a different stage or degree of the same disease. And hence another error and perplexity iii medical study. Alsahavarius thus unites them, and they are jumbled together or explained alike in nearly all the oriental dictionaries; in which beras or leprosy, and juzam or elephant-skin, arc, almost without an ex- ception, regarded as convertible terms. This oriental confusion of TJ« ««£«- two very different diseases was readily copied by the Latin trans- jmed^b^ lators, till at length, both in the east and west, beras or lepriasis,-^,*^ Plough literally scale-skin, became a sort of family name for almost of the Vol. HI.—35 £74 cl. m.] H ASIATIC A. [oan. iv Gsft.vnii Elephan- tiasis. Elephant- shim Baterhan's acknow- ledgment to the author. Elephan- tiasis called also leonti- asia, and why. How con- founded by i'rank. Species of elephan- tiasis. every foul disfigurement of the skin, whether tubercular or scaly, cutaneous or constitutional. And, on this account, elephantiasis and leprosy, and several other diseases even in the nosology of Lin- neus are included under the term lepra ; all which the disciples ol this school, extending a principle very widely adopted by them, ascribe to animalcules drunk in with the common beverage of water, especially the gordius marinus. The author ought not to conceal Dr. Bateman's acknowledg- ment of this communication, and his assent to its explanation con- tained in the following opening of a letter received a few days afterwards. " I thank you sincerely for your ready and interesting communica- tion, which satisfactorily explains the point, respecting which I was the least able to obtain satisfaction from the translators, viz. that the Arabians had applied the term elephant (elephas, according to the able translator of Haly Abbas,) or fil, as you state, to the swelled leg. This is some apology for the appropriation of the Greek term elephantiasis (though it actually denoted a different disease) to the Arabian thick leg ; but the appropriation of lepra, which is never mentioned by the Greeks but as a ' superficial, rough, and scaly affection,' to the tubercular juzam, has unfortunately misled and confused us for a thousand years." Dr. Bateman adds, that he apprehends the term elephantiasis had also a reference to the magnitude and duration of the disease, independently of the appearance of the skin. And it is very proba- ble, as the malady was likewise sometimes denominated leontiasis, that the formidable and frightful aspect of the patient labouring under it, may have been hereby compared to the general exterior of both the elephant and the lion : for while Aretaeus tells us, in de- scribing it, that " it is disgusting to the sight, and in all respects terrible like the elephant," Avicenna affirms, " it renders the coun- tenance terrible to look at, and somewhat of the form of the lion's visEge." The necessity of that stricter investigation into the nature of genuine elephantiasis thus anxiously desired by Dr. Bateman, will be the more obvious when the reader learns, that in the classical work of Professor Frank, it is arranged as a species of lepra ; as is also ichthyiasis, and various other cutaneous affections that should take their station in distinct quarters.* Besides the elephantiasis of the Arabians we have a disease of the same kind, or which seems to be of the same kind, common to some parts of Italy, and another common to some parts of Spain j both which seem indeed, to have issued from the Arabian stock. And hence elephantiasis, as a genus, offers us the three following species: 1. ELEPHANTIASIS ARABICA. 2.---------'---- ITALIC A.. 3.-------------ASTURIENSIS. ARABIAN ELEPHANTIASIS. ITALIAN ELEPHANTIASIS. ASTUKIAN ELEPHANTIASIS. De Cur. Horn. Moth. Epit. Tom. ir. j>. 211. 1792. cl. in.] SANGUINEOUS FUNCTION. (mw. j*\ 275 >\ SPECIES 1 ELEPHANTIASIS ARABICA. ARABIAN ELEPHANTIASIS. BLACK LEPROSY. TUBERCLES CHIEFLY ON THE PACE AND JOINTS ; PALL OP THE HAIR EXCEPT FROM THE SCALP : VOICE HOARSE AND NASAL : CONTA- GIOUS AND HEREDITARY. This species, which is the oldest of the three, is also the most Gen.VIII. inveterate : for we do not know that the Italian species is contagious, xh^form' though, like the Arabian, it appears to be hereditary: while the the oldest cs • ii • i :.i ; ■ i t„ »nd most topanish is, perhaps, neither contagious nor hereditary. inveterate, In some parts of the world, indeed, even the present species is i» ? few said not to be contagious, though all the writers concur in its being Itfm" not hereditary in every quarter. Thus Dr. Schilling, while he admits f°J^ucgon" the latter effect, asserts that it is not contagious in Surinam : and Dr. though be- T. Heberden asserts the same of this disease in Madeira. " I notredltary only," says he, " am a daily witness of communication between lepers aud other people without the least ill consequence, but know several instances where a leprous husband (afflicted with the Arabian leprosy or elephantiasis) married to a sound wife, has cohabited with her for a long series of years, and had several children by her, without her having contracted the least symptom of the disorder, although the children have inherited it; and vice versa between a leprous wife and sound husband."* That the disease, however, is contagious as well as hereditary in but gene- India and Arabia, we have the concurrent testimony of all the *essegPboth medical writers of both countries, native as well as foreign ; so that iualit«»- there can be no doubt upon the subject. And hence, the Madeira and Surinam juzam should seem to be a variety'of the oriental, influ- enced by peculiarity of climate, or some other incidental cause. This severe malady, wherever it shows itself, is sometimes slow in General its growth, and continues many years without deranging the func- efcr")tien"- tions of the patient: yet great deformity is advancing upon his ex- ternal make. The alse of the nose become swelled and scabrous, and the nostrils are preternaturally dilated ; the lips are tumid ; the external ears, particularly the lobes, are enlarged and thickened, and beset with tubercles. The skin of the forehead and cheeks grows dense and hard, and forms large and prominent ruga?, especially ever the eyes ; the hair generally, except on the head, falls' off; the voice becomes hoarse and obscure ; the external sensibility is ob- tunded or totally abolished, so that pinching or puncturing gives no pain. The tubercles at length begin to crack, and ulcerate ; ulcera- tions appear in the throat and nostrils; the breath is intolerably •' iMfclical Transaction*. Vol, i. n. 3.i 2?G cl. in.] ILJSMATICA. [ord. i>. 0"* GEN.vm. offensive ; the palate destroyed ; the nose falls off; the fingers and Sa'n toes, from the increased depth and virulence of the ulcerations, be- tiasis Ara- come gangrenous, and separate, and drop off one after another. The Arabian mental powers suffer less than in the tyo other species : the dreams, TS*11" however, are greatly disturbed, the manners, for the most part, morose mack le- and melancholy ; and sometimes there is an inextinguishable desire prosy. oj. gexuai intercourse. rrevaient This disease is also known in the high northern latitudes of Norway an^icfT* and Iceland. Infthe last place, it is peculiarly prevalent, produced, iaud. as j)r# Henderson justly observes, by the rancidity of the food usually fed on, wet woollen cloths, and insalubrious air, and want of cleanliness. It is called " Likthra," or " Putrefaction :" and a hospital is established for it in each of the four quarters of the island. It seems to be here both infectious and hereditary. " In its primary stage," says Dr. Henderson, " its symptoms are incon- ju appear- siderabde. A small reddish spot, scarcely larger than the point of a these re- needle, breaks out at first about the forehead, nose, corner of tlie ^ions. eyes, and lips: and in proportion as it increases other pustules make their appearance on the breast, arms, arm-pits, which generally dry up in one place and break out in another without pain, till the dis- ease has considerably advanced, when they cover almost the whole body, give the skin a scabrous appearance, stiffen it sometimes in shining scales which fall off like dust, sometimes in malignant tu- mours and swellings. The patient, in the mean time, labours under lassitude of body, anaesthesia and lowness of spirits." The mise- rable progress is nearly a transcript of the description just given. The patient is so worn out with fatigue and melancholy, as to be often tempted to make away with himself. He surrenders one part of the body after another to the insatiable malady ; " till at length," says Dr. Henderson, " death, the long-wished-for deliverer, comes suddenly and puts an end to his misery."* jts appear- Mr. D. Johnson, of the Bengal establishment, ascribes the disease "hnr'acter *n India to nearly the same causes as Dr. Henderson in Iceland. It iniudia. is found principally among the poorer castes, and "attacks chiefly sudi people as have their feet and hands frequently in cold water or earth, such as the peasants in the low marshy countries of Bengal and Orissa:—Dobys (washerwomen) and RJollies (gardeners) inthe upper provinces of India; and I conceive that cold and poorness of blood cause the circulation in the extreme capillary vessels to become too languid ; the consequence is a gradual decay or depolution of these parts." This writer admits that the disease appears in he- reditary descent, but as the different trades and occupations of the natives descend hereditarily also, he has some doubt whether tlie latter may not be the sole cause of its appearing in successive genera- tions, instead of a family tapit.t ^*r There seems to be a variety of this disease in which a tumour of the dipesse. a larger size than the rest seats itself in the inguinal glands, some- * Iceland, or the Journal of a Residcuce in that Island, Vol. I. p, 295. 8vo. Edin. 3818. 1 Miscellaneous Observations on certain indigenous Customs, Diseases, &c. in Indja. By Daniel Johnson, Esrj. ,l. iu.j SANGUINEOUS FUNCTION. [ord. iv. 277 times in both glands, and is subject to a regular paroxysm of inflam- Gen.VIII. mation once in about every fourth month, preceded by shivering and E^han-1' accompanied with a smart febrile excitement. These symptoms tiasis Ar»- usually subside in three or four day6, and leave the tumour as before. Arabian But not unfrequently that on the one side, or on the other, lately or ^g]£*n" never on both sides, advances to suppuration, and produces a trou- niac*' i<- blesome sore. Dr. Adams met with cases of this kind in Madeira, vrwy' and Dr. Kinnis has since observed the same in the Isle of France :* thus giving the disease an approach towards bucnemia tropica. The cure is extremely difficult; but a course of warm diaphoretics Medical succeeded by tonics, and especially the metallic tonics, seems to have nwphpre- constituted the most successful plan. Hence a free use of sarsa- J.1'*/^ parilla, mezereon, or guaiacum, has been found beneficial; and tonics. mercurial alteratives still more so ; though salivation appears to have been uniformly mischievous. Even the lobelia has had its advocates, and, upon the ground of its proving salutary in syphilis, it has proba- bly also been sometimes serviceable in elephantiasis. Dr. Schilling endeavours to increase the determination to the skin, by advising a use of the warm-bath and gentle exercise, and embrocating the body with spirit of wine or rum or exposing it to a vapour-bath of mastic, olibanum, benzoin, or lavender. In India the cabirajas, or native physicians, after bleeding and in India purging, immediately apply to the metallic tonics, and particularly {^h™**'" to the white oxyde of arsenic, which they give as in the case ofand. *p syphilis, and indeed of various other impurities of the blood, in the arseni J. form ,of pills; mixing the arsenic, which, in Hindustanee, is sane hya, and in Arabic, shucc, with six times its weight of black pepper into a mass with a little water ; so that each pill may contain about two thirds of a grain of arsenic and four grains of pepper, which is to be taken twice a-day. And this medicine is regarded almost as a specific antidote. It has no doubt proved often successful: and I have known various cases in our own country in which it has been found equally so in the form of the arsenical solution. In this quarter of the globe, however, Mr. Playfair has of late Asclepias years revived the use of one of the species of asclepias or swallow- e'S!08' wort. In Europe, the a. Vincetoxicum was formerly in high favour Jw*w< as an alterant and alexipharmic, and was often denominated con- trayerva Germanorum : but its virtues were not sufficient to sup- port its character. The swallow-wort employed by Mr. Playfair is. the a. gigantea, a native of the east, and appears from an account lately published by Mr. Robinson,tto be possessed of more active and possibly more salutary, qualities. It is the mudar or midaur of Mudar of Hindustan, a shrub not yet systematically arranged, but found on ailIndl*' the uncultivated plains of India, producing a milky juice, which is the part employed medicinally, not only in this complaint but in various herpetic affections, by being applied to the skin.| * Observations on Elephantiasis as it appears in the Isle of France. Edin. Med. Journ. Oct. 1824. p. 289. t Medico-Chirurg. Trans. Vol. x. X Miscellaneous Observations, &c. By Daniel Johnson, Esq. fornaerlv Sursreon in the Hon. Company's Service. £7S cl. ih.] ILEMATICA. [ORD. Gen.VIII. Spec. I. Elephan- tiasis Ara- bica. Arabian elephan- tiasis. Black le- prosy. Treatment. Bark in Madeira with ex- ternal sti- mulants. Their su 3- cess as re- lated by Heberden. The tonic found most useful by Dr. T. Heberden in Madeira was bark, which, however, has not proved of equal success in other places or in the hands of other practitioners; but he employed it in connexion with that course of external stimulants which has been found igenerally serviceable, and probably not a little contributed to its wonderful efficacy in the various cases he refers to, and particu- larly one of a confirmed and chronic attack. " I have," says he, " in this island experienced the use of the bark in four or five leprous patients with success. One had a confirmed elephantiasis ; the others were only incipient; having no other symptoms than florid or livid tubercles in the face and in the limbs. The confirmed elephantiasis was attended with livid and scirrhous tubercles whicii had overspread the face and limbs ; the whole body was emaciated; the eye-brows inflated ; the hair of the eye-brows fallen off entirely; the bones of the nose depressed ; the alae nasi tumefied, as likewise the lobes of the ears ; with a suffusion in both eyes which had almost deprived the patient of his sight. There was a want of sensation in the extremities ; and a loss of motion in the fingers and toes." For upwards of seven years Dr. Heberden had used every medi- cine he could think of to relieve this patient, but in vain. Antimo- nials and mercurials of almost every kind ; neutral salts, the warm diaphoretics, as sassafras, and sarsaparilla, warm baths, and medi- cated baths, were alike fruitless. On May 2, 1758, he made his patient commence an electuary of powder of bark, with a third part bark of sassafras root, inspissated with syrup ; and of this the quan- tity of a large nutmeg was ordered to be taken twice a-day. The pa- tient at the same time had his arms and legs bathed with an embro- cation, consisting of an ounce of lixivium of tartar and two drachms of spirit of sal ammoniac, intermixed with half a pint of proof spirit. By the latter end of May the tubercles were considerably softened ; by June 28 they were dispersed ; a red scurfy efflorescence alone remaining behind, which in ten days lost its florid hue and peeled off, leaving the cuticle sound and clean. " The patient," says he, '* gradually recovered the sensation in his legs and arms, and the use of his toes and fingers; the hair has grown again on his eye- brows ; and the only remainder of the distemper which I can per- ceive is, that the nose continues somewhat flatter, from the depress sion of the bones. The suffusion is quite cured, and the patient is w appears to have been Francis Frapolli, a physician of Milan, whose uene'rai work, " In morbum vulgo Pelagram dictum," was published at hitt0IJ' Milan in 1771, and who expresses himself doubtful whether the dis- ease, though not antecedently described, is not referred to occa- sionally by earlier writers, although he does not think that the pila- rella, as the syphilis was called when it proved depilatory to the chin and eye-brows, was the disease in question, notwithstanding this seems to have been an extensive opinion at the time. The next tract of any note upon the subject was published at Venice in 1784, by G. M. d'Oleggio, under the title of" A Theoretical and Practical Treatise on the Diseases of Vernal Insolation, commonly called Pellagra."* But the best account we have received of this com- plaint is from the pen«of Dr. Jansen of Leyden, which appeared in 1788, and asserts that it is endemic in the Milanese territory.! It is, in truth, common to both the Milanese and Venetian territories, as well as to other districts widely differing in soil and temperature : and can scarcely therefore be referred to either of these sources. There is little doubt of its being hereditary, but not contagious ; and it does not seem to have existed earlier than the middle of the last century.| -Jt is commonly ascribed, as we have observed above, to tlie heat or the sun's rays§ after the chill of winter, and is hence called thai del sole, which we have just seen was the view taken of it by d'Oleggio ; while by Odoardo it is attributed to a scrophuious habit,|| and by Videmari and others, who have too much limited themselves to the nature of the eruption, to an impetiginous impu- rity, yi But none of these explanations seem to rest on any very * Tratto teoretico-pratico delle malatlie dell insolato di primarera volgarimente dette della Pellagra. t De Pelagra morbo in Mediolanensi Ducatu endemic | Paralleli fra la Pellagra ed ulcuna malathie, che piu to rassemigliano, del P. Fanzago. Padova, 1792. § J. P. Frank, De Cur. Horn. Morb. Epit. Tom. iv. p. 43. Mannh. 8to. 1/92. |[ D'una spezia particolare di Scorbuto. Venet. 1776. IT Da quadam Impetiginis specie, morbo apud nos in rusticis nunc frequentior. mlgo Pellagra nuncupata, 8vo. 1790. 280 cl. m.J 1LEMAT1CA. LoKD- 1V- Spec^i' S0^ roun(^aJtion ; and, upon the whole, we have more reason for Biephan- ' regarding it as produced by the debilitating causes of hot, confined lie!!8 Ita a'r'want of cleanliness, and bad diet, operating in many cases upon Italian eio- a diathesis hereditarily tainted. It is found chiefly among the Mi- ptantiasis. ]anese an(j Venetian peasantry, whose hovels are full of wretched- ness,1'and rarely makes its appearance till after the age of puberty. Alibert, in his " Diseases of the Skin," has denominated it, but with little accuracy, Ichthyosis Pellagra.* Degerip. The first* symptoms of the disease are general languor, listless- ness, gloom, feebleness, and stupor in the legs, and hence unsteady walking, vertigo, and confusion of ideas. Domeier, another writer upon the subject, extends the stupor of the legs to the entire frame, and asserts that anaesthesia is a characteristic symptom of this spe- cies.! But this assertion is not confirmed by the history of other pathologists, though the languor and inertness is often very great as well as universal. First stage. These symptoms usually take place in the spring; and as the summer approaches, a sense of tension, burning, and itching is felt in every external organ except the head, followed by an eruption of rosy papula?, scattered over the skin generally* which terminate in tubercles of a shining red colour. After some days the tubercles desquammate, and the skin appears at first red, but soon recovers its natural colour. As the summer, however, advances, every symp- tom commonly subsides, and the strength is renewed with the win- ter ; but the symptoms return with increased violence with the return of the spring, and this for several years in succession. But if the symptoms do not thus subside, they soon become even on the first attack considerably exasperated, and form a second stage of the disease, in which the itching grows more pungent; the heat more fiery ; the skin harder, cracked, and chapped; the debility is greater; the mental functions are disturbed generally ; -the appetite is irre- gular ; the sleep broken with acute pain in the head and spine, soon rerniina- followed by delirium. The cutaneous affection now diminishes, but the nervous symptoms are greatly augmented. The vertigo increases; the patient is sad and loves solitude, and melancholy delirium alternates with furious mania. The taedium vitas is insup- portable, and self-murder is a frequent consequence. Strambi remarks that those who labour under this disease have tig? greatest tendency to drown themselves, " as by an hallucination," says he, " opposite to that of hydrophobia."! Coercion is at last neces- sary ; and diarrhoea, atrophy, or dropsy, closes the dreadful scene,' if the patient do not sink earlier from corporeal and mental ex- haustion. Dr. Holland tells us that at one time in the lunatic hos- pital at MUan, of five hundred patients more than one-third were PeUagrosi ;§ and he also informs us that morbid dissections have thrown little light on the pathology of this disease ; that the visceral organs have at times evinced indurations and enlargements, but by * Description des Maladies de la Pean, p. 175. t Baldinger, Journ. xxri. p. 9. t Dfc Pellagra, Obserrafiones. Ann. i. ii. in. Medio!. 1735. >S Medico-Chir. Trans. Vol. Tin. Part ii. Second stage. vl. ui.] SANGUINEOUS FUNCTION. [ord. rv. 281 no means constantly, and rather as effects than causes of the Gen.VIII. j;„„„o« Spec. II. disease. EiePh„n- The treatment needs not essentially differ from that of the pre- [!"=IS Ita ceding species. Pure air, habitual cleanliness, warm bathing, and Italian eie- a nutritious diet, with such tonics, whether vegetable or mineral, as Medical818' best agree with the constitution, have proved most successful where treatment. the disease has not advanced beyond the reach of recovery. The lichen Islandicus is one of the most popular remedies. SPECIES III. ELEPHANTIASIS ASTURIENSIS. ASTURIAN ELEPHANTIASIS. tubercles chiefly on the hands and feet ; crustaceous, des- quammating ; continual tremor of the iifad and upper part of the trunk ; baldness of the scalp, as well as of other Parts ; gloom and terror of mind. This species agrees in many of its symptoms with the Italic, and Gen.VIII. it is only worth while to notice the points in which they differ. How'dbtin" Upon the whole, we may observe that all the species Coincide in guiahed being founded on an exhausted constitution, in the general charac- theprtjce- ter of the tubercles and in their fatal termination by dropsy, atrophy, *}*« 8Pe" or some other asthenic disease. The Arabian species attacks the face, the roots of the hair, and the palate-bones before the remain- ing parts on which it preys are diseased, and the affection of the skin increases with the increase of the other symptoms. In the Italian species, the affection of the skin diminishes as the nervous and mental commotion augments. The pellagra also is distin- guished by thick urine, double vision, and a peculiar mouldy smell of the sweat. In the Asturian species, the crustaceous tubercles ix-scrip- are peculiarly painful, highly fetid, deeper furrowed with cracks,tlon' and more disgusting to the sight; attacking the head as well as other parts indiscriminately, and destroying thc roots of the hair. The mind is less affected than in the last, and with melancholy and terror rather than with raving delirium. This species constitutes the Asturian leprosy of Thiery, Vandcr- Forms tho monde, and Sauvages ; but genuine leprosy is rarely a constitutional leprosy of complaint; and the present is its proper place. As the tubercles ™"£. and desquammate, the skin appears of a glossy leprous red, and the and ti>4 disease is hence called by the Spaniards Mai de la Rosa. Roifof tho The causes are extreme poverty and its attendants, filth, bad diet, Spanish and crowded unvcntilated rooms In the deep and swampy valleys of w' the country, almost impervious to the rays of the sun ; and hence the medical treatment and general regimen recommended under tlie ^receding species will afford the fairest promise of success here. Voj,. TIL—36 J«^ i;l. ia. ILL MA TIC A. [orp. IV. GENUS IX. CATACAUSIS. CATACAUSIS. GENERAL COMBUSTIBILITY OF THE B0DV. Gen. IX. The peculiar state of the constitution which lays a foundation for the present genus of morbid affections is of a very singular and mysterious kind ; and the only medical work that has referred to it in our own country, antecedently to the author's own system of Nosology, is Dr. Young's Medical Literature, in which it is noticed under the Greek name here applied to it, derived from jmt*x*«« " exuro." One only species has hitherto been discovered as be- longing to it; which, from the peculiar habit under which it occurs, may be distinguished by the name of Rarely no ticed by medical writers hitherto. Only one known species. 1. CATACAUSIS EBRIOSA. INEBRIATE CATACAUSIS. SPECIES I. CATACAUSIS EBRIOSA. INEBRIATE CATACAUSIS. HIE CONSTITUTION INFLAMMABLE IN CONSEQUENCE OF A LONG AND IMMODERATE USE OF SPIRITUOUS LIQUORS : THE COMBUSTION EASILY EXCITED OR SPONTANEOUS. Gek. IX. Spec. I. The art of medicine seldom available. Disease not credible if it were not well au- thenticated. In this wonderful malady the art of medicine can be rarely of any avail; since the mischief is, in almost all instances, only to be discovered after a cessation of life, and the destruction of some part of the body by an actual flame, or fire, in many instances sponta- neously issuing from its surface. There may be some difficulty in giving credit to so marvellous a diathesis ; yet examples of its existence and of its leading to a migratory and fatal combustion are so numerous and so well authenticated, and press upon us from so many different countries and eras, that it would be absurd to with- hold our assent. In almost every instance, the combustion seems fo have taken place in females, advanced in life, and immoderatelv cl. in.] SANGUINEOUS FUNCTION. [ord. lv. 283 addicted to spirituous liquors.* In some cases the heat that has set Gen. IS.. them on fire appears to have originated in themselves ; in others to catacausis have been communicated by a stove, or candle, or a stroke of light- ebriosa. ning ;t but in no case has the fire or flame hereby excited in the body catacausis. been so powerful as essentially to injure the most combustible sub- ^""^ion. stances immediately adjoining it, as linen or woollen furniture. The body, in several instances, has been found actually burning, sometimes with an open flame flickering over it; and sometimes with a smothered heat or fire without any open flame whatever : while the application of water'has occasionally seemed rather to quicken than impede the igneous progress. This is the more extraordinary, as the human body, in every other state we are acquainted with, whether of health or disease, is scarcely at all combustible of itself, and cannot be reduced to ashes without the assistance of a very large pile of fagots or other fuel, as universal experience in this very ancient mode of sepulture, and the history of martyrs, who have been condemned to the flames, abundantly testily. The event has usually taken place at night when the sufferer has dually been alone ; and has ccmmonly been discovered by the fetid, pene- night. trating scent of sooty films which have spread to a considerable J^*"" distance ; the unhappy subject has, in every instance, been found The affect- dead, and more or less completely burnt up ; the burnt parts being foundXad reduced to an oily, crumbly, sooty, and extremely offensive matter. " I confess," says M. Pierre-Aime-Lair,Jthat these accounts at first appeared to me to be worthy of very little credit, but they are pre- sented to the public as true by men whose veracity is unquestiona- ble. Bianchini, Maffei, Rollin, Le Cat, Vicq d'Azyr, and other Aut^'f* men distinguished by their learning, have offered certain testimony ppca of the facts. Besides it is not more surprising to meet with such incineration than a discharge of saccharine urine, or an appearance of the bones softened to a state of jelly." Those who are desirous of pursuing this curious subject farther, and of entertaining themselves with the very extraordinary histories connected with it, as also of examining the various hypotheses by which they have been accounted for, may consult the Philosophical Transactions,§ which contains numerous examples ; as also a variety of foreign journals of established reputation, referred to, and cited in the running commentary to the author's volume of Nosology.|| We have not space to enter into these separate cases, though many of them are highly interesting ; but in a general course of medical Subject study, the phenomenon ought not to be passed by ; it forms one of ^Lomit- the most curious links in the long chain of morbid affections, and J*„J"eaof equally demands our attention as pathologists and physiologists. medical * Bartholin, Act. Hufn. i. Obs. 118. t Fouquet, Journ. de Med. Tom. lxviii. t Journ. de Physique, Ann. vm. § See especially Vols, xliii. xliv. |! Ploucquet, Literat. Med.—Dupont, De Corporis Hum. Incendiis Spontaneis. •'2.S4 (i„ iir.i I IF. MA TIC A. Ion... n GENUS X. PORPHYRA. SCURVY. LIVID SPOTS ON THE SKIN FROM EXTRAVASATED BLOOD ; LANGUOR AND LOSS OF MUSCULAR STRENGTH ; PAINS IN THE LIMBS. Gen. X. PoRPiivRvis in Greek what purpura is in Latin, literally " the tion"ofthe purple or livid disease." The latter has been very generally made ferm"°and use °^' Dut me roriner is here preferred on two accounts. First, reasons for that of technological simplicity,—the names of the genera under the tion. op^ present system being uniformly of Greek origin. And secondly, The Latin because the Latin purpura has been used in senses so numerous, so term pur- r r . . /. •* pura used vague, and unconnected, that at this moment it conveys no definite indefinitely. idea whatever. " The term purpura," observes Dr. Bateman, most correctly, " has been employed by different writers in so many ac- ceptations that some ambiguity would perhaps have been avoided by discarding it altogether; for some authors have used it as an appellation for measles, others for scarlet-fever, for miliaria, stro- phulus, lichen, nettle-rash, and the peteccliias of malignant fevers ; while formerly it was applied to petecchial spots only by Riverius, Diemerbroeck, Sauvages, Casson, and some others."* ordinary i«ne usuai synonym for purpura is scorbutus; but to this there are bums still stronger objections. For as a term it is neither Greek nor Latin, tobJiTuse.3 nor any language whatever ; but an intolerable barbarism, derived, as is commonly supposed, from the German compound schar-bocke literally "aggregate-pox," "cluster-pox;" but more likely from scharf-pocke, " violent," or " vehement pox ;" or schorf-pocke, " scurf," or " scurvy-pox," to which the inventor has endeavoured to give a sort of Latin termination. Independently of which, scor- butus," as employed at present, only indicates a particular species of scurvy ; and could not therefore, without imprecision, be used in a generic signification. The defini- The sense here expressed by porphyra, runs, as nearly as possible, nearly pa- parallel with the range assigned by Dr. Willan to purpura. " With theepu7Pu^ Riverius and some other authors," says he, " I propose to express ra of wu- by the term purpura an efflorescence consisting of some distinct, purple specks and patches, attended with general debility, but not always with fever." And again " cases of the purpura seem to have been studiously multiplied in periodical publications, and in medical or surgical miscellanies. I consider it under all the forms described * Synops. of Diseases, p. 102. cl. in.J SANGUINEOUS FUNCTION. [ord. iv. 2b5 as pertaining to the scurvy, though it is not Always attended with Gen. X. sponginess of the gums, and a discharge of blood from them according scurvy'*' to the definition of scorbutus in nosology."* Porphyra, in its present signification, is intended to include every I,s ran?'' description of petecchial eruption, and spontaneous ecchymosis not staled." y dependent on fever as their cause, in which case these affections are only symptomatic. The genus thus explained will associate under its banners the three following species: 1. PORPHYRA SIMPLEX. PETECCHIAL-SCURVY. 2.--------HEMORRHAGICA. LAND-SCURVY. 3. --■-----NAUTICA. SEA-SCURVY. SPECIES I. PORPHYRA SIMPLEX. PETECCHIAL SCURVY. SPOTS NUMEROUS, BUT SMALL AND FLEA-BITE-SHAPED ; CHIEFLY IN THE BREAST, ARMS AND LEGS ; PALENESS OF VISAGE. Pulicose or petecchial spots were at one time supposed to be, Gen. X. in every instance, the result of debilitating and putrid fever. Riverius f*™^}' is, perhaps, the earliest author who distinguishes between simple supposed petecchias, and petecchial fevers. Vascular debility or relaxation is, I'Jonefrom0 however, the predisposing cause in both cases.t They necessarily, P"^,dti}f" indeed, accompany each other, and, wherever they exist in any con- other siderable degree, they lay a foundation for those minute extravasa-1™™ ™*re tions which constitute the present species ; and whicii may take Riverius. place either from occasional ruptures of the weakened coats of the debility minute subcutaneous blood-vessels, in consequence of their being ^ [he3™ incapable of resisting the impetus of the blood that flows through predispo- them; or from the mouths of many of them, which should give forth 8ing cause" only the finer and limpid particles of the blood, yielding and allowing an exit to the red globules. Both these may follow upon atonic fevers; but the usual remote Usual causes in the species before us, are severe labour with innutritious or causes. spare diet, and especially with impure air ; an impoverished state of the system from a sudden and profuse loss of blood; a sedentary and inactive life, or some chronic and exhausting disease by which the general strength has been broken down. To these Riverius adds suppression of the catamenia, and a certain mild ebulliency of the blood in boyhood—levem quandam sanguinis ebullitionem; a phrase apparently importing an excess of sanguineous temperament: from both which he tells us he has frequently seen the disorder originate. * On Cutaneous Diseases, Ord. Hi. p. 453. t Plumbe, Practical Treatise on the Diseases of th«» Skin, p. 100. 8vo. 1S24. 2S6 CL, III.] IL'EMATICA. [ord. IV, Gen. X. Spec. 1. Porwhyra simplex. Petecchial scurvy. Remote cause sometimes unknown. Illustrated. The above case proba- bly refeiri- ble to debility. And he is confirmed in the last by a case hinted at by Dr. Perceval in his manuscript comment on the author's iS'osology, in which he observes, under the present species, that " in a young lady of a full habit, and florid complexion, if the skin of the face or neck were touched even slightly blood oozed from the pores." The disease seems also to be produced at times by some unknown cause ; of which Cullen has given a striking instance in his Materia Medica. " The patient," says he, " was a woman who had lived ' very constantly upon vegetable aliment and had not been exposed, so far as could be judged, to any febrile or putrid contagion ; and yet, without any feeling of any other disorder, was affected with nu- merous petecchiae over the whole surface of her body. After these had continued for some days without any symptoms of fever, she was affected with swelled and bleeding gums, with fetid breath and much thirst; and in the course of a week or two more almost every symptom of a putrid fever came on, and in a few days proved fatal." It is possible in this case that the brain may have lost its energy, and the blood become impoverished by too low a diet, though the history is not given with sufficient fulness to speak with much deci- sion upon this point. The fever was evidently produced by the irri- tability of weakness, and necessarily ran into a typhous type from the same cause. The disease, as it commonly shows itself, appears under two forms, which may thus be described as varieties : x Pulicosa. Simple Pulicose Scurvy. /3 Urticaria. Nettle-wheal Scurvv. Exhibiting from the first a pulicose, or flea-bite ap- pearance. The flea-bite spots preceded by reddish, rounded and nettle-sting wheals, but without the nettle-sting itching; fugacious and mi- gratory. cosaPuli" .The FIRST VARIETY is not only produced by debility, but attended simple pu- with languor and pains in the limbs, and chiefly affects women and scurfy. children in consequence of their greater laxity of fibre. ?»^'»Urti" The SEC0ND variety may possibly be accompanied with some CaTla.. 1 " J /* * * I 11 11 Nettie- Kind ot acrimony m the blood, and something more of a constitutional Srvy. affection ; for there is usually a loss of appetite, and an edematous swelling of the hands and ankles ; while the spots are brighter at night and darker in the day ; evidently proving great irritability in the capillaries, and especially towards" the period of the natural eve- ning paroxysm of fever, and great atony in the absorbents. This variety often continues fo» five or six weeks. Sent. .Better diet> freedom from hard labour, pure air, sea-bathing, the mineral acids, and other tonic medicines^ afford a prettv certain pro- cess of euro. '•h.m.{ .SANGUINEOUS FUNCTION. [okd.iv. J87 SPECIES II. PORPHYRA HEMORRHAGICA. LAND-SCURVY. SI'OTS CIRCULAR, of different sizes ; OFTEN in stripes or patches, IRREGULARLY SCATTERED OVER THE THIGHS, ARMS, AND TRUNK ; OCCASIONAL HEMORRHAGE FROM THE MOUTH, NOSTRILS OR VISCE- RA ; GREAT DEBILITY AND DEPRESSION OF SPIRITS. This species, the morbus maculosus Werlhofii of the German Gen.X. writers,* i3 sometimes marked by febrile paroxysms, with variable J^erl'i"' intervals, but usually occurring in the evening. It has no regular or description, stated termination. Dr. Willan has found it run on in different cases, from fourteen days to a twelvemonth, and upwards. It is met with at every period of life, but chiefly affects persons of a weak and delicate habit; often chUdren, principally women. The precursive symptoms are lassitude, faintness, and pains in Precursive the limbs, so that business or even company, is found fatiguing. Byu,Ptoms' After this there are often shiverings, nausea and vomiting. The Diagnos- purple eruption, for the most part, appears first on the legs, and tlC9, afterwards at irregular periods, on the thighs, arms, and trunk of the body; the hands and face generally remaining free. The spots, however, are frequent on the interior of the mouth, and particularly the tonsils, gums and lips: where they are sometimes raised or papulated. It is here the first hemorrhage commonly issues, though, as the disease advances, blood flows also from the nostrils, lungs, stomach, intestines, and uterus : all which organs, together with the heart, are sometimes found studded with spots on their surface, on examination after death.t The hemorrhage is often profuse and cannot easily be restrained, and is accompanied with anasarcous swellings. It sometimes precedes the purple spots, but more com- monly takes place a few days afterwards. It is this rapid erosion, or ulceration of the blood-vessels, and consequent discharge of blood, often accompanied with diarrhoea or dysentery, where the intestines associate in the complaint, by which land-scurvy is chiefly distinguished from sea-scurvy, and acquires the distinctive name of hemorrhagic; since, though these symptoms may also occur in the latter, they do so rarely, except in the last stage of the complaint. The most usual remote causes of the present, as of the preceding Remote species, are poor diet, impure air, anxiety of mind, and a sedentary causes* mode of life ; and if women under these circumstances, and affected with this complaint, be wet nurses, their infants participate in the disease from the milk not being sufficiently nutritious. It is also * Gcschichte eines gliichlicb geheilten Morbus Macnlosus Werlhofii, von Dr Marquett, &c. Magdeburg. t Erlin. Med. and Sur-. Journ. July, 182*? :iss CL. III. | 1LEMAT10A. [ord. rv, ^ Gen.X. Spec. II. Porphyra hemor- rhagica. Land- scurvy; Medical treatment must differ according to the difference of cause. Where a tonic plan adviseable from the first. importance of citric acid, or lemon- juice. Essential oil of tur- pentine. When to be pre- ceded by evacuauts. Sometimes cuied by a metastasis. Strikingly •llustrated. produced by habitual gluttony, and particularly by an habitual and j immoderate use of spirits; which have the strongest tendency to render torpid the collatitious organs of digestion,- and especially the liver ; whence congestions and other obstructions, and whence, too, the larger and more dangerous hemorrhages that occur in this species. As these causes are widely different in their mode of action, though they concur in producing the same effects, the treatment must vary in like manner. Where the source of the disease is poverty, with its miserable train of attendants, poor diet, impure air, hard labour, grief of mind, the mode of cure recommended for the preceding species will be found equally serviceable here : but the tonic and stimulant power may be carried to a higher range; the bark should be freely administered, wine be liberally allowed, and lemons, or citric acid in any other form, be used to an extent of three or four ounces of lemon-juice daily; which, however, is the smallest quantity from which any essential benefit may be expected. Of all the antiscorbutics this is by far the most effectual; and by some writers is regarded as a spe- cific. And as the weak action of the vessels is extreme, the tere- binthinate stimulants, as camphor and the rectified oil of turpentine, are often peculiarly adrantageous. The last has been strongly and judiciously recommended by Dr. Whitlock Nichol; and other prac- titioners have fully confirmed his views. The worst symptom is the tendency to hemorrhage, which is sometimes profuse, and restrained with great difficulty, and has been known to prove fatal. Occasionally, however, an accidental hemor- rhage has had a contrary effect, and carried the complaint away ; and hence Dr. Parry of Bath has found venesection serviceable. Yet in these cases, we may reasonably suspect the second cause we have noticed, namely, some visceral congestion, and especially that of the liver, to lie at the foundation ; and dissections have proved this to be no uncommon cause of the disorder.* The symptoms of visceral obstruction indeed, are often sufficiently clear ; and where these occur, antecedently to the tonic plan, we must freely and re- peatedly evacuate the bowels ; and may advantageously have recourse to the lancet: and the more so, as this form of the disease is some- times accompanied with inflammatory action, and is chiefly what is referred to by Dr. Stoker under the name of dynamic purpura.! In some cases of great laxity of fibre, the extremities of the larger capillary arteries seem to sympathize with the state of the liver or other visceral organs, and to relieve the oppression by a metastasis. Willan has related a singular case of this disease which it is diffi- cult to account for otherwise. A lady aged thirty-six, of the san- guine temperament, after experiencing, for several days, a painful inflation of the stomach, was seized on the 17th of June, 1792, with violent vomiting, which continued almost incessantly through the 18th and 19th, and was accompanied with excruciating pains in the bowels. The fluid discharged was clear, strongly tinged with green * Plumbe on Diseases of the Skin, p. 108. 8vo. 1824. •* Pathological Observations, &c. p. 110. Dubl. Pvo. 182". «;l. hi.] SANGUINEOUS FUNCTION. [ord. £\ &S9 bile, and amounted to three or four quarts a-day. The vomiting Gek. X. abated about the 20th, and she had loose stools of a green colour Porphvra1' intermixed with black coagulated blood. This kind of discharge Hoemdr- continued till the 25th, producing great languor and faintness, thirst Land-*' and restlessness, with a cool skin and remarkably slow pulse. On 8Curvy' the evening of the 25th, her extremities became suddenly cold, the pulse scarcely discernible, a cold sweat trickled from every part of the body, her voice was indistinct, and her breathing laborious. From this alarming state she recovered in the course of the night; and on the following day a rash appeared over the whole body in ■ small and circular patches, confluent on the neck, shoulders, and nates, but in other places distinct. The eruption diminished in two or three days, and assumed a livid colour ; and the discharge of blood ceased from this time. She improved generally, but for two months suffered greatly from languor and debility: the extremities were, for a long time, anasarcous, and two of the spots became gan- grenous. In the Transactions of the Medico-Chirurgical Society of Edinburgh, is a brief history of a case that proved fatal in less than forty-eight hours. The patient was a strumous child; and con- siderable congestion was found in the brain.* The account and causes now given of this species are such as we Usually meet with in the present day. But if we look back into the Land history of this disease as far as the seventeenth century, and espe- frequent0" cially to the state of this metropolis, we shall find hemorrhagic or j!nd 8Cyere land-scurvy making a much nearer approach to sea-scurvy than in th™ aV our own time : not only in its symptoms, but from the peculiar Pre3ent causes that seem to have given rise to it, and which are now, for the most part, removed. The population within the walls of the old Expiaoa- city, was, at that period, far greater than at present, since the streets assertion.18 have been very extensively widened, and many of them entirely pulled down ; and fashion, which does not always operate so use- u"\ent" fully, has led all who are capable of following its steps, into the sphere.' more salubrious air of the neighbouring villages. Independently Want of of this, the supply of fresh vegetable food for man, and of winter- tabic fooT fodder for cattle, was, at the period before us, so scanty as to render it necessary to salt a great quantity of the cattle that was killed in the summer season for winter's use. To which we have to add a far greater degree of dampness and uncleanness, not only in the public streets but also in private houses. All these are also causes of sea-scurvy ; and we find from the de- Hence scription of Willis and others, that they produced conjointly very o/forme7y similar effects ; and that the mortality hence ensuing was very great, f^^ The monthly deaths, according to the bills of mortality, occasioned sea-scurvy. by what is there called scurvy, were seldom less than fifty, and fre- quently as high as ninety. In the period of the plague, they are only set down at a hundred and five from this last cause for the vear It was not, indeed, till the beginning of the sixteenth cen- Kitchen jv/«i. .. -" , ■> i • i , »• i • i j gardening tury that any great progress was made in the art of kitchen-garden- mtie cuiti- ing in our own country. At this last period, so low was the know- ^Tstx-" teentb <;<" tnrv. • Vol. I, p. 680. Vrir, III.-37 20(3 cl. in.] HiEMATICA. [OJBL9. IV. Gen. X. Spfcc. II. Porphyra hemor- rhagica. Land- B«nrvvi Singular proof of this. Burning pit-coal esteemed poisonous: and pun- ished with* noalb. Public sew- ers defi- cient or wanting. I.ay-soTlls toiumon. Cause of the diminu- tion of land-scurvy operative upon other diseases, end other districts. i^pla'med more at - lj'.iirks of •JcUtucij. ledge of this art, that Queen Catharine of Arragon could not pro- cure a salad till a gardner was sent for from the Netherlands to raise it: nor were the most common articles of the kitchen-garden, such as cabbages, cultivated till this reign.* And such was the prejudice at one time entertained against pit-coal, from its being supposed to load the atmosphere with unhealthy fumes, but which is now become one of our most powerful ventilators, and consequently one of our most active agents in promoting the general health of the city, that a law was formerly in existence which made it a capital offence to burn it within the city walls; so that it was only allowed to be used in the forges of the environs. Sir Gilbert Blane informs us that the late Mr. Astle, keeper of the records in the Tower, told him that he had there discovered a document importing that under the operation of this law a person h ad been tried, convicted, and executed for this offence in the reign of Edward the First.—We learn also from Davenant,t that heaps of the most noisome filth were suffered to accumulate in consequence of the imperfection of the public sewers; and that par- ticular places were marked out and assigned for such accumulation, which were called lay-stalls ; and hence the name of Laystall street, which exists in one or two parts of the metropolis even in the present day. The same happy causes, therefore, which have delivered us so generally from dysentery, remittent fevers, and even the plague itself, have freed us also from land-scurvy. And it has operated over all the other large cities of England as well as over the metropolis : and over the open country as well as over the towns. Even the remote districts of Somersetshire, not more than a century ago, formed a striking theatre for the exhibition of this tremendous scourge, as we learn from Dr. Musgrave's work,J published in the year 1703. " Agri Somersetensis, uliginosi magna parte et depressi, aerem crassum et humidum trahentes, incola?, maculis subnigris, ulceribus malignis, crurum dolore, respiratione difficili, lassitudine spontanea, nervorum debilitate, hydrops., gangrsena, et istiusmodi aliis scorbuti exquisiti signis creberrime divexantur." The picture is strongly and fearfully sketched, and precisely cor- responds with the definition just offered. " How then comes the country, as well as the town, to be so wonderfully and beneficially changed in our own day ? " The same spirit of improvement," says an admirable writer,§ from whom I have often had occasion to quote, and whose words I would always give rather than my own, " which has constructed our sewers, and widened our streets, and removed the nuisances with which they abounded, and dispersed thc inhabitants over a larger surface, and taught them to love airy apart- ments, and frequent changes of linen, has spread itself likewise into tjie country ; where it has drained the marshes, cultivated the wastes, enclosed the commons, enlarged the farm-houses, and established cottages. Few, perhaps, even among physicians, are aware of the * Anderson's History of Commerce.—Sir XS. Blane's article, Med.-Chir. Trans. iv. p. 96.* t Page 351. ed. 1673. J De Arthritide Symptomatica. 5 Dr. HebenteD, Med. Tr.an». Vol. iv. Art. vu. cl. m.] SANGUINEOUS FUNCTION. [ouv. iv. 291 extensive influence of these measures. Few have adverted with the £**• ^- attention it deserves to the prodigious mortality occasioned formerly p0rPh>ra ' by annual returns of epidemical fevers, of bowel-complaints, and J^'"*'', other consequences of poor and sordid living to which we are now Larld- ,, * scurvy. entire strangers." In consequence of this extraordinary improvement in the best "^V'10 branch of physical philosophy, the same attentive pathologist tells nOW randy us, that " For ten years, during which time he was one of the physi- ^"public cians to St. George's Hospital, the cases of genuine scurvy that infirmaries-. were brought into this establishment and fell under his care did not amount to more than four ;—not one of which was severe. In St. Bartholomew's Hospital, however, about the year 1795, owing to the very great severity of the preceding winter, various poor patients were received with all the characters of true porphyry ; which, in one man, were carried to such a height that he died in a most offen- sive state the day after he was admitted." We have lately, however, and to the astonishment of every one, J^y*,*, witnessed a most severe and even fatal renewal of this disease in the peared in Penitentiary prison for convicts, established on the side of the {^ p'ttd, Thames at Milbank : and this to such an extent, that at one time tentiary_ there were not fewer than about four-hundred and fifty on the sick list, out of a prison-population of about eight hundred and fifty,* chiefly labouring under dysentery or diarrhoea from the effects of the disease on the stomach and intestines, which, on post-obit examina- tions, were generally found to be pulicose or ulcerated in various parts ; the complaint being at length apparently propagated by con- tagion. The cause of this disease has hitherto been involved in much doubt. The prison was throughout ascertained to be cleanly, and, for the most part, well warmed, the cells lofty and unobjectionable, and the courts airy and paved with flag-stone. The original soil was swampy ; but it is generally believed at present to be free from damp in consequence of the enormous expense of draining and other means of exsiccation that have been bestowed upon it: and the surround- ing neighbourhood is undoubtedly healthy. It was at first mainly attributed to a reduced scale of diet, and particularly of animal food, m which had been suddenly laid down for the prison : but a return to " a richer scale produced no advantage; and was accompanied with an extension rather than a diminution of the diarrhoea or dysenteric form of the disease. So that at the end of six months, after every remedial plan which tlie physicians to the establishment could devise in succession, that of mercury being the chief, at first given in small and alterant doses, and afterwards more freely and for the express purpose of producing salivation, the whole prison population, as well male as female, was removed from the Penitentiary, and transferred to the hulks at Woolwich. The real cause of this mischief has hitherto puzzled the ablest ami most acute physiologists, and is supposed to bid defiance to all con-' * R-epon. of a Select CommiUee of tlie H6n.se of Commojt?. 1923; if. 242- 2U2 cl. ui.j IL113JAT1CA. [ord. i>. Gen. *• jecture.* Yet I think it is by no means impossible to follow it up, Porphyra and drag it from its obscurity. h*am?r" In a population so large as that we are now considering, it is not Land- ' enough that the courts should be airy, and the air not manifestly scnrvy. loaded with moisture ; but it is equally necessary that such air should be free from confinement; that it should be in a constant state of perflation, and refreshed and purified by renewal: for without this, large as the courts are, the air they contain must equally be drained of its vivifying power, and tainted with the azotic vapour that every individual is perpetually pouring forth from his skin and his lungs : and consequently must tend, in a greater or less degree, to a gene- ration of the disease before us, or rather to all those morbid effects which the Milbank Penitentiary has so strikingly unfolded. Now it appears to me almost impossible to take a survey of this prison without coming to an admission that it is, with respect to ven- tilation, in the very condition just described. The inhabitants of the neighbourhood are healthy, because, notwithstanding the low- ncss and original swampiness of the ground-soil, and its exposure to exhalations, the fanning breezes which are daily playing around , them carry off the rising moisture, and supply them with a perpetual current of pure air. But the height of the terminal and intersecting walls of the prison, with only a few small openings for doors, and no opposite outlets, effectually prevent this within its limits. Air will here, indeed, find its way as it will every where else, unless opposed by an hermetical seal, but as soon as it enters the courts of the Peni- tentiary, it is almost as much imprisoned as the convicts themselves : it is in a considerable degree bottled up ; and the only change it can undergo is that of parting with its vivifying principle, and receiving a mischievous principle in return. Were it indeed entirely bottled up in the manner here spoken of, the result would be obvious instan- taneously : but this is not the case, for a part of it must necessarily fly off in consequence of its higher temperature, and greater specific levity, and its place be supplied with air from without. But the supply does not seem to be m proportion to the demand; the balance is not duly preserved, and the expired and tainted air is not suffi- ciently carried off. It is very possible also, that some degree of hu- midity, though not manifest to the senses, is perpetually ascending, from the low and once swampy soil beneath, which should be swept away by the winnow of a stirring breeze. But this is not necessary. It must be obvious to every one that where a large population is immured in a boundary of any extent, if the supply of pure air be in the least degree below the supply of foul air, the health of such popu- lation must be encroached upon; and that the less the difference, the more insidious the effect, because the more invisible. It is, however, an effect that must goon : its influence must at length be- come obvious, and challenge attention ; and the result, as already observed, must be, if I mistake not, a combination of symptoms more * An Account of the Disease lately prevalent at tbe General Penitentiary. By P. M. Laftraro, M.D. &fc p. 217. 8vo-. 1825 cl. ui.j SANGUINEOUS FUNCTION. L°*->- ™- 293 or less approaching to those which have of late been exhibited at the Gen. X. t» x x- l/> Spec. If. Penitentiary before us. Porphyra If the real cause be thus correctly traced out, the remedy will not h*™?x' be difficult in the hands of an able pathologist, and a skilful architect. Land-*' i scurvv. SPECIES III. PORPHYRA NAUTICA. SEA-SCURVY. SPOTS OF DIFFERENT HUES INTERMIXED WITH LIVID, PRINCIPALLY AT THE ROOTS OF THE HAIR ; TEETH LOOSE J GUMS SPONGY AND BLEEDING ; BREATH FETID ; DEBILITY UNIVERSAL AND EXTREME. This species is denominated sea-sccrvv, not from its being ex- Gen. X. clusively limited to mariners and extensive fleets, bat from its being whVde^ most common to persons thus occupied, and raging in such situations nominated with the most fatal havoc. For the peculiar, as well as the general, Has'beer/* causes which produce it at sea may also operate on shore, and have f^dagon at times operated with merciless ravage in besieged garrisons, and well as at among armies reduced to short provisions, or of unwholesome kinds,sea" and worn down by fatigue, anxiety, and exposure to a damp atmos- phere. Such seems to have been the condition of the Reman army Sometime! under the command of Germanicus as related by Pliny ; whose ac- man "army: count of the disease that preyed upon it, though vague and unsatisfac- tory, coincides with the general appearance of sea-scurvy. We have and in the similar descriptions in several of the expeditions that took part in the oly wars' Holy Wars, and particularly that of St. Lewis as related by Joinville. We may hence conclude that sea-scurvy is not a disease of recent Hence not times alone j* though it does not appear to have attracted any very 0f recent general attention, till the melancholy result of tlie famous voyage of {^"j; not VascodeGama, in 1497. Thespiritof maritime discovery was at this generally time in full vigour and activity : the Portuguese, the Spaniards, the to'tiif'V. Dutch, and the English, vied with each other in their efforts to explore and after- remote and unknown countries ; the means of providing suitably for voyages of so great length were little understood ; and hence the dis- ease frequently made its appearance during the progress of the next half century, and raged with tremendous violence. It is well known, indeed, that so late as 1741, the fleet under Captain, afterwards Lord Anson, lost half its crew in'the space of six months from the time it left England. The diagnostics and progress of the disease aTe neatly and accu- rately concentrated by Dr. Parr. Its first appearance is evinced by Symptoms a pale, bloated complexion, lassitude, and a disinclination to motion, JS rEy. with diminished energy in the muscular fibres : to which may be Accession. * Compare Richer, Pr. Disqoisitio in Hippocratieas fc'corbnfi afctiquitates &r -294 cl. m.J ILEMATICA. [onn. is. Gem. X. added some degree of stiffness or induration, and an intumescence of Porphyra ' the lower limbs. If the gums, even in this early stage, be examined, nautica. they will be found spongy and apt to bleed on being touched ; while scurvy. the teeth are loosened in their sockets. The skin is sometimes rough, but more generally smooth and shining, covered with blueish or livid spots, which do not rise above it; and these spots often coa- Progressj. lesce in large blotches, particularly in the legs and thighs. About the same period, old ulcers often break out again, and the slightest mercurial preparation quickly produces salivation. The ulcers dis- charge often a fetid sanies, or are covered with a coagulated crust which is renewed whenever it is separated. The edges are livid with irregular granulations, which sometimes run into a bloody fun- gus. During the whole of this period, the appetite continues good, and, though tensive pains arise, and are necessarily distressing, yet, on the whole, the patient feels little inconvenience. The state of the bowels is very various. The stools are often fre- quent and offensive, but there is sometimes an obstinate costiveness. The urine is commonly high-coloured and fetid ; the pulse feeble, but rarely quick. A weakness in the joints appears early, and increases with the disease; and a shrinking of the flexor muscles renders the limbs useless; producing the scorbutic paralysis of Dr. Lind. The calves of the legs fall away, with sometimes an irregular hardness, and at length become edematous, while the bones them- selves, no longer supplied with a sufficiency of calcareous earth, give way at the callus of fractures; and those which have been formerly broken and re-united, become again separate at the line of re-union.* Kinai stage. The last stage is truly distressing. Blood is frequently discharged from the intestines, bladder, and other organs. The slightest motion brings on faintness, and often immediate death. Catchings of the breath and syncope, slightly and occasionally, indeed, found earlier, are now frequent, and dangerous ; yet the sense of weak- ness is so much less than its real amount, that the patient often attempts exertion, and dies in the very effort: though, more fre- quently, he survives the attempt for a short time, and especially when animated by any powerful and pleasant motive, as the hope of getting on shore, or even of engaging in fight with an enemy. >iost obvi- The most obvious of the remote causes of sea-scurvy is salt pro- eause salt visions; and perhaps the most obvious of its proximate causes is a Most^b"!- putrescent state of the blood : and hence these are the causes that ous proxi- have been commonly assigned from the time of Sir John Pringle to putrescen-6 the present day. Dr. Cullen was so convinced of the active power of woodthe these two causes that he could hardly admit of the operation of any The second other. He supposes that the animal economy has a singular power ducaTby 0I* producing and evolving a saline matter from foods of every kind the first as which does not naturally exist in them, but more especially from, a "yCuiien. diet that is wholly vegetable or wholly animal, though more so in the latter case than in the former. And he supposes, next, that; such saline matter is of an ammoniacal kind ; and that whenever ib is produced or evolved in too large a proportion, it has a tendency * AillCeO. Essays on several important subjects in. Slirgcry, &c cl. ui.] SANGUINEOUS FUNCTION. [ord. iv. 293 like neutral salts applied to blood when drawn from the body, to Geh' *• dissolve the crasis of the animal fluids, and render them putrescent, porphyra * though, in a living state, they hardly ever proceed to an actually "aut>ca- putrid stage. And applying these general remarks to the disease scurvy. before us, he supposes that " the throwing into the body along with the aliment an unusual quantity of salt," which, by the action of the body, he further conceives to be changed into ammonia, must have a great share in producing that preternaturally saline, and conse- quently dissolved, or putrescent state of the blood, which constitutes, in his view, the proximate cause of scurvy.* In other places, indeed, Dr. Cullen supposes not merely that the introduction of an unusual quantity of salt into the blood may have a great share in producing sea-scurvy, but that it is probably its cnly cause. " Whether," says he, " it ever arises in any other cir- cumstances is extremely doubtful; for there is hardly any instance of the disease appearing unless where salt meats had been em- ployed, and scarcely an example where the long continued use of these did not produce it."t The" great stumbling block to this hypothesis is, that while the objection mineral acids, the most powerful antiseptics we are acquainted with, pc-thesis/ are of little or no avail, many of the plants most successful in curing the disease are those which are most alkalescent, and make the nearest approach to an ammoniacal property, as the alliaceous and tetradynamiae. This view is, therefore, too limited in every respect. That an Cullen'* excess of salt, and particularly of salted meat, is a powerful cause limned" in the production of scurvy, is unquestionable ; yet not more per- "use's"*- haps from its tendency to dissolve the fluids, for the blood retains a operate, buffy crust even to the last, than from its rendering the salted meat Smes^th-. less nutritious. But it is by no means the only cause. In the pre- out ?nlt • * * A provisions* ceding varieties, we have already seen it produced on land as well as at sea, and ki some cases where there was no employment of salt provisions. And even sea-scurvy itself has occasionally been found to arise where the diet has by no means been saline ; and in damp situations, whatever have been the diet, unless where peculiarly generous and stimulating : and we have one instance of its having occurred in a young woman who had subsisted almost wholly on tea. In like manner, though the fluids of the body are loose and inco- Muscular agulable, the muscular fibres are equally loose and incontractile ; so muchaf- that the latter, as justly observed by that excellent practical writer [^'fluids; Dr. James Lind,f are as much affected as the former: and, if we attend to the course of the symptoms as they arise, we shall find . that they are affected soonest; for the earliest signs of the disease are those of languor, debility, and dejection ; though, upon the whole, thc mental depression is less considerable than in land- scurvy ; and, as we have already observed, there is a sense of mental energy to the last which is far more than commensurate with the actual strength of the body. * Pract. of Phys. § mdcccxii. mdcccxhi. t Pract. of Phys. nt supr*. " Treatise on the Scurry, &c. p. 277. b23Q cl. hi.] HiEMATICA. [0KD. IV. Gen. X. Spec. III. Porphyra nautica. Sea-seurvy. and affect- ed before the fluids. Digestive organs suf- fer first: and influ- ence the assimilating powers. Effects of this influ- ence on the system; suid ulti- mately on the blood. Hence the soliduin vi vum alone asserted to be the seat of disease by some writers. Necessary induction. An acri- monious principle evolved. All the causes ne- cessary i to be at- tended to. in attempt- ing a cure: and hence the general health of English fleets in modern voyages: How far salt provisions alone might produce sea-scurvy it is scarcely worth while to inquire ; for there is no extensive history of the disease in which they have acted solitarily; having always been more or less united with a cold or damp atmosphere, great fatigue, or a want of proper and invigorating exercise, want of ventilation, neglect of cleanliness, and very generally short rations, or an un- wholesome diet of other aliments besides salt meat. Now these are causes which must have a direct influence on the fibrous structure, and consequently on the whole organization of the body before the fluids can become affected ; and it is easy to trace the changes which occur in them subsequently to, and through the medium of this influence. Under the circumstances we are now contemplating, the diges- tive organs suffer first; they become weakened in their power, and for the reasons already stated when treating of marasmus, the weak- ness will extend through the whole range of the digestive chain, and influence all the organs of assimilation ; whilst the lungs, the brain, the heart, and the skin, unite in the general debility. Hence none of the secretions will be sufficiently elaborated, or, perhaps in suf- ficient quantity: there will be a less supply of sensorial energy, and a less vigorous action of the vascular system : a smaller formation of gluten, and elimination of carbone from the lungs. And hence, as a necessary consequence, the looser texture, and deeper hue of the blood : for as the secretion of gluten becomes diminished, whose quantity is dependent upon the firmness and elasticity of the living fibre, the blood must evidently be attenuated ; and, as a smaller por- tion of carbone is discharged by the lungs, the blood must be pro- portionally of a darker colour. On this account Girtanner,* and other pathologists who refer sea- scurvy exclusively to a looseness of the solidum vivum, have more to advance in their behalf than those who refer it exclusively to a loose- ness of the fluids. But both are affected, and affected equally, though the former takes the lead. Sea-scurvy is, therefore, a disease whose proximate cause is a putrescent, though not a putrid state of the animal solids and fluids produced by an assemblage of antece- dents co-operating to a common effect. In the course of their action, an acrimonious principle is unquestionably evolved, which seems to exacerbate the disease by increasing the tendency to de- composition ; and it is highly probable that this acrimony is greatly augmented by the introduction of an excess of salt. It is assuredly, however, not necessary that all the causes we have adverted to should operate at the same time. But it is of the utmost importance, both in preventing the appearance of the disease and in effecting its cure where it is present, to have the eye cautiously directed to every one of them, and to destroy its agency as far as we are able. And it is owing to the unremitting attention which is paid to these points in the navy of our own country, that sea-scurvy has long been rarely heard of in English fleets or English merchant ships: and that the globe is perpetually sailed over, and the highest * In Blumenbacli, P.ibt. Band, lit. p. 5-27 ol. iii.J SANGUINEOUS FUNCTION. [oicn.lv. 297 as well as the hottest latitudes coasted and cruised in, without the Gen.X. generation of this destructive plague. And thus it has been ever porphyri since the celebrated and extraordinary circumnavigation of Captain <><»»*«««• Cook in the Resolution; in which, by first laying down a code of a^mI' regulations for the government of his crew, founded on the soundest ^^ judgment, and afterwards persevering in them with an unremitting oapt. spirit directed to all the subjects before us, he was enabled to fulfil wonderiu? his voyage of three years and eighteen days with a company of a "Jucb"5lof hundred and eighteen men, traversing all climates from fifty-two degrees north to seventy-one south, with the loss of only one man by disease, and that man apparently labouring under a consumption before he left home. The regulations and management adopted by Captain Cook are contained in his paper communicated to the Royal Society, and printed in its Transactions.* It is a paper of the highest merit, and was justly honoured with the Copley medal for the year. In con- ii»» reguia- junction with Sir John Pringle's additional remarks upon it,t it has basis o/aii laid the chief foundation of the present mode of treating this dis- Inwove™ ease, and particularly of providing against its attack. The prin- ments in ciples it unfolds should be canvassed by the nautical student in the ^aa well communications themselves, in conjunction with the later works ofasecono" Sir Gilbert BlaneJ and Dr. Trotter.§ treatment. With the auxiliaries of cleanliness, proper ventilation, a dry atmos- Wi* p«>- phere, and fresh provisions, tlie medical treatment of sea-scurvy is p^nytng°m sufficiently simple, and the disease is found to yield easily. The ?huexJH*dic*ai means more immediately effectual are the native vegetable acids, and treatment above all that of lemons, upon which we shall speak more at large cTiSfanti- presently, all sorts of fermented liquors, the alkalescent plants, as p»&* garlic, scurvy-grass, water-cress, garden-cress, brook-lime, which, Acids. notwithstanding their alkalescence, contain a great quantity of Ja^,cent acescent matter, and by their acrid property, promote the excretions of urine and perspiration ; and the spruce-fir, as well as other plants {;*»™ferou* of the coniferous tribe that contribute to the same purpose. The fruit of the rubus ChanU&morus, or cloud-berry, found on Rubu» boggy mountains in our own as well as in more northern countries, morus. is also a cheap and valuable antiscorbutic. In Sweden, from the recommendation of Linneus principally, the berries are eaten very largely as a confection ; the Laplanders, in whose gloomy region the plant grows in great abundance, preserve considerable quantities of the fruit in snow, and export them to Stockholm in casks. The burdocks were formerly very much extolled in scorbutic and Burdock' almost every other disease of the present order, and especially the £racti^m arctium Lappa, clotbur, or great burdock, common to the wastes of aw ' our own country, which was supposed to possess all the powers of the China and sarsaparilla roots. The root given in decoction is certainly a diuretic and diaphoretic ; but as an antiscorbutic it is of far inferior merit to the plants already mentioned. * Vol i xvi vcar 1776, p. 402. t A Discourse upon some late improvements of foe Means fo.- pfeaervuig <.sie V... III. - 33 29$ cl. m.J 1LEMATICA. [ord. IV Gen.X. Spec. III. Porphyra nautica. Sea-scurvy Malt infu- sions. Silvester's antiscorbu- tic drink. Russian quat. Soins. Pare fresh water: its great im- portance. Means of preserving water pure. Gases; The infusion of malt, as recommended by Dr. Macbride, does not seem to have answered all the expectation entertained concerning it. Dr. John Clark affirms freely and candidly, that in various cases ' in which he tried it, with all the concomitants of pure air and good nutriment, it had no influence either in removing the disease or in checking its progress; in consequence of which he preferred Dr. Silvester's antiscorbutic drink, which is made by boiling three ounces of cream of tartar, four ounces of juniper-berries, two drachms of ginger in powder, and five pounds of coarse sugar in six gallons of water. After boiling half an hour, the whole is poured into a tub and allowed to ferment. It may be drunk as soon as the fermenta- tion commences, from one to three pints daily.!* Captain Cook, however, thought very highly of malt sweet-wort, and esteemed it one of the most powerful antiscorbutics. The Rus- sians, for want of sweet-wort or table-beer, employ a brisk acidulous liquor called quas, formed by fermenting small loaves made of ground malt and rye-meal. Dr. Mounsey tells us that this is the common drink of both the fleets and armies of the Russian empire. Oat- meal is also occasionally used for the same purpose, in the form of an acidulated gelatinous food denominated soins; made by infusing the meal in water till a fermentation commences and the liquor grows sourish, which in a moderate temperature will take place in about eight and forty hours. The liquor is then poured off from the grounds, and boiled down to the consistence of a jelly, which, sweetened with sugar and mixed with a little wine, yields an aliment not less palatable than medicinal. Pure fresh water is also another material of great importance, not only in curing this disease, but in guarding against it: and of so much moment did Captain Cook esteem its purity, as well as its freshness, that he had the old stock poured away, though procured only a few days before, whenever he had an opportunity of obtain- ing a new supply. And at a time when it was universally conceived that the frozen water of the ice-bergs consisted of salt water, or was unwholesome as formed of frozen snow, it was matter of most agreeable surprise to him to find that the melted ice of the sea, from whatever quarter derived, is not only sweet, but soft,' and as wholesome as the purest spring or river water ; thus affording him a supply he had no expectation of finding. The best means of preserving water pure is by keeping it in casks charred for the purpose on their inner surface : and the best means for restoring it to purity when it has become foul and offensive, is by mixing a little fresh powdered charcoal with every cask before it is tapped, and in drawing it off through a stone filtering cistern, containing a bed of the same material. As fermented liquors have been found serviceable, many of the gases have been tried in their simple form, and some of them have been thought serviceable ; but their carriage, or the means of ob- taining them extemporaneously, is highly incommodious : and it was well observed by that excellent navigator La Perouse, that sea- * Qbserrations on Diseases in long Voyages, &c Bvn. ■ ;l. hi.] SANGUINEOUS FUNCTION. [one. iv. 239 men may be gorged with bottles of them without deriving a thou- Gen. X. sandth part of the benefit produced from good slices of fresh meat, p0rpb*vra fruits, and herbs. Sea-scu'rw Of all the antiscorbutics, however, that have thus passed under Specific our survey, the citric acid, or that of lemons, is the only one that can chricarid. make an approach towards the character of a specific for sea- scurvy ; and how well entitled this medicine is to the maintenance of such a claim, now that the mode of preserving it in a state of activity, firsl suggested by Dr. Lind, has been fully established, the following brief, but triumphant narrative of Dr. Baird, will suffi- ciently evince :—" The next time I saw this disease in a very spread- illustrated ing degree, so as to affect the whole fleet, at a period when the ex- istence of the country depended upon that fleet keeping the sea, was in the year 1801, when my Lord St. Vincent took the command of the channel fleet. A short time after we sailed, and in not more than a fortnight, the scurvy made its appearance, and spread very rapidly through the fleet. Fresh provisions were not then supplied to it as now, nor vegetables. Being aware that lemon-juice was then in store and could be drawn for the fleet, I expressed to the Commander-in-Chief my great anxiety that a fresh supply should be had as fast as possible. The fleet was then blockading Brest: a cutter was despatched to communicate the state of the health of the fleet; a supply of lemon-juice came out, and we gave it freely to those labouring under the disease, and daily, mixed with water and sugar, to the whole of the crews of the ships, and continued its use during the time we were at sea, which was nearly seventeen weeks; during which time the fleet had not, as a fleet, a single fresh meal, nor any thing in the shape of an antiscorbutic but lemon- juice. The disease under the use of this totally disappeared; we returned with twenty-four sail of the line into Torbay, out of which number there must have been ten or twelve three-deckers ; and I think, estimating fairly, there could not upon an average have been less than seven hundred men in each. When we arrived, the sur- geons of the fleet were desired to make a return of the number of patients fit for the hospital. They made a return of twenty-four. I was directed by the Commander of the fleet to examine them, to see whether they were subjects for the hospital. I found eight of them were cases of hernia, or surgical cases that could not be bene- fited by the hospital. I selected sixteen from them. Out of twenty- four sail of the line there was not a single case of scurvy ; and, what was extraordinary, to such a state of health was that fleet brought by the use of lemon-juice, that the Glory had only four men on her sick list; so that out of fifteen or sixteen thousand men, there were only sixteen subjects for the hospital; and some of the ships had not lost a man at that time."* As the vessel of a tainted crew approaches land, nothing is more common or apparently more reasonable, than for those that are most affected to be most anxious to be put on shore at the moment. Yet for reasons we have already urged, this should rarely be com- ^f.'f * Report of the Committee of the House of Commons upon the Penitentkry at me"vJdre Milbant. 1*25- P, "9 "^ 300 cl. m.j HiEMATICA. [ord. iv. Spec' UI pliied with ' for *e real debility is so mucu feater tnan tne aPPa" rorphyra ' rent, or, in other words, the energy of the mind is so much greater s"-sco t'ian tnat °^ tlie body, that they often sink under the labour of the often sink' removal, and sometimes die before they reach the asylum provided {Jin***1" for them. In cases of extreme weakness, the external air alone, and especially when sharp or in a current, is sufficient from its pres- sure and stimulus to puff out the little flame that flickers in the vital lamp : a fact which, to adopt the words of Dr. Trotter, " has been long observed, and recently confirmed by five men dying in the boat belonging to the Prince of Wales ship of war, between the Downs and Deal hospital." GENUS XI. EXANGIA. ENLARGEMENT, BREACH, OR OTHER MORBID PERFORATION OF A LARGE BLOOD-VESSEL, WITHOUT EXTERNAL OPENING. Gen. XI. Thb expediency of placing this genus in its present situation poaftton of among diseases dependent on a " morbid state of the blood or blood- the genua vessels," would be obvious to every one, even though the maladies JUS e' it embraces were in every instance local. This, however, is rarely the fact; for the first two species included under it result commonly from a peculiar diathesis; and the last is productive of severe, and often fatal constitutional, disorder. These species are as follow: I. EXANGIA ANEUEISMA. ANEURISM. 2. ------- VARIX. VARIX. 3. ■■ ■ CTANIA. BLUE-SKIN, cl. in.) SANGUINEOUS FUNCTION. [orD. iv. 301 SPECIES I. EXANGIA ANEURISMA. ANEURISM. PULSATING TUMOUR OF AN ARTERY. The disease of aneurism, which consists in a permanent dilata- Gen. XI. lion or breach of the coats of an artery, may be produced by ex- caused *' ternal violence as a strain or puncture', or by arterial debility. The That of de- last is the more common cause, and it may be local or general; it common?' may be limited to the part in which the aneurismal swelling occurs, j^ *• or it may extend through the whole range of the arterial system, general. which is sometimes found to be universally, though irregularly, feeble, and consequently feebler in some parts than in others. It £"XiSis'al is this last condition of the arteries which constitutes what has been called the aneurismal diathesis : and under its influence aneurismal producing tumours not unfrequently occur in different arteries of the same in- gatefor6 dividual, simultaneously or in succession.* De Haen gives a singu- s»«»«»kWi Jar example of this in a boy of seventeen :| and Lancisi has conjee- mai m- tured this diathesis to be produced by gout, rheumatism, apoplexy, supposed and a sedentary life ;| to which Guathani has added syphilis,§ and cau«es: Freer, still more lately, inflammation of the arterial tunics. In all all resoiva- which cases we can trace the common fact of great vascular debility cuh" debt*" induced generally, or in the particular limbs which have been the htr- seat of the predisposing disease. It is often accompanied with a calcareous thickening and rigidity of the arterial trunk in particular parts. Aneurism is ordinarily represented as appearing under only two Disease forms, the true, or, as Mr. B. Bell more particularly denominates it, undeTfour the encysted,|| and the false or diffused. To these it is necessary to varietir- add the varicose of Dr. Hunter, and the cardiogmus of the Greek writers ; thus presenting us with the four following varieties: x Cysticum. Encysted aneurism. 0 Diffusum. Diffuse aneurism. y Varicosum. Varicose aneurism. } Cardiogmus. Aneurism of the praccordia. The true or encysted variety forming the aneurism by dilata- «E.Anen- tion, of M. Petit,H is characterized by the tumour being circum- ticum.0'" scribed or having a defined outline ; and is produced by a yielding jf™*'^ Distinctive * Saporta, Dissertatio de Tumoribus. § De Aneurismatibus. f Rat. Med. iv. 2. § 7. II Syst. of Surg. Vol. i. Oh. iv. p. 196. f De Subitanea Morte, 100. IT Mem. de 1'Acad. des faiences, 1736. 302 cl. in.] II.EMATICA. [ord. IV. Gen. XL Spec I. a E. Aneu ristna cys- licum. Encysted aneurism. Description Internal aneurisms only to be suspected from gene- ral symp- toms. Sometimes mistaken for other diseases. How distin- guishable. The dis- ease some- times finds a natural cure when un- connected with an aneurismal diathesis. Sometimes cured by pressure. Compress in general should be easy and only afford support. But a tight compress has some- times ■proved most BHiTcassfii'l. or dilatation of the coats of an artery so as to form a sac, which . constitutes the sphere of the arterial enlargement. The tumour, when first observed, is small, and excites little at- tention ; lor there is no pain, the skin is of its natural appearance, and the tumour vanishes when pressed upon by the finger. But during the pressure a pulsation is clearly distinguishable, correspond- ing with that of the artery below. As the disease advances, the tumour increases ; and when it has gained considerable magnitude, the skin becomes pale, and even edematous ; the pulsation still con- tinues, though the tumour yields less regularly to the pressure of the finger than heretofore, being soft and fluctuating in some parts, but, from coagula lodged and hardened in the sac, firm and resisting in others. The seat of the aneurism at length becomes distressingly painful from the increased coagulation and swelling; the skin as- sumes a livid hue, and seems verging to a gangrenous state; a bloody serum oozes from it, and it often ulcerates • when the walls of the arterial sac, meeting with less support than hitherto, give way, the blood bursts forth with violence, and, if the artery be large, soon produces death by inanition. Such is the general course of encysted aneurisms that show them- selves externally; but as they occasionally occur in vessels more deeply seated, we cannot so readily mark their progress, and can often only guess at their existence. They have been discovered, however, by particular symptoms in the chest, neck, head, forehead, temples, and back, as well as in every limb ; and it is difficult to say which part is most subject to their appearance. In an early stage of the disease, it cannot easily be mistaken for any other ; for the signs of a regular pulsation, absence of pain, and disappearance of the tumour on pressure, are sufficient to distin- guish it. But when, in the progress of the complaint, the pulsation becomes almost imperceptible, and the tumour hard, it has been confounded with other encysted tumours, scrophuious swellings, and abscesses. The last is the most common error, and, by leading to an injudicious opening, has sometimes proved a fatal one.* The disease has occasionally been cured naturally by a deposite of coagula in the sac, which, as they have gradually increased, have gradually also filled up and obliterated the cavity of the sac. Mr. Hodgson has given a curious case of this kind, in his treatise " on the Diseases of Arteries and Veins." In such instances, however, it is probable that the disease is unconnected with an aneurismal dia- thesis, and is a result of some local cause. Pressure, under the same circumstances of local affection, has sometimes produced a like good effect. Dr. Albers of Bremen gives an instance of this even in an aneurism of the femoral artery.t It has commonly been said that the compress should never amount to more than an easy support to the weakened and enlarged organ :| and it is very probable that tight bandages, by impeding the circula- tion in the adjoining veins as well as arteries, have often proved in- * Reinesius, Schola Ictorum Medica, p. S2I. t Trans, of Medico-Chir. Soc. Vol. ix. I Cajrnior, Dessault, Journ. de Chir. Tom. n. ui. in.] SANGUINEOUS FUNCTION. [ord. iv. 303 jurious. Dr. Perceval, however, in the manuscript comment with Gen. XI. which he has enriched the author's volume of Nosology, has the „ E.EAnerj- followins notice under the present head; seeming to show that even r!B,n:i cys- • i i • ■ /> i i ■ i_ .. i i "cum. a tight compress has at times been ot tlie highest advantage ; and Encysted a like success is related by Acrel in an aneurism of the aorta.* " In u"u"iated the rebellion of 1798, an officer received a wound from a bayonet •"lom.Pet- which grazed the left carotid artery and produced a pulsatory tumour: notes." this was kept down by a spring collar, and at length disappeared. Many years after, having lived rather freely, he died dropsical. Pre- vious to his death, he had a most violent palpitation of the heart, and discharged by stool immense quantities of blood. The heart was not found enlarged, but the cavity of the left carotid was almost en- tirely obliterated." In connection with pressure, great benefit has also frequently re- phtttie,2t. suited from keeping the amount of the circulating fluid in a dimi- kept in a nished state by occasional venesections, purgatives, and a spare diet. J^,™"ed Morgagni relates a case in which such a regimen alone effected a Spare diet cure when commenced early.| Yet it is obvious that in some habits ejected™ a cure, even of the same artery, is obtained much more easily than in cure- others : and hence it seems sometimes to have taken place sponta- Aneurism neously, of which an example is given by Mr. Crampton in the Me- gpontane! dico-Chirurgical Transactions ;{ and by Mr. Ford, in a journal of an ous,y* earlier date.§ Every palliative mean should be had recourse to before an opera- Operation tion is resolved upon : for even under the most favourable circum- perfbrnied stances such a step is hazardous, and it is peculiarly so when the J.™™81"8 aneurism is connected with a diseased state of the arterial trunk or the whole arterial system, of which it is seldom possible for us to form a correct judgment. To describe the nature of the operation would be to travel into the province of surgery. I may, however, Yet has observe that in cases of necessity, it has often been performed with formed8' full success, and even a perfect use of the affected limb, in trunks of onC^tseBrf^7 a very large calibre. Sir Astley Cooper has given an account of two of large cases in which the operation was effected on the carotid artery. The ame er" first proved unsuccessful from the long standing and size of the sac which pressed with perpetual irritation on the larynx and pharynx, exciting frequent fits of coughing, and preventing deglutition. The second case terminated favourably ; but the tumour was smaller and of more recent growth. In the second variety or diffuse aneurism, the aneurism by 0 E- A?p' infusion of M. Petit,|| the coats of the artery, instead of being dilated fusum. into a sac, are divided; and, the blood flowing at large into the eel- anfurism- hilar or other surrounding parts, the tumour is extensive and unde- fined. This is usually the result of external violence : the swelling often J^jJJf spreads to an unlimited range, and the progress towards a rupture of by external the integuments is more rapid than in the last. Here, pressure is of P7eiesnuCre'of no avail, and even mischievous; since it will more effectually ob- n°db,ehneefit' operation * Chirureische Vorfalle. Band. i. 44. 5 Lond. Med. Journ. Vol. ix. mostly in- t De SedT et Caus. Ep. xvn. Art. 30,31. [[ Desault, Journ. de Chirurgia, p. S21. dispene* IVol. vn. p. 341. 304 cl. iii.] HiEMATICA, [okd. iv. Gen. XI. struct the course of the blood in the surrounding veins, than in the /JSE.BABeu- divided artery: and the operation can rarely be dispensed with. risma dif- Mr. B. Bell was fortunate enough to succeed in the case of a divi- Diffuse sion of the great ileac artery just at its egress from the pelvis. The SoiMemof mv'si°n was produced by an accidental and forcible entrance of a pair B.Beii in a of long-pointed scissors into the hip. The patient fainted from loss Me^rtsm1* of blood, and the wound on the surface was healed. The aneurism, of the ileac however, continued ; fresh blood was perpetually poured forth ; in six weeks, the tumour on the hip became enormous, the thigh was rigidly contracted, the ham recurvated, the leg shrunk, cold, and useless. On making an incision eight inches long, the blood issued in such torrents that the patiei tinted, and was supposed to be dead or dying, but the artery could not be traced. At this critical mo- ment, Mr. Bell ran the bistoury upwards and downwards, and at once made the wound two feet long : when thrusting his hand to the bottom of the tumour, he felt the blood still jutting warm from the artery, laid hold of it, and found it to be the posterior ileac cut through transversely. He tied it, and, loosely dressing the wound, left the patient on a bed in the operation-room, as he was too much reduced to be removed. In seven months he was completely restored to health, and recovered the entire use of the affected leg. y a. van- The third variety or varicose aneurism was first distinctly Varicose pointed out by Dr. Hunter, who characterized it by this name. It now'pro- *s Pr0(Iuced by puncturing an artery through a vein that lies imme- duced. diately above it and upon it, as in blood-letting at the arm, so that the arterial blood flows from the arterial puncture, not through the cellular substance, but into the superincumbent vein through the Description, corresponding venous puncture. In this case, the tumour is elon- gated, taking the course of the vein, which is hereby distended and rendered varicose. Sometimes, indeed, where the venous commu- nications are frequent, all the adjoining veins participate in the dis- tention, and are equally affected. The tumour, as in the first variety, disappears upon pressure; and, as soon as the pressure is removed, the blood issues from the arterial puncture with a whizzing sound and a tremulous motion, rather than a distinct pulsation. beast dan- This is the least dangerous of all the forms of arAurism, and that 'u the °a- in which pressure may be applied most successfully. It has some- reneraiia"d ^mes produced a radical cure ; but in all instances so far succeeded relieved by as to render the operation unnecessary, provided the patient passei pressure. a qUjet an(j unfatiguing life : for it has been known to exist twelve, twenty, and even thirty years, without any serious injury to the gene- ral health. , Acardi- The fourth variety is distinctly a constitutional affection, and AneurUm usually of considerable distress and oppression. It is characterized cordia.pne" °y an ODtuse intumescence and constant disquiet of the praecordia ; Description, with a sense of internal weight and pulsation increased on the small- est motion ; according to Corvisart the carotids throb, the pulse is strong, hard, and vibrating. It is the cardiogmus of Galen and Sau- vages ; the aneurisma praecordiorum of many authors, and the polypus :.'",«m°a coruses. *l. ui.J SANGUINEOUS FUNCTION. [ord. iv. m* stance of the heart, or the larger vessels in its immediate neighbour- Gen. XI. hood ; but whether, as Corvisart affirms, the enlargement be more jSAECardi- common to the left than the right ventricle,* is not satisfactorily de- ogmus. termined. It is sometimes accompanied with, and perhaps produced or the p«e- by, a polypous concretion ; and sometimes without any such sub- cordia' stance whatever: and, where the larger vessels are affected, they are here more than in any other variety thickened and rendered rigid by irregular deposites of calcareous or ossific matter. It is sometimes a result of violent exertion ; and is then mostly an affection of the young and the strong, of those who engage in manly exercises, or are subject to violent passions. But it is more frequently Found a result of debility, and chiefly to be met with in persons of advanced Suvancwi age. It is well observed, indeed, by M. Rostan, that a dilatation and ^ear"d thickening of the walls of the heart are not a consequence of great there u power or strength of constitution with energy of healthy action ; but SetStuiy. is generally caused by that state of the arteries whicii is an ordinary result of old age, in which they lose their natural elasticity, and be- come ossified, thick, inorganic tubes.t This ossification affects the valves of the heart as well as the vessels in its neighbourhood, whence the heart is perpetually oppressed, and called upon for increased ac- tion ; which increased action itself is another cause of increased thickening in the cardiac coats. This, however, is the passive 'enlargement of M. Corvisart; who Passive en gives us also a thickening and enlargement, whicii he calls active; 0f corvi- in which the increased action of the heart, instead of being confined Active «n- to itself, is extended to its parietes, to the vessels that issue from it, largemem. and consequently to the pulse generally. M. Laennec has acceded nypertro- to this last form of disease,! an^ ** constitutes his hypertrophia. His LaeVncc. stethoscope, of which we have already spoken, may often be advan- tageously employed, in this case, as a diagnostic.§ The disease not unfrequently proceeds from a distinct cyst some- Sometimes x j x j prodtiC6u times traced in the substance of the heart, as the right auricle, of by a dis- which an example is given by Bartholin :|| or of the left ventricle, as j^LTou'. stated by Dr. Douglas ;1I but more usually in the arch of the aorta, or adjoin. And in some instances this cyst, or some other morbid structure cyf°rsomo- has been found to become so much enlarged as to encroach in a very m™"jf "nr." considerable degree upon the natural capacity of the heart. And larged. hence though the general substance of the organ with its diseased increase of growth has weighed, upon dissection, fifteen pounds, the cavity, in a few rare instances, has hardly equalled that of a walnut. M. Portal, who is disposed to admit of M. Corvisart's division of the disease into active and passive, seems chiefly to object to the term dilatation as applied to the heart in this state of engorgement.** In many of these cases we can trace the cause ; for the aneurismal ^"'Ji capable of ^ , _ . boing traced * Sur lea Maladies et les Lesions Organjques de Coeur, &c. during life, t Nouveau Journ. de Medicine, Tom. 1 p. 367. % De 1'Auscultation Mediate: ou Traite" du Diagnostic des Maladies des Poumons et du Coeur, &c. 2 Tomes. Paris, 1819. 4 Supra, p. 186. II Act. Hafn. iv. Obs. 47. V Phil. Trans. Vol. xxix. 1414—1416. ** Metnoirea sur la Nature et le Traitenient de pntsieurs Maladies. Tom. Tv. 8vo< Paris, 1819. Vot,. III. — 39 306 cl. in.J IIJ2MAT1CA. [ord. iv. Gen. xi. artery is at times as contracted in the vicinity of the sac, as if it had i a. cardi- been tied by a ligature. The aorta has occasionally, in this mannerj, Aneurism ooen rendered altogether impervious, the circulation being continued of the prae- by an enlargement of the anastomosing vessels.* By Mor- ^n tms account, Morgagni ascribes the disease before us to a nar- ga?nii as- rowness of the larger arteries as its common cause; and hence ex- narrowness plains why it is so frequently found among tailors, and other seden- f.'rger'ar- taiT workmen.! tenes. The medical treatment can be rarely more than remedial. Fatigue L-eatm'nt. aml great exertion must be sedulously avoided, together with keen nental excitement. The diet should be light, the meals and hours of rest regular ; and the exercise should be that of a carriage. The bowels must be attended to ; and, where the palpitation or other distress is peculiarly troublesome, it may sometimes be relieved by camphor, volatile alkali, and tincture of hyoscyamus. We may observe, before quitting the subject, that the largest aneu- risms have been those of this quarter, and particularly of the aorta, as there is here the greatest force of action. Littre gives a descrip- tion of one of the superior trunk that ascended as high as tlie max- illa ;J and Teichmeyer of another that burst into the pericardium.§ From their extent and pressure they often erode the cartilaginous and even bony substance of the ribs ; and La Faye relates a case in which a part of the sternum as well as two cartilages of the ribs were hereby destroyed.il In an enormous aneurism of the abdominal aorta, Mor- gagni mentions that the posterior wall of the artery itself was destroyed, the neighbouring parts supplying the place of a wall: IT and in a like aneurism of the thoracic branch he found the bones in the vicinity broken and demolished by the force of its pressure.** * Cooper and Travers's Surgical Essays, i. p. 125. t De Sed. et Caus. Ep. xxi. 49. xxvi. 31—33. X Mem. de l'Acad. Royale des Sciences a Paris. Ann. 1707. § Dissert, de Stupendo Aneurjsmate Brachii, &c. Jen. 1734. j] Phil. Trans. N. 287. IT De Sed. et Cans. Morb. Ep. xl, 26. **Ep. XTH. 25—27. cl. in.J SANGUINEOUS FUNCTION. [ok». iv. 3U? SPECIES II. EXANGIA VARIX. VARIX. SOFT, LlVin TUMOCE OF A VEIN. This disease is to veins what the true or encysted aneurism is to G,KN- **"• arteries. The coats of the veins are preternaturally dilated, and Description. more in some parts than in others, so that a vein thus enlarged to any J^8necm~0 considerable extent often appears to be a chain of venous cysts; and the encyst- as contiguous veins often communicate, the enlargement is not un- *^"eu" frequently extended from one to another till the whole forms a plexus of varices, and every part seems ready to burst. In some instances, The varix they are said to have bursted. This assertion, however, wants con- "aSto™68 firmation: but if it were true, we should be put into possession of a ^^ ^ diffused as well as an encysted variety of veins, and the disease would n resem- make a still nearer approach to that of arteries. diffused This affection mostly occurs in the veins of the lower extremities aneurism. in consequence of their being the most dependent part. They often chiefly in arise spontaneously in persons of lax fibres; but are far more fre- ^J^!' quently a consequence of undue fatigue, strains, cramps, or pressure, ties. The most frequent cause is a pressure of the fetus in pregnancy duc^10 against the external ileac veins, in consequence of which the blood ascends with difficulty from all the veins below, which become dis tended and weakened by its accumulation. From strains or other causes, however, varices have been occa- Sometime* sionally traced in other large veins than those of the extremities. oti,"r part*. Thus Tozzetti discovered one after death, in the vena azygos ;* and Michaelis describes another that terminated fatally in the jugular vein.! They are also met with in the spermatic veins ; and in this cireoceia position have very generally been described under the incorrect name of circocele or varicose rupture. Morgagni asserts that the sper- matic varix appears more frequently on the left than on the right side, from the insertion of the spermatic vein into the emulgent.! They are often possessed of considerable irritability in themselves, often unh- and almost always add in a high degree to the irritability of diseased y,rrit* parts in their vicinity, so that if an ulcer or an erysipelas take place contiguously it will rarely admit of a cure till the varix be first removed.§ The best remedy in all cases where it can be applied is a moderate, Jjjjj*^, steady, and continued pressure : which, where the varix occurs in ■he legs, is easily accomplished by an elastic stocking, or, which is * Prima Raccolta di Osservstzioni Medici, Firene, 1753. t See Richter's Chirurgische Bibliothek in loco. De Sed. et Caus. Morb. Ep. xliii. Art. 34. ';. "VifT", de PAc-v'. Bovale de? Sriecres a Psrh- Ann. 1 >"• &«* cj,. ii^j HAEMATIC A. [oki*. iv. Gen. XI. preferable, a circular bandage of fine elastic flannel. Dauter's plan Exungia ' of using cold water is also a very simple, and, where the varix is Varix. fresh, not unfrequently a very efficacious remedy :* but how far a solution of mineral acids or metallic salts may add to its virtue, as recommended by some practitioners, the author cannot affirm from his own practice. tempted b From their disfigurement and great discomfort varices have some- division, times been attempted to be removed by a division between two liga- tures, not widely different from the operation for the aneurism. The attempt has succeeded where there is neither local nor constitutional irritability : but it has more frequently failed, and the inflammation PTtenfhl- hereby produced has occasionally proved fatal.! Yet where the inTre sefi- effect is less extensive it is apt to be followed by a serious and far in^s*ofe11" more diffuse enlargement of the vein with varicose prominences, ereiit similar to that which sometimes occurs in drawing blood from the engl ' arm ; of which, till of late years, no very intelligent explanation has been given, and which I shall therefore endeavour briefly to illustrate. Nature of This singular and painful line of swelling was at first supposed to ingsex-" arise from the prick of a nerve: and it is perfectly clear that the plained. tingling and shooting pains which succeed venesection, are sometimes produced by a partial division of a nerve, from an interesting case of Mr. Sherwen of Enfield that only yielded to an entire division of the nerve by a transverse section above the orifice, after every other attempt had been tried in vain.J But the nerves of the arm liable to be wounded in bleeding are mostly small and unimportant: while others are often pricked and wounded in many of the common ope- Nature of rations of surgery without any serious consequence whatever. The tended mischief has by other writers as Heister, Garengeot, and Haller, explained Deen ascribed to wounding a tendon or its aponeurosis ; but un- difterontiy luckily for such physiologists, tendons in other places are often torn wnfers!"3"1 or wounded with very little inconvenience. Even the Achilles- tendon, the largest in the body, is frequently broken, without any of the severe symptoms that sometimes arise from blood-letting. Besides which, the accident from bleeding occurs as frequently when a person has been bled in a vein which has no tendon near it, as where there is reason to expect that a tendon may have been wounded. It happens as often that a swelled arm is the consequence of bleeding in the cephalic or cephalic-median vein, as of bleeding in the basilic or basilic-median. j. Hunter's ]\|r> j# Hunter was the first physiologist who ascertained the real 0XT)I SHI" lion. cause of the mischief before us : and traced it to a general principle which he laid down as applicable to all internal cavities ; namely, that when injured or otherwise rendered imperfect they are often apt to inflame at the injured part, and to have the inflammation spread rapidly over their whole extent, as I have already had an opportunity of ob- * Von dem auserlichen ortlichen Gebranche des Kalten Wassers, &c. Leips. 1784. 4to. t Observations on Varix, &c. By Richard Carmichael, &c. Trans. King's and Queen's Coll. Dublin. Vol. ii. p. 345. 1824. t Edin. Med. Comment. Vol. r. p. 4^0.—See also Study of Med. Vol. it. Cl. in 'M. n. G«t». vi. Spec. v. cl. m.\ SANGUINEOUS FUNCTION. [ok». iv. 3G9 serving under peritonitis, puerperal fever, and on various other occa- <*en. X& sions. He was first led to this view of the cause in the case of veins Exangia from noticing what occasionally happens to horses. It is no uncom- Varix. mon thing for hostlers, out of an unnecessary or ill-judged care, to bleed these animals in the neck even when in perfect health : and in several instances of this kind Mr. Hunter had observed that the neck swelled, and the horse died ; and, on examining the nature of the disease by dissection, he found that the cavity of the vein was inflamed, and that the inflammation had spread along its internal surface to the chest, sometimes even to the heart itself. And he afterwards found a like effect produced in the veins of the human arm, where inflammation had succeeded to bleeding; and particu- larly in one case that occurred in St. George's hospital, being that of a man who died suddenly on the eighth day after having been bled in the basilic vein of the right arm, and having suffered from inflammation as a consequence. On dissecting the arm, he found not only that the cavity of the vein had inflamed, but that the inflammation had extended from the puncture, which had been made by the lancet in blood-letting, as high as the axilla ; proceeding also to some distance below the puncture. About the middle of the arm the vein had suppurated ; and, from the ulceration or absorp- tion of parts which attends abscesses, the vein was divided into two; and each extremity, like the internal surface of the abscess, was irre- gular and jagged. Mr. Hunter was disposed to think that the principal cause which produces the inflammation of a vein after bleeding is the want of a disposition to heal, arising either from its being exposed, ©r in con- sequence of the lips of the orifice in the skin not being properly brought together. And he hence strongly advises that the sides of an opened vein should at all times be made to approximate as accu- rately as possible, and that the orifice in the skin should be drawn to one side of that in the vein, so as to make the skin do the office of a valve to the venal opening.* There seems, however, in this explanation, to be a something Expiana- wanting ; and I cannot avoid thinking, as in the case of puerperal ^lebut «•.-■ fever, that there must be at the same time some peculiar local or con- J^^js stitutional irritability predisposing the injured part to run into an in- ing in it-. flammatory action : a striking instance of which, already slightly alluded to, occurs in a case communicated by Dr. A. Duncan. The s^n^A patient, himself of the medical profession, twenty-eight years of age, 3.' " had opened a boil on his hand with a lancet which had been applied to an obscure sore on the back of another person about a month pre- viously, but against which no proof of being either poisoned or un- clean could be brought forward. The inflammation, instead of sub- siding, after opening the tumour, increased, and spread up the arm to the axilla; but the swelling was attended with little redness, and no acute pain, though with considerable fever and restlessness. The Progress o. affected arm, three days afterwards, exhibited one or two red streaks running up from the elbow to the shoulder, in the course of the ce- * Kdin. Med. Comment. Vol, ill., p. 430. 310 ci. iii.j ha:matica. [OKI). IV. ©en. XL phalic vein ; the breathing was much affected, quick, and short, but Exangi'a ' without pain in the chest; there was a troublesome cough, and the Varix.' expectoration, though small in quantity, was tinged with blood. The countenance was anxious, depressed, and of a leaden hue ; the fea- tures sharpened, the eyes sunk and dull; tongue foul; pulse a hun- dred and ten strokes in a minute. These symptoms increased in vio- lence, with transient fits of delirium and subsultus tendinum ; the intumescence of the arm, however, remaining to the eye, much the Uonmina same' wi*h utt^e complaint of pain. The patient sunk gradually in just a week from about the first appearance of local affection ; and ten days after using the lancet. Post-obit On examining the body, much chronic disease was found in the tion?"n chest: the cartilages of the ribs on one side were slightly ossified : there was a general adhesion of the lungs to the costal pleura, peri- cardium and diaphragm, with a recent effusion of coagulable lymph; in some places a little coloured, and occasionally evincing a few fibrous shreds. The substance of the lungs appeared, also, generally unsound, and, in some parts, contained tubercles and calculi; one of the tubercles being as large as a nut, and filled with a yellow puru- lent-looking fluid. The general health had borne up under all these chronic sappings, undisturbed, to the time of the local affection of the hand ; as also under a protracted fatigue, through the whole of the preceding winter from a course of hard professional study ; augmented, still more lately, by great mental anxiety and disappointment. All these seem to have produced a morbid excitement of habit, which, though not fatal of itself, gave a fatal tendency to the inflammation on the band, or rather to the irritation of the cephalic vein which was probably pricked on opening the boil, as will be sufficiently obvious from the appear- ances of >the limb on dissection. Many livid spots were observed externally : the opened and unhealed ulcer was found to be accom- panied with a swelling of the cellular substance, extending more or less up the whole arm. And, on making a long incision, from this nicer to the top of the shoulder, a small abscess was accidentally en- tered into at the bend of the arm, which proved to be the cephalic vein accidentally divided, and unfolded the immediate seat of mischief. The vein appeared full of purulent matter; and, in consequence, was carefully traced through its entire range. " The disease of the vein consisted in external redness, arising from the increased size of thc vasa vasorum ; thickening of all its coats, so that it remained like an artery, round without collapsing : increased size, especially in the fore-arm ; its containing no blood in any part of its course, and being generally filled with purulent matter, except in a few places where it seemed empty; and, in the inner coat, being every where red and thickened. The veins coming from the back of the fore-finger, mid- dle, and ring finger, were all diseased : but that from the little finger was healthy." Phlebitis is far more easily produced than arteritis, as vein - are more irritable than arteries ; but we hence learn, that even lli- ■ormer is occasionally influenced bv constitutional excitement rL. in.] SANGUINEOUS FUNCTION. [ord. iv. 311 SPECIES III. | EXANGIA CYANIA. BLUE-SKIN. SKIN MORE OR LESS BLUE ; LIPS PI'RPLE ; GENERAL HEBETUDE, AM' INACTIVITY. This species is designed to express that singular appearance and Gem. XL diseased state of the entire system, produced mostly, by a connate §"^1 communication of the two ventricles of the heart, and consequently an character of imperfect discharge of the carbone of the blood at the lungs, which l e "peci constitute the proper organ of its elimination. From the Greek xvxtot, or " blue," Sir Alexander Crichton, in allusion to the colour of the skin by which it is peculiarly distinguished, has elegantly named it cyania, and the term has been adopted, as a specific appel- lation, on the present occasion. Antecedently to birth, the lungs are of small comparative impor- Ghen,j'»0 tance to the functions of life and growth, and hence no more blood state°ofSy' seems to circulate through them than is necessary for their develope- {***„""". ment and health. The florid, or decarbonated blood, instead of fore birth. being received from the lungs by the pulmonary veins, is received from the placenta by the venas cavae, and passes for the most part at once into the general circulation, chiefly by means of the foramen ovale by which the two ventricles communicate, and partly by means of the ductus arteriosus, by which the pulmonary artery at this time anastomoses with the aorta ; that portion of blood only which escapes through this canal flowing forward into the collapsed substance of the lungs ; amounting probably to not more than a third or a fourth part of the whole. Immediately on birth, however, the plan of decarbonization is im- Change mediately changed. The fetal duct and foramen are closed, and the byVrth! whole mass of blood flows, black instead of. florid, from the venae cava? into the heart, and is sent by the pulmonary artery to the lungs for ventilation, instead of to the placenta, in which organ, by the disengagement of the carbone with which it is loaded, and partly perhaps by the absorption of oxygene from the respired air (for the subject is still open to controversy), it acquires its perfect elabora- tion and florid hue. It is hence obvious that if, in consequence of any aberration from ^""^ the common law which regulates the wonderful change that thus takes i,e„Ce ob- place in the infantine heart and its attached vessels at the time of "^ birth, either of these communications should remain open, the venous w^'c- or black-blood must wholly i or in a very considerable degree, be thencirc'iiia thrown back again into the general circulation instead of passing to *™™m. the hmo-« : and the minute arteries on the surface, whicii give to the rH ,s h. 312 cl.id.] ILEMATICA. [onn. iv. Gen. XL complexion its tinge, being filled with the same, the general hue Exangia ' must DG changed from a florid to a blue or purple, more or less deep cyama. according as the pulmonary circulation is more or less impeded. load of ' It is this natural defect that constitutes the disease before us. In carbone. the varicose aneurism a small part of the florid or arterial blood flows through an accidental opening into the veins, but never in such a quantity as to disturb tlie economy of general health. In cyania a much larger, but variable proportion, of the^black or venous blood flows by a physical opening into the arteries ; and usually with se- rious inconvenience to the general health, most commonly indeed with fatal effects. Pretematu- How far the ordinary disengagement of carbone from the blood y&l openings »' o o in the fora- may be dispensed with, or, in other words, to what extent these con- may exist to nate communications may remain, and the present disease take a certain place without endangering the life, we have no exact means of ascer- outeerious taining. Dissections have shown us that the foramen ovale has con- mischief: tinued partially open to old age, without much or even any interference but never wfth the common functions of health :* but we may confidently assert BO ltlTffGlV . . asto allow that, whenever so large a portion of venous blood is thrown into the on'the skin! arterial circulation as to give a blue or purple tinge to the lips or the skin generally, all the functions will be performed feebly, and there is great danger that the infant will never reach the age of puberty. Why in- There may be living power enough in the blood to support the growth capable of of the frame during the retired and quiet tenour of infancy, in which enduring there are no sudden exertions or calls for a more than ordinary- ex- such a con- . . J dition, and penditure of sensorial power ; and hence, it is no uncommon thing orauoies-ty ror a child to survive the first three or four years of life with a skin cence. completely blue, and consequently with a full proof that tlie foramen ovale, or the ductus arteriosus, or both, are open to a very consider- able extent, and that not more than perhaps a third or fourth part of the general current of the blood passes into the lungs and under- Hence fa- g0es the process of ventilation. But as soon as a more active period last two of life commences, and the child is trusted to its feet, and engages, stages: or should engage, in the pursuits or even amusements of boyhood, with all its physical and moral excitements, the living power is not ade- quate to the demands made upon it, and he sinks beneath their op- ana even in pression, and generally expires in a fainting fit. There is commonly, productive moreover, through the short and pitiable term of his existence, the bT^and9" c^eares* Pr°of of general torpitude and deficient energy ; every exer- torpftnde. tion is a trouble, every stimulus produces fatigue : the muscles en- large, but they want vigour and elasticity : and, so far as I have seen, Blue-boy of the faculties of the mind are equally blunted. The celebrated blue- boy described by Dr. Sandifort, advanced farther towards an adult age than is by any means common. Here the aorta took its rise from both ventricles; the pulmonary artery was scarcely pervious to a small probe, and the difficulty of passing the probe from the heart to the lungs was greater than in the contrary direction. Thc patient was affected with an asthma from his second year, and tor- * Gescb.ieb.te einer Chirurg;. PrirateeselJfchaft in Kopenhasrcn.—Bertliolin. Anal- Reform. Lib. Li. cap. 8. yu. TO.] SANGUINEOUS FUNCTION. [onn. iv. SIS minated the miserable series of his sufferings in his thirteenth.* In Gen- *l. the case of a young female related by Morgagni, the term of life was Exangia protracted to the sixteenth year ; but there appears to have been a Bfuaemgak'in< somewhat freer communication with the lungs, notwithstanding that Examples the foramen ovale was open wide enough to admit the little finger, author.M The patient, however, was sickly from her birth, and laboured under great general debility ; her respiration was difficult, and her whole skin of a livid colour*! Dr. Holmes has lately communicated a simi- lar case, but where the passage was somewhat more free : the patient in consequence reached the age of twenty-one, and then died of dropsy.J Life, however, for a short time has been maintained under still Jf'^0™^ more complicated misformations of the heart, and adjoining arteries, heart still Mr. Standert gives the case of a blue child that lived ten days, in JSted,'"* which the two ventricles communicated, there was no pulmonary sometime* artery, but its place was supplied by an artery that branched off to sute'nf'w'itii the lungs from the aorta in the situation of the ductus arteriosus, *f "f?y with any particular cause. " Beginning," says he, " at the extre- mity of one or more of the small toes, in more or less time it passes on to the foot and ankle, and sometimes to a part of the leg, and, in spite of all the aid of physic and surgery, most commonly destroys the patient. It is very unlike to the mortification from inflammation, to that from external cold, from ligature, or bandage ; or to that which proceeds from any known and visible cause, and this as well in its attack as in its process. In some few instances, it makes its appearance with little or no pain ; but, in by much the majority of * Morgagni, De Cans, et Sed. Morb. Ep. Lv. Art. xxiv.—Bresl. Saramlunsr. 1724. ; n. 643. 320 cl. hi.] HJSMAT1CA. [ORD. IV. Gent. XIL Spec. II. Gangrsena ustilacinea. Mildew- mortifica- tion. In severer eases the mind af- fected as well as the body* Predispos- ing causes. Remedial treatment. Benefit of opium. these cases, the patients feel great uneasiness through the whole foot and joint of the ankle, particularly in - the night, even before these parts show any mark of distemper, or before there is any other than a small discoloured spot on the end of one of the little toes.—Each sex is liable to it: but for one female in whom I have met with it, 1 think I may say that I have seen it in at least twenty males. I think, also, that I have much more often found it in the rich and volup- tuous, than in the labouring poor ; more often in great eaters than free drinkers. It frequently happens to persons advanced in life, but is by no means peculiar to old age. It is not in general preceded or accompanied by apparent distemperature either of the part or of the habit." In its severer attacks, however, the constitution seems to be gene- rally contaminated, the mind and body become equally debilitated, there is great irritability, and a tendency to convulsive action. According to every statement this singular disease seems to be connected with a diseased state of the digestive organs, from excess of living, deleterious food, or some other cause in connection with great nervous debility :* and the tendency to gangrene proceeds rather from a deficiency of sensorial power, than from any morbid condition of the circulating system, whether atonic or entonic. And, hence, we find it best relieved by free doses of opium, in con- junction with a generous and even stimulant diet. Bark is of no avail, and the local use of spirituous fomentations and cataplasms, warm pungent oils and balsams, of as little. Mr. Pott tried them in every form, but without the smallest success: and at length em- ployed no other topical application than smooth soft unirritating poultices; and confined himself to the use of opium alone, of which he sometimes gave a grain every three hours. And under the influence of this medicine the progress of the gangrene has often become checked in a few days, and a line of separation distinctly marked ; soon after which, the mortified parts have sloughed away, the diseased bone dropped spontaneously from the affected joint, healthy granulations succeeded, and in due time a cure has been effected. Home, Facts and Experiment?, p. 81.—Lttdwiar, Adversar. i. i. 7. p. 188. «*.. m.j SANGUINEOUS FUNCTION. lonn. iv. tin SPECIES III. GANGR./ENA NECROSIS. DRY GANGRENE. I'lIE dead part dry, shrivelled, hard, and dusky. This singular species of gangrene seems to proceed from a ma- Gen. XIL iasmus or atrophy of the affected limb, in consequence of which, as HowCpro- in the atrophy of the body at large, the animal oil, flesh, and fluids duced. also are gradually absorbed, and the limb becomes emaciated and withered : " mummiae instar pars affecta,"* says Professor Frank. During the progress of this change, it necessarily grows feebler and more torpid, till at length it is no longer capable of being stimulated by the sensorial fluid, and its different parts turn dead and rigid. In palsied limbs, a termination of this kind is by no means uncommon. In some instances of this affection, the blood-vessels have col- Surface lapsed, perhaps become obliterated without a retention of any of natural?*" the constituent principles of the circulating fluid, and consequently the withered limb has preserved something of the natural colour of the skin. In others, the red particles of the blood, changed, as in sometimes the veins, to a dark or livid hue, have, to a certain degree, remained loured? in the vessels, and given to tlie limb a purple or variegated dye. accounted And hence the species has laid a foundation for the two following varieties : a, Albida. Retaining something of the natural White gangrene. colour of the skin. 3 Discolor. The natural colour changed to a livid. Black gangrene. or a mixture of hues. It has never hitherto been satisfactorily explained how it happens Why pU- that under this kind of mortification, or death, the parts should not, d'oBs™"" as in the preceding species, fall a prey to putrefaction. Perhaps the take P,ace- following remarks may afford some clue to this singular exception. We have already had occasion to observe, under the first species, Explained that a frost-bitten limb does not putrefy so long as it continues ph^no^ena frozen, because the accessories or co-operative powers of putrefac- °fa frost- tion,' without which this process cannot take place, are not present, limb. such as warmth, moisture, and a free influx of air. Now none of these are present in the species before us, for the limb is cold, com- pletely emptied of its fluids, and impervious to atmospheric influ- ence ; and consequently there are the same obstructions to putrefac- * Pe Cur. Horn. .Morb. Epit. Tom. H. p. 18. 8vo. Man'nTi. 1792, You TIT.— M Z%% rr, m.j IT.fiMATlCA. [ord. iv. Gev.xil tion in dry gangrene, as in a limb killed by the biting power of Gangraena HOSt. ntvr°nn-' ^° m tne Durmng sands of Egypt, a buried corpse is often found, pre"™.. if dug up a month or two after interment, with as few marks of pu- frnnfthose trefaction. I have said that warmth is a necessary auxiliary, but it of a corpse must be warmth to a certain degree only : for if it exceed this, all the burning the interior fluids will by the heat itself be raised towards the sur- E "vpt.°f ^ace' anc* P^s °ff rap^ly in the form of vapour; in consequence of which, the animal substance whence they issue will be as destitute of moisture as if it were frozen, and hence as incapable of putre- fying. Now this is the case with a body interred in the sultry sands of the Delta : all its fluids are so highly rarefied as to evaporate, and be drunk up by the bibulous soil by which it is surrounded before any organic decomposition takes place : and hence the buried corpse, instead of crumbling into dust, is converted into a kind of natural mummy, some parts of which exhibit proofs of that waxy fat to which the French chemists have given the name of adipocire : but no part of which undergoes the decomposition of putrefaction. I do not mean that this is always the case, but that it has occurred iu a variety of instances, where the antiseptic incidents have been pe- culiarly favourable to such an effect. a"a"?P-of "^n(* hence Dr. Frank tells us that the dry gangrene sometimes grene. changes into what is called humid, and at others converts the parts affected into a kind of mummy.* Singular j)r. Alix, of Altenburg, gives a singular example of the second sPEC- *v# kind of structure. Membrane is an expansion of gelatine richly sou"!?*" mapped with vessels and nerves, and containing a small proportion carti?a^©ah of albumen to give it a requisite degree of firmness; cartilage is aBtl wem* membrane with a larger proportion of albumen to give it a still bra"es• greater degree of firmness ; and bone is cartilage hardened by an absorption and deposite of lime through the whole of its make. And hence bones, notwithstanding their solidity, possess the same living power, and are subject to the same diseases as the soft parts. Like the soft parts, therefore, they are subject to a cessation or Expiana loss of this living principle, and the disease is in this case usually ^c?l.lhc called a caries, a Latin term, probably derived from the Hebrew term. JTO " careh," " to dig into, penetrate, or erode," " to scoop, or hollow out." It may originate in a bone itself, which constitutes a caries how proper caries; or it may be communicated from a superjacent elTfrwn'ca" ulceration, in which form it is more correctly denominated a carious lious ulcer ulcer. The history and treatment of caries belong rather to the depart- chiefly ment of surgery than of medicine, and are to be learnt from writers lne depart •" on this branch of the profession who have expressly treated of it, ™er"r°!'. among whom may especially be mentioned Wiseman,* Petit,! and Monro ;J particularly the last, as his learned and ingenious essay on this subject ought to engage the attention of every one. The * Surgery, Book u. CL. 7. tMalattfcs des OV Tom, jr. Ch. ^ ^ In. ;M'd. F»s?v«. Vol, v. r>. ?"0 Si i qL. uti.J 1LEMATICA. Caries. Caries. Causes. How dis- covered where no external ulcer. l\»w divi- ded by Pe- Spec ^iv' remarliS» therefore, to which the author will limit himself, will be uangrtena' general and pathological, and as summary as possible. Most of the causes that produce a gangrene in the soft parts may produce a caries or gangrene in the bones : as external injuries, cold, and a deficiency of nutrition in consequence of old age or deleterious food. It is also not unfrequently produced by some acrimonious or poisonous principle lurking in the circulation, as that of lues, porphyra, or scrophula; It is usually first ascertained, where there is no external ulcer, by an obtuse and deep-seated pain, which appears to issue from the bone ; an exostosis or protuberance of the bone, or periosteum in the part affected ; tenderness to the touch, a loose and flabby feel of the superincumbent integuments, and a discoloration of the skin. On being laid bare it evinces all the different modications of spha- celus which we have just noticed in the soft parts : for it is some- times moist and worm-eaten, forming the caries vermouille of M. Petit, the cells being filled with a corrupt sanies or spongy caruncles, so that the whole assumes a quaggy appearance ; and sometimes dry and wasted: and the dry variety, as in necrosis, is sometimes of a pale white, and sometimes of a black or livid hue. And hence M. Petit has subdivided the disease into four distinct species or varie- ties, founded on these remarks, but into which we have not space to follow him. The dry caries is generally the most superficial, and consequently exfoliates most easily ; the history and laws of which very curious process we have already pointed out under the genus apostema ; for the economy pursued by nature in the separation and removal of a dead soft part is precisely the same as that pursued separation m the separation and removal of a dead portion of bone. The an- tempted to cients attempted to expedite this by various means, some of which encdT11 were puerile, but others far more worthy of notice ; particularly the the an- destruction of the integuments by the potential cautery, and after- wards an application of the actual cautery to the dead bone itself. Celsus gives a detailed account of this operation, which, when thc caries was deep, was accompanied with numerous perforations into the bone, into each of which the hot iron was passed in succession. When the restorative power of art or of nature has succeeded in forming a healthy line of separation, and detaching the dead part from the living, the former is usually thrown off in a cylindrical plate; and before the exfoliation is accomplished, we are able to hear, as Severinus has justly remarked, a shrill sound whenever the carious plate is struck with a probe, as if it were hollow. Soon after this, the edges of the exfoliating part rise a little, and a little pus or even blood is easily pressed out at tlie margin. Here also granulations begin at this time to appear, which spread over thc sound bone underneath, and seem to assist the separation of the dead plate above, so that it gradually becomes loose, and can soon after- wards be taken away without violence. The dead part of a bone is sometimes detached and thrown off to onelT'orien a very great extent, and especially in the cylindrical bones.* Tin; Art. Hafn, Obs. 1.—"Nicholai Di;.«. Obsery. quaedam Mwlich-Cliir cients. Potential cautery. Actual cautery. Perfora- tions into the bone. Signs of separation. I'rogresji after wards. Iii the lnidric.i separated i.o a great ■r'ont. " * Bartholin, Ten. 17&.6V cl. in.J SANGUINEOUS FUNCTION. [ord. iv. 323 whole body of the tibia has in this manner been occasionally detached Gen- xn- by nature from its extremities, and its place supplied by a vicarious Gangrsena' callus which has run down the whole of the interior groove hereby caries. produced, and acquired the hardness of bone. Several cases of this Tibia and kind are given in the Edinburgh Medical Essays ;* in one of which f"°laat™ the caries appeared in both legs : the total tibia of one limb, as the bv art. writer, Mr. W. Johnston of Dumfries, informs us, being separated BotM?-*6' and thrown off at once ; while that of the other was detached in bias- small pieces and thrown out gradually. In five months from the removal of the entire tibia the patient, a boy of eleven years of age, was able to walk without crutches, continued well afterwards, and Was fit for any country work ; the legs being straight, with only a little thickness at the ankles. Justamond gives a similar case of the humerus, and Sherman of the thigh-bone. I have occasionally seen this natural process imitated successfully both in the tibia and thc bones of the fore-arm, and the diseased part taken out by a saw, by which process a very long period of pain and confinement has been saved to the patient. If the caries commence in the internal laminae, the superjacent sound part has sometimes been opened through its whole length by the trephine applied in a line of succession : the carious part has thus obtained an easy exit as soon as detached, and the entire bone has soon been renewed. The humerus was thus treated success- fully in the case of a negro-boy, as related by Mr. Walker to Mr. Else, in the Medical Transactions-! A caries of the spine from the tumid, and, so to speak, inflated Cariea 6f appearance of the superincumbent integuments, was formerly deno- spliTven minated spina ventosa : and th© term has, with great inconsistency,tosa whst* been since applied by many writers to all bones whatever affected in the same manner, and particularly those of the tarsus and carpus; as it has by others been applied, with equal incorrectness, to a ge- neral softness or flexibility of the bones, as in parostia fiexilis, or cyrtosis. In vertebral caries, Mr. Brodie has given cases which make it probable that here also the disease sometimes commences in the bones, and sometimes in the intervertebral cartilages ; for in various instances the loss of substance was greater in the former, and in others in the latter.J * Vol. i. p. 192-4. Vol. t. p. 370. t Vol. in. p. 27. \ Observations on Diseases of the Joints. $26 cl. hi.J ii^EMATlCA. [OliD. GENUS XIII. ULCUS. ULCER. GEN.XIII. Appertains chiefly to the depart- ment of surgery. Oiigin of generic term. Treated of under dif- ferent prin- ciples of sub-divi- s-lon. A PURULENT OE ICHOROUS SORE, PRODUCED BY THE SEPARATION OF A DEAD PART. This genus of diseases is, in every species, a subject of manual attention, and chiefly to be remedied or cured by external means. Its mode of treatment, therefore, must be learned under a course of surgical lectures: and it is only noticed in the present place to show the exact station which it ought to bear in a general system of nosology founded on a physiological basis. Ulcus is, strictly speaking, a Greek term with a mere change of one convertible vowel for another, to give it more of a Latin form : the derivative noun being sAkos, probably, as conjectured by Eustathius, from e\*u, " traho," in the sense of " distraho," hereby producing what the Greeks called a Xvo-k ovh%uxs, which is literally a " solution of con- tinuity." Ulcers have been treated of by different writers under a great variety of divisions and subdivisions; sometimes as being connected with a state of the constitution, or as being a mere local disease; sometimes as recent or chronic : and sometimes as mild or malig- nant ; but, as local ulcers may become constitutional, the constitu- tional may assume various forms, the recent be rendered chronic, and the mild and malignant change places, none of these characters are calculated for clear or permanent distinction. And hence another principle has been appealed to in the volume of Nosology derived from the variety of their external form, and they have been contemplated under the following species : 1. ULCUS INCARNANS. 2.-----VITIOSUM. 3.-----SINUOSUM. 4.-----TUBERCULOSUM. 5.-----CARIOSUM. SIMPLE HEALING ULCER. DEPltAVED ULCER. SINUOUS ULCER. WARTY EXCRESCENT ULCER, ( ARIOUS ULCER. rt. hi.] SANGUINEOUS FUNCTION. [ord. rv. 327 SPECIES I. ULCUS INCARNANS. SIMPLE HEALING ULCER. THE DISCHARGE PURULENT, THE SURFACE HEALTHY AND GRANU- LATING. When an ulcer assumes this form it is hardly to be called a dis- Gen.XHL ease ; being nothing more than the ordinary process of the instinc- in ^' ' tive or remedial power of nature to restore the substance that has ■t.ate a 8im' been lost by external violence, or some internal morbid action, and Ef6nature" to endow it with the same attributes of vascularity, feeling, and g°urndn°ess. motion. It is to this form that all the other species of ulcer must ah other be reduced before a cure can be accomplished or even hoped for. bTreduceif Even the surgeon has here little upon which to employ himself; for to this- with cleanliness, a fight and easy dressing, plain, unirritating diet, and regular hours, the processes of incarnation and cicatrization, which we have already explained under the genus apostema, will proceed spontaneously, and without obstruction, and a cure be speedily completed. SPECIES II. ULCUS VITIOSUM. DEPRAVED ULCER. WITH A YITIATED SURFACE AND SECRETION. This degenerate condition exhibits itself under various forms, and Gen.XIH. results from various causes. The modifications most worthy of PEC' ' notice are the following: x Callosum. The edges indurated and retracted. Callous ulcer. 3 Spongiosum. With fungous or spongy excres- Fungous ulcer. cences, often from a medullary base. y Cancrosum. With a hard, livid, lancinating, irre- Cnncerous ulcer. gular, and frequently bleeding tumour at its baep. 52b CL. III.] H^EMATICA. [ord. IV. GEN.XIII. Spec. II. Ulcus vi- liosum- Depraved ulcer. Causes constitu- tional or local. Constitu- ent From ge- neral de- bility: The causes in each of these may be constitutional or local; and, in managing the ulcer, it is of great importance to determine this point; for the patient may otherwise be put very needlessly upon a long course of alterants, or may omit such a course when absolutely necessary. If there be a cancerous, a scrophuious, a scorbutic, u venereal, or any other taint in the blood, it will be imperative upon us to pursue the respective modes of treatment already laid down for si0c?ficr°m tnese several complaints, since otherwise no topical applications taint: how can be of the least avail. There may be also a considerable degree of constitutional debility and relaxation, to which the depraved state of the ulcer is owing; and in truth this is the most common of all the constitutional causes, and one which demands quite as much attention as any of the rest. In treating of abscess, we endeavoured to show that one of the uses of pus is to produce healthy granulations ; and in treating of inflam- mation, we observed that a certain degree of vigorous and entonic, as well as inflammatory action is necessary for the secretion of pus. And hence if the system be without this condition the ulcer cannot heal; and, instead of genuine pus and healthy granulations, we shall find a watery, ichorous fluid poured forth, of no advantage whatever, and often of an acrimonious quality, that irritates and thickens, and sometimes erodes and extends the edges of the ulcer ; or a thin imperfect pus which gives rise to flabby and fungous gra- nulations that sprout up, indeed, rapidly and luxuriantly, but want firmness of texture, show a weak and morbid sensibility, and bleed and die away almost as soon as they are formed. Where this is the case, the ulcer, whatever modification it as- sumes, can only be brought into a healing train by increasing the health and vigour of the constitution. This, however, it is often difficult to accomplish ; for, in very numerous instances of obstinate ulcers, we find the constitution has been exhausted and worn out by hard labour, hard drinking, or a long exposure to a tropical sun, and is labouring under a long train of dyspeptic, hepatic, or podagral symptoms. It i3 not necessary to repeat the plan it will be incum- bent upon us to pursue under these circumstances, as we have already detailed it under the constitutional affections themselves. And if, by persevering in such general treatment, we can give to the constitution a sufficient degree of vigour, the only difficulty we shall have to encounter is the vitiated state, and perhaps habit, to which the ulcer has been reduced in consequence of the constitu- tional affection. Principles We hence come to the local treatment of ulcers which forms a ment when direct branch of surgical, and even manual attention. And I shall Use of to- hence only farther observe that the principles which seem to have been productive of the best success, are those of changing the nature of the vitiated action by a local application of irritants ; and increasing the tone of the vessels by warm suppuratives and astrin- gents, and the pressure of elastic bandages, which should be made of calico or the finest flannel. Mr. Baynton preferred the former on every occasion, as less cumbrous and more cleanly, and as being ■• a better conductor of that morbid heat whieh so con>tantlv affeet<- 2 low to be treated. pical irri- tants : Use of as tringents: Handajes: cl. iii. J SANGUINEOUS FUNCTION. [ord. iv. 329 inflamed parts." In many cases, however, and particularly in cold, GenXIIL edematous limbs, it is rather desirable to accumulate than to carry ufcusvi- " off heat; and here the use of flannel will be preferable to that of J*osum- . calico ; it possesses, moreover, more elasticity, and when thin and ulcer/ fine is neither more cumbrous nor more uncleanly. When the edges or intersections of an ulcer have acquired a Actual callous thickness, or scirrhosity, the, actual cautery has often been how far applied with success, and especially in the manner recommended Suunrir'a by M. Maunior, who has given an instructive history of his practice method of in the ninth volume of the Medico-Chirurgical Transactions. The uon.°a instrument he employs he calls, from the form of its bulb, an iron olive. It is, in effect, an iron rod with a bulb at the end, of the size of a tonquin-bean. For the sake of rapid execution he heats several of these at the same time in a fierce fire, and uses them at a white heat, passing each in succession with great speed over the morbid part, so as to make a considerable rut or groove as he pro- ceeds. The pain endured seems to be far less than might be ex- pected. The cautery thus prepared and applied, has been frequently found the most effectual as well as the shortest means of extirpating can- cerous scirrhosities about the lips, and other parts of the surface. And it is peculiarly calculated for radically destroying many of those Fungua irregular and spongy excrescences which, from their readiness to todes. bleed freely, have been distinguished by the name of fungus hje- matodes. The nature and origin of these parasitic substances have not been very satisfactorily explained. By some writers, and especially by M. Roux, they are regarded as soft and fungous cancers, but they seem to be without any of the pathognomic signs by which cancers are distinguished. They are not known to be hereditary, nor to become scirrhous in any stage, nor do they chiefly affect a glandular situation. They are found in every part of the body, appearing at ^"cter first like a small sarcomatous tumour, with a soft or medullary feel: origin and the tumour enlarges, and secretes an acrimonious fluid which con- Pro»'reiS- taminates the parts adjoining, whether gland, muscle, cellular mem- brane or periosteum, and converts them into its own nature. At the same time it erodes the skin and soon sprouts above it in a loose, luxuriant, and cauliflower form, of a dark red, or purple hue, loaded with blood-vessels, and bleeding profusely upon a slight puncture or even pressure. This singular fungus has often sprung g™*^ up in internal cavities, as the ball of the eye, the lungs, the testicles, internal and the uterus : and has occasionally appeared in the breast, the cav,tle,,■ spleen, and the liver. In these situations it is apt to ravage without restraint, and there is great difficulty in destroying it without destroying the organ from which it issues. But wherever the hand Treatment, can follow its sproutings they are often repressed, and have been • sometimes extirpated by caustics, and particularly by being sprinkled with a mixture of powder of arsenic and opium, or with charpie ; and sometimes, where it is seated on a narrow peduncle, by a liga- ture The actual cautery, however, wherever it can be applied, ceems to afford the quickest and mo?t cfWtunl CUre, and m *b*> Vol. m.--4f? 330 cl. iii. j 1LEMATICA. ' [ord. IV. Gen.XIII. peduncular variety offers tlie best mean of preventing a profuse ricus Vi- ' hemorrhage, by being applied to the stump after the body of the DeS"aved tuinour has been removed by the knife. There are some surgeons, ulcer. however, who depend almost entirely for the cure of all ulcers, on Treatment. a rcstoratjon 0f tjie constitutional health ; and contend that with the accomplishment of this, the remedial power of nature is adequate to all the rest, with local cleanliness, rest, and the use of mact!ca,of warm or co^ water according to the nature of the case. Such Rem. especially is the practice of Professor Kern in the Imperial Hos- pital at Vienna, who makes a boast of proscribing ointments, plas- ters, lotions, charpie, caustics, and even bandages themselves, except in a few cases, trusting entirely to the use of water and a simple covering of linen ; and this too even in gangrenous, scro- phuious, and venereal ulcers.* This practice is too simple to become very popular, but his success is undisputed. SPECIES III. ULCUS SINUOSUM. SI]YUOUS ULCER. COMMUNICATING WITH TIIU NEIGHBOURING PARTS BY ONE OR MORE CHANNELS. Gen.XIH. We have already seen that inflammations of every kind propagate Pathoi'o111' themselves by continuous sympathy ; and hence one cause of the How first spread of those that are ulcerative. But ulcerative inflammations formed. ^Q nQt Sprea(j equaily ; for those parts are most subject to their action, and consequently give way soonest, where the living principle is weakest, or the structure is most loose and cavernous. And hence a more frequent origin of hollows and sinuses in the cellular substance, particularly in the more dependent parts, as about the rectum and the urethra. How deep- These sinuses or hollows are soon filled with lymph or some other fluid, and this fluid, in a vitiated state of the ulcer, soon becomes acrimonious and erosive ; and we have hence a chemical cause of extension or elongation added to that of a structural. And to this cause we are chiefly to ascribe the origin of the fistula lachrymalis. When these sinuosities are first formed or scooped out, their walls Whenc« are soft, irritable, and of the common cellular web ; but when they eijioui. have remained for a considerable period of time, they become callous and insensible : forming the two following varieties noticed in the volume of Nosology; * Annalem der Chirurchischcn Klinik. 2 VoJg. 8vo. Wien. 1809. cl. ui.] SANGUINEOUS FUNCTION. [brd. »-. 881 x Recens. The channel fresh and yield- <*EN.xm. Recent Sinus. ing. mcns 'ginn*. & Fistulosum. The channel chronic and in- ?,um- ~ _. 1 j omuous Fistulous or Pipy-sinus. durated. ulcer. The form assumed by a sinus is determined by the course of the Th# fo™ probe ; its capacity by the quantity of water or any other fluid it will how ascer- contain when injected by a syringe. ta,n,d* Three modes of cure have been attempted, that of incarnation, or Modes rhole. SPECIES IV. ULCUS TUBERCULOSUM. WARTY EXCRESCENT ULCER. WITH TUBERCULOUS EXCRESCENCES, LOBED BY RAGGED AND SPREAD- ING EXULCERATIONS. This is the noli me tangere of many writers, and the lupus of GenXJ^- others ; evidently referring to the caustic acrimony of the discharge synonyms.' which flows from it, and affects the fingers or whatever other parts J™11^ come in contact with it; and the ravenous or wolf-like voracity with Lupus. which it preys on the neighbouring organs, spreading in ragged and SlSSi. fungous lobes, or with cracking and callous edges, and destroying the skin through an extensive range, and the muscles to a considerable depth. A valuable practical paper upon this disease is to be found in the Why cai^ Philosophical Transactions,* addressed to the Royal Society by M. cer* w Daviel, surgeon to Lewis XV. of France ; who describes it as a can- cer, to which, indeed, from its tendency to ramify and the virulence • Vol. xnx. year 175ft. aaa <*. m.] HifiMATlCA. [ord. ly. Gen.XIH. ©fits discharge, it has some resemblance ; and whence Sauvages de- Ulcus tu- ' nominates it cancer Lupus. It commences in the subjacent perios- iwrcuio- teum or perichondrium, from a diseased condition of the organ : at Warty ex- first assumes externally the form of a tubercle or wart; and though woscent foun(j over the body generally, is most common to the eye-fids, Origin and nostrils, cheeks, and other parts of the face. It is highly irritable ; progress. &q^ wjjen tne tubercle has acquired the size of a fig or filbert it ulcer- ates the cuticle, sho'ws a callous edge, and spreads with a most offen- sive ichor in every direction ; often throwing forth fungous excres- cences from the bottom. heretic* on Occasionally before it opens externally, from the acrimony secreted (he surface, below, an herpetic vesication is formed on the surface. If partially extirpated it grows again with rapidity and to a greater ?i!f!ical, extent; caustics always exacerbate it; and the only radical cure con- treatment. • . • V • L V 1 1 ■ i ../», sists in dissecting the diseased part, and removing the whole of the periosteous or cartilaginous base, as far as it appears to be affected. Where, however, the case is recent, and there is no morbid irritability in the habit, the diseased action has yielded to a skilful application of counter-stimulants, as a dilute solution df the nitrate of silver, or aromatic vinegar; after which the tar ointment has been found most serviceable. SPECIES V. ttLCUS CARIOSUM. CARIOUS ULCER. 5THE ULCER EXTENDING INTO THE SUBSTANCE OF THE SUBJA- CENT BONE. Gen.XHI. When a portion of a bone is killed by an ulcerative process com- Carioua mencing in itself, it forms, as we have already observed, a caries pro- uicerhow perly so called. When it is destroyed by the spread of a sore com- guished mencing in the integuments or muscles above it, the disease is called from ca- a CAKIOtjs ulcer : and when the ulceration extends to the medulla Artiirocace of the bone, it is often denominated an arthrocace. what Upon this subject, however, it is not necessary to enlarge in the General present place ; as we have already discussed the general nature and scribed the ordinary forms of ulceration under the second species of the already. genus before us, and the mode by which the death and separation qf one portion of bone from another are effected, under the foubth species of the preceding genus. END op VOL. in. *** ' r. ' -"U^ Jtv. ^ fJ^fJE-" " T ^r-J^J,-." »w »• C ? fiT >. • 'm-0 XVj- X ? IE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRA 1 /V!V\ I- /W! V\ | /Wl 1 --=^1 .» ^5S- z ^-S*S - 'N 3NI3I03W JO 11*1111 IVNOUVN 3NI3I03W JO A S V «8 I 1 IVNOUVN 3NI3IQ3W JO AS' .* f i My i *i NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAl IE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAl • X -'U/?&-y 2 I /\tf | i^XI t ^ s. <£--■- i N 3NI3I03W JO AlVliail IVNOUVN 3NI3IQ3W JO UVJ8I1 IVNOUVN 3NI3IQ3W JO A»V nKik It NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAl N 3 N 13 Id 3 W JO ASVSSI1 IVNOUVN 3NI3IQ3W JO ASVSSn IVNOUVN 3NI3I03W JO A a V IE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL lIBRAl NLM032779368